ANALYSIS: New Report on Best and Worst States for Healthcare Misses Important Factors

The exterior of the Houston Methodist Hospital in Houston, Texas on June 9, 2021. (Brandon Bell/Getty Images)

Mississippi ranked the worst among the 50 states and Washington, for overall healthcare access, quality, services, costs, and outcomes, according to a new Commonwealth Fund Scorecard on State Health System Performance.

Oklahoma, West Virginia, Texas, and Arkansas rounded out the bottom five states, according to the 2023 report compiled by the nonprofit foundation. The report was released on June 22 and is based on the most recently available 2021 data.

The study evaluated state performance across five categories, including access and affordability, prevention and treatment, potentially avoidable hospital use and cost, healthy lives, and reproductive care and women’s health.

Massachusetts earned the top ranking for overall performance, followed by Hawaii, New Hampshire, Rhode Island, and Vermont.

Life Expectancy Fell

Life expectancy and access to health care declined significantly nationwide between 2019 and 2021. Every state experienced COVID-19 deaths, along with premature, avoidable deaths from suicide, drug overdoses, alcohol-induced, and some treatable chronic conditions.

“These premature deaths have lowered the nation’s average life expectancy, with people of color experiencing the steepest declines,” the report noted.

The pandemic exacerbated mental health and behavioral health issues for many Americans leading to the highest number of combined deaths from suicide, drug overdoses, and alcohol, claiming a record high of more than 200,000 lives in 2021, an increase of 50,000 avoidable deaths over 2019.

Arizona, Louisiana, Mississippi, New Mexico, and Texas saw a more than 35 percent spike in avoidable deaths between 2019 and 2021. And Arizona’s avoidable death rate jumped by the greatest percentage of 45 percent.

The average life expectancy at birth dropped from 78.7 years in 2018 to 77 years in 2020, according to the U.S. Centers for Disease Control and Prevention.

Wide Variances in Women’s Health Outcomes

A new category was added to the 2023 Scorecard—reproductive care and women’s health—which explored health outcomes for women, mothers, and infants. The results found wide variances in performance from state to state.

“Maternal death rates were as low as 9.6 per 100,000 live birth in California but higher than 40 deaths per live births in Arkansas, Alabama, Louisiana, Tennessee, and Mississippi,” the report said. “It’s important to note that California has made concerted efforts to address racial equity in maternal health over the past decade.”

Health Insurance Coverage

Massachusetts performed the best when it came to health insurance coverage and access to care, followed by Hawaii, Rhode Island, New Hampshire, and Washington, D.C.

“Temporary federal policies during the COVID-19 pandemic drove uninsured rates to record lows, with nearly all states realizing gains in health coverage. But some of those policies have ended, and high health costs still saddle millions of Americans with medical debt,” the report stated.

Meanwhile, Texas had the highest rate of uninsured adults, 24.3 percent, in the nation in 2021. Wyoming, Oklahoma, Georgia, Wyoming, and Mississippi, respectively, followed Texas for the most uninsured adults.

Comparing the Data

The Scorecard report presumes future declines in healthcare access and maternal outcome, citing abortion bans and restrictions “could also limit access to providers that offer important preventive health care like contraception and reproductive cancer screenings.”

“Maternal mortality and death related to substance abuse rose quickly among women of reproductive age during the pandemic — a particular concern given new state policies limiting reproductive care access,” the report stated, pointing to the Supreme Court’s overturning of Roe v. Wade in June 2022.

However, abortion was still available across the nation during the period reviewed but included the height of the COVID-19 pandemic leading many to delay or skip preventive care, general medical, and mental health visits.

The Commonwealth Fund report makes no mention of the high rates of missed medical and mental health visits, which would assumedly lead to higher rates of negative outcomes across all groups, including pregnant women. It also didn’t discuss how the lockdowns in many states led to the temporary or permanent closing of some medical facilities.

According to a study published in the Journal of the American Medical Association (JAMA) in January 2021, researchers found 41 percent of respondents reported forgoing medical care during the initial phase of the pandemic between March and July 2020. The sample of 1,337 adults nationwide was made up of 840 White individuals, 160 Black, and 223 Hispanics with an average age of 48 years.

Nearly 30 percent of those surveyed said they missed a preventive care visit during the three-month period, 26 percent said they skipped a general medical appointment, and eight percent missed a mental health appointment.

Respondents said they missed appointments for a variety of reasons, such as the temporary or permanent closing of the medical facility, fear of being exposed to COVID-19, and a small percentage blamed financial reasons caused by the pandemic.

Young adults under 35 were more likely to miss taking prescription medications compared to older adults over the same period. Twenty-two percent of respondents between the ages of 18 to 34 reported missing prescription medication vs. six percent of those 65 and older and 16 percent of respondents 35 to 49 years old, the survey showed.

The survey also found those who skipped medical care did not vary by sex, but it did find a larger percentage of Hispanics reported missing medications compared to White individuals.

The Prevent Cancer Foundation found similar results in its survey of missed doctor visits across an 18-month period in December 2020, May 2021, and January 2022.

Nearly two years into the pandemic, the number of skipped doctor appointments in January 2022 increased over the previous survey in May 2021, many also citing fear of exposure to the omicron variant of the coronavirus.

In January 2022, the survey showed approximately 39 percent of adults 55 and older missed appointments scheduled during the pandemic, up from 34 percent in May 2021 and 30 percent in December 2020

Still, young adults missed appointments at a higher rate than their older counterparts.

“[O]ne in two (50%) of adults ages 18-34 are significantly more likely to have not caught up on all missed appointments. (Compared to 36% in December 2020 and 45% in May 2021),” the U.S.-based nonprofit said in a news release.

The study found that minority groups were most likely to miss their appointments.

“There was a significant increase in the number of Native Americans who missed appointments as a result of the pandemic,” the report said, adding that 43 percent reported missing doctor visits in January 2022, jumping from 34 percent and 30 percent in the previous surveys, respectively.

“Out of all ethnicities surveyed, Hispanics (46%) were the most likely to miss a scheduled appointment.”

There was an improvement in one category, children’s health. The early 2022 survey found parents were “catching up” on their children’s vaccination schedules and missed appointments.

“One in five parents (20%) indicate one or more of their children have missed a scheduled vaccination due to the pandemic,” marking a decrease from 26 percent in May 2021, the release stated.

Expanding Postpartum Care to 12 Months

In recent years, Republican and Democrat lawmakers have recognized the high maternal mortality rate among women leading more states to pass legislative measures to extend Medicaid postpartum coverage from 60 days to 12 months.

More than 4 out of 10 births in the U.S. are covered by Medicaid, according to the CDC (pdf).

Many pregnancy-related deaths are preventable when mothers receive care during and after pregnancy. Mental health conditions, hemorrhage, heart conditions, infections, and thrombotic embolism account for the majority of pregnancy-related deaths.

In 2021, 1,205 women died from pregnancy-related causes, up from 861 deaths in 2020 and 754 in 2019, according to the CDC’s Maternal Mortality Rates report published in March 2023 (pdf).

Nationwide, Black women had a higher maternal death rate at 69.9 deaths per 100,000 live births compared to White women at 26.6 deaths per 100,000 live births in 2021.

This year, Montana, Mississippi, Missouri, South Dakota, Texas, Utah, Wyoming, and Alaska have joined dozens of states that have already implemented the Medicaid postpartum expansion plan in hopes of decreasing the number of pregnancy-related deaths.

Arkansas, Idaho, and Wisconsin failed to pass legislation to extend postpartum Medicaid coverage. Arkansas has the highest maternal mortality rate in the nation (pdf).