Despite its image as the land of sunshine and tofu, California ranks 23rd in the nation for healthy living, down a notch from last year, according to a study released Tuesday. The good news: The Golden State has among the lowest rates of smoking, infant mortality and cancer deaths. The bad news: California has a relatively low rate of immunization coverage and high rates of infectious diseases and residents lacking health insurance. And in a marked finding, nearly one in four Californians is obese, up from one in 10 in 1990. In the past year, California has seen a slight decrease in work-related deaths, poor children, bad physical health days and cardiovascular- and cancer-related deaths. On the downside, the number of smokers, traffic deaths, premature deaths and uninsured patients has increased by a small margin. Among the other findings for California: Violent crime dipped to 526 per 100,000 residents, a decrease of 43 percent since 1990. The number of residents killed by cars ticked up to 1.3 per 100,000 miles driven. While the number of smokers in California has increased to 15 percent, the Golden State had the second-lowest incidence of tobacco use. Among the state’s “strengths” were the nation’s third-lowest infant mortality rate at 5 deaths per 1,000 births and the eighth-lowest cancer death rate of 191 per 100,000. Among the “challenges” cited were California’s high incidence of infectious diseases – nearly 25 per 100,000 residents; low immunization coverage of 78 percent. The study also noted 19 percent of Californians lack health insurance – fourth-highest in the nation – with an estimated 6 million to 7 million uninsured residents. Gov. Arnold Schwarzenegger has declared health-care reform will be his top priority next year, with a proposal expected to be announced during his State of the State address in January. But the governor has been vague about what direction he will lean. In the past, however, he has opposed several proposals from Democrats, including a single-payer system and a plan to force employers to expand health coverage. He said Tuesday he and his staff are studying all options “so that no stone is unturned.” “One has to look at all the different options of how can we solve this, because it’s a very, very difficult issue, and very difficult to solve,” Schwarzenegger said. Democrats are expected to propose a wide range of their own proposals, including re-introducing single-payer, and expanding government programs for children’s health care. An independent health advocacy group is also circulating petitions to obtain the 373,816 signatures needed to qualify a single-payer measure for the 2008 ballot. Republican legislators favor free market-based approaches that use financial incentives and are expected to oppose any plan that involves tax increases or increased burdens on employers. In Los Angeles, some advocated for more education funding to help residents ward off infectious diseases in dense city neighborhoods, as well as the one in three emergency room visits caused by alcohol. “The public needs to be educated and reminded of the hazards of living in dense communities,” said James Lott, a senior vice president with the Healthcare Association of Southern California, which represents hospitals across the region. The stress of living in the Golden State, according to the study, causes nearly four poor mental health days a month. “That’s not bad,” said Dr. Joseph Harasztic, a Pasadena psychiatrist and a professor of psychiatry at USC. “I would figure California to be closer to the top of the most stressful areas. “I know I have more than 3.5 mental health days on which I feel stressed.” Harasztic said that Angelenos must learn to budget their time, be aware of their limits and learn to say `no.’ It’s especially important, he added, to exercise at least three days a week to reduce stress. The health report was compiled by the United Health Foundation, a not-for-profit a subsidiary funded by the UnitedHealth Group and a coalition of medical associations. Tuckson, a former health commissioner for Washington, D.C., said he awakens each day to 5 a.m. workouts. He said residents must strive to better their health, target health problems in their communities, invite visits by local health officials and call for more spending on public health. “For at the end of the day,” Tuckson said, “what’s more important than human survival? That’s what it’s all about.” Staff Writer Harrison Sheppard contributed to this report. dana.bartholomew @dailynews.com (818) 713-3730160Want local news?Sign up for the Localist and stay informed Something went wrong. Please try again.subscribeCongratulations! You’re all set! “It is more important than ever for the citizens, for the people of California to get motivated, to get involved and to make a difference in health and survival,” said Dr. Reed Tuckson, senior vice president of the Minnesota-based United Health Foundation and a co-author of the report. Californians, he said, must “make the choices today to have healthy behaviors – daily exercise, putting on a seat belt and deciding not to smoke tobacco.” The 17th annual America’s Health Rankings analyzed 20 health factors in all 50 states, from Maine to Alaska. Based on a variety of factors – such as smoking, medical care and living and work environments – Americans are nearly 19 percent healthier than in 1990, the study found, but just 0.3 percent healthier than last year. For the fourth year, Minnesota ranked as the healthiest state while Louisiana limped in at No. 50.