By Rose Hoban

Last week, headlines across North Carolina (and the U.S.) touted a recent “study” from the personal finance website, WalletHub.

In Florida, the headline was “Florida Among The 10 Worst States for Health Care,” and in South Carolina, it was “SC Ranks One Of The Worst States For Health Care.”

In the one-page report, Vermont’s health care system ranked first, while Louisiana’s ranked last. North Carolina came out near the bottom of the list, ranking 47th in health care systems.

But what does that really mean?

For example, one of the metrics in the WalletHub report was the number of hospital beds per capita, where North Carolina was on the lower end.

“I just walked out of Duke Hospital, where you can get a vast investigation,” said health economist Don Taylor while walking across the Duke University campus where he works. He said that just looking at the number of beds in a state is inadequate and doesn’t take into account distribution. “Durham has got to have some of the highest numbers of hospital beds around, but Greene County where my people come from doesn’t even have a hospital.”

Some of the 40 metrics considered in the WalletHub study included average monthly insurance premium, the numbers of physicians, nurses, geriatric specialists and dentists per capita, urgent care centers per capita and the share of patients readmitted to the hospital before 30 days, along with the infant, maternal and child mortality rates.

North Carolina's ranking is high for the number of at risk adults who have seen the doctor in the past year.
In the WalletHub report, this metric boosts North Carolina’s overall ranking.

“It sounds like what they did was suck in existing data that was easy to get and spit something out,” Taylor said.

That’s basically WalletHub’s strategy: In the past year, the company produced reports on the happiest states, most patriotic states, the best cities for pets, best and worst places to be a teacher and more. Once at the company’s website, curious readers are urged to get a new credit card or check their credit score.

So, what’s a person to believe when they see headlines like the ones above? That’s a question we posed to a number of health economists and health policy experts around the state.

‘Some’ truth

The WalletHub survey broke down the data into three categories — cost, access and outcome — before bestowing a final score. The ranking for “patient outcomes” placed North Carolina at 30th in the nation.

The outcomes ranking is about right, said health policy researcher Mark Hall from Wake Forest University. He noted that as a state, North Carolina tends to do better than the rest of the South on patient outcomes, but worse than places such as Minnesota or Vermont, where the state makes significantly higher investments in local health care systems.

Hall also said that WalletHub’s assessment of North Carolina health care costs (50th in the nation) squared with the fact that the state has not expanded Medicaid.

“That hurts us and you can see that in a number of other states that haven’t expanded Medicaid are near the bottom of [WalletHub’s] rankings,” he said. “The out-of-pocket costs for the uninsured create higher costs via cost shifting for uncompensated care.

screenshot of ranking on insurance premiums, North Carolina is 45th highest in the nation
In the WalletHub report, this metric drags down North Carolina’s overall ranking.

He also said that not expanding Medicaid has resulted in higher premiums for everyone else in the state.

Hall pointed to what he considered to be a better report produced every spring by the Commonwealth Fund, an organization which focuses on health policy research. That report focused on how well states’ health systems perform. In that assessment, North Carolina ranked 35th.

Commonwealth examined data from the U.S. Census, such as how many households were below 200 percent of the federal poverty level (35 percent, higher than the national average) and median household income ($53,402, below the national average of $62,470). That study also looked at indicators from the federal Centers for Medicare and Medicaid Services about how well patients have their diabetes controlled or whether heart attack patients take aspirin.

The Commonwealth study allows readers to examine each metric in detail, creating comparisons to other states. And because the focus is narrow, it can tell a more nuanced story about what’s happening in a given state. Because Commonwealth has been performing the same study, year after year, for many years, the organization is able to note where states have  made changes and made progress.

In general, these organizations look at a narrow portion of health care and refrain from making sweeping judgments about the sector as a whole.

Ask a friend

Other health policy experts noted that most consumers don’t really care that a health care system is good or bad, they’re more interested in knowing whether their local doctor or hospital is good or bad. And that’s still a word of mouth thing, said Oscar Aylor, who teaches health policy at Campbell University as well as at UNC-Chapel Hill.

“Most health care choices are largely subjective,” Aylor said.


He said that there are better ways of looking at information about health care systems, such as the annual United Health Foundation report, which rates a state’s health care systems by examining information such as rates of poverty, infectious disease outcomes, air and water pollution policy, smoking rates, physical activity and dozens of other metrics, in exhaustive detail.

United Health Foundation boils all this information down into state profiles that look mostly at outcomes for individuals. This year, the organization determined that North Carolina’s health system ranked 33rd in the nation, somewhat similar to the outcomes score for WalletHub and the Commonwealth Fund.

Aylor said he also likes to look at the data contained on the Kaiser Family Foundation website, which takes the approach of amassing lots of data but doesn’t create “scores” for individual states.

So, how to assess who’s doing well?

“I was afraid you’d ask that,” Aylor said. Instead, he made the argument that like politics, “all health care is local.”

“I think the average person doesn’t go looking at these sites,” he said. “They go and talk to someone they trust.”

Not there yet

If people really want data about their local systems, the place to go is the annual Robert Wood Johnson Foundation county health rankings.

Aylor noted that for two decades many have tried to crack the nut of helping consumers make decisions about health care quality. He mentioned the Leapfrog Group which uses many metrics to rate hospitals on safety, a pretty narrow target.

Leapfrog surveys hospitals and uses peer pressure in order to get those hospitals to cough up data about safety. The data are collected from around 2,000 hospitals, they crunch the numbers and give each hospital a letter grade.

“By making the Hospital Safety Grades public, we’ve galvanized major changes in these states and many communities,’’ Leapfrog Group president Leah Binder said in 2017.

NC Institute of Medicine head Adam Zolotor likes directing people to a federal website:, which uses the massive amounts of data collected by CMS to generate some safety and quality scores.

Related: North Carolina Hospitals Continue to Improve on Safety

He also said that publicly reported patient surveys are a “new, interesting source of data.”

But Zolotor, who also practices family medicine at UNC Health Care, said the problem with patient surveys is that people usually fill them out when they’re really happy, or really angry.

“It’s enough that you can make a judgment,” he said. “I’m not so sure it’s a sound way to make a judgment.”

Two decades into a national effort to measure health care quality, Zolotor said, “we’re still not there.”

“I actually believe we’re gonna get there,” he said. “The fact that we get quality information about almost every other transaction we have is going to push health care to catch up.”

But in the meantime, he and the others said there are better resources to learn about a state’s health system than  “studies” like the one produced by WalletHub.

Creative Commons License

Republish our articles for free, online or in print, under a Creative Commons license.

Rose Hoban

Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter. Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees...