WalletHub ranked the best and worst states for healthcare, comparing the 50 states and the District of Columbia by cost, access and outcomes using 43 metrics and grading states on a 100-point scale.

Many states in the top 10 best list had some of the lowest average monthly insurance premiums rates in the country, with Massachusetts, Idaho and Rhode Island having the lowest rate.

However, not all states ranked high in the metrics.

Here are the 10 worst states for healthcare in 2019:

1. Alabama
2. Texas
3. Louisiana
4. Oklahoma
5. Georgia
6. Arkansas
7. South Carolina
8. Mississippi
9. North Carolina
10. Alaska

Alaska ranked dead last in terms of overall cost but fared better with outcomes and access. Utah, Mississippi, Nevada, Wyoming and Idaho had the fewest physicians among all the states, while Kentucky, Delaware and Pennsylvania had the highest cancer rates in the nation.

Several of the states at the bottom of the list are also those that did not expand Medicaid under the Affordable Care Act.

“The 2012 SCOTUS decision allowing states to opt out of Medicaid expansion has created the very odd situation that individuals lose their subsidies if their incomes fall,” said Carolyn A. Watts, PhD, Richard M. Bracken Chair and Chairman of Department of Health Administration at the College of Health Professions at Virginia Commonwealth University. “The Kaiser Family Foundation estimates that 2.5 million Americans fall into the ‘coverage gap’ in the 14 states that have still not expanded their Medicaid programs.”

See the full findings here.