A new analysis by the personal finance publication WalletHub ranks Alabama’s health care system as the nation’s sixth worst.

To make their determinations, researchers examined three categories: cost, access and outcomes, looking at things like average monthly insurance premium, share of high out-of-pocket medical spending, hospital beds per capita, average emergency-room wait time, infant mortality rate and heart disease rate, among others.

Alabama ranked a constant 44th across the board, putting it just behind Oklahoma and ahead of North Carolina.

Jill Gonzales, a WalletHub analyst, attributed Alabama’s low ranking in part to not expanding Medicaid, a characteristic it shares with other low-ranking southern states.

“The bottom ten states have not expanded Medicaid, which is more so why they rank where they do rather than where they are geographically,” Gonzalez told Yellowhammer News. “Typically, states that have expanded Medicaid have lower uninsured rates, which translates to higher rates of access to health care.”

Alabama fared worst in the category of Share of High Out-of-Pocket Medical spending. There, 20 percent of Alabamians under age 65 had out-of-pocket medical spending equaling 10 percent or more of their income, the highest in the country, according to Gonzalez.

The state also has the third lowest number of dentists per capita and the highest infant mortality rate, according to the rankings.

Alabama’s Department of Public Health could not immediately be reached for comment on the study’s findings.