Vermont leads the nation in the delivery of its health care, while Mississippi is rated the worst, according to a non-partisan study that compares all 50 states and the District of Columbia.
Vermont, Hawaii, Iowa, Minnesota, Maine and New Hampshire ranked 1 to 5 in 38 indicators of health care.
At the bottom were Mississippi, along with Oklahoma, Louisiana, Arkansas, Nevada and Texas.
The Commonwealth Fund Commission's "Scorecard on Health System Performance," which was released today, rated the states on access, quality, costs and health outcomes in a follow up to their 2007 report.
Overall, the states which did best on the Commonwealth scorecard were in New England and the upper Midwest, and the worst states were in the South.
"We're small. There are 19 cities larger than the state of Vermont," said Susan Besio, director for health care reform and Medicaid for Vermont.
"But I believe there is something unique about Vermont in terms of its culture," she told ABCNews.com. "We want to take care of each other and we are a healthy state."
In Mississippi, however, about 20 percent are uninsured despite having some of the highest rates of hypertension, diabetes and asthma.
According to the report, only 35.7 percent of adults 50 or over in Mississippi receive recommended screening and preventive care.
"When you compare Mississippi on almost any socio-economic profile, we are a struggling population that has a large percentage of low-income individuals, high unemployment rates, low rate of education," said Robert Pugh, director of the Mississippi Primary Health Care Association.
The scorecard "paints a picture of health care systems under stress, with deteriorating health insurance coverage for adults and rising health care costs," according to co-author Cathy Schoen, who is senior vice president of the commission.
"Where you live matters for access, quality of care and whether you live a long and healthy life," she told ABCNews.com. "These wide and persistent gaps among states highlight the need for national reforms and federal action to support states."
"It's very hard to have a high performing health care system and hospitals that do well for everyone if you have a high rate of uninsured in the state," said Schoen.
In 1999-00, there were only two states with 23 percent or more of adults uninsured. But by 2007-2008 there were nine.
Children fared much better, due in large part to the Children's Health Insurance Program (CHIP) under Medicaid. The number of states with 16 percent or more of children uninsured dropped from nine to three during the same time period.
Other findings of the report were that in a, costs rose and quality improved in areas where outcomes were reported to the public.
The Green Mountain state was cited for its model "Blue Print" program. Launched by Republican Gov. Jim Douglas, it covers everything from teaching children healthy eating to helping seniors stay in their homes rather than going to costly nursing homes.
"You betcha, I feel good about the reforms we put in place," Douglas told ABCNews.com. "It's centered on quality and containing costs. Care shouldn't start in the emergency room."
All Vermonters are encouraged to have yearly exams and adults are notified when they are due for check-ups.
Douglas talks to children about "getting off the couch" and set an example just this week by joining elementary students on a walk to school.
With the second oldest population in the nation, Vermont subsizes care for seniors and the disabled to defray the costs of home care. Nursing home beds were reduced by 200 last year.
In one pilot program, electronic medical records can avert expensive tests like MRIs and x-rays. One emergency room doctor seeing a woman with stomach pains discovered in her online medication history that she had not filled her prescription for ulcer medicine.
"It takes time and so a lot of the fruits come from years of work and planning and cooperation," said Douglas.
But Mississippi, with the highest infant mortality and low birth rates in the nation, makes access to these Medicaid programs more difficult, according to Roy Mitchell, director of the Mississippi Health Advocacy Program (MHAP).
"I am not at all surprised we were 51st on the list," he told ABCNews.com. "We are last on several health indicators. Our policy makers work hard at being last."
Despite one of the highest matches of federal to state dollars in Medicaid funding, the state mandates "face-to-face" eligibility, requiring all new applicants and those reapplying for benefits to come in for an interview.
"As a direct result, 65,000 children have fallen off the rolls," Mitchell said.
"Mississippi does virtually no outreach at all. They don't publish where these face to face stations are and what times," he said. "It's a bureaucratic maze even to find out where to go. And when they get there they don't have a certain document."
Of those, about 77 percent would be eligible, he said. "It's touted as fraud prevention."
These disparities between the highest and lowest ranked states could be alleviated with national reform, according to Commonwealth.
The report emphasizes the need for insurance reform that rewards good outcomes, payment reform with an emphasis on prevention and advanced information systems that travel with the patient from physician to physician, saving time, money and preventing errors.
"What the scorecard is showing is that we have a system under stress, no matter where we live," said co-author Schoen. "The costs are rising more than people's incomes. We need to act."
Schoen said she has hope for reform. "There is real leadership and people are taking reform seriously."