New York, NY, March 16, 2017—Two years after the Affordable Care Act’s (ACA) major coverage expansions, fewer Americans lacked health insurance in every state and people benefitted from better quality and safer health care, according to the Commonwealth Fund’s new state health system scorecard.
States that expanded Medicaid, such as Arkansas, California, Kentucky, and Washington made some of the biggest strides between 2013 and 2015 in covering people and ensuring they are able to get the care they need. Specifically, Aiming Higher: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition, finds that:
- The uninsured rate among low-income working-age adults dropped an average of 14.1 percentage points in states that expanded Medicaid, compared to 8.9 points in nonexpansion states.
- The percentage of low-income adults who said they went without care because of its cost dropped an average of 5.5 points in expansion states compared to 2.3 points in nonexpansion states. Likewise, the share who lacked a regular health care provider dropped an average of 2.7 points in expansion states, compared to 1.0 points in nonexpansion states.
- Kentucky, the state with the biggest decline in uninsured working-age adults, saw the share of adults who said they went without care because of costs drop by 7 percentage points—more than any other state. Arkansas and Oregon were close behind, each seeing a five-point drop.
- Some Medicaid expansion states saw gains beyond coverage. For example, California, which expanded Medicaid eligibility as soon as federal resources became available, improved on indicators that spanned all age groups and care settings, including a substantial decrease in 30-day hospital readmissions for Medicare beneficiaries. Washington, which also expanded Medicaid in January 2014, experienced substantial increases both in the share of adults and young children who were up-to-date on vaccines.
“The scorecard gives us a comprehensive picture of how states are doing on crucial aspects of health care, allowing us to see how things look now compared to the years before the major provisions of the Affordable Care Act were implemented,” said Commonwealth Fund President David Blumenthal, M.D. “It’s clear that states, especially those that have expanded Medicaid, have made substantial progress ensuring that their residents have health insurance, and millions are better able to get the health care they need since the law was passed. Any plan to repeal or amend the ACA must hold on to those gains.”
How States Rank
The Scorecard ranks the health care system in every state and the District of Columbia based on 44 indicators of health care access, quality, cost, and outcomes. In addition to the interactive digital report, an accompanying data center enables users to compare the performance of their state with that of other states.
Vermont is the top-ranked state overall, followed by Minnesota, Hawaii, Rhode Island, and Massachusetts. Lowest-ranked are Arkansas, Louisiana, Oklahoma, and Mississippi. California climbed the most in the rankings between 2013 and 2015, from 26th to 14th. Colorado, Kentucky, New York, and Washington also made big jumps. Kentucky improved on 21 scorecard indicators, more than any other state.
Efforts to Improve Patient Safety and Quality Are Paying Off
Improving health care quality and patient safety have been health care system priorities in recent years, and the scorecard finds that many states are doing better:
- Medicare beneficiaries in 46 states were less likely to be prescribed a high-risk medication that could be harmful to them in 2014 than in 2012.
- Deadly central line-associated bloodstream infections declined relative to a national benchmark in 20 states and the District of Columbia between 2013 and 2014. Among the remaining states, 21 saw no change and nine saw increases.
- The ACA’s program to reduce hospital readmissions among Medicare patients has resulted in lower readmission rates in 33 states and the District of Columbia. Kentucky, Illinois, and D.C., which had the highest rates to begin with, also saw the biggest drops, with reductions of 12 to 13 readmissions per every 1,000 Medicare beneficiaries between 2012 and 2014.
“This year’s scorecard demonstrates that when the federal government, states, and health care systems work together to make improvements, people’s health care gets better,” said David Radley, lead author and senior scientist at the Commonwealth Fund. “However, despite all of the gains we have seen, every single state has room to improve further. Our hope is that states will use the scorecard to see what is possible and learn what works from better-performing states.”
Areas for Concern
Despite the gains, the scorecard identified areas of concern:
- The rate of premature deaths before age 75 that could have been prevented by timely access to effective health care increased slightly in 30 states and the District of Columbia between 2011/12 and 2013/14, reversing a decade-long trend. This time period largely precedes the recent health insurance coverage expansions.
- There continued to be wide differences between states across all measures, with performance in the highest-ranked state on a given indicator three times better, on average, than that in the lowest-ranked state. These variations translate into very different experiences based on where people live. For example, in Utah, 9 percent of adults smoke, compared to 26 percent in Kentucky and West Virginia.
- Disparities in health care continue for people with low incomes and ethnic minorities and are most pronounced in low-ranked states. According to the report, 34 percent of low-income adults in Texas have skipped needed health care because of costs, compared with only 9 percent in Vermont. Twenty-six percent of African Americans in Oklahoma skipped care because of costs, compared with 10 percent in California.
With the ACA and its Medicaid expansion facing repeal and replacement, it is likely that states will take on more responsibility for creating and implementing health policy. According to the report, state improvement efforts could have real national impact. If all states could do as well as the top-ranked states:
- 20 million more adults and children would have health insurance.
- 500,000 more children would be up-to-date on all recommended vaccines by their third birthday.
- 12 million more adults would get age- and gender-appropriate cancer screenings.
- 26 million more adults would have a regular health care provider.
The Commonwealth Fund’s 2017 Scorecard on State Health System Performance includes 44 indicators grouped into four dimensions of performance: access and affordability, prevention/quality, avoidable hospital use and costs, and healthy lives; with a subset of measures stratified by income and race/ethnicity to assess equity. The analysis ranks states on each indicator within a dimension and averages the ranks for each dimension to produce an overall rank. For 39 performance indicators available over time, the report assesses change over two years, generally from 2013 to 2015, although time periods differ by indicator.