New 50-State Scorecard Exposes Missed Opportunities to Address Health Equity

Today The Commonwealth Fund released its annual scorecard on state health system performance. The report pulls together 49 indicators of health coverage, spending, quality and outcomes data to rank state health system performance. The accompanying state profiles provide additional context on the rankings, allowing states to get a comprehensive look at each state’s health care landscape in one place. Wide variation exists between states, not surprisingly given the importance of both federal and state actions. Across all domains, Hawaii, Massachusetts, Minnesota, Iowa and Connecticut lead the pack; West Virginia, Missouri, Nevada, Oklahoma and Mississippi trail at the bottom.

While there is a LOT of data for health policy wonks to unpack, the press release offers an important takeaway:

Americans are living shorter lives than they did in 2014, and Blacks are twice as likely as whites to die from treatable conditions. Black Americans, who also have suffered disproportionately during the COVID-19 pandemic, were twice as likely as whites to die early from treatable conditions such as diabetes, heart disease, appendicitis, and certain cancers. Several of these conditions are key risk factors for COVID-19. These disparities were found in every state.

As a growing number of cities, counties and states declare racism as its own public health crisis, this year’s scorecard offers additional state-level data on within-state racial and ethnic disparities that may inform policy or practice changes to address healthy disparities.

The report calls out federal and state policy decisions that not only put Affordable Coverage Act (ACA) coverage gains at risk, they also threaten to worsen persistent racial and ethnic inequities in coverage that had started to narrow after the ACA took effect. Many of these consequential decisions we know all too well: failure to take up the Medicaid expansion in the remaining 12 states and the recent stalling of health coverage gains aligned in part with federal ACA actions under this administration that have had the effect of reducing enrollment. As we have detailed, Medicaid coverage is a very important coverage source for children of color, for example.

The scorecard also details other important health system gaps that are impacted at least in part by access to health coverage—the price of admission to get needed care—and the broader health services infrastructure. Access to mental health care is one example.  At least 18% of children 3 and above did not receive needed mental health care, while 57% of adults with mental illness are not getting needed care.

State public health spending is a new and timely addition, as the COVID pandemic has shown what is at stake without a robust public health infrastructure. Most states remained flat in per capita public health spending, stretching public health dollars thin and forcing administrators to choose between critical public health investments like emergency preparedness, disease prevention or health promotion activities.

What is the ultimate impact of all of these missed opportunities?? The report estimates that if all states were able to meet the same performance rates as the top states (see Appendix B1 below), the nation would achieve, among other things:

  • 18 million more adults and children with health coverage (15 million more adults, 3 million more children)
  • 600,000+ more young children receiving recommended immunizations
  • 8 million more children with a medical home, or a regular source of primary care
  • 9 million more children accessing recommended annual medical and dental check-ups
  • 91,000 fewer deaths among adults under age 75 from treatable diseases

Of course, the available data compiled for this year’s scorecard represent years before any impact of COVID, so it places even more urgency on federal and state policymakers to consider ways to mitigate the likely exacerbated challenges in our health system. The data underscore the importance of strong leadership at all levels to ensure a health system that works for every American.

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