States made little progress in improving health care access, quality, and outcomes and lowering costs in the five years preceding implementation of the major coverage provisions of the Affordable Care Act (2007-2012), according to the Commonwealth Fund's third state health system scorecard. The majority of states declined or failed to improve on two-thirds of the 34 scorecard indicators that could be tracked over time.
Wide gaps among states persisted since the last scorecard, with top states sometimes performing two to eight times better than the lowest-performing states. For example, the rates of elderly receiving high-risk medications, children hospitalized for asthma, Medicare hospital readmissions, and potentially preventable deaths before age 75 were more than twice as high in states near the bottom of the scorecard compared to states with the best performance.
The report, Aiming Higher: Results from a Scorecard on State Health System Performance, 2014, ranks the health systems of every state and the District of Columbia based on 42 health care measures, 34 of which are used to reveal trends between 2007 and 2011-12. All states saw meaningful improvement on at least seven of the 34 trend measures. However, more than half of states lost ground on at least 9 indicators.
Indicators for which performance improved in a majority of states were often the targets of concerted federal and state efforts. Gains in safe prescribing for the elderly, reductions in avoidable hospital admissions and readmissions, higher childhood vaccination rates, and fewer cancer-related deaths chiefly resulted from greater attention being paid at both the national and state levels, including investment to promote better health outcomes.
For example, Vermont - which ranks near the top of the scorecard, along with Hawaii, Massachusetts, Minnesota, and New Hampshire - has been a national leader in guaranteeing access to care and investing in primary care. In these states, between 5 percent and 17 percent of working-age adults were uninsured in 2011-12. In contrast, the states at the bottom of the scorecard - Mississippi, Arkansas, Oklahoma, and Louisiana - had adult uninsured rates between 22 percent and 28 percent in 2011-12.
"This state scorecard underscores the importance of national and state actions to ensure that no matter where a person lives, they have access to an affordable, high-quality health system," said Commonwealth Fund Senior Vice President Cathy Schoen. "In the five years before the Affordable Care Act's major insurance expansions, access to health care declined and, too often, states declined or failed to improve, with only pockets of progress. Leading states raised the bar on some measures, and most states improved on key areas for the elderly. But the overall pace of change was slow and less than we should expect given how much we pay for health care."
Coverage and Access to Health Care Declined; Costs Were a Barrier to Care
According to the scorecard, in the five years before the Affordable Care Act's full implementation, uninsured rates for adults grew and health care became less affordable:
- In 2011-12, the uninsured rate for working-age adults ranged from a low of 5 percent in Massachusetts to 25 percent or more in Arkansas, California, Florida, Georgia, Louisiana, Montana, Nevada, New Mexico, Oklahoma, and Texas.
- Between 2007-08 and 2011-12 the uninsured rate for working-age adults rose from 19 percent to 21 percent nationally, increasing in 20 states.
- The percentage of adults going without health care because of costs increased in 42 states over the five years that included the Great Recession. By 2012, it ranged from a low of 9 percent in Hawaii, Massachusetts, and North Dakota to highs of 21 or 22 percent in Arkansas, Florida, Mississippi, South Carolina, and Texas.
- Sixteen percent of individuals under age 65 came from homes with high medical costs relative to their household incomes in 2011, ranging from 10 percent in Minnesota and the District of Columbia to 22 percent in Idaho and Utah.
"In the United States, where you live has long determined the kind of health care you receive, and it shouldn't," said Commonwealth Fund President David Blumenthal, M.D. "The Affordable Care Act has the potential to level the playing field, as all states have the opportunity to make substantial improvements to their health care systems if they take full advantage of the law, including Medicaid expansion."
Millions Would Benefit If All States Met Top Benchmarks
Substantial benefits would be seen across the country if all states elevated their performance and reached the benchmarks set by the leading states. For example, if all states could do as well as the top-performing states:
- More than 35 million children and adults would gain health insurance.
- An additional ten million older adults would receive preventive care, like cancer screenings.
- More than a million fewer Medicare enrollees would be exposed to an unsafe prescription drug.
- Some 84,000 fewer people would die prematurely each year from conditions that could have been prevented with timely and effective care.
The authors note that while improvements among low-performing states would have some of the most substantial effects, there is room for improvement across all states - even those at the top. That's because none of the best-performing states scored near the top on all 42 measures.
Additional State Scorecard Highlights
- Some states stood out for improving on multiple measures while declining on only a few: Colorado improved on 16 measures and declined on only six; Maryland improved on 14 and declined on four; New Hampshire improved on 15 and declined on six, and New York improved on 16 and declined on seven.
- Preventive care rates in a majority of states highlight the need to strengthen primary care: 30 states saw a decrease in the rate of older adults receiving recommended preventive care, such as screening for cancer. In 27 states, the percentage of children with a "medical home" that helps coordinate care fell.
- Improvement, but wide variation in high-risk medications for seniors seen: Nationally, fewer seniors with Medicare were prescribed high-risk medications. But rates varied from 12 percent in Massachusetts and Vermont to 29 percent in Alabama and Mississippi.
- Asthma hospitalization rate for children remains high in many states: The rate of hospitalization for children for asthma ranged from 26 per 100,000 in Vermont to more than 200 per 100,000 in New York and Louisiana.
- Medicare hospital 30-day readmission rates declined in a majority of states but rates vary widely: Just 26 per 1,000 beneficiaries in Hawaii and Idaho experienced 30-day readmission rates, compared to more than 60 per 1,000 in D.C., Kentucky, Michigan, and West Virginia.
- Mortality measures improved in many states: 44 had lower colon cancer death rates and 35 had lower breast cancer death rates.
- Preventable deaths rates varied widely: Twenty-five states improved on a key mortality measure - deaths before age 75 from conditions that could have been treated through early detection and high-quality care. But rates varied from a high of 136 preventable deaths per 100,000 in Mississippi to 57 per 100,000 in Minnesota.
- Racial and ethnic disparities in premature deaths persist: Rates of premature death remained higher among blacks than whites in all states, although the gap did narrow nationally between 2004 and 2009-10. However, wide gaps persist in some states: in Maryland, the premature death rate per 100,000 for whites was 76; for blacks, it was 149.
"The scorecard shows us that improvement is possible," said David Radley, Project Director for the Commonwealth Fund's Health System Scorecard Project at the Institute for Healthcare Improvement, and the report's lead author. "We hope to see progress accelerate and spread in the future. But for that to happen, states and local health care systems must make concerted efforts to set goals, aim to achieve them, and learn what works from one another."
The scorecard and an interactive map that allows users to download individual state profiles and compare states are available here.
A Viewpoint on the scorecard findings, "Opportunities to Aim Higher for State Health System Performance," is also published in the Journal of the American Medical Association.