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May 29, 2018

The 5 best (and worst) states for health care, according to the Commonwealth Fund

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    The Commonwealth Fund recently released its 2018 Scorecard on State Health System performance, which ranked Hawaii as the top state health system in the United States.

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    Scorecard details

    The scorecard takes a comprehensive look at state health system performance trends between 2013 and 2016. The Commonwealth Fund examined states and the District of Columbia based on 43 measures across four categories:

    • Access and affordability, which consists of seven measures, including rates of insurance coverage and out-of-pocket expenses;
    • Prevention and treatment, which consists of 16 measures, including preventive care and quality data;
    • Potentially avoidable hospital use and cost, which consists of 10 measures, including "hospital and emergency department (ED) use that might be reduced with timely and effective care;" and
    • Healthy lives, which consists of 10 measures, including premature death and smoking rates.  

    State rankings

    The Commonwealth Fund used the scores to rank state health systems. The top 5 state health systems, according to the scorecard, were:

    1. Hawaii;
    2. Massachusetts;
    3. Minnesota;
    4. Vermont; and
    5. Utah.

    The lowest-ranked state health systems, according to the scorecard, were:

    1. Arkansas (tied);
    2. West Virginia (tied);
    3. Florida;
    4. Louisiana;
    5. Oklahoma; and
    6. Mississippi.

    Health care access and quality improve

    Overall, The Commonwealth Fund found state health care systems saw "more improvement than decline between 2013 and 2016," representing "a reversal of sorts from the first decade of the century, when stagnating or worsening performance was the norm."

    Some key highlights from the report include:

    • A widespread increase in health care access, particularly in states that expanded Medicaid;
    • A decline in the uninsured rate and adult smoking rates in nearly every state;
    • Fewer adults skipping needed care over cost concerns in more than half of states;
    • Increased care quality in nursing homes and home health care; and
    • Lower readmission rates among Medicare beneficiaries in about half of states.

    The Commonwealth Fund said several positive trends could be directly linked to state and federal policy interventions. For example, the researchers found a connection between the federal government's financial penalties on hospitals with high readmission rates and the reduction in hospital readmission rates among Medicaid beneficiaries.

    David Radley, a senior scientist at The Commonwealth Fund, attributed many of the gains to the Affordable Care Act (ACA), but warned the progress made is "at risk as premature deaths from treatable diseases and opioid overdoses rise across the country."

    National trends

    In addition to the overall rankings, The Commonwealth Fund identified four national trends based on the scorecard:

    • Gaps in mental health care are pervasive across states, with 41% to 66% of adults with mental health symptoms not receiving treatment between 2013 and 2015;
    • Premature death rates from preventable or treatable conditions increased in two-thirds of states from 2014 to 2015, reversing "a decade-long downward trend" and resulting in "more than 3,550 additional premature deaths;"
    • The combined death rate from alcohol, suicide, opioids, and other drugs—known collectively as "Deaths of Despair"—increased by 50% from 2005 to 2016, with all states seeing an increase; and
    • Obesity is a rising public health threat, with obesity rates in 2016 ranging from about 25% of residents in states with the lowest rates to 39% in Mississippi and West Virginia.

    The Commonwealth Fund CEO David Blumenthal said while the scorecard offers "good news about the direction we are heading, we do continue to see wide disparities between states." Blumenthal said, "Also of concern are some areas where we see no progress or even reversal of positive trends. For example, life expectancy has fallen, in large part due to the opioid epidemic; premature deaths from preventable or treatable causes are increasing in many states; and obesity rates continue to rise representing a public health crisis of grave concern."


    The Commonwealth Fund suggested a range of measures that states can take to improve their health systems, such as:

    • Encouraging secure and efficient methods for providers, insurers, and state programs to share electronic health information to drive quality improvement;
    • Ensuring U.S. regions, particularly underserved areas, have access to an adequate number of primary care providers;
    • Establishing rules to ensure insurance markets function well;
    • Expanding Medicaid eligibility under the ACA;
    • Supporting efforts to address the social determinants of health; and
    • Using value-based purchasing in state employee benefits programs and Medicaid (Rege, Becker's Hospital Review, 5/7; Brooks, Medscape, 5/3; Commonwealth Fund scorecard, accessed 5/8; The Commonwealth Fund release, 5/3).

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