Commonwealth Fund Report Shows Healthcare Differences Among the States

In the latest report detailing declining US life expectancy and growing health disparities between states, the Commonwealth Fund released a scorecard on Thursday that assessed all 50 states and the District of Columbia on more than 40 measures of access to healthcare, quality of care, efficiency in care delivery, health outcomes, and income-based healthcare disparities.

The report showed that states are falling behind on key measures related to life expectancy. On most other measures, performance continues to vary widely across states; even within individual states, large disparities are common.

However, the report found more improvement than decline between 2013 and 2016 in the functioning of state healthcare systems. This represents a bit of a reversal from the 2000s, when progress stalled.

Hawaii, Massachusetts, Minnesota, Vermont, and Utah were the top-ranked states according to the organization’s 2018 Scorecard on State Health System Performance. Mississippi, Oklahoma, Louisiana, Florida, and Arkansa rounded out the bottom. Northern states generally fared better than Southern states.

Last month, a JAMA study called for more action to address health disparities, risk factors, and social determinants of health, and said that the nation needs to focus more on disease prevention after releasing a similiar report.

Key findings in the Commonwealth report include:

Deaths of despair are rising

The combined rate of deaths from suicide, alcohol, and drug use—sometimes referred to as “deaths of despair”—soared 50% from 2005 to 2016. Rates rose in all states, but at least doubled in Delaware, New Hampshire, New York, Ohio, and West Virginia.

Premature deaths are rising

Sometimes called "deaths amenable to care," premature deaths started creeping upward after a period of decline. Two-thirds of states experienced an increase from 2014 to 2015. In Colorado, Maine, Nebraska, Oklahoma, Vermont, and Wyoming, the increase was greater than 5%.

Obesity is a rising public health threat

In West Virginia and Mississippi the proportion of obese adults hit 39%. States with the lowest rates still have 25% of their adult population suffering from obesity.

Gaps in mental health care are pervasive

Patients are going without treatment—up to 25% of adults and up to 30% of children.

Where you live matters

The highest-ranked state generally performed as much as 3 times better than the lowest-ranked one. But health disparities existed not only between states but within them.

States are not getting good value for what they spend

Examples included both too much low-value care and too little high-value care, including inappropriate back imaging tests and a failure to get the right cancer screenings.

States made progress in improvement targets

The adult uninsured rate fell by at least 5% in 47 states in the 3 years following the passage of the Affordable Care Act (ACA). Fewer adults skipped care because of costs. States with expanded Medicaid programs saw the biggest gains.

Nursing home care improved and home health patients gained mobility

The Commonwealth Fund said the change likely results from the National Partnership to Improve Dementia Care in Nursing Homes, which supports state-based coalitions in efforts to reduce inappropriate antipsychotic drug use and improve care for residents with dementia.

Tobacco use fell

Adult smoking rates fell by at least 3% in all but 4 states between 2011 and 2016.

Avoidable hospital use has fallen

Hospital readmission rates for elderly Medicare beneficiaries continued to fall in nearly half the states in between 2011 and 2015.

As with the JAMA study, the Commonwealth scorecard said there are steps states could take to improve public health. However, some of those efforts could be undermined by the repeal of the ACA’s individual mandate penalty and by regulatory changes to state insurance markets, such as the Trump administration’s approval of short-term health plans.

Although states can strengthen their individual insurance markets by moderating premium increases with methods such as reinsurance mechanisms, there are limits to what the health law can do, the Commonwealth Fund said. Insurance coverage is a necessary but not sufficient condition for improving healthcare and outcomes.

On specific health system indicators, states ranked lower overall performed better than higher-performing states. If every state achieved the performance of the top-ranked state on each individual indicator, the performance gains in healthcare access, quality, efficiency, and outcomes would be dramatic, the report said.

Some examples are:

• 26 million more adults with a usual source of care
• 18 million more adults/children with insurance
• 14 million fewer adults skipping care
• 11 million more adults receiving cancer screenings
• 5.7 million fewer nonemergency department visits
• 1 million fewer Medicare beneficiaries receiving high-risk prescription drugs