Life expectancy fell by 1.5 years in the United States in 2020. The decline, driven by the COVID-19 pandemic and the opioid crisis, represents the worst regression in public health in the United States since World War II.

While the most recent dip in life expectancy in the U.S. is alarming, there are many parts of the country where poor health outcomes and other socioeconomic hardships have long been the norm.

Life expectancy at birth, along with educational attainment and per capita income, are the three core measures used by the United Nations Development Programme’s Human Development Index — a tool used for gauging and comparing quality of life across geographies. Inspired by the HDI, 24/7 Wall St. created an index consisting of three measures — life expectancy at birth, bachelor’s degree attainment, and poverty rate — to identify the worst counties to live in in every state. Our list also includes independent cities that do not fall within the boundaries of a county or county equivalent. Only independent cities, counties, and county equivalents with populations of 10,000 or more were considered. 

In most cases, the county that ranks as the worst place to live in a given state struggles with other socioeconomic problems beyond those used in the index. For example, the majority of counties on this list have higher unemployment than the state as a whole. Each county also has a lower median household income than the state as a whole. The majority of counties on this list are also shrinking and are home to fewer people today than five years ago. Here is a look at the fastest shrinking place in every state. 

Several counties on this list fall entirely or partially within Indian Reservations. For a number of reasons — including historical mistreatment, mismanagement, and convoluted barriers to economic development — Indian Reservations are often among the poorest places in the country. Here is a look at the states with the most Indian Reservations and tribal areas.  

Click here to see the worst county to live in every state.

To determine the worst U.S. counties to live in, 24/7 Wall St. constructed an index of three measures: poverty, bachelor’s degree attainment among adults, and average life expectancy at birth. Our list also includes independent cities that do not fall within the boundaries of a county or county equivalent. Only counties and county equivalents with populations of 10,000 or more were considered.

Data on the share of individuals living below the poverty line as well as the share of adults 25 and older with at least a bachelor’s degree came from the 2019 U.S. Census Bureau’s American Community Survey and are five-year estimates.

Data on average life expectancy at birth came from the 2021 County Health Rankings, a joint program of the Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute, and are based on mortality data from the years 2017 to 2019.

Supplemental data on population, income, and median home value are five-year estimates from the ACS. Data on unemployment in May 2021 came from the Bureau of Labor Statistics and are seasonally adjusted.