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Aiming Higher: Results from a Scorecard on State Health System Performance, 2014

Doctor explaining treatment plan

The Commonwealth Fund’s Scorecard on State Health System Performance, 2014, assesses states on 42 indicators of health care access, quality, costs, and outcomes over the 2007–2012 period, which includes the Great Recession and precedes the major coverage expansions of the Affordable Care Act. Changes in health system performance were mixed overall, with states making progress on some indicators while losing ground on others. In a few areas that were the focus of national and state attention—childhood immunizations, hospital readmissions, safe prescribing, and cancer deaths—there were widespread gains. But more often than not, states exhibited little or no improvement. Access to care deteriorated for adults, while costs increased. Persistent disparities in performance across and within states and evidence of poor care coordination highlight the importance of insurance expansions, health care delivery reforms, and payment changes in promoting a more equitable, high-quality health system.

The mixed performance of states’ health systems over the five years preceding implementation of the Affordable Care Act’s major reforms sends a clear message that states and the nation are still a long way from becoming places where everyone has access to high-quality, affordable care and an equal opportunity for a long and healthy life. In tracking 42 measures of health care access, quality, costs, and outcomes between 2007 and 2012 for the 50 states and the District of Columbia, The Commonwealth Fund’s Scorecard on State Health System Performance, 2014, finds that, on a significant majority of measures, the story is mostly one of stagnation or decline. In most parts of the country, performance worsened on nearly as many measures as it improved.


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On a positive note, the Scorecard also shows that combined national and state action has the potential to promote performance gains across the country. Yet the improvements uncovered in the Scorecard are not as widespread as Americans should expect, given the high level of resources the nation devotes to health care.

During the Scorecard’s time frame, a period that encompassed the Great Recession, health care spending rose $491 billion, reaching $2.8 trillion nationally according to government estimates.1 Spending increased in all states on both a per-capita basis and as a share of total state income. And still, the Scorecard points to deteriorating access to care for adults, stagnant or worsening performance on other key measures such as preventive care for adults, and widespread disparities in peoples’ health care experience across and within states. These findings together suggest that the return on our nation’s health care investment is falling woefully short.

The Scorecard also reminds us, however, that that improvement is possible with determined, coordinated efforts. The most pervasive gains in health system performance between 2007 and 2012 occurred when policymakers and health system leaders created programs, incentives, and collaborations to raise rates of children’s immunization, improve hospital quality, and lower hospital readmissions (Exhibit 1). These gains illustrate that state health system performance reflects a confluence of national policy and state and local initiatives that together can make a difference for state residents.

Like earlier scorecards in this series, the 2014 State Scorecard tracks and compares health care experiences across the states and recent trends in key areas of performance to help policymakers and health system leaders identify opportunities for improvement (Exhibit 2). In comparing the level of performance in each state to that in the top-performing states, it offers attainable benchmarks. Moreover, the Scorecard documents the trajectory of states’ health system performance in the years leading up to the Affordable Care Act’s major insurance coverage reforms, which will allow us to track in future editions how state and local policy and care system responses to health reform may alter this trajectory in the future. (See Scorecard Methodology for a detailed description of the Scorecard’s methods and performance indicators.)

Key Findings

In assessing change over the five years leading up to 2011–12, the Scorecard reveals persistent geographic disparity in the performance of state health care systems as well as variation in rates of change. These variations may partly reflect differences in state policies and funding of health care programs such as Medicaid, as well as in local norms and practices (Exhibits 3 and 4). Several themes stand out:

There were some improvements in state health system performance in recent years, but widespread gains remained the exception.

  • On two-thirds of the 34 Scorecard indicators for which longitudinal data exist, there was no meaningful improvement or decline in performance in most states. On nine of the 34, meaningful improvement occurred in a majority of the states (Exhibit 1).2 A few states (Colo., Md., N.H., and N.Y.) stand out for their net improvement across indicators.
  • Most states improved on indicators that have been the focus of national and state attention, including immunizations for children, safe prescribing of medications for the elderly, patient-centered care in the hospital, avoidable hospital admissions and readmissions, and cancer-related deaths.
  • Lower premature mortality rates, including lower rates of cancer-related death, suggest that improvements in medical care are contributing to better health outcomes. Fifteen states saw meaningful reductions on each of two measures of premature death (mortality amenable to health care and years of potential life lost), but even greater progress may be possible through health system improvement.
  • States lost ground in insurance coverage for adults and affordability of care. As a consequence, a greater number of adults in 42 states reported going without care because of its cost—a trend that likely reflects lingering effects of the 2007–2009 recession.
  • Health care spending continued to rise, but to a greater degree in the private market than in Medicare, which saw a historic moderation in spending.

Troubling disparities and gaps in care persisted for children and other vulnerable populations.

  • For children, changes in health system performance were mixed. There have been some promising gains in recent years, such as a lower rate of asthma hospitalizations. But troubling declines on other health care indicators, such as the proportion of children with a primary care “medical home,” emphasize the need for continued diligence to secure the health of future generations.
  • Disparities in health care and outcomes remained wide between vulnerable and more-advantaged groups within all states. While states made progress in reducing disparities in premature mortality and certain other key Scorecard indicators, disparities also widened for others, such as poor health-related quality of life.

Widespread geographic variations in health system performance persist, providing benchmarks and illustrating opportunities to do better.

  • There were two-to-eightfold gaps between leading and lagging states on multiple indicators of health care access, quality, prevention, costs, and outcomes (Exhibit 2).
  • Although the range between top- and bottom-performing states remained wide on most indicators, the gap narrowed for several of the key indicators on which there was also widespread state improvement—illustrating that lagging states can close the gap, even as top states improve.
  • The top-performing states—Minnesota, Massachusetts, New Hampshire, Vermont, and Hawaii—lead the nation across most dimensions of care, and have done so over time (Exhibits 3 and 4). Their consistently high performance may be the result of their willingness and wherewithal to address health system change with focused initiatives spanning the public and private sectors.
  • Opportunities for improvement abound. Even leading states did not perform consistently well—or consistently improve—across all performance indicators.

How National Policies Combined with State and Local Action Can Spur Better Performance

It is notable that those indicators in which more than half the states improved have been the focus of national as well as state policy and attention. Health care gains for Medicare beneficiaries in the quality and use of hospital care occurred in the majority of states, providing a platform for further state and local action. States can build on national policy—as they did by expanding children’s coverage through the federal–state Children’s Health Insurance Program—to influence health system performance in many ways, such as by promoting accountable care in Medicaid and value-based purchasing of coverage for state employees and by supporting collaboration among public and private stakeholders to consistently measure and improve care.

Looking Toward the Future

Findings from the Scorecard on State Health System Performance, 2014, signal both promise and caution for the future. Massachusetts’ experience with insurance coverage expansion suggests that cost-related barriers to care should ease for individuals and families who gain coverage under the Affordable Care Act.3 This increased access, in turn, should support broader improvements in quality of care and health status.4 

It is possible, however, that geographic disparities in performance will widen, and health care inequities within states worsen, if such health system reforms and innovations are not evenly spread across states. Throughout this report, we demonstrate that better access to care is associated with better primary and preventive care services and improved health outcomes. To the extent that some states take the lead in expanding health coverage—through Medicaid and high-quality private insurance choices in the new marketplaces—while other states lag, we may see a widening rather than a narrowing of health outcomes and quality of care. Conversely, if many states seize on new federal opportunities and flexibility for creative action and learn from each other, we could hope for accelerated gains in the years ahead.


The Commonwealth Fund’s Scorecard on State Health System Performance, 2014, evaluates 42 key indicators grouped into four dimensions (Exhibit 2):

  • Access and Affordability (six indicators): includes rates of insurance coverage for children and adults, as well as individuals’ out-of-pocket expenses for medical care and cost-related barriers to receiving care.
  • Prevention and Treatment (16 indicators): includes measures of receiving preventive care and the quality of care in ambulatory, hospital, and long-term care and postacute settings.
  • Potentially Avoidable Hospital Use and Cost (nine indicators, with one indicator, hospital admissions for ambulatory care–sensitive conditions, reported separately for two distinct age groups): includes indicators of hospital use that might have been reduced with timely and effective care and follow-up care, as well as estimates of per-person spending among Medicare beneficiaries and the cost of employer-sponsored insurance.
  • Healthy Lives (11 indicators): includes indicators that measure premature death and health risk behaviors.

In addition, the Equity dimension includes differences in performance associated with patients’ income level (nine indicators) or race or ethnicity (10 indicators) that span the four other dimensions of performance.

The following principles guided the development of the Scorecard:

Performance Metrics. The 42 performance metrics selected for this report span the health care system, representing important dimensions of care. Where possible, indicators align with those used in previous state scorecards. Since the 2009 Scorecard, several indicators have been dropped either because all states improved to the point where no meaningful variations existed or the data to construct the measures were no longer available. Several new indicators have been added, including measures of premature death, out-of-pocket spending on medical care relative to income, and potentially avoidable emergency department use.

Measuring Change over Time. We were able to construct a time series for 34 of 42 indicators. There was generally five years between a historical and current year data observation, though the starting and ending points, as well as total length of time, varied somewhat between indicators. We considered a change in an indicator’s value between the historical and current year data points to be meaningful if it was at least one half (0.5) of a standard deviation larger than the indictor’s combined distribution over the two time points—a common approach in social science research.

Data Sources. Indicators draw from publicly available data sources, including government-sponsored surveys, registries, publicly reported quality indicators, vital statistics, mortality data, and administrative databases. The most current data available were used in this report. Appendix B provides detail on the data sources and time frames.

Scoring and Ranking Methodology. The scoring method follows previous state scorecards. States are first ranked from best to worst on each of the 42 performance indicators. We averaged rankings for indicators within each dimension to determine a state’s dimension rank and then averaged dimension rankings to determine overall ranking. This approach gives each dimension equal weight, and within dimensions weights indicators equally. Ranking in the earlier period (i.e., revised 2009 data) was based on 34 of 42 indicators; if historical data were not available for a particular indicator, the most current year of data available was used as a substitute ensuring that ranks in each time period were based on the same number of indicators and as similar as possible.


1 National health expenditure data (Table 1):; State health expenditure data:

2 Changes in an indicator’s value between the historical and current year data points are considered to be meaningful if they were at least one half (0.5) of a standard deviation larger than the indicator’s distribution over the two time points. One indicator—hospitalizations for ambulatory care–sensitive conditions among Medicare beneficiaries—was measured for two age subpopulations: those ages 65 to 74, and those age 75 and older. We consider these a single measure for purposes of scoring and tallying state improvement counts. Refer to the Scorecard Methodology for additional information.

3 A. H. Pande, D. Ross-Degnan, A. M. Zaslavsky et al., “Effects of Healthcare Reforms on Coverage, Access, and Disparities: Quasi-Experimental Analysis of Evidence from Massachusetts,” American Journal of Preventive Medicine, July 2011 41(1):1–8.

4 P. J. van der Wees, A. M. Zaslavsky, and J. Z. Ayanian, “Improvements in Health Status After Massachusetts Health Care Reform,” Milbank Quarterly, Dec. 2013 91(4):663–89.

Publication Details



D. C. Radley, D. McCarthy, J. A. Lippa, S. L. Hayes, and C. Schoen, Aiming Higher: Results from a Scorecard on State Health System Performance, 2014, The Commonwealth Fund, May 2014.