The Bayou State ranks last in a recent survey of healthcare systems. Obesity, poverty, and smoking are just a few of the reasons.

How does your state’s healthcare system compare with the rest of the nation?

According to a new report from WalletHub, Louisiana has the worst healthcare in the country.

Meanwhile, Hawaii has claimed the best state healthcare title once again.

Last year, Healthline reported on annual healthcare rankings by the United Health Foundation, the nonprofit arm of UnitedHealth Group.

WalletHub’s report is similar, but uses its own set of metrics for weighting its rankings.

Their results are similar, despite the different varying methodologies.

WalletHub assigned point values based on three primary scores:

  • Cost included factors such as the price of medical and dental visits, as well as average insurance premiums.
  • Access assessed things like the number of physicians per capita, quality of public health systems, and Medicaid acceptance rates.
  • Outcomes looked at major health concerns, including infant mortality, heart disease, and cancer risks.

At the top of the list, Hawaii is followed by Iowa, Minnesota, New Hampshire, and the District of Columbia for best healthcare.

On the other end of the spectrum, the worst begin with Louisiana, followed by Mississippi, Alaska, Arkansas, and North Carolina.

Mark Diana, PhD, chair of Tulane University Department of Global Health Management and Policy, told Healthline that while he’s not happy with the rankings, he’s not surprised by them.

“I think it’s true that it’s fairly consistent that Louisiana ranks near the bottom in most efforts to evaluate the general health of states,” he said. “Typically we go back and forth with Mississippi for 49 and 50.”

“Louisiana is a poor state, and it’s a very rural state,” said Diana. “Those two things tend to go hand in hand, and they also go hand in hand with poorer health outcomes.”

Recent census data indicate that Louisiana is one of the poorest states in the United States.

Median household income there is only $45,727, meanwhile the state’s poverty rate is 19.6 percent — the third highest in the country behind New Mexico and Mississippi.

To combat this, Louisiana is one of 31 states that have expanded Medicaid coverage under the Affordable Care Act (ACA). Diana regards the expansion as a real success.

About 1.5 million people out of 4.5 million are on Medicaid in Louisiana, he noted. That’s a third of the population.

“If you accept, and I do accept this, and I think that most health policy people agree, that having insurance improves access, and if you have access to a usual source of care, whether it’s a primary care physician or whatever, that tends to mean that you have better health outcomes,” he said.

The state will need to fight for improved outcomes because, along with poverty, major health epidemics are also plaguing Louisiana.

Currently, the state has some of the highest rates of cancer and heart disease in the country.

Louisiana’s rate of heart disease is mirrored in its rates of obesity and smoking, both of which are above the national average.

“I think it’s also poor diet,” says Diana. “Louisiana obviously has a reputation for really good food and really unhealthy food.”

Community or behavioral elements of healthcare, such as diet and exercise, are factors that will impact a healthcare system, but tend to reside outside the medical community’s direct control, said Diana.

Delivery of medical care — acute moments when healthcare is sought out by an individual due to an illness — Diana believes is only a smaller element of a state’s health, dwarfed by many more external factors.

That connection is relevant to the state’s high cancer rates, which Diana attributes to industry and chemical manufacturing.

“Louisiana has a stretch along the Mississippi River just west of New Orleans that’s populated with lots of refineries and plants that have earned it the reputation of being called ‘cancer alley,’” Diana said.

“My suspicion is that if you remove those [areas] from the data, we probably would not be in the top any longer. I think that’s not a statewide phenomenon,” he added.

Diana is also confident that Louisiana is making strides in certain areas of healthcare, even if they aren’t necessarily reflected in this year’s rankings.

Infant mortality rates have dramatically improved over the past few years. Diana said that’s thanks largely to Medicaid, which has provided insurance to single pregnant women and children.

Diana also said that through the Medicaid expansion, the state is continually looking into improving their programs.

Finally, he stressed that were some of these rankings better controlled for certain outside factors, they could perhaps look different.

“In defense of Louisiana, I’d argue that some of these things, like poverty and rurality, are very difficult to influence,” says Diana. “I suspect if we adjusted for the level of poverty or how much rural population there is, we wouldn’t look quite so bad.”