Every year we examine data provided by the U.S. Census Bureau’s American Community Survey (ACS) which provides the most comprehensive look nationally and by state at important trends impacting America’s families – including health insurance. Today we are sharing our analysis of data that came out just yesterday for calendar year 2024. Our analysis is focused on health insurance status of children 18 and under, and we looked at all 50 states and the District of Columbia. We examined a two-year period from 2022 to 2024. During this period, most states started and completed their “Medicaid unwinding” process – an unusual historic event in Medicaid policy where pandemic era protections of continuous coverage were lifted and states had to check eligibility for tens of millions of Americans covered by Medicaid.

As many of you know, we were very worried about eligible children being disenrolled by mistake during this process – especially in states that did not approach the process with the utmost care. Because children are much more likely than their parents or other adults to be eligible for Medicaid/CHIP – with a national median income eligibility level of about 255% of FPL – large numbers of children losing coverage during the unwinding was a sign that children who remain eligible were being disenrolled for procedural reasons. We monitored these trends very closely tracking indicators of how well states were meeting the unwinding challenge and found wide variability on state performance. This huge state variability is reflected in the data we are examining today.

Before I get into the findings, let’s talk about why having health insurance is important for children and families. Sometimes we hear hints being dropped in policy debates that health insurance is not important. For most American families (except perhaps the uber wealthy) there is no need to explain why having health insurance is important for their children. No parent wants to have to think twice about costs when taking their child to the doctor or picking up their prescription at the pharmacy. Health care is expensive; and families can be bankrupted by even a short gap in coverage for a child. An accident on the playground, or untreated asthma can result in trips to the emergency room which cost thousands and thousands of dollars. This is just common sense, but there is also plenty of research that makes clear that having Medicaid coverage for children results in better access to care, improved health, educational and economic outcomes in adulthood. Covering children is a good deal for taxpayers as the Congressional Budget Office has made clear. Having health insurance is not a guarantee that you will be healthy, but NOT having health insurance is a guarantee that parents will be subject to worry and economic stressors, and that children will have less access to needed care. When care is delayed due to lack of insurance, children can become sicker and wind up in the hospital requiring more expensive care. It goes without saying that children, families and society are better off when all children have the health care they need to succeed.

There has been widespread bipartisan support for reducing the number of children without insurance for many decades and as this chart shows the number was going down for many years following the passage of CHIP in 1997 – and going further back would also show reductions as a consequence of Medicaid expansions for poor children that were passed in the 1980’s by a Democratic Congress and President Ronald Reagan.

From 2022 to 2024 the rate of uninsured children increased from 5.1% to 6%. This was a statistically significant change and equates to an 18% increase in the number of uninsured children nationwide. This is the highest rate of uninsured children in nearly a decade, and unfortunately, we believe it is only going to get worse – full stop. This is a dramatic reversal on the progress our nation had made improving child health coverage.

This rise in the number of uninsured children was seen across all races and ethnicities with one exception, Asian children, whose coverage level remained steady. American Indian/Alaska Native children have the highest uninsured rate (12.4%), followed by Hispanic/Latino children (9.7%).

It is also worth noting that the uninsured rate for adults did not rise during this period. It’s important to note that child eligibility levels did not change during this time frame. Historically, most uninsured children are eligible but not enrolled in Medicaid or CHIP coverage.

Let’s look at state trends now: Twenty-two states saw a statistically significant increase in the rate of uninsured children over the two-year period. One state, New Hampshire, saw its rate of uninsured children go down by 1.1 percentage points – so congrats to the Granite state. The remaining states saw small movement in either direction that was not statistically significant.

Let’s take a closer look at the states where the number of uninsured children rose. The worst state, unquestionably, for children’s access to health insurance is Texas – which led the country by far disenrolling 1.3 million children during the unwinding. Texas’ child uninsured rate rose from 10.9% to 13.6% from 2022 to 2024 – a 29 percent increase in the number of uninsured children in Texas with 1.1 million uninsured children in the Lone Star state in 2024 – almost one quarter of the nation’s uninsured children live in Texas. If all states had done as poorly as Texas did with unwinding, we would have seen a much higher jump in the number of uninsured children nationwide.

Other states with large increases in their child uninsured rate (in order) include Delaware and Idaho that are tied for second in the country behind Texas. New Mexico comes in fourth, while Arkansas, Kansas and South Dakota are tied for 5th with Georgia coming in close behind.

The remaining states that saw significant increases in their child uninsured rate are Alabama, Colorado, Oklahoma, South Carolina, Tennessee, Florida, Ohio, Washington, Michigan, Missouri, New Jersey, Virginia, North Carolina and Massachusetts.

In terms of raw numbers, the top 3 states by a wide margin for increases in the number of uninsured children are Texas (+246,000), Florida (+67,000) and Georgia (+48,000).

Another point worth making is that states that have not picked up the Medicaid expansion for adults saw much greater increases in child uninsured rates (which were higher to begin with) than those that have expanded for adults. This is an important finding for two reasons: In the recently concluded Congressional debate over H.R. 1, proponents of making cuts to the Medicaid expansion for adults often argued that it was necessary to do so because the expansion was harming “traditional” Medicaid enrollees like children. This is false for many reasons and this slide underscores one of those reasons– children in these non-expansion states are not doing better in fact they are doing worse than children in expansion states. (Note that the only state that bucked this negative trend – New Hampshire – is an expansion state.) And, arguably, according to the arguments made by supporters of the massive Medicaid cuts in H.R. 1, these non-expansion states should have done a better job for children since they supposedly could focus on them as the largest single group enrolled in Medicaid for the most part. That just wasn’t the case.

Where a child lives is becoming increasingly important as to whether or not they have health insurance. We know that Medicaid enrollment is closely correlated with the child uninsured rate. And the choices states made during the unwinding process, including how quickly they went and how successfully they automated their process, made a critical difference in outcomes.

Where do we go from here?

As concerning as these trends are, this is data from 2024 and there are many reasons that the situation for children’s access to health care will substantially worsen. One of the mitigating factors preventing larger increases in the child (and adult) uninsured rate as we saw earlier this week was the growth of the subsidized Marketplaces – children’s enrollment in Marketplace coverage pales in comparison to the importance of Medicaid and CHIP – but it has grown substantially thanks to the enhanced subsidies enacted in 2021. Compared to 2020 enrollment among children under age 18, child Marketplace enrollment is up more than 2.5 times. But these enhanced subsidies are due to expire at the end of this year; in the absence of Congress taking action more children will become uninsured.

Second, for the same reasons that the number of uninsured children began to grow during the first Trump Administration we expect the number to grow again – and probably much more quickly. These reasons include most prominently a “chilling effect” on mixed status families, by which we mean citizen children living with at least one immigrant parent or other household member. One out of four children in the U.S. has an immigrant parent. With the extraordinary fear gripping these communities today based on aggressive deportations as well as the unprecedented sharing of personal Medicaid data by federal CMS with Immigration and Customs Enforcement, the concerns that parents have about sharing their information with the government right now are real. We have already heard many anecdotes about children not going to well-child visits and other medical appointments as a consequence of this climate of intimidation that has been created by the Trump Administration. Cuts to outreach, limits on Marketplace enrollment periods, chaos and confusion caused by misinformation and discussion of cuts to come all erode the more welcoming climate that existed just last year.

Finally, the implementation of H.R. 1 with an unprecedented cut of almost $1 trillion to Medicaid and CHIP cut lies ahead and children will not be spared. With almost half of the nation’s children covered by Medicaid and CHIP, they cannot be shielded from a cut of approximately 11% to Medicaid’s overall funding. As their parents get disenrolled due to onerous work reporting requirements, we know that will mean it’s likely that their eligible children will lose coverage too. (We call this the “unwelcome mat” effect as it works in the opposite way that the “welcome mat” works in which children come in the door to coverage when their parents become eligible.) The restrictions affecting state financing of Medicaid will result in deep cuts affecting everyone who is covered by Medicaid, including children. The storm clouds are gathering for people to lose health insurance, but for children they are already here.

The Affordable Care Act’s (ACA) Medicaid expansion expanded Medicaid coverage to nearly all adults with incomes up to 138% of the Federal Poverty Level ($21,597 for an individual in 2025) and provided states with an enhanced federal matching rate (FMAP) for their expansion populations.

To date, 41 states (including DC) have adopted the Medicaid expansion and 10 states have not adopted the expansion. Current status for each state is based on KFF tracking and analysis of state expansion activity.

These data are also available in a table format. The map may be downloaded as a Powerpoint.

A Closer Look at the Work Requirement Provisions in the 2025 Federal Budget Reconciliation Law Print Email Copy Link

Note: This analysis was updated to include the Congressional Budget Office’s (CBO) latest cost estimates for the reconciliation package that was enacted on July 4, 2025, as well as new provisions in the law.

On July 4, President Trump signed into law a budget reconciliation package once called the “One Big, Beautiful Bill” that includes significant changes to the Medicaid program. The Congressional Budget Office (CBO) estimates the Medicaid work requirement provisions in the passed budget reconciliation law will be the largest source of Medicaid savings, reducing federal spending by $326 billion over ten years and cause millions to become uninsured.

Implementing work requirements on a national scale, requiring states to verify individuals’ monthly work status (at least every 6 months) and implement a long list of exemptions are policies that proved challenging for Arkansas and Georgia to operationalize and led to 18,000 people losing coverage in Arkansas. KFF analysis shows most Medicaid adults under age 65 are working already (without a requirement) or face barriers to work. Many Medicaid adults who are working low-wage jobs are employed by small firms and in industries that have low employer-sponsored insurance offer rates. In previous analysis, CBO found that a Medicaid work requirement would not have any meaningful impact on the number of Medicaid enrollees working, and cited research from Arkansas indicating that “many participants were unaware of the work requirement or found it too onerous to demonstrate compliance,” resulting in coverage loss.

The law will require states to condition Medicaid eligibility for adults in the Affordable Care Act (ACA) Medicaid expansion group at application and following enrollment on meeting work requirements starting January 1, 2027, with the option for states to implement requirements earlier. Currently, 41 states (including DC) have expanded their Medicaid programs under the ACA to nearly all adults up to 138% FPL ($21,597 for an individual in 2025). As of June 2024, over 20 million people were enrolled through Medicaid expansion, representing nearly a quarter of total Medicaid enrollment across all states and 31% of total enrollment in expansion states. The Medicaid expansion population includes adults without dependents as well as many parents and people with disabilities or chronic conditions who do not receive SSI.

Key takeaways include:

CBO estimates. Of the Medicaid provisions included in the law, CBO estimates implementing work requirements will account for the largest share of federal Medicaid savings. Earlier CBO estimates found work requirements will cause the largest increase in the number of people without health insurance.

Of the Medicaid provisions included in the law, CBO estimates implementing work requirements will account for the largest share of federal Medicaid savings. Earlier CBO estimates found work requirements will cause the largest increase in the number of people without health insurance. Verification requirements. The law requires states to verify at application and at renewal that individuals in the ACA expansion group meet work requirements (80 hours of work activities per month) or exemption criteria. States can also require verification more frequently.

The law requires states to verify at application and at renewal that individuals in the ACA expansion group meet work requirements (80 hours of work activities per month) or exemption criteria. States can also require verification more frequently. Implementation timeline. The law requires HHS to release an interim final rule by June 2026 leaving states with limited time to develop or change implementation plans, protocols, and systems (and to test systems changes) before the January 2027 work requirement implementation deadline.

The law requires HHS to release an interim final rule by June 2026 leaving states with limited time to develop or change implementation plans, protocols, and systems (and to test systems changes) before the January 2027 work requirement implementation deadline. State implementation choices. State choices to impose more stringent requirements than the minimum federal requirements outlined in the law (e.g., requiring more frequent verification or imposing longer “look-back” periods when verifying coverage) as well as state effectiveness in using existing data to automate verification processes, will affect the number of individuals at risk of losing coverage.

State choices to impose more stringent requirements than the minimum federal requirements outlined in the law (e.g., requiring more frequent verification or imposing longer “look-back” periods when verifying coverage) as well as state effectiveness in using existing data to automate verification processes, will affect the number of individuals at risk of losing coverage. Comparison to other waivers and proposals. The Medicaid work requirement policies included in the law are more stringent than previous policies considered by Congress and work requirements implemented under state Medicaid demonstration waivers; for example, the law makes it harder to gain coverage and to re-enroll and does not exempt older adults from requirements

What does CBO say?

Of the Medicaid provisions included in the enacted reconciliation package, CBO estimates implementing work requirements will account for the largest share of federal Medicaid savings; earlier CBO estimates also found work requirements will cause the largest increase in the number of people without health insurance. Over ten years, work requirements are estimated to reduce federal Medicaid spending by $326 billion, representing the largest share of the estimated $911 billion in total Medicaid cuts included in the law (Figure 1). (CBO also projects indirect effects from the work requirement provision will decrease federal revenues by $8.65 billion over a decade.) The savings will largely stem from coverage losses. CBO has not published updated estimates of the number of people who will lose Medicaid under the reconciliation package previously referred to as the “One Big, Beautiful Bill.” Earlier CBO analysis of the House-passed version of the reconciliation bill estimated 18.5 million people will be subject to the requirements each year and by 2034 federal Medicaid coverage will decrease by an estimated 5.2 million adults, with work requirements ultimately increasing the number of people without health insurance by 4.8 million in 2034. CBO expects few of those disenrolled to have access to employment-based coverage and that no one will be eligible for Marketplace premium tax credits (as the law makes those losing or denied Medicaid coverage due to work requirements ineligible for premium tax credits to purchase coverage through the ACA Marketplaces).

What does the law require?

Expansion adults will be required to complete 80 hours of work or community service activities per month or meet exemption criteria to enroll in and maintain coverage (Figure 1). (Work requirements will also likely apply to states like Wisconsin and Georgia that have partial adult coverage expansions under 1115 waivers.) Individuals applying for coverage and those enrolled in coverage will need to work or engage in specified “qualifying activities” for at least 80 hours per month. States will be required to verify qualifying activities or exemptions in (at least) the month before application and (at least) one month between eligibility redeterminations (see Figure 2 and additional discussion below). The law specifies mandatory exemptions including parents and caretakers with children ages 13 and under, individuals who are “medically frail,” and individuals who are pregnant or postpartum, among others (Figure 1). The “medically frail” designation includes individuals who are blind or disabled, individuals with physical, intellectual, or developmental disabilities, individuals with substance use disorder or a “disabling” mental disorder, and those with “serious or complex” medical conditions. States may allow short-term hardship exceptions from work requirements, for enrollees (or applicants) experiencing certain extenuating circumstances (Figure 2).

At a minimum, states will be required to verify individuals’ work or exemption status when individuals apply for coverage and at eligibility renewal (Figure 3). At application, states will be required to “look back” one or more consecutive months (immediately preceding the application month, up to three total months) to confirm compliance with the requirements. Every six months when eligibility is redetermined (or more frequently as determined by states), states will be required to “look back” one or more months (consecutive or non-consecutive) to verify compliance. In effect, states could require individuals to comply with work requirements for multiple months before they can enroll in coverage or for multiple months within any six-month eligibility period (or more frequently than every six months). The law directs states to use available information (e.g., payroll data) “where possible” to verify compliance with work activities or exemption status, without requiring additional documentation from individuals.

When a state is unable to verify compliance with the requirements or that an individual meets exemption criteria, it must issue a “notice of noncompliance” and deny the application or disenroll the individual from coverage if the individual is unable to show compliance (Figure 3). Individuals will have 30 days to show compliance (coverage will be maintained during this period if already enrolled). After 30 days, if an individual is unable to demonstrate compliance with the requirements or show they are exempt, the state will be required to deny the application or disenroll the individual from coverage (no later than the end of the month following the 30-day period). States will be required to follow standard Medicaid termination processes, including determining whether an individual qualifies for Medicaid coverage on another basis and provide written notice and opportunity for a fair hearing. To regain Medicaid coverage, individuals will need to reapply (triggering another compliance check at application). Individuals will also be barred from receiving subsidized Marketplace coverage, as the law makes those losing (or denied) Medicaid coverage due to work requirements ineligible for premium tax credits to purchase coverage through the ACA Marketplaces.

What is the timeline for implementation?

The law specifies key work requirement implementation and compliance dates (Figure 4). The law directs the Secretary of HHS to issue an interim final rule on implementing work requirements by June 1, 2026 (the law specifies the interim rule will not be subject to public notice or public comment). States will be required to condition Medicaid expansion eligibility and coverage on meeting work requirements by January 1, 2027, with an option to implement requirements sooner. States must begin outreach to notify individuals of the new requirements at least three months before the start of the first compliance “look-back” period and notify individuals “periodically thereafter.” The law allows the Secretary to exempt states from compliance with the new requirements until no later than December 31, 2028, if the state is demonstrating a “good faith” effort to comply.

Figure 4

A forthcoming HHS interim rule may identify implementation parameters and additional state requirements; however, if the rule is slated to be released by June 2026, states will have limited time to develop or change implementation plans, protocols, and systems (and to test systems changes). The work requirement provisions outlined in the law raise many operational and implementation questions (Appendix Table 1). The law includes references to areas where additional HHS guidance may further define standards and processes for states (Table 1). Implementing work requirements will involve complex systems changes (e.g., developing or adapting eligibility and enrollment systems), enrollee outreach and education, staff training, and coordination with managed care plans, providers, and other stakeholders. The law allows states flexibility to impose more stringent requirements than the minimum requirements specified (e.g., requiring more frequent verification or imposing longer “look-back” periods when verifying coverage) and allows states to implement requirements sooner than January 2027.

How could implementation vary across states?

States will have flexibility to impose more stringent requirements than the minimum federal requirements outlined in the law. For example, states will have flexibility to determine how many months to “look back” at application (up to three months) and redetermination to verify compliance (and whether to verify compliance more frequently than at redetermination). In effect, states could choose to require compliance with work requirements for multiple months prior to the application month and for every month following enrollment (Box 1).

Box 1 The impact of choosing different “look-back” periods John lost his job and was out of work in April and May. In June, he started in a new seasonal position and worked 80 hours during the month. In July, John applies for Medicaid in an expansion state, as he qualifies for Medicaid on the basis of his income. State A uses a 1-month look-back period when determining compliance with work requirements at application. John would be able to enroll in Medicaid (provided he meets all other program requirements).

uses a 1-month look-back period when determining compliance with work requirements at application. John would be able to enroll in Medicaid (provided he meets all other program requirements). State B uses a 3-month look-back period when determining compliance with work requirements at application. John would not qualify for Medicaid, as he was out of work in two of the three months.

State data matching process decisions and how effective states are with data matching will affect how many individuals will need to submit proof of work hours or exemption status, and ultimately the number of individuals at risk of losing coverage. States with older or weaker systems or less integration (e.g., with SNAP or TANF) may be less effective. But even with effective systems, not all work can be verified through existing data sources, including, for example, community service and self-employment. As noted earlier, the law directs states (“where possible”) to data match work activities and automate the verification of exempted individuals/groups. Some exemptions may be easier to identify with existing data including parent/caretaker status, recent incarceration, and compliance with SNAP/TANF work requirements. Others may be more difficult such as participation in SUD program or meeting the “medically frail” definition (e.g., individuals with SUD, individuals with physical, intellectual, or developmental disabilities, those with “serious or complex” medical conditions).

How does this law compare to state waivers and previous proposals?

The Medicaid work requirement policies included in the law are more stringent than previous policies considered by Congress and work requirements implemented under state Medicaid demonstration waivers (Table 2). The law shares some similarities in structure to other federal legislative proposals and waivers, including requiring 80 hours per month of qualifying activities such as employment, community service, or work programs, and allowing exemptions for parents and individuals with certain health conditions (although Georgia’s waiver currently offers no exemptions). However, the law will condition eligibility at initial application and after enrollment on meeting work requirements, making it harder to gain coverage and to re-enroll (than in Arkansas or under the Limit, Save, Grow Act considered by Congress in 2023). Individuals lost coverage after three months of noncompliance in Arkansas and under the Limit, Save, Grow proposal, while under the law individuals could lose coverage more quickly (if the state chooses to verify monthly). The policy in the law will also extend to older age, through age 64 (unlike Arkansas’s waiver and the Limit, Save, Grow Act). In Georgia where the work requirement extends through age 64, the state’s interim evaluation found that work requirements have had a significant impact on lowering program enrollment, particularly for adults ages 50-64. For more on lessons learned from Arkansas’ and Georgia’s experience implementing work requirements (under demonstration waivers), see KFF’s previous explainers.

Appendix

American business is in the grips of a serious labor shortage, even though hiring has slowed and artificial intelligence is picking up more of the slack. The U.S. Chamber of Commerce says that for every 100 job openings, only 92 workers are available to fill them. That means the nation is short about 1 million workers. To try and meet the demand, companies are seeking locations that are attractive to prospective employees. That makes quality of life a business imperative. Each year, CNBC’s annual rankings of state business climates — America’s Top States for Business —considers Quality of Life among ten categories of competitiveness. Under this year’s methodology, the category makes up 10.6% of a state’s overall score. We consider factors like crime, health care, air quality, and the price and availability of child care. We also consider inclusiveness of state laws, such as legal protections against discrimination. And with data showing younger workers considering reproductive rights in their choice of where they are willing to live, we factor those state laws in our rankings as well. Some states are particularly welcoming to workers. These are not those states. They are the states with America’s worst quality of life in 2025.

Oklahoma

File: A Tulsa Police officer takes cover behind a car with a weapon at the scene of a fatal shooting. Mike Simons | Tulsa World | AP

Just like in the rest of the country, violent crime in Oklahoma has been trending gradually lower in recent years. But at roughly 418 offenses per 100,000 people in 2023, the Sooner State’s violent crime rate is the 14th highest in the country, according to FBI statistics. Of particular concern is a sharp rise in domestic violence homicides, which State Attorney General Gentner Drummond recently called an “epidemic.” “We must continue strengthening our statewide efforts to hold abusers accountable and to provide protection and support for victims,” Drummond said in a statement in February. Oklahoma offers limited protections against discrimination, according to the National Conference of State Legislatures, and it has one of the nation’s strictest abortion bans. 2025 Quality of Life Score: 97 out of 265 points (Top States Grade: D-) Strengths: Child Care, Air Quality Weaknesses: Crime, Health, Reproductive Rights

Arkansas

Arkansas Gov. Sarah Huckabee Sanders speaks before U.S. Agriculture Secretary Brooke Rollins signs three new SNAP food choice waivers for the states of Idaho, Utah, and Arkansas in her office at the United States Department of Agriculture Whitten Building on June 10, 2025 in Washington, DC. Andrew Harnik | Getty Images News | Getty Images

Life can be rough in the Natural State, which has the sixth-highest percentage of adults in frequent mental distress, according to the United Health Foundation. Nearly 19% of Arkansas households are food insecure. That’s the highest rate in the country. One in five Arkansans, and one in six Arkansas children, face hunger. “It’s clear that our state is in critical need of comprehensive solutions to address these sobering statistics and ensure that all Arkansans have access to sufficient and nutritious food,” said Gov. Sarah Huckabee Sanders, who issued an executive order last fall directing state agencies to address the problem. She has also signed legislation providing free breakfast for public school students regardless of their family’s income. The violent crime rate in Arkansas is the fourth highest in the country, and the state has among America’s most restrictive voting laws. 2025 Quality of Life Score: 95 out of 265 Points (Top States Grade: D-) Strengths: Child Care, Air Quality Weaknesses: Health, Crime, Inclusiveness

Alabama

Christa White (L) and her daughter attend a rally at the Alabama State House to draw attention to the anti-transgender legislation introduced in Alabama on March 30, 2021 in Montgomery, Alabama. Julie Bennett | Getty Images News | Getty Images

The Heart of Dixie might pride itself on Southern hospitality, but its state laws suggest that the hospitality does not extend to everyone. Alabama is one of just five states with no law protecting non-disabled people against discrimination in public accommodations, according to the National Conference of State Legislatures. And in February, Gov. Kay Ivey signed the “What is a Woman Act,” defining a person’s gender based on the sex organs they were born with. “If the Good Lord made you a boy, you’re a boy,” said Ivey. “And if he made you a girl, you’re a girl.” Opponents said the law will be used to justify widespread discrimination against transgender people. The state eschews most worker protections, according to Oxfam America, which ranks Alabama 49th on its annual Best States to Work scorecard. 2025 Quality of Life Score: 92 out of 265 Points (Top States Grade: F) Strengths: Air Quality, Child Care Weaknesses: Inclusiveness, Worker Protections

Georgia

Police officers work the scene of a shooting at a Northside Hospital medical facility on May 3, 2023 in Atlanta, Georgia. Megan Varner | Getty Images News | Getty Images

While the overall violent crime rate in Georgia is roughly in line with the national average, it has one of the highest homicide rates in the country. That is but one factor in an overall unhealthy environment in The Peach State. More than 11% of the population lacks health insurance, the third-highest rate in the country. The state ranks 40th for primary care doctors per capita, and 48th for mental health providers, according to the United Health Foundation. The Commonwealth Fund ranks Georgia 45th in its latest Scorecard on State Health System Performance, which grades the states on health care access, prevention and treatment, efficiency, healthy lives, and health disparities. Georgia is another one of the five states with no anti-discrimination protections for non-disabled people, and it offers few protections for workers beyond a guarantee of equal pay based on race and gender. 2025 Quality of Life Score: 89 out of 265 Points (Top States Grade: F) Strength: Child Care Weaknesses: Worker Protections, Health, Inclusiveness

Louisiana

A New Orleans police vehicle parked on the street ahead of Super Bowl LIX on February 05, 2025 in New Orleans, Louisiana. Aaron M. Sprecher | Getty Images Sport | Getty Images

At around 521 violent crimes per 100,000 people in 2023, the Pelican State has America’s fifth-highest crime rate. And those statistics predate this year’s New Year’s Day attack on Bourbon Street in New Orleans, where a man drove a pickup truck into a crowd of revelers, killing 14. Louisiana also has among the nation’s strictest abortion bans, according to the Guttmacher Institute, banning the procedure in all except very limited circumstances. The state passed eight new voting laws last year that the Brennan Center for Justice deems “restrictive,” including multiple crackdowns on absentee voting. 2025 Quality of Life Score: 87 out of 265 Points (Top States Grade: F) Strengths: Child Care, Air Quality Weaknesses: Crime, Inclusiveness, Reproductive Rights

Utah

Patricia Marroquin | Moment | Getty Images

The Beehive State derives its nickname from the industriousness of its workforce. But those workers get few protections in exchange for their hard labor. Even as the cost of living rises in fast-growing parts of the state like Silicon Slopes outside Salt Lake City, the state has kept the minimum wage at the federal rate of $7.25 an hour. And unlike in many states, Utah prohibits local governments setting their minimum wages any higher. With an average household size roughly 17% higher than the national average, according to Census data, Utah families have a lot of children to care for. And the state is doing poorly in meeting their needs. Utah ranks 48th in licensed child care centers per capita, according to Child Care Aware of America, which also says that a married Utah couple with a median income can expect to spend about 12% of it on child care. 2025 Quality of Life Score: 87 out of 265 Points (Top States Grade: F) Strength: Crime Rate Weaknesses: Child Care, Worker Protections, Air Quality

Indiana

Daniela Guerrero addresses the IDEM representatives during a public meeting to discuss air permitting for BP Products of North America. Chicago Tribune | Tribune News Service | Getty Images

The U.S. Department of Health and Human Services defines affordable child care as costing no more than 7% of a household’s income. In Indiana, it costs twice that for a two-parent household. For a single parent, it can cost a stunning 46%. Business groups like the U.S. Chamber of Commerce have identified child care as one of the major factors in getting people back into the workforce. It is also a major quality of life consideration for young families, and it is one of the areas where Indiana falls short. But it is not the only one. Air quality is poor, according to data from the American Lung Association and First Street Foundation, with high levels of ozone and particulate matter. Indiana also has a strict abortion ban and limited anti-discrimination protections. 2025 Quality of Life Score: 73 out of 265 Points (Top States Grade: F) Strength: Crime Rate Weaknesses: Child Care, Reproductive Rights, Inclusiveness, Air Quality

Texas

Anti-abortion rights supporters take part in a “Rally for Life” march and celebration outside the Texas State Capitol on January 27, 2024, in Austin, Texas. Suzanne Cordeiro | Afp | Getty Images

The Lone Star State is consistently a top destination for skilled workers — they flock to Texas for its robust economy and one of the best job markets in the nation. But that does not mean that the quality of life there isn’t lacking. Despite world-class institutions like the Texas Medical Center and the MD Anderson Cancer Center, access to care for the average Texan is poor. According to the United Health Foundation, Texas has the nation’s lowest number of primary care doctors per capita, the second-lowest number of mental health providers, and it consistently has the highest rate of people without health insurance. The state has among America’s strictest abortion bans, and crime is on the high side. 2025 Quality of Life Score: 72 out of 265 Points (Top States Grade: F) Strengths: Child Care, Air Quality Weaknesses: Health Care, Reproductive Rights, Worker Protections, Crime

2025’s worst state for quality of life: Tennessee

Transgender rights supporters rally outside of the U.S. Supreme Court as the high court hears arguments in a case on transgender health rights on December 04, 2024 in Washington, DC. The Supreme Court is hearing arguments in US v. Skrmetti, a case about Tennessee’s law banning gender-affirming care for minors and if it violates the Constitution’s equal protection guarantee. Kevin Dietsch | Getty Images News | Getty Images