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South Carolina has for years ranked poorly in a variety of health measures compared to other states. Recent reports add to that data.

In one, the Palmetto State ranked ninth worst for mental and physical well-being, and in the other it ranked as the 11th least healthy state.

In the 2024 Kids Count report from the Annie E. Casey Foundation, the state ranked 46th overall for child health.

And in its 2023 annual state health report, the United Health Foundation ranked South Carolina 38th. 

But what’s behind these concerning numbers? 

There’s no easy answer to that question, said Dr. Brannon Traxler, chief medical officer at the state Department of Public Health.

“This is not new,” she said. “We didn’t get to where we are overnight, and we won’t be able to reverse it overnight.”

Many factors affect health and there’s a lot of interplay between them that can lead to negative results, she said.

One, Traxler said, is that South Carolina has many rural areas with limited access to health care, affecting both physical and mental health.

“For instance, we have 14 counties in the state without an OB/GYN,” she said. “For pre-labor and post-partum care, it can really be problematic. And maternal and infant mortality is a problem.”

Lack of insurance is another important factor, Traxler said, and it particularly impacts the ability to get preventive care. 

“Insurance is pretty foundational to being able to access the rest of the health care system,” said David C. Radley, a senior scientist with The Commonwealth Fund, a private foundation that advocates for a better health care system.

“In South Carolina, rates of uninsurance are higher than average,” he said. “There are 15 percent uninsured in South Carolina compared with 12 percent in the U.S.”

The Commonwealth Fund scores health system performance every year gauging quality, efficiency, and eight measures of access and affordability, such as the percent of adults without health insurance, Radley said. When last done in June of 2023, South Carolina scored 37th out of 51, he said.

And when it comes to income, South Carolina ranks 41st in health care experience based on income disparities, he said.

“Low-income people in every state have a harder time accessing care,” he said. “In South Carolina, there are even bigger disparities.”

One in four low-income people, or 26 percent, don’t have insurance – a 19-percentage point gap between the experience of high-income people in the state, he said.

“Not having access to care is definitely a contributor to poor health,” said Radley. “And living in poverty is a major contributor to poor health.” 

Another measure is the percent of people with a credit report who have medical debt in collections. That represents 22 percent of people in South Carolina compared to 13 percent nationally, Radley said. 

Also, 77 percent of adolescents in the state with a major depressive episode did not receive mental health services compared to 60 percent nationally, he added. 

On the other hand, Radley said, South Carolina has the highest percentage of Medicare spending on primary care compared to other states – 7.6 percent compared to 5.5 percent nationally.

“There is value in the role of primary care to help identify … and manage chronic disease,” he said. “That’s an important role in the health care system.”

Radley said that the University of Wisconsin attributes 20 percent of someone’s health to health care and 80 percent to factors known as social determinants of health, including poverty, housing, food insecurity, access to clean air, and healthy environment.

The Palmetto State’s health rankings also can be attributed to the fact that it has higher rates of certain chronic diseases, such as diabetes, Traxler said. And those conditions can worsen without adequate access to health care, leading to amputations among diabetics, for example, she added.

In 2021, the state had the sixth highest rate of adult diabetes in the nation, according to the department, and the seventh highest rate of stroke deaths.

“Things like kidney failure and dialysis rates and amputations are often related to diabetes,” Traxler said. “If you can’t afford insulin, things get worse.” 

South Carolina also has more health disparities than other states, which may reflect lower income, education, and race, or a combination of socioeconomic factors, she said.

“We know that less-educated people have poorer health – any number of studies have proven that over time,” she said. 

“In South Carolina, we have a good education system and have made a lot of improvements, but we’re still technically below average. But we are very focused on eliminating disparities,” she added. “And I know the health care industry is as well.”

Children’s health also impacts the rankings.

“South Carolina is one of the poorest states for children’s health and well-being … (and) these outcomes put stress on families and have immeasurable costs to society,” said Bett Williams, spokeswoman for The Children’s Trust of South Carolina.

Some 10 percent of the state’s babies born in 2022 weighed less than 5.5 pounds, putting them at higher risk for short- and long-term complications, she said. 

“A tiny baby may have a harder time gaining weight and fighting infections,” she said. “In the long term, people born smaller are more likely to develop diabetes, obesity, heart problems, and high blood pressure.”

Other areas of concern for children and teens include mental health and deaths from injuries such as auto accidents, drownings, and accidental discharge of firearms, she said.

“The child and teen death rate, which is for children ages 1 to 19, has jumped significantly from 2019 when the death rate was 25 deaths per 100,000,” she said. “For 2022, the death rate is 39 deaths per 100,000.”

Traxler said that a shortage of health care professionals also contributes to the access dilemma – and hence the rankings – noting that those shortages will only worsen as the population ages and requires more care.  

Meanwhile, training those professionals takes years, she said.

“I did four years in medical school and five years in general medical surgery,” she said. “I was 32 when I got my first job as an attending.” 

There are some efforts to increase the pipeline of people choosing health care careers, such as programs that target high school students, increase the number of nursing faculty to grow class sizes, and open more medical school slots. 

But, she said, more needs to be done. 

“The state has done some very good things … using telepsychiatry (to address the shortage of psychiatrists). That’s a big need. Especially post-pandemic,” she said.

“We’re doing the best we can to adapt, not only using nurse practitioners and physician assistants,” she said, “but also using health care workers in skills and roles they’re not trained for, such as paramedics and pharmacists giving immunizations.”

A lack of access to healthy food in both rural and urban areas as well as cultural eating habits also plays a role in the state’s health, Traxler said. 

“Healthy food choices are influenced by access and affordability – it is cheaper to eat fast food than healthy food. And that’s truly a shame,” she said. 

“But also, choice,” she added. “Here in the South, we like our food cooked in fatback. Families have been eating this way for generations. We are very proud of who we are as Southerners and don’t want to lose that. But we want to make adjustments around food and how we cook it.”

And while rates of smoking have improved, the state still a way to go on that front, she said, adding she’s now also concerned with vaping among teenagers. 

The state’s rural areas also account for farming accidents, leading to serious injury and even more tragic outcomes, and contributing to the rankings, she said.

In addition, Traxler said, public health needs stable and flexible funding to be able to respond appropriately to emergencies like the pandemic. 

Making improvements in other areas, such as mental health, can involve overcoming stigma, especially for men, who may see it as a sign of weakness, she said. Reducing stigma also would help in combating sexually transmitted infections, which are increasing, she said. 

The research on mental and physical well-being, compiled by Leafwell – a group dedicated to unlocking the medicinal benefits of cannabis – evaluated life expectancy, income, physical inactivity, mental distress, and other factors. South Carolina scored 29 out of 100, accounting for its poor ranking.

The worst state for mental and physical well-being was West Virginia, with a score of 5.6 out of 100, according to the study, which noted that of the 10 worst states, eight were in the South.

The research that ranked South Carolina as the 11th least healthy state was generated by Forbes Advisor, an online platform that provides information on personal finance issues. It compared all 50 states across 21 metrics.

“It’s just more data telling us what we already know from other studies,” Traxler said. “We’re working as hard as we can to reverse it. But it won’t happen in a matter of months or weeks.”