Health Care in the Two Americas: Findings from the Scorecard on State Health System Performance for Low-Income Populations, 2013

September 18, 2013

Authors: Cathy Schoen, M.S., David C. Radley, Ph.D., M.P.H., Pamela Riley, M.D., M.P.H., Jacob A. Lippa, M.P.H., Julia Berenson, M.Sc., Cara Dermody, Anthony Shih, M.D., M.P.H.
Contact: Cathy Schoen, M.S., Senior Vice President for Policy, Research, and Evaluation, The Commonwealth Fund


Visit the U.S. Health System Data Center to compare states' health system performance.Low Income Scorecard Datacenter


Health insurance coverage expansions hold promise to begin closing gaps in primary care and prevention. Broader gains will require improvements to health care delivery and a greater focus on population health.
Our findings across states indicate that expanding insurance coverage will begin to close the income and geographic divide. In multiple states, insured low-income individuals report a similar rate of having a usual source of care and receiving recommended preventive care as high-income adults (Exhibit 3).

However, the care experiences of low-income Medicare beneficiaries, all of whom have insurance, show that there are additional opportunities to improve health system performance. For example, the Scorecard finds that one-third of all emergency department (ED) visits by low-income Medicare beneficiaries (i.e., those also receiving Medicaid) are potentially preventable with more accessible primary care. There is a more than twofold variation across states in the potentially avoidable ED use indicator. Efforts to improve health care delivery, particularly primary care, and public health could lower the need for emergency department visits and the risks of receiving an unsafe prescription drug, being admitted or readmitted to hospitals, and dying prematurely or having a disability.

Exhibit 3Also required are targeted approaches for pockets of health care need across the country, such as communities with high rates of potentially avoidable hospital admissions among low-income children with asthma and adults with chronic lung disease. Successful intervention in these health care “hot spots” will likely require a combination of enhanced primary care and collaboration with community, social, and public health resources. The same is true for combatting higher state rates of smoking, obesity, infant mortality, and premature death in vulnerable populations. Acting early to reduce risks to health from unsafe workplaces, homes, communities, or behaviors would result in a healthier overall population and reduce health care costs over time.

Potential gains from raising the bar and bridging the income divide.

 If health care access and care experiences among vulnerable populations in all states were to attain state benchmarks for higher-income or otherwise more-advantaged populations, we might see the following gains:

  • Over 30 million more low-income adults and children would have health insurance—reducing the number of uninsured by more than half.
  • About 34 million fewer low-income individuals would face high out-of-pocket medical costs relative to their annual income and about 21 million fewer low-income adults would go without needed care because of cost.
  • About 11 million additional low-income adults over age 50 would receive timely preventive care, including cancer screenings and immunizations.
  • 750,000 fewer low-income Medicare beneficiaries would receive an unsafe prescription drug.
  • There would be over 300,000 fewer readmissions within 30 days of hospital discharge among low-income Medicare beneficiaries.
  • Fewer people would die prematurely, resulting in about 6.8 million potential years of life to work and participate in communities, or 86,000 fewer deaths each year assuming average life expectancy.
  • 33,000 more infants born to mothers with a high school diploma or less would survive to see their first birthday.
  • Nearly 9 million fewer low-income adults under age 65 would lose six or more teeth because of tooth decay, infection, or gum disease.