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America's Health Rankings chart, relabeled by Kentucky Health News.

Kentucky again ranks near the bottom in two big health measures: 48th for health behaviors and 46th for health outcomes, according to the America's Health Rankings report from the United Health Foundation.

Most of the reasons are familiar, such as a high percentage of Kentuckians with more than one chronic condition -- such as diabetes, which has become more common in recent years, and cardiovascular disease, including high blood pressure.

Only one state, West Virginia, has more residents with multiple chronic conditions.

But while many of the reasons for the low ranking are familiar, some of them have become worse in recent years.

For example, in the last four years of the rankings, the percentage of Kentuckians who met the federal guidelines for physical activity -- 150 minutes of moderate aerobic activity or 75 minutes of vigorous aerobic activity, plus two days a week of muscle strengthening -- has declined, while the national percentage has been going up. Kentucky is now last in the nation for this metric.

Unlike previous annual reports, the 31st America's Health Rankings does not assign states an overall ranking, citing the health challenges of the coronavirus pandemic. However, a comparative look at the overall numbers places Kentucky 44th among the states.

That's better than the state's two main rankings, due to other ranking categories.

The latest America's Health Rankings used a new model that examines 74 measures of population health in categories that include social and economic factors, physical environment, clinical care, behaviors and health outcomes. Prior reports have only examined 35 measures of health.

The measures are in several categories. One where Kentucky did well, raking 19th, is Physical Environment, which includes a wide range of factors that influence where individuals live, work and play, and include things like air and water quality, climate change, housing and transit.

The shining star in this category is the state's No. 1 ranking for water fluoridation, a scientifically proven policy that appears to be under attack.

Kentucky health regulations require most water systems to add fluoride to reduce tooth decay, a significant problem in the state. Sen. Steve West, R-Paris, filed a bill in the last legislative session to let local governments or special districts exempt themselves from the rule. It appears that a similar bill will likely be filed during the upcoming one, since advocates both for and against adding fluoride to water testified in September at the Interim Joint Committee on Local Government, WTVQ reports.

Also in the physical environment category, Kentucky ranked 31st in the percentage of residents who are covered by 100% smoke-free laws applying to workplaces and public spaces. As of Oct. 1, 36.2% of Kentuckians are protected by such laws, according to the Kentucky Center for Smoke-Free Policy.

In the Clinical Care category, Kentucky ranked 31st, largely due to its low share of uninsured adults, 6.4%, which has driven down by the state's embrace of the Patient Protection and Affordable Care Act and its expansion of Medicaid. The uninsured rate rose from 5.6% in 2018 to 6.4% last year.

Another strength in the Clinical Care category is the percentage of Kentuckians who report having a dedicated health-care provider, nearly 82%. That may also be a reflection of the Medicaid expansion.

But gaps remain. The category includes bottom-10 rankings for adult dental visits, childhood immunizations and preventable hospitalizations.

In the Social and Economic Factors category, Kentucky ranked 34th. Its strengths in this category were a No. 3 ranking for high-school graduation rate, 90.3%, and a No. 10 ranking for decreasing the racial gap in graduates. Another strength is the state's low rate of violent crime.

The state had two measures in this category that ranked in the bottom 10 of states: a high index of high economic hardship, which compares financial strain between states, and a high percentage of Kentucky households with food insecurity, 14.7%.

In Health Outcomes, Kentucky ranked 46th. Of these measures, Kentucky ranked among the bottom 10 states for nine measures, including: depression (49th), frequent mental distress (45th), drug deaths (41st), premature deaths (47th), frequent physical distress (48th), multiple chronic conditions (49th), high blood pressure (46th), high cholesterol (49th) and obesity (45th).

In the Healthy Behaviors category, Kentucky ranked 48th, which should come as no surprise since the state ranked in the bottom five states for insufficient sleep (48th), exercise (50th), fruit and vegetable consumption (50th), physical inactivity (48th), teen births (47th) and smoking (49th).

Those are all determinants of health, a sub-category in which Kentucky ranked 43rd among the states.

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