NAIC-Integrated · Through CY2024

The U.S. Medical Malpractice Climate

Where physicians face the heaviest liability exposure, how the underwriting environment has shifted over fifteen years, and what specific states look like over time.

Section 1 · Where We Are Now

Composite Climate, 2024

Each state scored 0–75 from three components: damage cap structure, NAIC-reported premium burden per physician, and litigation environment.

Lower scores favor physicians. Pennsylvania and New York anchor the hostile tier; Texas, Wisconsin, and North Dakota anchor the favorable tier.

Favorable · score 0–25
Mixed · score 26–45
Hostile · score 46+

Scoring components

Cap structure (0–35)

State statutes and supreme court rulings. Strong fixed cap or PCF state = 0; moderate cap = 10; weak/partial = 20; no cap (struck or never enacted) = 30; constitutional bar = 35.

Premium burden (0–25)

NAIC 2024 direct premium written per active physician. <$5,500 = 0; thresholds at $7,500, $10,000, $13,000, $16,000.

Litigation environment (0–15)

ATRA 2025–26 Judicial Hellholes. Watch List = 5; Hellholes #5–8 = 10; Hellholes #1–4 = 15.
Bucket thresholds: 0–25 = Favorable · 26–45 = Mixed · 46+ = Hostile
Sources: NAIC Countrywide Summary of Medical Professional Liability Insurance (2024) · AAMC 2023 State Physician Workforce Data Report · ATRA Judicial Hellholes 2025–26 · State statutes (per-state citations in repository)
Section 2 · How It Got That Way

Underwriting Loss Ratio, 2010–2024

Each tile shows the same map, colored by that year's loss & DCC ratio per state. A ratio above 100% means insurers paid out more in losses and defense costs than they collected in earned premium.

Watch the warm colors expand and deepen from left to right. Hover any state in any year to track it across all years.

Loss & DCC Ratio (Direct Losses + Defense Costs ÷ Direct Premium Earned)
25%·
50%·
75%·
100%Break-even
125%·
150%+·
The countrywide median state loss ratio rose from 44% in 2010 to ~75% by 2019, then settled around 65–72%. The number of states exceeding the 100% break-even line went from zero in 2010 to seven or more annually since 2016.
Section 3 · Drill In

State-by-State Comparison, 2010–2024

Pick a preset or build your own comparison. Track how the underwriting climate and premium burden have moved within specific states over fifteen years.

Preset:
Toggle states (click to add or remove)