The U.S. health care system faced new levels of scrutiny in the past year amid the COVID-19 pandemic. Some hospitals were dangerously close to exceeding their capacity as  COVID-19 patients flooded emergency rooms and ICU wards. 

Even before the pandemic, some states were much better equipped to handle both everyday health needs — and the pandemic — than others. There are many states in which residents are much more likely to lack access to care or insurance to help pay for it and have to contend with underfunded medical hospitals.

To identify the states with the worst health care systems, 24/7 Tempo constructed an index comprising six health measures for each state: the share of residents without health insurance, state per capita expenditures on health care and on hospitals, and the ratios of dentists, doctors, and mental health providers per 100,000 people.

Of the 25 states with the worst health care systems, 14 are located in the South. This means that just two Southern states’ health care systems rank outside the bottom half. Conversely, none of the nine Northeastern states ranks in the bottom half of state health care systems. The Midwest has seven states among the worst, and the West has four states.

Much of the quality of a state’s health care system relies on money — both the funding that hospitals and other medical institutions receive and the ability of residents to afford basic care. Of the 25 states with the worst health care systems, just two have a higher median household income than the U.S. median of $65,712. These are America’s richest and poorest states.

Click here to see 25 states with the worst health care systems

To identify the states with the worst health care systems, 24/7 Tempo constructed an index comprising six health measures for each state: the share of residents without health insurance, state health care and hospital expenditures per capita, and the number of dentists, doctors, and mental health providers per 100,000 people. Each of these measures was weighted equally in the index. 

Population estimates and the share of residents without health insurance came from the U.S. Census Bureau’s 2019 American Community Survey. The percentage of adults who report fair or poor health came from the 2021 County Health Rankings & Roadmaps, a Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute joint program, and is based on data from 2018. 

State health and hospital expenditures were obtained from the U.S. Census Bureau’s 2019 State and Local Finance data. 

Data on hospital beds per 1,000 people was gathered from Becker’s Hospital Review rankings published in March 2020 — the magazine’s ranking is based on analysis of data from the American Hospital Association’s annual survey from 1999 to 2018. Single payer and family employee premium contributions by state were obtained from the Commonwealth Fund, December 2018.