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Press Release


Jun 12, 2019

State Health Care Scorecard Finds Deaths from Suicide, Alcohol, Drugs Are a Regional Epidemic; Impact Varies Widely Across States

States’ Progress in Expanding Health Care Coverage Stalls; Rising Health Costs a Growing Burden for Working Families

Hawaii, Massachusetts, Minnesota, Washington, Connecticut, and Vermont rank at the top of the Commonwealth Fund’s 2019 Scorecard on State Health System Performance. The scorecard assesses all 50 states and the District of Columbia on 47 health care measures, covering access, quality, service use and costs of care, health outcomes, and income-based health care disparities. Arkansas, Nevada, Texas, Oklahoma, and Mississippi rank at the bottom in the report.

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California had the largest jump in rankings, and Rhode Island improved on the most indicators that are tracked over time. Only Delaware, which fell 17 spots in the rankings, Hawaii, New Mexico, and Wyoming performed worse on more measures than they improved on over a five-year period.

Key findings from the scorecard, released today:

  • Deaths from suicide, alcohol, and drugs are a national crisis, but affect states in different ways. States are losing ground when it comes to deaths from suicide, alcohol, and drugs. A number of states in New England, the Mid-Atlantic region, and the Southeast have been hard-hit by the opioid epidemic. West Virginia had the highest rate of drug overdose deaths in 2017 (57.8 deaths per 100,000 residents) — more than double the national average. Ohio, with 46.3 drug-related deaths per 100,000 residents, had the second-highest rate.
    Montana, Nebraska, the Dakotas, Oregon, and Wyoming had higher rates of death from suicide and alcohol use than from drugs in 2017. The state differences show that approaches for combating these challenges must be tailored to local circumstances, the authors say.
  • States’ progress in expanding health care coverage and access since the Affordable Care Act (ACA) was enacted has stalled. Although nearly all states saw widespread reductions in their uninsured rates between 2013 and 2016, progress stalled after 2015. Between 2016 and 2017, more than half of states simply held on to earlier coverage gains among working-age adults. And 16 states, including those that have expanded Medicaid and those that have not, experienced one-percentage-point upticks in their adult uninsured rate.
  • Medicaid expansion is associated with lower uninsured rates and better access to care. For example, uninsured rates among adults ages 19 to 64 ranged from a low of 4 percent in Massachusetts — which expanded Medicaid and made coverage enhancements like offering extra subsidies — to a high of 24 percent in Texas, which did not expand Medicaid. Of the 17 states that have yet to expand Medicaid, five had the highest adult uninsured rate in 2017 in the U.S., ranging from 18 percent to 24 percent.
  • Health care costs are the primary driving force behind rising premiums, which are an increasing financial burden to working families in all states. Per-enrollee cost growth in employer plans grew at a faster pace than in Medicare from 2013 to 2016 in five of eight regions of the country and in 31 states. Across states, per-enrollee spending growth in employer plans was more variable than in Medicare.


From the Experts


“The gains made in people’s coverage and access to health care following enactment of the Affordable Care Act have stalled and even eroded in some states. There are a number of steps — including expanding Medicaid eligibility, enhancing subsidies, and changing the way providers are paid in private plans — that states and the federal government can take to improve access to care and lower costs.”
   — Sara R. Collins, study coauthor and Commonwealth Fund Vice President for Health Care Coverage and Access


“What we’re seeing is a regional epidemic when it comes to premature deaths from suicide, alcohol, and drugs. It’s going to take solutions that meet local need, and greater cooperation across all sectors — at both the federal and state level — to end the crisis that is shortening life expectancy in the United States.”
   — David Blumenthal, M.D., Commonwealth Fund President



Ultimately, national improvement in health system performance will require the involvement of both states and the federal government. The authors note that all states, in partnership with the federal government, have the ability to improve health care performance. In fact, many are already taking important steps by:

  • Expanding Medicaid eligibility with no restrictions. Currently, 33 states and the District of Columbia have implemented ACA-backed expansion of their Medicaid programs. Idaho, Nebraska, and Utah passed expansion ballot initiatives in November 2018, but lawmakers in all three states have taken steps to restrict the expansion. Fifteen states have either approved or pending waivers to impose work requirements as a condition of Medicaid coverage, which could further erode coverage gains by adults with low incomes.
  • Ensuring well-functioning individual insurance markets. The ACA’s reinsurance program, which protected insurers against unexpectedly high claims and helped to reduce marketplace premiums, expired in 2017. Seven states are now operating their own reinsurance programs to stabilize and strengthen their individual insurance market, and additional states are seeking federal approval to establish state-based reinsurance programs. However, without federal financing, some states may struggle to sustain these programs in the long term.
  • Mitigating premium and cost growth. Some states are developing public plan options offered through the marketplaces, which may help lower provider payment rates and premiums. Several congressional bills also propose such options. Other state and federal strategies for lowering spending include using “value-based purchasing,” changing the way prescription drugs are paid for, and promoting the use of electronic health information.

However, the authors stress that states can’t be successful alone. A strong federal partnership with all states will be critical to achieving and maintaining progress in the nation’s health system performance. This includes efforts to curb the opioid crisis by improving access, bolstered by Medicaid expansion, to life-saving opioid overdose–reversal medications like naloxone, and passing legislation that sets guidelines or limits for opioid prescriptions.

How This Study Was Conducted

The Commonwealth Fund’s 2019 Scorecard on State Health System Performance evaluates 47 health care indicators as well as income-based differences in performance within states. Findings are based on the authors’ analysis of the most recent publicly available data from federal agencies including the U.S. Census Bureau, Centers for Disease Control and Prevention, and the Centers for Medicare and Medicaid Services, as well as other data sources. For more detail, see “Scorecard Methods” in the report.

Publication Details


Jun 12, 2019


Bethanne Fox, Vice President, Outreach and Strategy, The Commonwealth Fund

[email protected]