States that ranked poorly are those with high rates of diabetes and obesity; those with high rankings have long-term commitments to getting people insured.
Southeastern states with high rates of diabetes and obesity fared poorly, while Vermont and Massachusetts—2 states that kept an individual mandate scrapped in the new tax law—ranked highly in a report that looked at how well states fare in offering healthcare.
The WalletHub 2018 Best & Worst States for Health Care measured things such as what people pay in healthcare premiums, the numbers of doctors and hospital beds per capita, and whether people with chronic disease have seen a physician in the past 2 years. To some degree, the results line up with long-term underlying health trends, but some individual measures appear to reflect state-level health policy decisions, such as whether to expand Medicaid.
The 5 best states for healthcare, in order, were Vermont, Massachusetts, New Hampshire, Minnesota, and Hawaii; the worst were North Carolina, Arkansas, Alaska, Mississippi, and Louisiana, which came in dead last despite expanding Medicaid in 2016.
By region, healthcare was best in New England and the upper Midwest; it was average in the Western and Mid-Atlantic states, and it was subpar in the Southeast.
A common connection among the low-ranking states? Setting aside Alaska, which has some unique cost and delivery challenges (it ranked in the top half of states in outcomes), states that ranked poorly have high costs and poor outcomes given what people spend. Four of the bottom 5 states are at least partly within the CDC's “diabetes belt,” with Mississippi entirely within it. North Carolina ranked next-to-last in cost and in the bottom 5 states in access, despite being home to some of the nation’s top medical schools.
The access criteria may be key to Louisiana’s poor ranking, as these items include the quality of the public hospital system, hospital beds per capita, response times for emergency medical services, emergency room wait times, presence of urgent care, retail clinics, presence of medical paraprofessionals, and transfer times. For generations, healthcare for the poor in Louisiana was delivered through a unique public charity hospital system that was dismantled under former Governor Bobby Jindal, and several emergency rooms closed. While a system of community health centers arose in New Orleans to replace Charity Hospital after Hurricane Katrina, access for the poor outside the city remains limited and underfunded.
What were the common threads of the high-ranking states? At least 4 of the 5 states have high rates of people with health insurance. Massachusetts’ and Vermont's commitments to lowering uninsured rates both predate the Affordable Care Act (ACA). The ACA's concept of the individual mandate—that everyone must have health coverage or pay a penalty—began in Massachusetts and remains a state law. Vermont has stopped short of a single-payer system, but when the 2017 tax bill overturned the individual mandate, Vermont and New Jersey passed state-level requirements. Minnesota is home to several leading healthcare companies and providers, including Mayo Clinic, UnitedHealth, and Medtronic.
High infant mortality, which has been recognized as a problem in the United States, overlapped with several states with poor overall healthcare. The 5 states with the highest rates were Delaware, Louisiana, Arkansas, Mississippi, and Alabama, which had a rate 3 times higher than that of Vermont, which had the lowest.
In 2017, Bloomberg declared Hawaii’s healthcare the best in the country, noting that the high rates of union and military employment meant more people had coverage. The article also noted a higher share of Asians in the population, who had a stronger tradition of healthy living. Notably, the WalletHub survey found Hawaii ranked first in the country for number of dentists per capita, and good dental health is often tied to good overall health. The states with the fewest dentists per capital were Mississippi, Tennessee, Alabama, Idaho, and Louisiana.
Giving people access to care makes fiscal sense, according to Richard C. Boothman, JD, executive director of clinical safety at the University of Michigan Health System and chief risk officer, Michigan Medicine, who spoke with WalletHub.
“I only see what most Americans completely miss: that we all pay for the uninsured and underinsured," he said. "No American hospital can refuse to care for patients who have emergencies regardless of their insured status or ability to pay. Our failure to offer coverage for every American in whatever form (single payer, subsidized insurance), causes most uninsured people to miss any preventative care or even urgent care, leading to extreme medical emergencies that are far more costly from a medical cost perspective, as well as a social perspective.”
Not only do the financial costs go unpaid, but the social costs are never addressed, Boothman said.
“The current predicament is stupid financially, corrosive socially, and often devastating individually. … The cost to all of us is staggering and unnecessary.”