Special Report

The Least Healthy City in Every State


To determine the least healthy city in every state, 24/7 Wall St. created an index composed of 35 health outcomes and health factors with data from the 2019 County Health Rankings & Roadmaps, a joint program of the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute. We calculated composite scores for outcomes and factors separately, then combined the two scores to form a single score that determines the metropolitan statistical area’s rank. 

All data used in the index came from the CHR, with the exception of the MSA 2018 annual unemployment rate, the most recent annual figures available from the Bureau of Labor Statistics’ Local Area Unemployment Statistics program. County-level data was aggregated to the MSA level using 2017 five-year population estimates from the U.S. Census Bureau’s American Community Survey. 

We also considered measures from the ACS including median household income, poverty, and educational attainment. These measures were not included in the index. 

Values selected for the index are standardized into Z-Scores, which assumes a mean of 0 and a standard deviation of 1. Z-scores are calculated for each index measure by MSA within each city’s respective state. If an MSA spans multiple states, then the city is indexed according to its primary state, as designated by the Census Bureau. Note that four states — Rhode Island, New Hampshire, Vermont, and Delaware — only have one MSA.

Health outcomes with the heaviest weights in the index include the age-adjusted premature mortality rate, the percentage of births with low birthweight, the percentage of adults reporting fair or poor health, and the age-adjusted average number of mentally and physically unhealthy days per month. The premature mortality rate is defined as the number of deaths under the age of 75 per 100,000 people. Unhealthy days are determined by the average number of days out of the month the adult population (18+) self-identifies as being unwell. This is used as an indicator of how chronic disabilities or illnesses (physical and mental) affect the members of a particular geography.

Health factors with the heaviest weights in the index include the smoking rate, the 2018 annual unemployment rate, injury mortality, and the child poverty rate. Injury mortality measures the rate at which the total population is killed due to injury, whether intentional (for example suicide), or unintentional (drug overdose, car accidents, accidental suffocation, etc). Air quality is also considered in the health factors category and is determined by measuring the average daily density of particulate matter at 2.5 micrograms (or PM2.5 for short). 

The remaining measures included in the index, as well as an explanation as to why they were used, can be found at County Health Rankings & Roadmaps.

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