The United States spends far and away the most on health care per capita, yet the nation lags nearly two years behind the average life expectancy among developed nations. The Affordable Care Act will mark its five-year anniversary this upcoming March. While the plan has helped reduce the share of Americans who lack insurance — a significant burden on public health — much more will need to happen to align the U.S. health care system with that of other developed nations.

To provide a more complete picture of where the country is succeeding and where it is failing when it comes to public health, the United Health Foundation’s 2015 America’s Health Rankings report examined both determinants and health outcomes. The UHF included such factors as healthy behaviors, quality of health care, health policy, the presence of diseases, and preventable deaths across the nation. Each of these areas varies considerably between states. Based on this year’s edition of America’s Health Rankings, Hawaii is once again the healthiest, and for the first time since 2011, Louisiana is the least healthy state in the nation.

While this report includes measures of the quality and accessibility of health care, it also focuses on what leads to the poor health of Americans. Many would argue the poor health is as much a cause of high health costs as any other inefficiencies in the system.

Click here to see the most and least healthy states.

In an interview with 24/7 Wall St., Dr. Reed Tuckson, senior medical advisor for United Health Foundation, echoed this sentiment. “Almost always, the conversation about health in America is a conversation about insurance and access to medical care as opposed to being about the prevention of disease and promotion of health. We are producing far too many unnecessarily sick people who are being delivered every day into the hands of a medical care system that we can no longer afford.”

Two of the most significant factors driving up the rate of serious diseases and reducing life expectancy are obesity and tobacco use. According to Tuckson, while tobacco use has declined in the United States, 18.1% of Americans still smoke. As evidence of the impact smoking has on overall health, the 10 least healthy states are also among the 10 states with the highest smoking rates.

Obesity, meanwhile, has increased in the United States and now approaches 30% of the adult population. According to Tuckson, while tobacco remains the greatest cause of preventable illness and death, obesity is a close second. All ten of the least healthy states have above-average obesity rates.

Another factor that strongly correlates with health is income. Eight of the 10 least healthy states are among the bottom 10 in the country in median household income. Dr. Tuckson explained that this correlation is likely due to many considerations. People with lower incomes are less likely to obtain an education, are less likely to be able to afford better healthcare, and are more likely to live in areas where healthy options are not readily accessible. Tuckson added that there may be less tangible elements contributing to the relationship as well. “From my experience as a public health official, when you don’t have as much of a sense of hope and optimism about your future, you tend not to take the steps necessary to protect that future.” he added.

To consider any one of the critical factors that make up public health on its own is to ignore the complex, interrelated nature of these factors. For example, residents in areas with low violent crime rates tend to be healthier. This does not mean, however, that less exposure to violence is all that is needed to live a healthy lifestyle. Violent crime rates tend to be lower in communities with higher incomes, which can in turn afford their residents healthier options.

According to Tuckson, the fact that many of these determinants are both causes and effects of one another, particularly all of the factors that are tied to income, has resulted in a disturbing national trend. “Overall, we are concerned that we are becoming two nations, when it comes to our health. Those that are socioeconomically more privileged have significantly better health statistics than people that are not doing as well socioeconomically.” Tuckson concluded.

Based on data provided by United Health Foundation’s America’s Health Rankings, 24/7 Wall St. reviewed and ranked all 50 states based on their overall scores. These scores were based on a number of measures that fall into two separate categories: health determinants and health outcomes. Determinants were further divided into behaviors, such as smoking and drinking; community and environmental factors, such as children living in poverty; policy factors, such as public health funding and immunization rates; and clinical care factors, such as the availability of dentists and doctors. Outcomes included rates of death from cancer and cardiovascular diseases, as well as infant mortality rates. Additionally, we also reviewed supplementary data provided by America’s Health Rankings, including economic factors such as median household income based on the U.S. Census Bureau’s Current Population Survey.

1. Hawaii
> Pct. obese 22.1% (2nd lowest)
> Cardiovascular deaths per 100,000 people: 203 (3rd lowest)
> Primary care physicians per 100,000 people: 141 (9th highest)
> Pct. with health insurance: 94.0% (2nd highest)

Hawaii ranks for the fourth consecutive year as the healthiest state in the country, according to the UHF. It has never ranked worse than sixth overall since the organization introduced the ranking in 1990. The state rates among the top 10 in the majority of health measures as they relate to policy, behavior, and outcomes. It is second best in the country for health insurance coverage, public health funding, and cancer deaths. No state has a lower incidence of preventable hospitalizations than Hawaii.

While it is the healthiest — ranking high in most measures — Hawaii also ranks low in some of the indicators. Specifically, the state has one of the highest rates of chronic drinking, and 44% of Hawaii’s adults fail to get sufficient sleep, a worse rate than in any other state.

2. Vermont
> Pct. obese 24.8% (5th lowest)
> Cardiovascular deaths per 100,000 people: 220 (14th lowest)
> Primary care physicians per 100,000 people: 181 (3rd highest)
> Pct. with health insurance: 93.9% (3rd highest)

Vermont is the second healthiest state in the nation, trailing only Hawaii. The state has some of the nation’s safest communities and strongest health services. With just 121 violent crimes per 100,000 people, Vermont has the lowest violent crime rate in the country — a figure that, when high, can discourage physical activity and cause mental stress. For residents of the state, medical care is very accessible. For every 100,000 Vermonters, there are 181.3 primary care physicians, the third most doctors per capita nationwide. A high prevalence of physicians often coincides with a high health insurance coverage rate. Almost 94% of Vermonters have health insurance, the third largest share in the country.

Vermonters also eat well. The average adult in the state eats 1.5 servings of fruit and 2.0 servings of vegetables every day, a higher consumption and a healthier diet than in all but a few other states.

3. Massachusetts
> Pct. obese 23.3% (3rd lowest)
> Cardiovascular deaths per 100,000 people: 206 (4th lowest)
> Primary care physicians per 100,000 people: 207 (the highest)
> Pct. with health insurance: 96.5% (the highest)

Massachusetts ranks as the third healthiest state for the second consecutive year. One of the strongest indicators of a population’s health is the prevalence of obesity. Obesity can raise the risk of such diseases as heart disease and diabetes, which are some of the most common causes of death. While it is on the rise nationwide, obesity remains a relatively minor problem in Massachusetts compared to most states. Only 23.3% of the state’s adult population is obese, third lowest in the country and well below the 29.6% obesity rate nationwide.

The state also excels in another important health indicator, access to health care. Massachusetts launched health care reform in 2006 that provided near-universal coverage, one of the first states to do so. It now leads the nation in health insurance coverage. Just 3.5% of state residents are not insured, compared to the 13.1% of U.S. residents who are not.

4. Minnesota
> Pct. obese 27.6% (15th lowest)
> Cardiovascular deaths per 100,000 people: 187 (the lowest)
> Primary care physicians per 100,000 people: 146 (7th highest)
> Pct. with health insurance: 93.0% (4th highest)

Minnesota moves back up into the top five after falling to sixth place in the UHF 2014 ranking. While healthy behaviors and healthy outcomes tend to correlate, Minnesota’s residents appear to be in better health than their actions might suggest. The state ranks below the healthiest 10 in smoking, physical inactivity, and obesity, and it has one of the highest excessive drinking rates in the country.

Still, Minnesota has some of the best health outcomes in the country. Residents report the fewest days of poor physical health per month of any state, and they are the least likely to die from cardiovascular diseases. Each year, the state loses a nation-lowest 5,414 years per 100,000 residents on average due to premature death, versus a national rate of 6,997 years lost per 100,000 Americans.

5. New Hampshire
> Pct. obese 27.4% (14th lowest)
> Cardiovascular deaths per 100,000 people: 213 (7th lowest)
> Primary care physicians per 100,000 people: 138 (11th highest)
> Pct. with health insurance: 90.1% (16th highest)

After ranking seventh healthiest last year, New Hampshire improves by two places to rank as the fifth healthiest state in the country today. The improvement is partially due to a decline in sedentary behavior. The share of New Hampshire adults claiming to be physically active increased from 77.6% last year to 81.7% this year.

New Hampshire also has fairly high immunization coverage. Of adolescents between the ages of 13 and 17, 94.4% receive the Tdap vaccine, which protects against tetanus, diphtheria, and pertussis. This is significantly higher than the 87.6% of adolescents who get the vaccine nationwide. The spread of infectious disease is very low in New Hampshire, not just due to high immunization but also responsible and healthy habits. The incidence of chlamydia, for example, is the lowest in the nation. Strong economic conditions are closely tied to positive health outcomes. Just 11.1% of New Hampshire children live below the poverty line, the second lowest child poverty rate in the nation.

6. Connecticut
> Pct. obese 26.3% (8th lowest)
> Cardiovascular deaths per 100,000 people: 218 (11th lowest)
> Primary care physicians per 100,000 people: 169 (6th highest)
> Pct. with health insurance: 91.8% (6th highest)

The relationship between income and health is complicated. In general, however, people with greater economic resources tend to be able to afford healthier choices and better health care, and they live in communities that promote healthier behaviors. Connecticut has the fourth highest annual median household income in the nation, at $71,161. For many in the state, the higher incomes mean better access to medical care. Nearly 95% of adolescents are immunized against meningitis, for example, the second highest such share nationwide. Additionally, 83.1% of adults have had their blood cholesterol checked in the last five years, also the second highest share in the country. Connecticut has some of the lowest rates of premature death in the country. Each year, residents lose 5,573 years of life due to premature death for every 100,000 residents, third-lowest in the country.

7. Utah
> Pct. obese 25.7% (6th lowest)
> Cardiovascular deaths per 100,000 people: 219 (13th lowest)
> Primary care physicians per 100,000 people: 91 (7th lowest)
> Pct. with health insurance: 86.7% (17th lowest)

Utah is one of the healthiest of all states — likely due in part to its large Mormon population, for whom certain unhealthy behaviors are restricted. Just 9.7% of state adults smoke, the lowest smoking rate nationwide. Similarly, just 12.1% of Utah adults drink excessively, the third smallest share in the country. Healthy behaviors in the state have likely contributed to its relatively strong health outcomes. Utah has the lowest share, 7.1%, of adult residents with diabetes, which is the seventh leading cause of death in the United States. Utah also has a relatively low death rate from cancer, which nationwide is the second leading cause of death. There are 146.1 cancer deaths per 100,000 people in Utah annually, the least in the nation per capita.

8. Colorado
> Pct. obese 21.3% (the lowest)
> Cardiovascular deaths per 100,000 people: 196 (2nd lowest)
> Primary care physicians per 100,000 people: 123 (23rd highest)
> Pct. with health insurance: 87.8% (24th lowest)

Obesity is an important factor in measuring an area’s health. It correlates with such healthy behaviors as exercise and diet, and increases the risk of certain diseases. Obesity, along with tobacco use, is one of the leading causes of preventable death in the country — and Colorado has the lowest obesity rate in the country. While nearly 30% of American adults are obese, just 21.3% of Colorado adult residents are.

On the other hand, Colorado residents report relatively high rates of binge drinking. Also, exposure to the state’s cold weather may contribute to the relatively high incidence of pertussis — whooping cough — at 27.3 cases per 100,000 people annually, fifth highest. Still, its residents tend to live longer and healthier than most Americans. Residents report a very low incidence of a range of maladies, ranking in the best three for heart disease, diabetes, cancer deaths, cholesterol, and stroke.

9. Washington
> Pct. obese 27.3% (13th lowest)
> Cardiovascular deaths per 100,000 people: 213 (6th lowest)
> Primary care physicians per 100,000 people: 128 (16th highest)
> Pct. with health insurance: 88.4% (24th highest)

The primary factor contributing to good health in Washington is its strong clinical care. Just 6.4% of babies are born with low birthweight, less than the 8.0% of babies born with low birthweight nationwide. Good prenatal care may also be partially responsible for the state’s low infant mortality. In Washington, five children die before turning one year old out of every 1,000 live births, one of the lowest infant mortality rates in the country.

Many Washington residents only visit the hospital when they actually need to, reducing unnecessary exposure to disease. The incidence of preventable hospitalizations in Washington is the sixth lowest in the country.

10. Nebraska
> Pct. obese 30.2% (20th highest)
> Cardiovascular deaths per 100,000 people: 225 (16th lowest)
> Primary care physicians per 100,000 people: 123 (24th highest)
> Pct. with health insurance: 89.5% (17th highest)

Educated Americans are far less likely to adopt unhealthy behaviors like smoking, and heavy drinking. The higher earning potential from high school and college education also often leads to longer, healthier lives. In Nebraska, 88.5% of ninth graders graduate within four years, the second highest graduation rate in the country. Drug deaths, a rapidly rising cause of death nationwide, is also fairly low in the Midwestern state. Drugs cause 7.3 deaths per 100,000 residents in Nebraska, compared to 13.5 per 100,000 residents in the country as a whole.

When surveyed about their mental health habits, Nebraska residents responded on average that they experienced 2.8 days of poor mental health and 3.0 days of poor physical health out of the last 30 — both the third lowest of any state.

11. New Jersey
> Pct. obese 26.9% (10th lowest)
> Cardiovascular deaths per 100,000 people: 246 (22nd highest)
> Primary care physicians per 100,000 people: 145 (8th highest)
> Pct. with health insurance: 87.9% (25th lowest)

Two primary causes of preventable death are tobacco use and obesity, and New Jersey’s population is among the healthiest by both of these measures. Roughly 15% of the state’s adult population smokes, versus the 18.1% of U.S. adults who do. Similarly, the state’s obesity rate of 26.9% is the 10th lowest and compares to a national rate of just under 30%.

One potential area of concern is the recent increase in drug-related deaths in the state. In the past two years, drug-related fatalities increased from 6.9 deaths per 100,000 people to 13.1 deaths per 100,000 residents.

12. North Dakota
> Pct. obese 32.2% (9th highest)
> Cardiovascular deaths per 100,000 people: 225 (17th lowest)
> Primary care physicians per 100,000 people: 122 (25th highest)
> Pct. with health insurance: 90.9% (10th highest)

North Dakota has undergone a recent economic boom due to the development of new oil fields in the state. As a result, the state now has an unemployment rate of just 2.8%, the lowest in the country. The state’s median annual household income of $60,730 is well above the national median of $53,657. A strong economy and good-paying jobs usually contribute to better health outcomes in a state, and that appears to be the case in North Dakota. In the last five years, the incidence of preventable hospitalizations declined by nearly 27%, one of the larger declines in the country. On average, North Dakota residents report just 2.9 days of poor physical health per month, lower than in any other state and a full day below the national average.

13. New York
> Pct. obese 27.0% (12th lowest)
> Cardiovascular deaths per 100,000 people: 259 (17th highest)
> Primary care physicians per 100,000 people: 170 (5th highest)
> Pct. with health insurance: 90.3% (13th highest)

Poor people living in areas with greater income inequality tend to have worse health than poor people living in areas with less disparity. New York has the greatest level of inequality of any state, yet is the 13th healthiest in the country, in part because of its residents’ relatively healthy behavior. The state reports low chronic drinking and obesity rates, as well as the fourth lowest smoking rate of all states. However, New York also has relatively high incidence of heart disease, high blood pressure, high cholesterol, and deaths due to cardiovascular diseases.

14. Rhode Island
> Pct. obese 27.0% (12th lowest)
> Cardiovascular deaths per 100,000 people: 230 (20th lowest)
> Primary care physicians per 100,000 people: 180 (4th highest)
> Pct. with health insurance: 90.5% (12th highest)

Rhode Island has some significant public health issues. For example, the state has one of the highest rates of drug deaths in the country. Each year, the state records nearly 20 drug-related deaths per 100,000 people, more than seven times the rate in North Dakota, where the least drug deaths per capita occur. Also, over one in five adults in the state report excessive drinking, higher than the 17.6% of Americans who drink excessively nationwide.

Still, the Ocean State ranks highly in several other health related measures. It has the highest immunization rate among children, as well as a high concentration of primary care physicians per capita. The state also spends a great deal — $111 per capita — on programs intended to advance public health. That is roughly $25 more in public health funding per person than the country as a whole.

15. Maine
> Pct. obese 28.2% (18th lowest)
> Cardiovascular deaths per 100,000 people: 219 (12th lowest)
> Primary care physicians per 100,000 people: 135 (12th highest)
> Pct. with health insurance: 89.3% (19th highest)

While not among the healthiest states, Maine improved significantly in public health in the past year. The state’s ranking improved from 20th last year to 15th this year. One reason for the state’s improvement is a marked increase in the newborn vaccination rate. Maine’s immunization rate for children aged 19 to 35 months is 84.7%, a significant increase from 68.0% a year prior, and the highest percentage of all states. Maine is also among the best in the country in preventing the spread of infectious diseases such as chlamydia and salmonella.

16. California
> Pct. obese 24.7% (4th lowest)
> Cardiovascular deaths per 100,000 people: 234 (23rd lowest)
> Primary care physicians per 100,000 people: 123 (22nd highest)
> Pct. with health insurance: 85.2% (13th lowest)

Based on health-related behavior alone, California is one of the healthiest states in the country. Smoking and obesity are the greatest causes of preventable deaths in the country, and California has the second-lowest smoking rate nationwide. Of adults in the state, 12.8% smoke, versus the national smoking rate of 18.1%. Similarly, while nearly 30% of U.S. adults are obese, the obesity rate in California is only 24.7%.

Other elements, however, negatively affect California’s health ranking. For example, the state has the highest rate of air pollution in the country, with the average state resident exposed to 12.5 micrograms of unhealthy particulate matter per cubic meter. By contrast, in Wyoming, the state with the least air pollution, residents are exposed to just 5.0 micrograms of particulate. This could explain California’s environmental laws, which are some of the most numerous and strict regulations in the country.

17. Idaho
> Pct. obese 28.9% (22nd lowest)
> Cardiovascular deaths per 100,000 people: 228 (19th lowest)
> Primary care physicians per 100,000 people: 82 (the lowest)
> Pct. with health insurance: 85.1% (12th lowest)

Idaho has an above-average rate of public health spending. According to the United Health Foundation, an additional $10 per person spent on public health programs can markedly improve health outcomes, and in Idaho, $130 are spent per person on public health programs, the fourth highest rate in the country. However, by many other measures of health policy, the state does not compare so favorably. For example, only 65.9% of the state’s children are immunized, the sixth lowest rate in the country. Nearly 30% of adolescents are not vaccinated against tetanus, diphtheria, and pertussis, the second lowest rate in the country. Also, nearly 15% of state adults do not have health insurance, one of the worst uninsured rates in the United States.

18. Maryland
> Pct. obese 29.6% (25th lowest)
> Cardiovascular deaths per 100,000 people: 250 (21st highest)
> Primary care physicians per 100,000 people: 184 (2nd highest)
> Pct. with health insurance: 91.0% (9th highest)

Higher income is typically a strong indicator of a healthy population, but that connection is not as strong in Maryland. The typical household in the state earns $76,165 annually, the highest of all states, and well over $20,000 above the U.S. median income. Despite the high incomes, with the exception of heart disease and heart attack, the state is not among the top 10 in the majority of health outcomes measured by the United Health Foundation’s annual report. This may be due in part to the high level of health inequality in the state. The gap between the health of those residents with a high school education and the 15% of adults who did not graduate high school is one of the widest in the country.

19. South Dakota
> Pct. obese 29.8% (23rd highest)
> Cardiovascular deaths per 100,000 people: 233 (22nd lowest)
> Primary care physicians per 100,000 people: 115 (22nd lowest)
> Pct. with health insurance: 89.5% (17th highest)

South Dakota ranks as less than optimally healthy by several measures. For example, the state reported an above average rate of heart attacks and one of the highest rates of infant mortality in the nation. However, South Dakota leads the nation in one important measure — sleep. According to the National Center on Sleep Disorders, “Each year, sleep disorders, sleep deprivation, and sleepiness add an estimated $15.9 billion to the national health care bill.” South Dakota residents are the least likely in the country to deal with the negative health impacts associated with a lack of sleep. Only 27.8% of residents report sleeping less than seven hours each night, versus 34.2% of U.S. adults who report sleeping so little. Perhaps due in part to sleeping better than most Americans, state residents on average report just 2.7 days of poor mental health each month, the lowest in the country.

20. Oregon
> Pct. obese 27.9% (17th lowest)
> Cardiovascular deaths per 100,000 people: 212 (5th lowest)
> Primary care physicians per 100,000 people: 135 (14th highest)
> Pct. with health insurance: 87.8% (24th lowest)

No state had a worse decline in its health ranking compared to the 2014 report than Oregon. The state ranked as the 12th healthiest in the country last year. This year, Oregon ranks 20th overall. One reason for the change may be the recent increase in health inequality among state residents. Oregon has the lowest high school graduation rate in the country, and the difference in health between those who graduated from high school and those who have not has gotten worse. Over the past two years, the health gap between adults with a high school education and those without a diploma widened by 16%. This year, the disparity is the 15th worst gap in the country.

Not everything is negative, however. Oregon has the second lowest rate of physical inactivity among adults. Physical activity can help reduce the likelihood of certain cancers, diabetes, heart disease, and obesity. Just 16.5% of Oregon adults report doing no physical activity or exercise on a regular basis, the second lowest rate in the U.S.

21. Virginia
> Pct. obese 28.5% (20th lowest)
> Cardiovascular deaths per 100,000 people: 239 (25th lowest)
> Primary care physicians per 100,000 people: 127 (17th highest)
> Pct. with health insurance: 88.4% (24th highest)

Violence can lead to premature death, and residents of unsafe communities frequently endure higher levels of stress that can also lead to poor health outcomes later in life. Virginia’s violent crime rate of 196 incidents per 100,000 residents each year is nearly the lowest in the nation. However, state residents are by no means the healthiest Americans. In fact, by several measures, the health of Virginians has declined. Drug-related fatalities, while not especially high compared with other states, increased 13% from 8.4 deaths to 9.5 deaths per 100,000 residents. Also, Virginia’s smoking rate of 19.5% is slightly higher than the nationwide share of 18.1% — it also increased from 19.0% over the past two years.

22. Iowa
> Pct. obese 30.9% (16th highest)
> Cardiovascular deaths per 100,000 people: 245 (24th highest)
> Primary care physicians per 100,000 people: 89 (6th lowest)
> Pct. with health insurance: 92.8% (5th highest)

Across the country, 17.6% of Americans drink excessively. In Iowa, 22.3% of residents drink excessively, the third highest share of any state. Heavy drinking may be widespread in the Midwestern state, but drug abuse is not. Drug overdose, a rising cause of death nationwide, is relatively uncommon in Iowa. While each year there are 13.5 deaths from drug overdose per 100,000 Americans nationwide, there are 8.7 drug deaths per 100,000 Iowans — the fourth lowest annual drug death rate in the nation.

Completing high school dramatically increases the likelihood of leading a healthy life. While Iowans are not the healthiest state residents in the nation, strong education in the state has likely contributed to relatively healthy outcomes. In Iowa, 89.7% of high school students graduate within four years, the highest graduation rate in America.

23. Montana
> Pct. obese 26.4% (9th lowest)
> Cardiovascular deaths per 100,000 people: 228 (18th lowest)
> Primary care physicians per 100,000 people: 103 (10th lowest)
> Pct. with health insurance: 84.7% (11th lowest)

Montana has a generally poor immunization record among both adults and children. The state ranks in the bottom 10 for the immunization of human papillomavirus (HPV) — a common sexually transmitted disease — among men, meningitis immunization among adolescents 13 to 17, and the immunization of children aged 19 to 35 months for a variety of ailments. Perhaps in part due to the state’s poor immunization rate, Montana has the highest rate of new cases of pertussis – or whooping cough – at 66 cases per 100,000 people, versus a national rate of nine cases per 100,000 Americans.

Two other health problems that are likely related and that Montana is struggling with are a high suicide rate — the highest in the country — as well as one of the highest rates of chronic drinking. Alcohol abuse has been identified as a determinant of suicide. The state’s suicide rate of 24 suicides per 100,000 residents each year is nearly double the national rate of 13 suicides per 100,000.

24. Wisconsin
> Pct. obese 31.2% (14th highest)
> Cardiovascular deaths per 100,000 people: 237 (24th lowest)
> Primary care physicians per 100,000 people: 125 (19th highest)
> Pct. with health insurance: 91.8% (6th highest)

Excessive drinking can lead to fetal damage, liver disease, hypertension, cardiovascular disease, and other health problems. In Wisconsin, 23.3% of adults drink excessively, a higher share than in any state but North Dakota.

An education is one of the most important steps to leading a healthy life. On average, educated Americans live longer than their less-educated peers. While Wisconsin residents are by no means the nation’s healthiest, 88.0% of students in the state complete high school within four years, tying Texas for the third highest graduation rate nationwide.

25. Wyoming
> Pct. obese 29.5% (24th lowest)
> Cardiovascular deaths per 100,000 people: 231 (21st lowest)
> Primary care physicians per 100,000 people: 89 (5th lowest)
> Pct. with health insurance: 87.3% (21st lowest)

Although Wyoming ranks as the 25th healthiest state, it is leading in one factor that can contribute to better health — child poverty. Children living in poverty are three times as likely to have unmet health needs, and Wyoming’s child poverty rate of 10.6% is the lowest in the country — it is also nearly half the national child poverty rate of 21.1%. However, child immunization rates are relatively low. For example, just 64% of state children aged 19 to 35 months are properly vaccinated. Nationwide, 71.6% of children are vaccinated.

26. Kansas
> Pct. obese 31.3% (13th highest)
> Cardiovascular deaths per 100,000 people: 245 (25th highest)
> Primary care physicians per 100,000 people: 108 (16th lowest)
> Pct. with health insurance: 88.8% (20th highest)

While Kansas residents are moderately healthy compared with other states, the state spends very little on health and the low investment is likely a factor in poor outcomes such as low immunization rates. Each year, just $44 per person is spent on health, one of the lowest per capita health expenditures nationwide. While infants in the state are more likely than most to get vaccinated, older Kansas residents are behind on immunizations. Teenagers, for example, are among the least likely compared to teens in other states to receive basic vaccines.

The percentage of adults in Kansas who are obese, at 31.3%, is slightly higher than the national obesity rate of 29.6% — and the rate may improve in the near future. The state’s youth obesity rate of 12.6% is one of the lower rates compared with other states. Youth smoking is also fairly uncommon in Kansas, with just 10.2% of high school students reporting the habit.

27. Alaska
> Pct. obese 29.7% (24th highest)
> Cardiovascular deaths per 100,000 people: 215 (8th lowest)
> Primary care physicians per 100,000 people: 114 (20th lowest)
> Pct. with health insurance: 82.2% (4th lowest)

Despite spending $227 in public health expenditures per resident, the most of any state, Alaska has some of the lowest immunization coverage nationwide. Just 56.9% of adolescents are vaccinated for meningitis, significantly less than the 79.3% of adolescents nationwide who are vaccinated. Also, just 73.8% of Alaskan adolescents receive the Tdap vaccination, which covers tetanus, diphtheria, and pertussis — the fourth lowest share of any state.

Despite these poor factors, which are often significant limitations on health, Alaskans’ health outcomes are among the best in the country. Just 7.4% of Alaska adults have diabetes, less than all but two other states. Likewise, just 214.9 per 1,000 residents die of heart disease, one of the lowest cardiovascular death rates in the nation.

28. Illinois
> Pct. obese 29.3% (23rd lowest)
> Cardiovascular deaths per 100,000 people: 253 (19th highest)
> Primary care physicians per 100,000 people: 139 (10th highest)
> Pct. with health insurance: 88.8% (20th highest)

By many measures, Illinois is about as healthy as the country as a whole. Nationwide, 29.6% of Americans are obese. Similarly, the obesity rate in Illinois is 29.3%. The share of adults with diabetes, which has risen nationally from 4.4% 20 years ago to 10.0% today, is likewise 10.1% in Illinois.

Illinois residents also earn similar incomes to Americans overall. The typical household in Illinois makes $54,916 annually, only about $1,300 more than the national median household income. Income can dictate an individual’s ability to afford a healthy diet, preventative medicine, and quality care. The similar incomes may partially explain the similarities in health between Illinois residents and Americans nationwide.

29. Pennsylvania
> Pct. obese 30.2% (20th highest)
> Cardiovascular deaths per 100,000 people: 260 (16th highest)
> Primary care physicians per 100,000 people: 135 (13th highest)
> Pct. with health insurance: 90.9% (10th highest)

While the national average state public health spending is roughly $86 per person, Pennsylvania spends only $48 per capita. Still, in Pennsylvania, 95.2% of adolescents in the state are immunized against meningitis, a larger share than in any other state in the country. Additionally, only 9.1% of the population is uninsured. Nationally, 13.1% of Americans do not have health insurance. Despite the high immunization and insurance rates, the state struggles with several negative health factors and outcomes.

Of adults in the state, 19.9% smoke, and there are roughly 200 cancer deaths per 100,000 people annually, each the 14th highest rates nationwide. Also, there are roughly 18.7 drug-related deaths for every 100,000 state residents each year, a considerably larger share than the 13.5 drug deaths for every 100,000 Americans.

30. Arizona
> Pct. obese 28.9% (22nd lowest)
> Cardiovascular deaths per 100,000 people: 217 (10th lowest)
> Primary care physicians per 100,000 people: 100 (9th lowest)
> Pct. with health insurance: 84.6% (10th lowest)

A basic education is a key indicator of a population’s health. Those with a better education are less likely to use tobacco and abuse alcohol, and they are more likely to earn more money, which also correlates strongly with better health. Arizona, however, has one of the lowest high school graduation rates in the country. Barely 75% of state ninth graders complete high school within four years, compared to a national graduation rate of 81.4%.

Public health funding can have a meaningful impact on state residents’ health outcomes, but relative to its population, Arizona dedicates among the smallest amount to public health funding in the country. Arizona spends just $38.50 per person each year on public health, less than half the 50-state average spending of $85.52 per person.

31. North Carolina
> Pct. obese 29.7% (24th highest)
> Cardiovascular deaths per 100,000 people: 251 (20th highest)
> Primary care physicians per 100,000 people: 120 (24th lowest)
> Pct. with health insurance: 85.6% (15th lowest)

Ranked as the 37th healthiest state last year, North Carolina improved more than any other state in 2015. Compared to last year, a larger share of children in the state are immunized, the share of adolescent women are vaccinated against HPV, and more relatively more residents report engaging in physical exercise.

Despite recent improvements, North Carolina still lags behind most of the nation by several measures. With slightly more than seven in 1,000 infants dying before their first birthday, infant mortality is more common in North Carolina than in all but a handful of other states. Additionally, 41.0% of adults have high cholesterol. By comparison, the national rate of adults with high cholesterol is 38.4%. Some of the state’s poor health outcomes may be partially attributable to inadequate public health funding. The state spends roughly $44 per resident, roughly half the per capita health expenditure nationwide.

32. Delaware
> Pct. obese 30.7% (17th highest)
> Cardiovascular deaths per 100,000 people: 246 (23rd highest)
> Primary care physicians per 100,000 people: 114 (21st lowest)
> Pct. with health insurance: 91.5% (8th highest)

Despite allocating nearly $100 per resident to public health, significantly more than the national average per capita spending of $86, Delaware lags behind most other states in several health measures. With roughly 568 recorded cases of chlamydia for every 100,000 people in Delaware, chlamydia is more common in only five other states. Additionally, 35.6% of adults in the state have high blood pressure, the 10th largest share in the country and more than the 31.4% of adults nationwide with high blood pressure. The state is also home to a relatively high rate of death due to drug use, at 17.2 premature drug-related fatalities for every 100,000 state residents annually. In contrast, only 13.5 drug deaths are recorded for every 100,000 Americans annually.

33. Florida
> Pct. obese 26.2% (7th lowest)
> Cardiovascular deaths per 100,000 people: 221 (15th lowest)
> Primary care physicians per 100,000 people: 112 (19th lowest)
> Pct. with health insurance: 81.7% (2nd lowest)

Floridians are less likely to be insured than the residents of every other state except for Texas. Roughly 18% of people in the Sunshine state are uninsured. By comparison, the national uninsured rate is only 13%. Cases of salmonella are relatively common in Florida. There were nearly 32 reported cases for every 100,000 state residents last year, the highest rate in the country.

Despite its relatively low ranking, Florida does fairly well in some health measures. Only 26.2% of adults in the state are obese, lower than the national obesity rate of 29.6% and the seventh lowest rate of all states. The lower than average obesity rate likely contributed to the lower rate of cardiovascular deaths. In Florida, cardiovascular-related problems resulted in 221 deaths for every 100,000 residents last year. The corresponding national rate was roughly 251 deaths per 100,000 people.

34. Texas
> Pct. obese 31.9% (11th highest)
> Cardiovascular deaths per 100,000 people: 254 (18th highest)
> Primary care physicians per 100,000 people: 99 (8th lowest)
> Pct. with health insurance: 79.4% (the lowest)

Texas has the largest share of uninsured residents, as just 79.4% of the population has health insurance. By contrast, 96.5% of the population of Massachusetts — the most insured state — has health insurance. The low insurance coverage contributed to the state’s relatively low rank.

Despite the state’s low insured rate and health ranking, an average of 7,084 years of potential life per 100,000 residents are lost annually due to premature death, only about 100 years more than the 6,997 years lost to premature death nationwide. Texans have relatively healthy behavior. Just 14.5% of Texas adults smoke, for example, the fifth lowest share in the country.

35. Michigan
> Pct. obese 30.7% (17th highest)
> Cardiovascular deaths per 100,000 people: 284 (9th highest)
> Primary care physicians per 100,000 people: 124 (21st highest)
> Pct. with health insurance: 90.3% (13th highest)

Smoking is the leading cause of preventable death in the United States, and excessive alcohol consumption can lead to fetal damage, liver disease, cardiovascular disease, and other major health problems. In Michigan, 21.2% of adults smoke and 20.4% drink excessively, significantly higher than the corresponding national rates of 18.1% and 17.6%, respectively.

Another factor detracting from the health of Michigan’s residents is poor immunization rates. Just 65.0% of children in Michigan receive proper vaccination in early childhood — which, if administered, protects against 14 separate diseases. This is the fourth lowest immunization rate among children nationwide.

36. Missouri
> Pct. obese 30.2% (20th highest)
> Cardiovascular deaths per 100,000 people: 281 (10th highest)
> Primary care physicians per 100,000 people: 115 (23rd lowest)
> Pct. with health insurance: 87.7% (22nd lowest)

Based on health outcomes, Missouri has one of the least healthy populations in the United States. For example, the state has a worse-than-average rate of cancer deaths, cardiovascular deaths, stroke, and diabetes. Each year, more than 8,000 years of life are lost per 100,000 residents due to premature death, compared to less than 7,000 years lost per 100,000 people on a national level.

The high incidence of life threatening ailments is likely due in part to the habits of Missouri’s population. State residents are more likely to smoke than the average American and less likely to engage in regular exercise.

37. New Mexico
> Pct. obese 28.4% (19th lowest)
> Cardiovascular deaths per 100,000 people: 216 (9th lowest)
> Primary care physicians per 100,000 people: 120 (25th lowest)
> Pct. with health insurance: 83.4% (6th lowest)

Fatal drug overdoses, the nation’s leading cause of deaths due to injury, are on the rise, increasing from 12.2 deaths per 100,000 Americans in 2013 to 13.5 deaths per 100,000 Americans today. The situation is magnified in New Mexico, where 24.4 residents die from drug overdose for every 100,000 residents — more than in any state except for West Virginia.

New Mexico is a relatively dangerous place. Violent crime, which can discourage physical activity and cause disability or death, is fairly prevalent in the Southwestern state. About 613 violent offenses are reported per 100,000 residents in New Mexico each year, a higher violent crime rate than in all but one state.

38. Nevada
> Pct. obese 27.7% (16th lowest)
> Cardiovascular deaths per 100,000 people: 275 (13th highest)
> Primary care physicians per 100,000 people: 86 (4th lowest)
> Pct. with health insurance: 82.1% (3rd lowest)

Deaths from drug overdose have increased from 12.2 deaths per 100,000 Americans in 2013 to 13.5 deaths today. The situation is even worse in Nevada, where 22.4 deaths are caused by drug abuse per 100,000 residents, the fourth most of any state.

Nevada’s insured rate and public health spending are among the least conducive to health of any state. Just 82.1% of Nevada residents have health insurance, the third smallest share in the nation. By contrast, in Massachusetts, the most insured state, 96.5% of residents have health insurance. Public health funding could help the state establish preventive and educational programs to improve health across the state. However, Nevada spends just $33 per person in public health expenditure — the lowest amount in the country relative to the population.

39. Ohio
> Pct. obese 32.6% (8th highest)
> Cardiovascular deaths per 100,000 people: 276 (11th highest)
> Primary care physicians per 100,000 people: 130 (15th highest)
> Pct. with health insurance: 90.3% (13th highest)

Two of the bigger challenges in Ohio are high obesity and diabetes rates, both rising health issues nationwide. Ohio’s obesity rate of 32.6% is significantly higher than the national obesity rate of 29.6%. Obesity is a leading factor in preventable conditions such as heart disease, type 2 diabetes, stroke, cancer, and other diseases. In Ohio, 11.7% of adults have diabetes, the ninth highest share in the country.

40. Georgia
> Pct. obese 30.5% (19th highest)
> Cardiovascular deaths per 100,000 people: 270 (15th highest)
> Primary care physicians per 100,000 people: 107 (15th lowest)
> Pct. with health insurance: 82.7% (5th lowest)

Education contributes significantly to an individual’s health, as those with more education are less likely to smoke, drink heavily, or be overweight. They are also more likely to have access to jobs that can provide higher incomes to afford healthier food, health insurance, and quality medical care. In Georgia, however, just 71.7% of students graduate high school within four years, the third lowest graduation rate nationwide. Perhaps as a result, the typical household in Georgia makes just $49,555, about $4,000 less than the national median household income of $53,657.

A relatively large share of Georgians lack health insurance. Just 82.7% of state residents are insured, the fifth smallest share in the country. By contrast, in Massachusetts, the most insured state, 96.5% of residents have health insurance.

41. Indiana
> Pct. obese 32.7% (7th highest)
> Cardiovascular deaths per 100,000 people: 275 (12th highest)
> Primary care physicians per 100,000 people: 107 (13th lowest)
> Pct. with health insurance: 87.1% (20th lowest)

The unhealthy behavior of state residents contributes to Indiana’s rank among the least healthy states. The obesity rate in Indiana — largely a product of poor diet and exercise — is 32.7%, the seventh highest share nationwide. Likewise, 22.9% of Indiana adults smoke — also the seventh highest share of any state. Regardless of their smoking habits, residents’ lungs are taking a hit. Americans are exposed to an average of 9.5 micrograms of particulate per cubic meter daily. Things are significantly worse in indiana, the state’s population breathes in 11.3 micrograms of particulate per cubic meter each day, the fourth highest concentration of any state.

Public health funding, which could improve health by allowing the state to establish preventive and educational programs, is particularly low in Indiana. The state spends just $39 per capita on public health, the third least of any state. By contrast, Alaska, which spends the most on public health per capita, spends $227 per resident.

42. South Carolina
> Pct. obese 32.1% (10th highest)
> Cardiovascular deaths per 100,000 people: 272 (14th highest)
> Primary care physicians per 100,000 people: 109 (17th lowest)
> Pct. with health insurance: 85.3% (14th lowest)

In South Carolina, 9.7% of babies are underweight at birth, the fourth highest such rate in the country. The prevalence of low birthweight likely contributed to high incidence of infant mortality. With slightly more than seven out of every 1,000 infants dying before their first birthdays, infant mortality is more common in South Carolina than in all but a handful of other states.

Many of the state’s negative health outcomes are preventable. With a rate of 542 incidents per 100,000 state residents, chlamydia is more common in South Carolina than it is in all but six other states. Smoking is also prevalent in South Carolina. Nearly 22% of adults in the state identify as smokers, the eighth highest smoking rate in the country.

43. Tennessee
> Pct. obese 31.2% (14th highest)
> Cardiovascular deaths per 100,000 people: 299 (7th highest)
> Primary care physicians per 100,000 people: 126 (18th highest)
> Pct. with health insurance: 87.1% (20th lowest)

Tennessee has one of the highest smoking rates in the country, with nearly one-quarter of adults identifying as smokers. Additionally, roughly 27% of adults in the state do not exercise, a higher physical inactivity rate than in all but a handful of other states. Unhealthy habits in Tennessee lead to bad health outcomes. The state’s 16.9% youth obesity rate is the fourth highest in the nation. Tennessee residents are also more likely to report poor mental health. State residents reported an average of 4.8 poor mental health days a month, the most in the nation.

44. Kentucky
> Pct. obese 31.6% (12th highest)
> Cardiovascular deaths per 100,000 people: 298 (8th highest)
> Primary care physicians per 100,000 people: 107 (14th lowest)
> Pct. with health insurance: 88.6% (23rd highest)

Kentucky has a relatively high graduation rate, with over 86% of ninth graders completing high school within four years. The state has the fifth lowest violent crime rate, at just 210 incidents per 100,000 people, a factor that — like high education levels — also contributes to safer and healthier communities. Despite these strengths, Kentucky is the seventh least healthy state in the country.

While Kentuckians tend to drink less excessively compared to most Americans, 26.2% of adults report a smoking habit, a rate second only to West Virginia. Nearly two in five adults report getting insufficient sleep on a regular basis, also the second highest share. Unhealthy habits such as these contribute to a greater risk of death from diseases such as cancer, which results in around 229 deaths per 100,000 people each year, the highest cancer death rate nationwide.

45. Oklahoma
> Pct. obese 33.0% (6th highest)
> Cardiovascular deaths per 100,000 people: 323 (3rd highest)
> Primary care physicians per 100,000 people: 85 (3rd lowest)
> Pct. with health insurance: 83.5% (7th lowest)

There were roughly 323 cardiovascular deaths and 91 deaths due to injury for every 100,000 state residents in 2014, each the third highest rate in the nation. A higher insured rate might have reduced the frequency of such preventable deaths. Nearly 17% of Oklahoma’s population does not have health insurance, a much larger share than the 13% of uninsured Americans.

Unhealthy habits begin early in Oklahoma. Of all the state’s high school students, 18.5% identify as smokers, a much higher rate than the 15.7% of American high school students who smoke. Furthermore, there are roughly 43 teen births for every 1,000 teenage females in the state, the third highest teenage birth rate in the nation.

46. Alabama
> Pct. obese 33.5% (5th highest)
> Cardiovascular deaths per 100,000 people: 330 (2nd highest)
> Primary care physicians per 100,000 people: 104 (11th lowest)
> Pct. with health insurance: 87.1% (20th lowest)

All factors combined, Alabama is the fifth least healthy state in the nation. The Southern state’s biggest challenge is its poor health outcomes. In Alabama, 8.7 out of every 1,000 infants die before reaching the age of one, the second highest infant mortality rate in the country. This may be partially due to the state’s high prevalence of low birthweight. One in every 10 children born in Alabama weigh less than 5 pounds, 8 ounces, the third highest prevalence of low birthweight nationwide.

Low incomes often coincide with poor health, and Alabama is no exception. The typical household in Alabama makes just $42,278, more than $11,000 less than the $53,657 the typical American household makes.

47. West Virginia
> Pct. obese 35.7% (2nd highest)
> Cardiovascular deaths per 100,000 people: 300 (6th highest)
> Primary care physicians per 100,000 people: 109 (18th lowest)
> Pct. with health insurance: 88.7% (22nd highest)

Nearly 20% of high school students and nearly 27% of adults in West Virginia smoke regularly, each the highest smoking rate of any state. West Virginia’s obesity rate of 35.7% is also higher than the rate in every other state except for Arkansas. Both smoking and obesity are among the factors most closely tied to negative health outcomes. West Virginians are the most likely state residents to report heart disease, high blood pressure, heart attacks, and diabetes — all drivers of premature death. West Virginians are also more likely to die from drug abuse than Americans overall, with 32.4 drug deaths per 100,000 residents reported annually, the highest drug death rate in the nation. Many people in the state are aware of their poor health. Just 41.7% of adults in the state say their health is good or excellent, the lowest percentage in the nation.

48. Arkansas
> Pct. obese 35.9% (the highest)
> Cardiovascular deaths per 100,000 people: 313 (4th highest)
> Primary care physicians per 100,000 people: 105 (12th lowest)
> Pct. with health insurance: 86.1% (16th lowest)

Nearly 30% of children in Arkansas live in poverty, the third highest percentage nationwide and up considerably from 1990, when the state’s child poverty rate was 25.2%. Financial stress in families is closely tied with poor health outcomes. A high teen birth rate also often reflects weak social and economic conditions, which in turn can lead to poor health outcomes.There are specific economic costs associated with teen births, including increased health care and foster care costs. Children of teen parents also tend to have lower educational attainment and a higher likelihood of incarceration. Arkansas leads the nation in teen births, with roughly 44 births for every 1,000 female teens each year.

As in a number of other Southern states, Arkansas also has an obesity problem. The state’s obesity rate of 35.9% is the highest in the country.

49. Mississippi
> Pct. obese 35.5% (3rd highest)
> Cardiovascular deaths per 100,000 people: 345 (the highest)
> Primary care physicians per 100,000 people: 85 (2nd lowest)
> Pct. with health insurance: 84.2% (8th lowest)

Mississippi’s annual median household income of $35,521 is the lowest in the country — one of a range of weak social and economic measures contributing to the especially poor health among state residents. Ultimately, poor economic conditions and poor health lead to untimely deaths. For example, the incidence of infant mortality often reflects the health of the mother, the quality of prenatal care, and the ease of access to quality health care. Infant mortality is far more common in the South than it is elsewhere. In Mississippi, the infant mortality rate of 9.3 deaths per 1,000 live births is the highest in the nation. The state also reports the nation’s highest incidence of premature death, at an estimated 10,744 years lost per 100,000 people annually due to preventable deaths. Unhealthy choices drive the prevalence of premature death in Mississippi. Residents are among the most likely to smoke and some of the least likely to consume recommended servings of fruits and vegetables.

50. Louisiana
> Pct. obese 34.9% (4th highest)
> Cardiovascular deaths per 100,000 people: 306 (5th highest)
> Primary care physicians per 100,000 people: 125 (20th highest)
> Pct. with health insurance: 84.3% (9th lowest)

Louisiana is the least healthy state in the country. Roughly 35% of adults in the state are obese, a higher obesity rate than in all but three other states. Additionally, 10.9% of babies born in the state have a low birthweight, the largest share of any state in country after Mississippi. Low birthweight has likely contributed to a high infant mortality rate in the state. With slightly more than eight out of every 1,000 infants dying before their first birthday, infant mortality is more common in Louisiana than in every state but nearby Mississippi and Alabama.

Negative health outcomes in Louisiana are likely the result of pervasive bad habits. Nearly one in four adults in the state identifies as a smoker, a larger share than in all but a handful of other states. Furthermore, roughly 30% of adults in the state do not exercise, the third highest rate of physical inactivity in the country.

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