The long debate over the Affordable Care Act (ACA) has, if nothing else, put the spotlight on the poor state of the country’s health and health care system. The United States ranks behind most developed nations in life expectancy despite spending more per capita on health care than any other country.

Across the country, health outcomes vary greatly. More than 30% of the adult population of Madera, California, reported being in less than optimal health, while only 6.4% said the same in Ames, Iowa, the healthiest city in the country by our measure. This vast disparity is one issue the ACA is, at least in part, intended to address. Cities such as Ames — that have populations with extremely high physical and mental well-being — can teach us much about what is necessary to create healthier populations — be it income, healthy behavior, or access to care. 24/7 Wall St. created an index to identify the least healthy city in each state.

Click here to see the least healthy city in every state

Click here to see the healthiest city in every state

Each city was ranked based on overall health outcomes, including length and quality of life. Also considered in the index are a range of factors that influence these outcomes, including healthy behaviors, clinical care, social and economic indicators, and physical environment.

While the least healthy city in most states tends to be unhealthy compared to the country as a whole, this is not always the case. And while urban dwelling has many positive impacts on the health of a population — including access to healthy food, places to exercise, and job opportunities — even large metro areas earned the distinction of a state’s least healthy city.

In states such as Minnesota and Hawaii, the least healthy metro area scored better than the national levels in most key health metrics. For the most part, however, these cities have poor health outcomes.

Not surprisingly, unhealthy behaviors tend to correlate strongly with less healthy populations. High rates of inactivity, for example, were especially common in these cities compared to the national levels of inactivity. Obesity, too, correlates very strongly with many of the leading causes of death in this country, and in many of the most unhealthy cities the obesity rates were higher than the national rate. Smoking also appears to be an important health indicator. Less than a third of the most unhealthy cities in each state had below national average smoking rates.

Many of the least healthy cities had low rates of health insurance coverage. There are several reasons for this, explained Bridget Catlin, co-director of the County Health Rankings and Roadmaps Program. While people without insurance can still access care, they “have to go to the places that will take them.” Those with insurance, on the other hand, find it easier to access care, and they have “choice of care [and] resources available to them.”

Another important factor in the least healthy metro areas is education. The vast majority of city with relatively unhealthy populations has below average rates of adults who have completed at least some college. Better-educated populations are more likely to make better health decisions, but education also comes into play in other ways.

“Education definitely contributes to decision-making, but it also contributes to income and then opportunity,” Catlin said. Better-educated people often work in better-paying jobs, which allows them easier access to healthy food and exercise options — much more than people with lower incomes. “There are multiple pathways going on here, but education is at the crux of increasing people’s opportunity for leading a healthier life.”

24/7 Wall St. created an index modelled after analysis conducted by County Health Rankings & Roadmaps, a Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute joint program. To identify the healthiest city in each state, 24/7 Wall St. reviewed all U.S. metropolitan statistical areas. The index rankings are based on overall health outcomes, a weighted composite of length of life, quality of life, and overall health factors. The health factors component is itself a weighted composite of healthy behaviors, clinical care, social and economic factors, and physical environment measures.

These are the least healthy cities in every state.

1. Gadsden, Alabama
> Pct. without health insurance: 14.2%
> Pct. food insecure: 8.6%
> Obesity rate: 33.8%
> 2014 unemployment rate: 7.0%

Alabama is one of the nation’s least healthy states. So Gadsden, the state’s least healthy metro area, is also one of the least healthy areas in the nation. Nearly 23% of Gadsden adults reported fair or poor health, higher than the comparable state rate of 20.5%, which itself was the fourth highest such level of poor health compared to other states. An estimated 9,508 years of life are lost annually per 100,000 people in Alabama, the third highest statewide level of premature death. In Gadsden, preventable deaths resulted in an estimated 11,057 years of life lost per 100,000 area residents.

2. Anchorage, Alaska
> Pct. without health insurance: 17.2%
> Pct. food insecure: 4.9%
> Obesity rate: 27.9%
> 2014 unemployment rate: 5.8%

Anchorage and Fairbanks are the only two metro areas in Alaska, and Anchorage earns the distinction of least healthy. However, as is the case across the nation, residents living in more urban areas tend to be healthier than residents living in more rural areas. As a result, even though Anchorage is the least healthy urban area in Alaska, it still performs better than the rest of the state in several health measures. For example, the incidence of premature death in the area, measured at 6,889 years lost annually per 100,000 people, was lower than the state’s estimate. However, preventable death nationwide resulted in fewer years lost compared to Anchorage. Both Anchorage residents and Alaskans statewide reported above-average alcohol consumption. Close to one in five people in Anchorage reported binge or heavy drinking, in line with the state proportion, but higher than the national proportion.

3. Lake Havasu City-Kingman, Arizona
> Pct. without health insurance: 18.2%
> Pct. food insecure: 17.3%
> Obesity rate: 26.6%
> 2014 unemployment rate: 8.8%

Lake Havasu is one of the widest points in the Colorado River, which separates Arizona from California. The city on the lake is about an hour drive from Kingman, which is also part of the metro area. While Arizona residents had relatively healthy habits, residents of the Lake Havasu-Kingman metro area were more likely to smoke and less likely to exercise than their peers across the state and nationwide. Less than 17% of Arizonans reported a smoking habit, while in the Lake Havasu area, 26.9% smoked. And while just over 20% of Arizona residents were physically inactive, 30.8% of the metro residents were, likely contributing to the higher obesity rate. Nearly 27% of area residents were obese, higher than the state’s obesity rate of 23.9%.

4. Pine Bluff, Arkansas
> Pct. without health insurance: 13.4%
> Pct. food insecure: 9.0%
> Obesity rate: 37.8%
> 2014 unemployment rate: 8.6%

Arkansas is one of the nation’s least healthy states. Partially as a result, Pine Bluff is not just the state’s least healthy metro area, but also one of the least healthy cities in the country. Only 57.6% of residents had adequate access to locations for physical activity, lower than the state share of 65.8% of residents, which itself was the fourth lowest compared to other states. The poor access likely contributed to Pine Bluff’s obesity rate of 37.8%, one of the highest of any U.S. area.

While Pine Bluff residents were more likely to have health insurance than both their statewide peers and Americans nationwide, practitioners are relatively scarce in Pine Bluff. There is one dentist for every 4,154 area residents, for example, far worse than the state ratio of one dentist for every 2,338 people, the worst ratio of all states. Similarly, there are roughly 1,749 people for every doctor in Pine Bluff, a worse ratio even than the already relatively poor state ratio.

5. Visalia-Porterville, California
> Pct. without health insurance: 19.4%
> Pct. food insecure: 8.1%
> Obesity rate: 28.3%
> 2014 unemployment rate: 13.2%

California residents had some of the nation’s healthiest behaviors as well as some of the best health outcomes, in contrast with the Visalia metro area — the state’s least healthy urban region. Nearly one in four area residents reported fair or poor health, versus the comparable state and national proportions of 18.4% and 16.0%, respectively. Lack of health insurance may have contributed to worse health outcomes in the area — health insurance is important not just because it reduces the economic burden on the sick, but also because it encourages people to get routine checkups. California had good health outcomes despite its relatively high uninsured rate of 17.2%, the eighth highest. The Visalia area had an even higher rate of 19.4%, significantly greater than the national uninsured rate of 14.5%.

6. Pueblo, Colorado
> Pct. without health insurance: 12.8%
> Pct. food insecure: 16.0%
> Obesity rate: 26.5%
> 2014 unemployment rate: 7.3%

Colorado had the nation’s lowest obesity rate and lowest rate of physical inactivity, at 15.2% and 20.4%, respectively. But while Pueblo, the state’s least healthy metro area, also reported some relatively strong health measures, it fared very poorly in others. For example, while Pueblo’s obesity rate of 26.5% was well above the state’s rate, it was still lower than the national rate of 28.3%. Yet, the incidence of premature death in the area was abysmal. An estimated 5,756 years are lost annually per 100,000 people in Colorado, versus the national figure of 6,622. In Pueblo, however, 8,686 years are lost annually per 100,000 area residents due to premature deaths.

7. New Haven-Milford, Connecticut
> Pct. without health insurance: 8.8%
> Pct. food insecure: 4.0%
> Obesity rate: 26.9%
> 2014 unemployment rate: 6.8%

Healthy behaviors and outcomes are closely associated with strong economic circumstances. Residents earning higher incomes can afford better health care, and those with higher levels of education often work in higher-paying jobs that also tend to lead to healthier lifestyles. Relatively high incomes in Connecticut largely explain the relatively strong health outcomes. And while 64.7% of New Haven area adults had completed at least some college — lower than the state share of 67% — it was still higher than the nationwide rate of 63%.

8. Dover, Delaware
> Pct. without health insurance: 8.9%
> Pct. food insecure: 4.8%
> Obesity rate: 32.7%
> 2014 unemployment rate: 6.4%

Because Dover is the only metro area in Delaware, it is both the healthiest and the least healthy city in the state. Delaware ranks generally well in health measures. While the capital area’s population is not as healthy as the state’s population, it still fares better than the nation as a whole for several measures of health. For example, 14.7% of Dover adults reported fair or poor health. This was higher than the 12.4% of adults in Delaware who said the same, but better than the 16% of U.S. adults who reported less than optimal health. Uninsured people are less likely to have primary care providers or receive preventive care. As a result, health conditions often go undiagnosed or are diagnosed at a later stage. In Dover, just 8.9% residents did not have health insurance, far lower than the national uninsured rate of 14.5%.

9. Homosassa Springs, Florida
> Pct. without health insurance: 13.7%
> Pct. food insecure: 9.2%
> Obesity rate: 29.2%
> 2014 unemployment rate: 8.5%

Compared with the least healthy areas in other states, residents of Homosassa Springs have exceptionally good access to health care services. For every doctor and for every dentist in the area, there are 559 and 882 people — the two ratios are significantly better than the respective statewide ratios. In addition, less than 14% of people did not have health insurance, versus 20% of Floridians, which was third highest uninsured rate of all states. Still, the Homosassa area is the least healthy in the state. Inline with the nation, about 16% of Floridians reported fair or poor health. In Homosassa Springs, 18.4% of adults reported such low levels of health. Relatively unhealthy behaviors likely contributed to the poor self-reported health in the area.

10. Macon, Georgia
> Pct. without health insurance: 19.1%
> Pct. food insecure: 6.1%
> Obesity rate: 29.9%
> 2014 unemployment rate: 7.7%

Many Macon residents live in relatively poor social and economic environments, which likely contributed to the area’s distinction as Georgia’s least healthy metro area. An estimated 57.9% of current ninth graders are expected to graduate, far lower than the statewide graduation rate of 70.4%, which itself is nearly the lowest rate of all states. Last year, 7.7% of the area’s workforce was unemployed, higher than the state’s rate of 7.2%, which was the sixth highest compared to all states. Such factors are associated unhealthy behaviors as well as help lead to a higher incidence of premature death. In Macon, an estimated 10,059 years are lost per 100,000 people each year due to premature death, well above both the state and national levels. Macon is also one of only 11 metro areas where years lost to preventable death exceeded 10,000 years annually.

11. Kahului-Wailuku-Lahaina, Hawaii
> Pct. without health insurance: 8.9%
> Pct. food insecure: 8.7%
> Obesity rate: 22.7%
> 2014 unemployment rate: 4.5%

The Kahului-Wailuku-Lahaina metro area is one of two in Hawaii, one of the healthiest states. Like in Hawaii, the smoking and physical inactivity rates in the Kahului area, at 15.4% and 17.1% respectively, were lower than the national rates. Perhaps as a result, the incidence of premature death and the obesity rates were also lower than the corresponding nationwide figures. In addition, while the metro area’s uninsured rate of 8.9% was higher than the statewide rate, it was well below the national rate of 14.5%. Still, area residents are the least healthy of any metro area in the state. More than one in five area adults reported a binge or heavy drinking habit, and nearly half of the area’s households reported at least one housing problem such as overcrowding or high costs — problems that can impede a healthy lifestyle.

12. Lewiston, Idaho
> Pct. without health insurance: 10.3%
> Pct. food insecure: 4.1%
> Obesity rate: 32.3%
> 2014 unemployment rate: 4.6%

Despite relatively healthy habits, and a low share of adults reporting fair to poor health, the Lewiston metro area had a high incidence of premature death and is Idaho’s least healthy metro. Just over one in 10 area residents did not have health insurance, a better coverage rate than across the state and the nation. Also, less than 15% of Lewiston’s population participate in physical activity in their spare time, versus the state and national shares of 19.5% and 27.0%, respectively. Yet, and estimated 8,594 years are lost per 100,000 area residents annually due to premature death, well above both the state and national estimates of 6,046, and 6,622, respectively.

13. Danville, Illinois
> Pct. without health insurance: 11.3%
> Pct. food insecure: 6.9%
> Obesity rate: 34.3%
> 2014 unemployment rate: 8.6%

More than 25% of adults in Danville are smokers, and more than 26% are physically inactive, each well above the respective state and national shares. These relatively poor habits among residents living in Illinois’s least healthy metro likely contributed to worse health outcomes. The incidence of premature death in Danville, measured at 8,656 years lost per 100,000 area residents annually was far worse than the state and national estimates. Also, Danville’s obesity rate of 34.3% was one of the highest rates of any U.S. urban area, while the state’s obesity rate of 27.3% was slightly lower than the nationwide rate of 28.3%.

14. Muncie, Indiana
> Pct. without health insurance: 12.4%
> Pct. food insecure: 7.0%
> Obesity rate: 33.4%
> 2014 unemployment rate: 7.1%

More than 20% of adults in Muncie said they were in fair or poor health, versus around 16% of Indianans. At least some respondents reporting such poor health were likely smokers, as more than 25% of area adults reported a smoking habit, in contrast with the statewide rate of 22.8%, itself the fifth highest of all states. The share of area residents with access to locations of physical activity, at just over 75%, was slightly higher than the statewide share. However, compared with 85% of Americans reporting such access, Muncie residents had relatively poor exercise opportunities. Partially as a result, more than one in three areas residents were obese, higher than the state’s obesity rate of 31.3%.

15. Sioux City, Iowa
> Pct. without health insurance: 11.5%
> Pct. food insecure: 9.6%
> Obesity rate: 31.9%
> 2014 unemployment rate: 4.4%

Iowa is one of the healthier states in the country, with just 11.2% of adults reporting fair or poor health in 2015 compared to 16% of the country’s adults. Consequently, while the Sioux City metropolitan area is unhealthy relative to the other metros in the state, it is still healthier than the rest of the country. Just 12.4% of adults were in fair or poor health, higher than the state’s share but still lower than the national share. Residents, however, participate in some less-than-healthy behaviors. The metro area had slightly higher obesity and smoking rates than the comparable national rates.

16. Wichita, Kansas
> Pct. without health insurance: 13.1%
> Pct. food insecure: 8.8%
> Obesity rate: 30.3%
> 2014 unemployment rate: 5.2%

Safe communities are often healthy communities as well. In Wichita, the least healthy metro in Kansas, 568 violent crimes were reported in 2013, contributing to a rate well above corresponding state and national rates. Living in unsafe neighborhoods is associated with higher stress levels and other poor health factors, which can accelerate aging and lead to a higher incidence of premature death. In Wichita, an estimated 7,420 years are lost per 100,000 residents each year due to preventable deaths, well above both the state and national estimates. Wichita also reported 512 cases of chlamydia per 100,000 residents, also much higher than the comparable state and national rates. Higher occurrences of sexually transmitted diseases are more common among people leading unhealthy lifestyles.

17. Bowling Green, Kentucky
> Pct. without health insurance: 14.7%
> Pct. food insecure: 2.7%
> Obesity rate: 30.6%
> 2014 unemployment rate: 5.9%

Few metro areas have worse health outcomes than the Bowling Green, Kentucky metropolitan area. Each year, an average of 8,058 years of life are lost due to premature death per 100,000 residents, compared to the 6,622 years lost on a national level. Nearly 20% of adults reported fair or poor health compared to 16% of all adults nationwide. A lack of exercise in the metro area is likely contributing to the poor health outcomes. Just 67% had access to physical activity locations compared to 85% of adults nationwide. Also, nearly 37% of the area’s population are physically inactive — about 10 percentage points higher than the national share.

18. Monroe, Louisiana
> Pct. without health insurance: 17.3%
> Pct. food insecure: 17.6%
> Obesity rate: 34.2%
> 2014 unemployment rate: 0.1%

According to a recent study, residents of communities with high income inequality are more likely to die before the age of 75. While researchers do not agree over the reasons behind the poor health in such areas, they agree that inequality exacerbates poor health outcomes beyond the effects of low income levels alone. In Monroe, the 80th percentile incomes were more than seven times greater than the 20th percentile incomes, the widest such income gap not just in Louisiana but of any U.S. metro area. Each year, an estimated 9,355 years are lost per 100,000 area residents, higher than the statewide incidence of premature death of 9,131 per 100,000 Louisianans, which was the fourth highest state figure.

19. Lewiston-Auburn, Maine
> Pct. without health insurance: 10.0%
> Pct. food insecure: 2.9%
> Obesity rate: 31.3%
> 2014 unemployment rate: 5.5%

While Lewiston-Auburn, located in the southern part of Maine, is the least healthy metro area in the state, it is actually relatively average compared to the rest of the nation. Lewiston area residents reported 3.7 physically unhealthy days in the past 30, compared to an average of 4.0 per month across the country. The metro area had a slightly higher adult obesity rate than the national rate, at 31.3% versus 28.3%, which may be one of the reasons it fares worse than other Maine metro areas. Higher obesity rates often correspond with many other negative health indicators.

20. Cumberland, Maryland
> Pct. without health insurance: 11.7%
> Pct. food insecure: 15.6%
> Obesity rate: 28.0%
> 2014 unemployment rate: 7.3%

The Cumberland metropolitan area is interesting because while half of it is located in Maryland, one of the healthiest states, the other half is in West Virginia, one of the least healthy states. The metro area, which includes Allegheny County in Maryland and Mineral County in West Virginia, is worse than the national averages by most measures of health behavior and outcomes. Socioeconomic factors may have had a significant impact on outcomes in the region. More than 15% of the area’s residents did not have adequate access to healthy food because of income restraints, which is nearly three times the national share. Education levels often correlate strongly with healthy behavior. In Cumberland, just 52.4% of adults had at least some college education, about 10 percentage points below the national rate.

21. Springfield, Massachusetts
> Pct. without health insurance: 3.9%
> Pct. food insecure: 5.6%
> Obesity rate: 27.4%
> 2014 unemployment rate: 6.8%

Massachusetts was the first state in the country to have near-universal health care. Since health insurance is one of the key determinants of health outcomes, it is not surprising that Springfield, the least healthy metropolitan area in the state, is still relatively healthy by national standards. Just 3.9% of metro area residents did not have health insurance in 2013, compared to 14.5% of Americans. While the metro area had a higher than average rate of reported days of poor mental health, it had fewer days of poor physical health than the national average, as well as fewer years of life lost due to premature death per capita.

22. Flint, Michigan
> Pct. without health insurance: 9.4%
> Pct. food insecure: 9.0%
> Obesity rate: 36.9%
> 2014 unemployment rate: 7.8%

Nearly 19% of adults living in Flint reported fair or poor health versus 14.3% of Michigan residents and 16% of all Americans. At least some of the adults reporting less than optimal health were likely among the area’s obese population, which made up nearly 37% of residents. This was far higher than the state’s obesity rate of 31.6% and in stark contrast with the national rate of 28.3%. Less than 10% of Flint residents did not have health insurance, although the strong coverage has not significantly lowered the incidence of premature death. An estimated 9,092 years are lost per 100,000 people each year due to premature deaths, versus the state and national estimates of 7,218 and 6,622.

23. Duluth, Minnesota
> Pct. without health insurance: 8.2%
> Pct. food insecure: 7.6%
> Obesity rate: 27.4%
> 2014 unemployment rate: 5.2%

Minnesota is the healthiest state in the country by a number of measures. Just 10.5% of adults reported fair or poor health, the lowest of all states. Similarly, the incidence of premature death, at an estimated 5,038 years lost per 100,000 people annually, was the lowest of all states. While the Duluth metro area is the state’s least healthy, its residents are still healthier than many Americans. For instance, while 18.0% of area adults smoked — higher than the state’s smoking rate of 16.2% — it was still lower than the nationwide smoking rate of 20.0%.

24. Gulfport-Biloxi-Pascagoula, Mississippi
> Pct. without health insurance: 20.4%
> Pct. food insecure: 15.8%
> Obesity rate: 32.0%
> 2014 unemployment rate: 7.5%

Mississippi is one of the least healthy states in the country, and the Gulfport-Biloxi-Pascagoula metropolitan area, located near Gulf of Mexico, is by most measures just as unhealthy. Nationally, an annual average of 6,622 years of life are lost due to premature death. In the Gulfport region, more than 9,300 years are lost due to premature deaths per year. Like the state as a whole, the metropolitan area struggles with obesity, which has one of the strongest relationships with overall health. While 28.3% of the nation’s adults were obese, 34.1% were in the Gulfport area.

25. St. Louis, Missouri
> Pct. without health insurance: 10.4%
> Pct. food insecure: 6.1%
> Obesity rate: 33.2%
> 2014 unemployment rate: 6.3%

St. Louis is slightly less healthy than Missouri as a whole, and far less healthy than the United States. In St. Louis, 29.7% of residents smoked compared to 22.6% in Missouri and 20.0% in the rest of the country. Similarly, 33.2% of St. Louis residents were obese compared to 30.9% across Missouri and 28.3% across the nation. St. Louis had an impressive graduation rate, with 89.9% of high schoolers graduating compared to an 80.0% high school graduation rate across the country. Education is important to physical health as it provides access to higher-paying jobs that can support healthier lifestyles. This, coupled with an active job market, can significantly improve the health of a city. Last year, 6.3% of the St. Louis workforce were unemployed, which was slightly above the state unemployment rate of 6.1%.

26. Great Falls, Montana
> Pct. without health insurance: 14.2%
> Pct. food insecure: 8.2%
> Obesity rate: 28.9%
> 2014 unemployment rate: 4.4%

The cities in Montana are all fairly similar in general measures of health. Great Falls is the least healthy city in Montana, but has average health outcomes for an American metropolitan area. Compared to the national obesity rate of 28.3% and the 27.0% of Americans who reported being inactive, Great Falls is roughly in line with a 28.9% obesity rate and 27.0% of adults reporting inactivity. The share of uninsured people in Great Falls — 14.2% — is similar to the national uninsured rate of 14.5%. Of all driving deaths in the state, 46.9% were alcohol related, the highest of all states. In Great Falls, the percentage was even higher, with 50% of all driving deaths caused by alcohol.

27. Omaha-Council Bluffs, Nebraska
> Pct. without health insurance: 10.7%
> Pct. food insecure: 4.0%
> Obesity rate: 28.7%
> 2014 unemployment rate: 3.7%

Unhealthy habits among Omaha residents likely contributed to the area’s poor overall health. About 18.5% of people in Omaha identified as smokers, slightly more than the 17.6% smoking rate in Nebraska. Additionally, slightly more than 21% of area residents reported excessive drinking, higher than both the corresponding statewide and national figures of 19.5% and 15%, respectively. While across Nebraska, 35.4% of deaths behind the wheel were the result of alcohol impaired driving, in Omaha, alcohol was the cause of 42.3% of fatal car accidents. Unhealthy habits and avoidable driving deaths helped contribute to the nearly 6,000 years of life lost due to premature death per 100,000 Omaha residents.

28. Las Vegas-Henderson-Paradise, Nevada
> Pct. without health insurance: 21.6%
> Pct. food insecure: 2.0%
> Obesity rate: 24.9%
> 2014 unemployment rate: 7.8%

Nevada is the second least insured state in the country after Texas and it had the second most people per primary care physician. In the Las Vegas metro area, 21.6% of residents were uninsured and there were 1,807 people per primary care physician, both worse than the state levels. Such poor insurance coverage and scarcity of doctors make it more difficult for residents to receive primary and preventive care. For example, Nevada had the fourth lowest rate — 77.4% — of diabetic Medicare patients aged 65-75 receiving regular HbA1c monitoring and the third lowest rate — 56.2% — of Medicare enrollees aged 67-69 receiving mammography screenings. In the Las Vegas area, 76.7% received HbA1c monitoring and 54.4% received mammography screenings.

29. Manchester-Nashua, New Hampshire
> Pct. without health insurance: 10.4%
> Pct. food insecure: 3.4%
> Obesity rate: 27.2%
> 2014 unemployment rate: 4.2%

Manchester-Nashua is the only metropolitan area in New Hampshire, so it qualifies as both its healthiest and least healthy city. Compared to the rest of the country, the Manchester metro area is reasonably fit and fosters an environment conducive to healthy lifestyles. About 16% of area residents smoke, which was 4 percentage points lower than the national smoking rate. Impressively, at 95.9%, almost all of the metro area’s population had adequate access to locations for physical activity. Strong economic conditions in the Manchester area and across New Hampshire contributed to healthier lifestyles, particularly among younger residents. The child poverty rate of 10.9% is the lowest in the country, and in Manchester-Nashua, the child poverty rate is 11.0%. New Hampshire also had the lowest teen birth rate in the country, with only 16.6 teen births per 1,000 women aged 15-19. The rate was 19.6 teen births in Manchester-Nashua. still well below the national teen birth rate of 37 births per 1,000 teenage women.

30. Vineland-Bridgeton, New Jersey
> Pct. without health insurance: 16.5%
> Pct. food insecure: 9.2%
> Obesity rate: 33.9%
> 2014 unemployment rate: 9.9%

New Jersey is a fairly healthy state and fares slightly better than the rest of the country in health measures such as smoking, obesity, and inactivity rates. However, the Vineland-Bridgeton metro area, the least healthy city in the state, does not fare as well. In a state where nearly all residents have access to locations for physical activity, at 95.6%, the Vineland metro area provides adequate access for just 77.5% of its residents. In a state that beats the country’s 20% smoking rate by 4.4 percentage points, the Vineland area’s smoking rate was 4.1 percentage points higher than the nation’s. Likewise, in a state that beats the national obesity rate of 28.3% by 3.9 percentage points, the Vineland-Bridgeton area’s obesity rate is much higher, at 33.9%.

31. Farmington, New Mexico
> Pct. without health insurance: 24.9%
> Pct. food insecure: 13.6%
> Obesity rate: 30.2%
> 2014 unemployment rate: 6.3%

Farmington has the sixth highest uninsured rate of any metro area in the country, and the third highest outside of Texas. Uninsured individuals are less likely to receive routine checkups, which can catch conditions in their earliest stages. And about one-fourth of Farmington residents were uninsured, likely contributing to worse health outcomes. There were 93.9 deaths from injuries per 100,000 people in New Mexico, highest of any state. In Farmington, the injury death rate was more than five times as high, at 533 deaths per 100,000 people. This likely contributed to the high incidence of premature death in Farmington, estimated at 9,220 years lost per 100,000 people annually, well above the state and national estimates. In measures of physical health such as smoking and obesity rates as well as inactivity, Farmington trailed the nation only slightly. In Farmington, 22.7% of residents smoke, 30.2% are obese, and 23.2% are physically inactive, compared to the national shares of 20.0%, 28.3%, and 27.0%, respectively.

32. Elmira, New York
> Pct. without health insurance: 7.5%
> Pct. food insecure: 6.0%
> Obesity rate: 30.7%
> 2014 unemployment rate: 6.3%

Almost 92% of Elmira residents have health insurance. Having health insurance allows for better access to medical treatment and increases the likelihood conditions will be diagnosed and treated early. Despite Elmira having one of the top 25 insured rates of any metropolitan area, residents still had unhealthy behaviors and poor health outcomes, and the area is New York’s least healthy city. It lags just behind New York and the nation, with a 30.7% obesity rate compared to 28.3% nationwide, and a 23.4% smoking rate compared to a 20.0% national smoking rate. Besides New York City, Elmira had the lowest high school graduation rate of any city in New York. High school education is especially important to the overall health of a population, as a diploma can allow for jobs with higher incomes that afford healthier lifestyles.

33. Rocky Mount, North Carolina
> Pct. without health insurance: 15.8%
> Pct. food insecure: 6.1%
> Obesity rate: 34.8%
> 2014 unemployment rate: 8.6%

North Carolina is similar to the rest of the country in general measures of health. The health of its cities vary, however, and Rocky Mount is the least healthy, largely due to relatively unhealthy behaviors and a poor economic environment. Rocky Mount’s obesity rate was 34.8%, 6.5 percentage points higher than the national level. Lack of exercise may have contributed to the obesity rate, as 31.4% of Rocky Mount residents were physically inactive. By contrast, only a quarter of North Carolina’s residents were physically inactive. The economic climate of Rocky Mount is also in poor shape. The area’s 8.6% unemployment rate last year was the highest of any city in North Carolina. Rocky Mount also had a 32.2% child poverty rate, again the highest in the state, and higher than the comparable national percentage.

34. Bismarck, North Dakota
> Pct. without health insurance: 8.2%
> Pct. food insecure: 6.9%
> Obesity rate: 29.3%
> 2014 unemployment rate: 2.8%

Bismarck is the least healthy city in an otherwise very healthy state, and it is generally in better shape than the rest of the country. Cities across North Dakota have fairly uniform levels of healthy behaviors, but Bismarck reported far worse health outcomes. Health insurance is important to a population’s health, and at about 92%, Bismarck’s insured rate is about 7 percentage points higher than the rest of the country’s. Child poverty is another important indicator of current health and a good predictor of future health. North Dakota had the second lowest child poverty level in the country, and at 11.8%, Bismarck also had one of the lowest child poverty rates of any metro area. Bismarck shares many healthy behaviors with the rest of North Dakota, but loses more years of potential life than any other city in the state. In Bismarck, 7,513 years of potential life per 100,000 people are lost by those who die before age 75. This is 1,125 more years lost than the estimated incidence of premature death for North Dakota.

35. Springfield, Ohio
> Pct. without health insurance: 10.8%
> Pct. food insecure: 7.0%
> Obesity rate: 30.1%
> 2014 unemployment rate: 5.6%

Ohio is about as healthy as the nation. A poor social and economic environment accounts for Springfield’s status as the least healthy city in Ohio. An important indicator of current and future population health is the prevalence of child poverty, as lifestyle habits developed in childhood are likely to carry into adulthood. About 28% of Springfield children live in poverty, 6 percentage points higher than the national share. While Springfield’s high school graduation rate was similar to the national rate, area residents were less likely to have completed at least some college compared to most Americans. In other measures of healthy behavior such as obesity and physical inactivity, Springfield is on par with Ohio and the rest of the country.

36. Lawton, Oklahoma
> Pct. without health insurance: 17.0%
> Pct. food insecure: 14.5%
> Obesity rate: 33.5%
> 2014 unemployment rate: 4.8%

Lawton is the least healthy city in one of the least healthy states. About 34% of Lawton residents were obese, about 6 percentage points higher than the nationwide obesity rate. A potentially related measure, 31.4% of residents were physically inactive, 4.1 percentage points higher than the national average. Oklahoma had the third highest smoking rate of any state, and Lawton’s smoking rate of 29.7% was even higher. In Lawton, more than one in five residents report fair or poor health, which is 4 percentage points higher than the proportion of Americans reporting less than optimal levels of health.

37. Grants Pass, Oregon
> Pct. without health insurance: 12.5%
> Pct. food insecure: 5.5%
> Obesity rate: 25.1%
> 2014 unemployment rate: 9.6%

Education is a major determinant of a population’s health. Without a high school diploma, workers are less likely to find jobs with higher incomes which often support healthier lifestyles. Just over 67% of ninth graders in Grant Pass are expected to graduate high school, even lower than Oregon’s graduation rate, which itself was the second lowest the country. Oregon residents are relatively fit. About 16% of residents reported physical inactivity, the second lowest share of all states. In Grants Pass, however, residents are far less active, with a whopping 63% of residents reporting no physical activity whatsoever in their spare time.

38. Johnstown, Pennsylvania
> Pct. without health insurance: 7.6%
> Pct. food insecure: 6.7%
> Obesity rate: 31.9%
> 2014 unemployment rate: 6.9%

Pennsylvania is a fairly healthy state. While Johnstown is its least healthy city, it is about as healthy as the rest of the nation. In Johnstown, 27.9% of residents were physically inactive, in line with the 27.0% of physically inactive Americans. Likewise, 17% of Johnstown residents reported fair or poor health, again, in line with the share of Americans who reported poor health. Health insurance is very important to a population’s health, as insured individuals are more likely to seek preventive care. In Johnstown, about 92% of residents are insured, higher than the nation’s 85.5% insured rate. Still, area residents exhibited some unhealthy behaviors, as can be seen by the area’s high incidence of alcohol-related deaths. Nearly half of all driving deaths in Johnstown are alcohol-related compared to 31% across the country.

39. Providence-Warwick, Rhode Island
> Pct. without health insurance: 9.0%
> Pct. food insecure: 4.5%
> Obesity rate: 28.6%
> 2014 unemployment rate: 7.5%

Providence-Warwick is the only metro area in Rhode Island, so it is both the healthiest and least healthy city in the state. Compared to the rest of the country, the metro area is in pretty good shape. Only 9.1% of residents are physically inactive, significantly less than the 27.0% of Americans who do not exercise regularly, and one of the lowest proportions compared with all U.S. metro areas. Health insurance is important to a population’s health. Insured people have better access to medical care and are more likely to have potentially overlooked health conditions diagnosed during routine checkups. Only 9.0% of Providence-Warwick residents do not have health insurance, significantly lower than the national uninsured rate of 14.5%. However, area residents have a smoking habit — one-fifth of area adults smoke, on par with the rest of the nation.

40. Florence, South Carolina
> Pct. without health insurance: 14.6%
> Pct. food insecure: 8.2%
> Obesity rate: 36.0%
> 2014 unemployment rate: 7.5%

Exercise and access to physical activity locations such as parks and recreation centers are important to a population’s health. Only 61.6% of Florence residents had adequate access to such locations, compared to the 71% in South Carolina. This is especially poor relative to the national average of 85%. Potentially related, Florence’s 36% obesity rate leads the state average by 4.3 percentage points and the national by about 7.7 percentage points. Children are among the most vulnerable to poor economic conditions, which in turn can lead to unhealthy behaviors that often carry on into adulthood. As many as 32.1% of Florence’s children live in poverty, which is 10.1 percentage points higher than the national child poverty rate. A healthy job market also factors into the physical health of a city’s population, as access to jobs affords more residents healthy lifestyles. Last year in Florence, 7.5% of the workforce were unemployed, versus the national unemployment rate of 6.2%.

41. Rapid City, South Dakota
> Pct. without health insurance: 12.7%
> Pct. food insecure: 7.3%
> Obesity rate: 27.5%
> 2014 unemployment rate: 3.4%

South Dakota is one of the nation’s least populous states, and Rapid City is the state’s second largest city. Rapid City is situated next to the Black Hills mountain range, home to Mount Rushmore and numerous parks. Perhaps as a result, 94.9% of the area’s population reported access to locations for physical activity. Despite this, the metro area is the least healthy city in South Dakota. South Dakota is a relatively healthy state, so while Rapid City is its least healthy city, it is still nearly as healthy as the rest of the country. Rapid City reported smoking and obesity rates of 20.1% and 27.5% respectively, roughly in line with the rest of the nation. However, drunk driving deaths are more common in the area than across the country. More than 40% of all driving deaths in Rapid City are alcohol-related, higher than the state’s rate and nearly 10 percentage points higher than the national rate.

42. Morristown, Tennessee
> Pct. without health insurance: 18.4%
> Pct. food insecure: 6.0%
> Obesity rate: 29.3%
> 2014 unemployment rate: 7.4%

Like Tennessee, Morristown residents report high rates of smoking and low rates of heavy drinking. Tennessee has the sixth highest smoking rate in the country, 22.6%, and Morristown’s was even higher at 24.6%. Conversely, with 9.3% of adults reporting heavy or binge drinking, Tennessee is the second driest state in the country, and Morristown is even more so with a heavy drinking rate of 4.8%, the second lowest of any metro area in the country. Physical activity is a major determinant of overall health, and 34% of Morristown’s population did not exercise in their spare time, 7 percentage points higher than the national rate. Unhealthy behaviors likely contributed to a higher incidence of premature death. An estimated 10,079 years are lost per 100,000 residents annually by those who died before the age of 75. The incidence of premature death was greater than 10,000 years in only 10 other metro areas.

43. Odessa, Texas
> Pct. without health insurance: 24.4%
> Pct. food insecure: 8.4%
> Obesity rate: 31.5%
> 2014 unemployment rate: 3.4%

People with health insurance are more likely to seek preventive care, and higher coverage rates often lead to better health outcomes. Texas is the least insured state in the nation, and Odessa has an even lower uninsured rate. About one-fourth of Odessa’s residents are uninsured, and about one-fifth of its residents said they were in fair or poor health. This is about 5 percentage points higher than the proportion of Americans reporting such low levels of health. Education is also a strong determinant of health, as it provides access to the higher incomes that that can lead to healthier lifestyles. Also, more educated individuals are more likely to have the knowledge necessary to stay healthy. Odessa’s high school graduation rate is 70.2%, which lags behind the country’s by 9.8 percentage points. The proportion of Odessa residents who after graduating high school attained at least some college education is 47.2%, which is much lower than the national rate of 63.0%.

44. Salt Lake City, Utah
> Pct. without health insurance: 15.7%
> Pct. food insecure: 3.3%
> Obesity rate: 24.3%
> 2014 unemployment rate: 3.7%

Utah is a relatively healthy state, and even Salt Lake City, the state’s unhealthiest city, is in good shape compared to the rest of the country. Utah boasts the lowest incidence of alcohol-related driving deaths, and less than one in 10 Utah adults smoked, the lowest proportion compared to states. While it is ranked as the least healthy city in Utah, Salt Lake City shares characteristics with Utah. Only about 12% of both Salt Lake City and Utah residents reported being in fair or poor health. And Salt Lake City and Utah each have an obesity rate of less than 25%, versus the national rate of 28.3%. High income inequality frequently leads to poor health outcomes in a community. Incomes in the top 80th percentile were less than four times greater than incomes in the bottom 20th percentile in Utah, the smallest such income gap compared to all states. Salt Lake City had a similarly low income gap.

45. Burlington-South Burlington, Vermont
> Pct. without health insurance: 6.2%
> Pct. food insecure: 2.8%
> Obesity rate: 23.2%
> 2014 unemployment rate: 3.3%

Burlington-South Burlington is the only metropolitan area in Vermont. While this means that it is the least healthy metro area by default, residents were actually on the whole healthier than the rest of the state, which itself was one of the healthiest in the nation. Just over 9% of Burlington residents reported fair or poor health, a smaller share than the 10.6% of Vermonters and significantly less than the 16% of Americans who reported such poor health. Healthy behaviors help explain the area’s relatively good health. Only 13.1% of the Burlington area population identified as smokers, less than the 16.1% share of Vermonters and the 20% of Americans who said they smoked. Additionally, nearly 16.5% of Burlington residents were physically inactive in their spare time, a smaller share than the corresponding figure for both the state and the nation of 18.4% and 27%, respectively.

46. Winchester, Virginia
> Pct. without health insurance: 13.9%
> Pct. food insecure: N/A
> Obesity rate: N/A
> 2014 unemployment rate: 4.9%

In Winchester, an estimated 8,596 years are lost to preventable deaths per 100,000 residents annually, well above the incidence of premature death across Virginia. Less than optimal living conditions may have contributed to the high occurrences of death before age 75. More than 43% of children lived in a single parent household, and nearly a quarter of all Winchester children lived in poverty. Childhood poverty is only part of the problem in Winchester. More than 28% of area adults reported less than optimal health, a significantly higher share than the corresponding statewide figure of 13.5%. Additionally, parks and recreational facilities in the metro area are scarce. Only 19.1% of the population had adequate access to locations for physical activity, a much smaller proportion than the 81.5% of West Virginia residents and 85.0% of Americans who had access to such locations.

47. Yakima, Washington
> Pct. without health insurance: 26.2%
> Pct. food insecure: 4.6%
> Obesity rate: 31.3%
> 2014 unemployment rate: 9.0%

In Yakima, Washington’s least healthy city, only 13.8% of adults reported heavy drinking compared to the corresponding statewide figure of 16.9%. Despite a lower frequency of heavy drinking, nearly half of all fatal car accidents in the state were attributable to alcohol impaired driving. This figure was higher than both the national and statewide rates of 31% and 40%, respectively. Yakima residents were also less likely to receive preventive care such as regular checkups. More than a quarter of the Yakima population was uninsured, a significantly larger share than the 14% of Washingtonians who did not have insurance.

48. Beckley, West Virginia
> Pct. without health insurance: 14.3%
> Pct. food insecure: 8.4%
> Obesity rate: 32.4%
> 2014 unemployment rate: 7.5%

More than one-fifth of West Virginians reported fair or poor health, the highest share of any state. In Beckley, West Virginia’s least healthy city, nearly 23% reported such poor health, a significantly higher share than the 16% of Americans who reported less than optimal health. Along with higher than average obesity and smoking rates, the Beckley population also had higher than average STD rates. About one in 100 Beckley residents have chlamydia, roughly double the reported incidents of chlamydia per 100,000 Americans.

49. Milwaukee-Waukesha-West Allis, Wisconsin
> Pct. without health insurance: 9.6%
> Pct. food insecure: 3.7%
> Obesity rate: 30.3%
> 2014 unemployment rate: 6.0%

The Milwaukee metro area is the least healthy in Wisconsin. At just over 30%, the area’s obesity rate hovers slightly above the national rate of 28.3%. Home to several microbreweries and one major brewery, MillerCoors, alcohol is a major part of Milwaukee’s economy and culture. Wisconsin led the nation for heavy drinking, with 24.4% of adults reporting such a habit. In Milwaukee, 22.3% of adults reported binge or heavy drinking, lower than the state proportion, but a far higher share than the 15% of Americans who reported excessive drinking. Additionally, 40% of all fatal car accidents were attributable to alcohol impaired driving, significantly higher than the corresponding nationwide figure of 31%.

50. Casper, Wyoming
> Pct. without health insurance: 14.9%
> Pct. food insecure: 12.1%
> Obesity rate: 27.1%
> 2014 unemployment rate: 4.2%

In Casper, the least healthy metro area in Wyoming, residents lose 8,193 years of life to premature death per 100,000 residents annually, versus the statewide incidence of premature death of 7,360. Pervasive bad habits may be responsible for much of the area’s health woes. Over 26% of Casper residents are smokers, significantly more than the corresponding state and national figures of 19.8% and 20.0%, respectively. Slightly more Casper adults reported excessive drinking as well. While only 15.0% of Americans reported binge or heavy drinking, 17.6% of adults in Casper reported unhealthy drinking habits. Additionally, nearly 25.0% of Casper residents reported no physical activity in their spare time, a slightly higher share than the 22.8% of adults in Wyoming. Lack of exercise may be partially responsible for the area’s obesity rate of 27.1%, which was higher than the state’s obesity rate, but lower than the national obesity rate of 28.3%.

Thank you for reading! Have some feedback for us?
Contact the 24/7 Wall St. editorial team.