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