August 14, 2026
Dear Interested Readers,
Looking at the Worst and the Best States For Healthcare
When I was in practice, my office mailbox was flooded with “throwaway” medical journals such as “Hospital Practice” and “Medical Economics.” It was pretty obvious that the likely intent of this “medical literature” was the hope that some article might catch my eye and, in my interest to uncover enough of it to read it, I would glance at, and perhaps be influenced by, one of the many pharmaceutical ads under which the article of interest was buried. Usually, either because I had no interest or time, as the name implies, I would “file” the journal in my circular filing container as junk.
As I was leaving practice, more and more of these “free” publications were going online. Despite being retired for over twelve years, I am still on some of the mailing lists, and the detritus continues to arrive online daily. I don’t know what percentage of my 140,000 unread emails are today’s equivalent of the old office throwaway. I do know that requests for political and charitable donations make up the bulk of my unopened mail, and, like you, a lot of email probably ends up in “junk” without any effort from me. It’s not that I don’t delete or “unsubscribe” a lot of emails, probably at least fifty a day; it’s just that the tsunami is so great I am overwhelmed by the task of keeping up.
My comments about throwaway publications are a partial explanation for the fact that this letter is based on an “online throwaway” article in a “Medical Economics Newsletter” that I received on Tuesday. The article caught my eye because of the enticing title of “The 10 worst states for healthcare in 2026.” When I clicked on “read more,” I discovered that the author was a writer named Austin Littrell.
I also learned that his data source was WalletHub, a privately held company based in Miami, Florida, with 110 employees that provides financial analysis for individuals and organizations. I admit that WalletHub is not the academic equivalent of The New England Journal or Health Affairs, and one should be advised to be cautious about its accuracy, but I took the bait and was hooked.
If you want more info about WalletHub, you can visit their website by clicking here. What I also learned as I explored WalletHub was that the list of the “ten worst states” that “Medical Economics” had published was lifted from a longer report from WalletHub that ranked the quality of medical care in all fifty states and the District of Columbia on over forty dimensions, including the usual: costs, access, and outcomes. The ranking criteria also included less frequently observed dimensions, such as the number of medical students who chose to remain in the state after graduating from medical school. “Medical Economics” used WalletHub data in its eye-catching report on the 10 worst states. There is also a link to a discussion of the ten best states, which also included comments on individual states. That article contained one big surprise for me, which I will reveal a little later as you read on. But first, the ten worst, along with a few comments on the deficiencies that put them at the bottom. As you might expect, eight of the ten are red states from the South that have not accepted the Medicaid expansion offered by the ACA.
Tennessee is the tenth-worst state for healthcare, according to WalletHub’s criteria. The summary and editorial comments by “Medical Economics” were:
Tennessee is the 10th-worst state for health care with a composite score of 50.57, but cost is not the reason. It ranks 18th nationally on affordability. Outcomes are what sink it at 46th out of 51, with the fourth-highest rate of stroke and heart disease in the country. Access sits at 30th. Care that is affordable but does not produce healthy patients is a chronic disease management problem, and it lands squarely on primary care.
Perhaps as an expression of a long-standing bias, I was surprised to see that Arkansas ranked as high as #42 nationally, which translates to ninth worst when looking up from the bottom. When I lived in Texas, I would hear jokes based on the motto that appeared on Arkansas license plates from 1941 until the late 80s. The tags proclaimed “Land of Opportunity.” The joke was that Arkansas was so backward that the only way for the state to go was up. In the late 80s, the motto became “The Natural State.” Well, there must have been progress because there are eight states with worse healthcare than Arkansas. The analysis of why they rank where they do is:
Arkansas ranks 15th on cost and 26th on access, both respectable. Then outcomes come in at 49th. The state has the second-highest infant mortality rate in the country, the third-highest rate of stroke and heart disease, and the highest share of adults who have not seen a dentist in the past year. It also has the fourth-most hospital beds per capita. Capacity is not the constraint here.
I want to say “ouch” when I read “forty-ninth” in the outcomes. Of all the parameters, “outcomes” seems to me to be the most important dimension that is the sum of all other indices. Arkansas is still fertile for “Opportunity” in its healthcare outcomes.
New Mexico was number eight. That was a little bit of a surprise because I have been to New Mexico many times to visit my son, who lived in Albuquerque for almost twenty years, and to attend medical conferences, and to visit a dear friend of my wife who lived in Santa Fe for many years. New Mexico is a “blue state” and accepted the Medicaid expansion under the ACA. My blue-state bias and my experience in New Mexico led me to assume that the care was “better.” The problem with New Mexico is that there isn’t much density, as the analysis reveals. As in other primarily rural states, achieving equity and improving healthcare will require specific programs designed to compensate for the distances between people and resources. I will underline this by jumping to tell you that, according to the WalletHub analysis, the state with the worst healthcare is Alaska, where a long boat ride or a flight in a light plane is required to reach a physician. In both states, robust telehealth programs such as the “ECHO” program developed by a gastroenterologist at the University of New Mexico are beneficial, but it is hard to deliver a baby, do complex trauma surgery, or even perform an adequate rectal exam with a screen and a keyboard. Here is the quick explanation for New Mexico:
New Mexico has the lowest cancer incidence rate in the country and still finishes 44th on access and 40th on outcomes, with cost at 31st. It is one of two states in the bottom 10 from outside the South. Access is the number to watch. In a state that large and that thinly populated, distance does most of the damage, and the care that exists is not always near the people who need it.
In seventh place on the list of the worst is Louisiana. Louisiana is an enigma to me. It has culture, diversity, good academic institutions, and a physician elected as one of its senators. Unfortunately, Dr. Bill Cassidy’s diligent analysis of the moment is mixed. He voted in favor of impeaching the president after the January 6th insurrection at the Capitol, but then cast the deciding vote in the path to the confirmation of Robert Kennedy, Jr., as Secretary of Health and Human Services. Cassidy, who was once a Democrat (prior to entering politics) and is still a gastroenterologist, continues to surprise me because, after the president blocked his re-election aspirations, presumably in retaliation for his impeachment vote, Cassidy has now cast the deciding vote in the confirmation of Todd Blanche as attorney general. What further frustrates me is that when a strong opinion won’t make a difference, the doctor/senator will sound pretty forceful, as he did this week when he strongly disagreed with the change in pediatric immunization recommendations from the president and Mr. Kennedy, neither one of whom has a medical degree or any acceptable competency in public health. But, I digress. The analysis of Louisiana is interesting. It has a very high rate of cancer. Could that be because the state has been willing to attract polluting industries, as suggested by Professor Arlie Russell Hochschild in her 2016 classic, Strangers in Their Own Land: Anger and Mourning on the American Right. It’s hard to be healthy when you have let your state become a tax break for an industry-induced health hazard. Considering what healthcare in Louisiana could be, WalletHub’s summary is thought-provoking. Looking at Louisiana, we can see that the environment around the office and hospital is as important to outcomes as access to care.
Louisiana ranks 13th in the country on access, better than three of the states in WalletHub’s top 10. It ranks 48th on outcomes. The state has the fourth-highest infant mortality rate, the fifth-highest cancer incidence rate and the fifth-highest rate of stroke and heart disease. Louisiana’s problem sits downstream of the office visit, in the population health measures that follow patients home.
Race makes a difference in outcomes. Alabama ranks sixth worst in the nation, although I know for a fact that the University of Alabama Medical Center in Birmingham offers world-class care. My sister and the mother-in-law of one of my sons have benefited greatly from the life-saving and life-extending care they have received at UAB in Birmingham, which has always had excellent cardiology and oncology programs. The overview presented in the article of why Alabama ranks so poorly beyond the care available to some doesn’t confirm my concept of race as a factor, or it glosses over it, and it focuses on the very low number of doctors and dentists in the state. My bias is that race and implicit biases may be the explanation for how this shortage plays out as not a problem for some privileged individuals while it is a disaster for many of Alabama’s less affluent citizens.
Alabama ranks 14th on cost and 48th on access. The workforce numbers explain the split: Alabama has the fourth-fewest physicians per capita and the third-fewest dentists per capita in the country. Outcomes land at 45th. Affordable care that nobody is available to deliver does not help a patient, and for the physicians who are there it means panel sizes with very little room in them.
John Denver’s hauntingly beautiful song “Mountain Mamma Take Me Home” describes West Virginia as “almost heaven.” We won’t need healthcare in heaven, and the healthcare that you can get in West Virginia may be a cheap ticket for a ride to the hereafter. West Virginia is beautiful if you are passing through, but keep on going if you are not feeling at the top of your game. I was surprised that it wasn’t closer to the bottom of the standings. How can a state be both the most expensive state for care, have seemingly adequate resources, and simultaneously be the most likely place in the country to have a heart attack or stroke? WalletHub’s analysis leaves us wondering and offers no insight:
West Virginia has the highest average monthly health insurance premium in the country. It also has the highest rate of stroke and heart disease, and the second-highest cancer incidence rate. Access is the one relatively bright spot at 19th, helped by the third-most hospital beds per capita of any state. Cost ranks 41st and outcomes 47th. West Virginia is the clearest case in this ranking of a state with the infrastructure in place, but the health results do not follow.
At number four, we have my boyhood state of Texas. Texas is an enigma; it has the financial resources, the doctors, and the institutions that one might expect would make it one of the best rather than the worst. Its political conservatism is a reality that is serviced by the religious right and many extremely wealthy individuals. If you have been to the Texas Medical Center in Houston (click to see a picture), you have seen the most dense collection of medical resources and educational institutions in the world. In the midst of this amazing resource, care is denied to many, which seems at variance with the strong religious affiliations of many of Texas’ voters and politicians. Why do deeply religious people not notice that much of the Gospels is about the concern Jesus had for the poor and the sick? My conclusion is that being the fourth worst must be some sort of very strange choice that Texans have made. The brief analysis in “Medical Economics” supports my bias, since Texas has the largest percentage of uninsured citizens, a choice it has made since it has not accepted the Medicaid expansion.
Texas has the lowest share of insured adults and the lowest share of insured children of any state in the country. Access ranks 50th of 51 and cost 46th. Outcomes, at 39th, are the best of its three categories. Texas does hold onto physicians: It has the fifth-highest share of medical residents who stay in the state after training. The coverage gap is the operational issue, and for practices it surfaces as self-pay volume, bad debt and patients who present late in the course of an illness.
I know the “deep” South, and currently have close family members living in North Carolina, South Carolina, Georgia, and Alabama. Florida, where my oldest son and his family live, doesn’t count as the Deep South. Florida has been invaded and conquered by too many folks from the Northeast and the Midwest. More distant relatives are in Tennessee and Louisiana, and I spent the largest portion of my childhood in Texas. The modern South has impressive cities as well as a plethora of excellent medical schools and hospitals. So why are eight of the ten states with the worst healthcare in the country in this region? Georgia and Texas are not “backward” states. They do have significant rural areas where the density of medical resources may be thin, but so do California, Pennsylvania, Maine, Vermont, and even New Hampshire, the state where I now live. I am left with racial history, culture, religion, and right-leaning politics as possible explanations. Clearly, access in these Southern states is compromised compared to other states by their unwillingness to accept the Medicaid expansion offered by the ACA. Georgia is a state with the resources to be in the top ten, but it has chosen a path that currently puts it in the bottom three. Below is WalletHub’s explanation of Georgia’s position.
Georgia ranks 49th on access and 43rd on outcomes, with cost at 37th. It has the third-lowest share of insured adults aged 19 to 64 in the country. Georgia does not post the worst mark in the bottom 10 of any single category. But it sits near the bottom in all three at once, which is a harder problem to fix than one bad number.
For as long as I can remember, jokesters in other Southern states have said: “Thank God for Mississippi!” It spoils a joke if it needs an explanation, but until recently, with remarkable efforts that have produced significant improvements in educational testing, Mississippi has, in most categories of social development, spared other states the ignominy of being last. Of the lower forty-eight states, Mississippi still has the worst healthcare. One can hope that some lessons learned from their attempts to improve educational scores will spill over into healthcare delivery, but one must expect that the road to better care won’t be easy until access improves. The first step in that direction would be to accept the Medicaid extension of the ACA. We read that many areas beg for improvement.
Mississippi has the worst health outcomes of any state or the District of Columbia, ranking 51st. It has the highest infant mortality rate in the country and the fifth-lowest share of insured adults. It also has the second-most hospital beds per capita and the third-fewest physicians per capita, a combination that describes a state with the buildings but not the clinicians to staff them. Cost, at 32nd, is the least of its problems.
Finally, we come to the state that has the greatest healthcare challenges. My wife and I visited Alaska in June about ten years ago. It is beautiful and very empty. There are 8,700 small planes registered in Alaska. Of all our states, Alaska has more small planes per capita than any other state. Many of these planes are equipped to land on water. Anchorage is an attractive city that uniquely has a lake where hundreds of these planes are lined up around its shore, much like a parking lot at a suburban shopping center. Scale is a big deal in Alaska. The national park that contains Denali is larger than the state of Massachusetts. Including Denali, there are six national parks and reserves larger than Connecticut. Many towns are not accessible by road, which is why boats and planes are so critical to life in Alaska. Alaska’s healthcare system has been innovative in addressing these geographic challenges. Google’s AI summarizes the efforts:
Alaska overcomes massive geographic barriers through innovative programs like the Alaska Native Tribal Health Consortium (ANTHC), extensive telemedicine networks, and the Community Health Aide Program (CHAP), which trains local residents in remote villages to provide primary care and emergency triage where roads and hospitals do not exist. [1, 2, 3, 4]
As great as these efforts have been, and as much as rural areas in the lower forty-eight can learn from what the efforts in Alaska have produced, Alaska ranks last overall but probably first in efforts to improve a difficult combination of vast geography, difficult climate, and sparse population. WalletHub sounds charitable as it lays out the realities:
Alaska is the worst state for health care in 2026, and cost is what puts it there. It ranks 51st on affordability, last in the country, with the second-highest average monthly insurance premium of any state. Access is the strongest of its three categories at 20th. Outcomes rank 41st.
Alaska also keeps the second-highest share of medical residents in the country after training, which makes it an unusual market: a state that holds onto the clinicians it trains and still cannot make care affordable for the people who live there.
I hinted near the beginning of the letter that I was surprised by WalletHub’s analysis of all fifty states. “Medical Economics” has a companion article, based on WalletHub’s work, that lists the 10 best states for healthcare. To my surprise, my state, New Hampshire, is number one, beating out Massachusetts, New York, California, and other progressive states where care is also quite good to take the blue ribbon for number one! Their analysis was:
New Hampshire is the best state for health care in 2026, and it wins in the two categories that are hardest to win at once. It ranks first in the country on outcomes and second on cost. The average monthly insurance premium runs about $469, the lowest of any state, and out-of-pocket medical spending is the second-lowest. Residents have the lowest prevalence of stroke in the country and the fourth-lowest prevalence of type 2 diabetes.
The workforce picture leans heavily on physician assistants and nurses. New Hampshire has the fifth-most physician assistants per capita and the 10th-most nurses, plus the most urgent care centers per capita certified by the Urgent Care Association of America. Access is the softest of its three categories at 17th, and the state keeps the fourth-lowest share of its medical residents after training. It is a strong market to practice in and a hard one to staff.
The top ten contained some other unexpected surprises. The full list is:
- New Hampshire
- Minnesota
- Iowa
- Rhode Island
- Hawaii
- Massachusetts
- Maine
- Wisconsin
- Colorado
- Nebraska
I will leave it to you to find your state and explore the analysis of its pros and cons in the original WalletHub publication from which Medical Economics lifted its “worst” and “best” articles. The article includes interesting graphics and provides rankings by the sum of cost, access, and outcomes for each state.
Obviously, every state, no matter its ranking, can improve. One significant question is what must be done locally versus what must be done collectively at the federal level. The practice of medicine is regulated by each individual state. Ironically, the most impactful policies to improve access to care have been national issues. As federal support has been offered or withdrawn for access and other aspects of the closely related social determinants of health, variation has occurred as states make their different choices about how to backfill the losses, or, as has been the case with abortion and fertility care, how the state chooses to replace or augment what the federal policies have changed. Much of the variation from state to state could be mitigated, and I believe we would all benefit if we agreed that adequate healthcare is a fundamental right supported by our collective resources rather than an issue of personal responsibility that varies across states. Not today, but I do believe, some day.
The Days Dwindle Down
I have always liked September Song, the 1938 standard written by Kurt Weill and Maxwell Anderson. I particularly like Willie Nelson’s version. I think the line in the song that moves me is:
“Oh, the days dwindle down to a precious few”
The days of this summer are dwindling down to a precious few. Today’s header reveals the blooms of my Rose of Sharon and some Phlox sitting next to the shrub. Both bloom in August and indicate to me the summer days are dwindling down to a precious few.
There is conventional wisdom that reminds us that we make our plans and then we see what happens. My wife and I had planned to mitigate the end of summer with a river cruise on the Danube that included Prague and Budapest. We planned the trip with a group of friends who would help us celebrate my wife’s eightieth birthday. If you are keeping up with the horrendous weather in Europe this summer, you probably know that the Danube has dwindled down to a trickle, and the boats are sitting on their bottoms. I am hoping that, as a consolation, pleasant summer-like weather here in New Hampshire will extend into September. We will see. I should be thankful that we have been spared most of the violent weather, heat, floods, and fires that have been the big summer events for much of the country.
Wherever you are, and whatever you have planned, my hope is that all will go well for you during the dwindling days of summer.
Be well,
Gene
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