(CNN) — A new report puts U.S. states’ health care systems on a scorecard, with Massachusetts coming out on top. But it also highlights alarming trends across the country, especially in areas like premature deaths and women’s health care.
Released Thursday, the Commonwealth Fund’s 2023 Scorecard on State Health System Performance uses federal health data from 2021 — the most recent available — to rank all 50 states and the District of Columbia on 58 measures of health outcomes, equity and affordability.
And for the first time, researchers from the independent research group measured performance on reproductive care and women’s health, including 12 measures to track prenatal and postpartum care access, reproductive cancer screenings and maternal mortality.
Three states top the 2023 rankings: Massachusetts, Hawaii and New Hampshire. Oklahoma, West Virginia and Mississippi bring up the bottom of the list, facing some of the nation’s most pressing health care concerns.
Illinois came in at No. 23.
The researchers found a surge in preventable deaths in every state, with Black and American Indian/Alaska Native (AIAN) people experiencing the highest mortality rates in many places. Researchers also noted that many Americans with mental health needs face barriers to obtaining the care they need, and millions of people — particularly in the South — struggle to pay off medical debt.
“Comparing states on how well their health care systems support people of all ages, races, ethnicities, and income levels is critical to our understanding of what is and isn’t working in American health care,” Sarah R. Collins, a co-author of the report and the Commonwealth Fund’s vice president for health care coverage and access, said in a statement. “It’s clear from these findings that people in every state desperately need better access to high-quality, affordable health care — especially women of reproductive age.”
Surges in avoidable, premature deaths
Every state had an increase in the premature death rate, defined as deaths before the age of 75 that ordinarily could be prevented by effective public health measures or timely, accessible health care.
Some states, however, did worse than others. Rates in Louisiana, Mississippi, Texas and New Mexico climbed over 35% from 2019 to 2021; Arizona’s rose 45%.
That spike was largely driven by COVID-19 deaths, the report says. The pandemic also contributed to heightened substance abuse and barriers to care for chronic but treatable diseases like diabetes and cancer. And there were major delays in routine checkups, which turned some ordinarily treatable diseases into fatal illnesses.
“Pandemic-era disruptions lead to people with chronic illnesses delaying or completely forgoing routine care and disease management activities, contributing further to the trends we see,” said David Radley, a senior scientist at the Commonwealth Fund.
In many states, Black and AIAN communities, two of the groups most affected by COVID-19, had some of the highest rates of premature mortality. Along with Hispanic Americans, those groups faced the largest declines in life expectancy, according to the report.
Beyond illnesses, gun violence took the lives of 48,830 people in 2021, and gun-related deaths increased 23% from 2019 to 2021, in part due to an increase in mass shootings and suicides.
The study also highlighted an increase in mental and behavioral health issues during the pandemic: In 2021, for the first time, combined deaths from drug overdoses, alcohol and suicide claimed more than 200,000 lives — an increase of 50,000 from 2019.
Despite the rise in mental health crises, the report found that 60% of adolescents who had a major depressive episode did not receive treatment. The same was true of 55% of adults facing mental illness: More than 40% found treatment too expensive.
Challenges to women’s health
The U.S. maternal mortality rate nearly doubled between 2018 and 2021, with COVID-19 as a “contributing factor” in more than 30% of maternal deaths, the report found. During the pandemic, maternal mortality increased the most for Black and AIAN women.
The death rate for AIAN mothers jumped by nearly 70 deaths per 100,000 live births — far more than that of any other racial or ethnic group. The study’s authors attribute this inequity to a number of causes, including poverty, food insecurity and disparities in insurance coverage.
And across the board, deaths from all causes among women of reproductive age (ages 15 to 44) jumped nearly 40% from 2019 to 2021. Maternal deaths helped drive that increase, but preventable deaths from COVID-19 and substance abuse also played a major role.
However, those “all-cause” death rates among women varied widely from state to state. West Virginia, for instance, had an all-cause death rate of 238.6 per 100,000 women, triple that of Hawaii (78.9 pe 100,000 women).
“It is disheartening to see the rising disparities in women’s health among states,” Laurie C. Zephyrin, a study co-author and the Commonwealth Fund’s senior vice president for advancing health equity, said in a statement.
“Now, our country’s fractured landscape of reproductive health access will only make it more difficult to close these widening gaps, especially for women of color and women with low incomes in states that have restricted access to reproductive care,” she said.
The report uses reproductive health data before the U.S. Supreme Court overturned Roe v. Wade in June 2022.
Since then, 26 states have imposed restrictions on abortion, including 12 of the 15 states ranked lowest in reproductive care and women’s health by the scorecard.
The researchers warn that continued restrictions could limit access to high-quality preventive health care, including contraception and reproductive cancer screenings, that could exacerbate disparities for women.
“Instead of limiting care, states should work to ensure that women have access to the full continuum of care throughout their lives,” Zephyrin said.
Health insurance coverage
With pandemic-era policies designed to expand coverage, the number of Americans covered by health insurance reached record highs in 2021.
Federal funding increased for Affordable Care Act marketplace enrollment, and several states expanded Medicaid eligibility between 2019 and 2021. As a result, uninsured rates dropped in all but seven states.
But as those policies begin to expire, the researchers warn that 15 million people may lose Medicaid coverage in the next year. About 6.2 million are at risk of becoming uninsured, with postpartum mothers and young adults aging out of the Children’s Health Insurance Program at the highest risk of losing coverage.
“Coverage expansions implemented in response to the pandemic, such as keeping people continuously enrolled in Medicaid … [have] helped many Americans who lost jobs or may otherwise become uninsured retain coverage,” said Jesse Baumgartner, a senior research associate at the Commonwealth Fund.
Despite national gains in insurance coverage, the report also found that millions of people are struggling to pay off debt from medical bills, particularly in the South. In West Virginia, nearly a quarter of residents are saddled with medical debt.
In total, according to the study, medical debt amounts to $88 billion nationwide.
‘We have to center equity’
The report also proposes a few key policy solutions designed to combat the alarming trends.
The authors pointed to increasing the primary care workforce as an option to reduce barriers to accessing health care while emphasizing policies that target racial disparities in health care outcomes.
“We truly have to center equity,” Zephyrin said. “When we when we design a healthcare system that focuses on people that are most marginalized, that improves health care delivery and outcomes for all.”
Other recommendations included states expanding their Medicaid coverage — especially in the Southeast — to ensure equitable access to health insurance, expanding postpartum Medicaid coverage to 12 months, and supporting “the continuum of reproductive and women’s health care,” Zephyrin said.
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