The Commonwealth Fund on Friday released its 2020 Scorecard on State Health System Performance, which ranks all 50 states and the District of Columbia on key measures of health care system effectiveness.

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Methodology

For the scorecard, researchers looked at 2018 data and some preliminary data from 2019—all of which pre-dated the Covid-19 pandemic—from all 50 states and the District of Columbia on 49 factors that affect health outcomes across four categories:

• Access and affordability, which includes seven indicators of insurance coverage, out-of-pocket expenses, and more;
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• Prevention and treatment, which includes 15 indicators of preventive care utilization, care quality in a variety of facilities, and more;
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• Potentially avoidable hospital use and cost, which includes 14 indicators of avoidable hospital and ED use, per-capita health care spending, and more; and
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• Healthy lives, which includes 13 indicators of premature death, obesity and smoking rates, and more.

This year, the report added two new measures: state-based public health spending, as well as primary care spending among Medicare beneficiaries and people with employer-sponsored coverage. In addition, the report includes data on racial and ethnic inequity for 10 of the 49 indicators spanning three of the four categories; however, this data is not used to calculate state rankings.

The best, worst state health systems

According to the report, the five states with the best-performing health systems in the country were:

1. Hawaii;
2. Massachusetts;
3. Minnesota;
4. Iowa; and
5. Connecticut.

Meanwhile, the five states with the worst-performing public health systems were:

51. Mississippi;
52. Oklahoma;
53. Nevada;
54. Missouri; and
55. West Virginia.

Key findings

Overall, the researchers found that Americans "are dying in greater numbers, and earlier than expected, from treatable conditions." According to the researchers, suicide and alcohol deaths rose slightly in 2018, but—for the first time in decades—deaths from drug overdoses decreased.

The researchers also found that Black Americans are twice as likely than white Americans to die from treatable conditions such as diabetes and heart disease—some of which also "are key risk factors for Covid-19." These disparities were found in all 50 states, the researchers added.

The researchers identified several other key trends:

• Gains in health care coverage have stalled since 2016, with insurance coverage becoming less affordable and out-of-pocket costs increasing relative to household income;
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• Prices paid by commercial insurers for inpatient hospital care were higher than Medicare prices in all 50 states—costs that, according to the researchers, often got passed along to employees via higher premiums and deductibles in employer-sponsored insurance; and
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• Per-capita health spending was flat, or increased minimally, between 2014-2015 and 2017-2018.

Discussion

While the scorecard relied on data from before the Covid-19 epidemic, it highlights "serious deficiencies in the U.S. health care system that have left the nation far less prepared than other wealthy nations to deal with the Covid-19 [epidemic]," the researchers said.

The researchers added that while it's too early to measure the specific effects of Covid-19, it's likely "the U.S. will see a further decline in life expectancies, especially for people of color, and an increase in deaths related to suicide, alcohol, and drug overdoses." Rising health care costs could also potentially "place a further strain on consumers who may have less income as a result of the severe economic contraction," they wrote.

Looking ahead, the researchers said the federal government will face two key challenges as it heads into the presidential election: "rebuilding an underperforming health care system" and "controlling the pandemic" (Ellison, Becker's Hospital Review, 9/11; Commonwealth Fund Scorecard, accessed 9/16; Commonwealth Fund report, accessed 9/16; Commonwealth Fund release, 9/11).