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Mirror, Mirror 2024 is your opportunity to explore the impact of policy choices on health and well-being across 10 countries, including the U.S. Read the report here.

Area of Focus

Achieving Universal Coverage

Scorecard

2025 Scorecard on State Health System Performance

Fragile Progress, Continuing Disparities

Authors
David C. Radley, Kristen Kolb, Sara R. Collins
Downloads
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Scorecard Highlights

  • Topping the 2025 Scorecard’s overall health system rankings are Massachusetts, Hawaii, New Hampshire, Rhode Island, and the District of Columbia, based on 50 measures of health care access and affordability, prevention and treatment, avoidable hospital use and costs, health outcomes and healthy behaviors, income disparity, and equity.
  • The lowest-ranked states are Mississippi, Texas, Oklahoma, Arkansas, and West Virginia.
  • Uninsured rates fell to record lows in all states by 2023, and differences in health coverage and access to care narrowed between states. These improvements were in all likelihood due to the Affordable Care Act’s coverage expansions, recent state expansions of Medicaid eligibility, and more affordable marketplace plan premiums.
  • The number of children receiving all doses of seven recommended early childhood vaccines fell in most states between 2019 and 2023. In five states, including Nebraska and Minnesota, the decline exceeded 10 percent.
  • The infant mortality rate (deaths within the first year of life) worsened in 20 states between 2018 and 2022, with considerable variation across states.
  • Premature, avoidable deaths vary considerably across states — the rate in West Virginia is more than twice as high as the rate in Massachusetts. Not only are avoidable mortality rates higher in the United States than in other high-income countries, but they are also on the rise, even as they fall elsewhere.
  • Wide racial disparities in premature deaths are the norm in most states. In 42 states and D.C., avoidable mortality for Black people is at least two times the rate for the group with the lowest rate.
  • When it comes to having affordable health coverage, good-quality care, and the opportunity to live a healthy life, where you live matters in the U.S. Targeted, coordinated federal and state policies are needed to raise health system performance across the nation.
Radley_2025_state_scorecard_Exhibit_01

 

 

Overview

Every year, the Commonwealth Fund’s Scorecard on State Health System Performance uses the most recent available data to assess how well the health care system is working for people in every state. This edition of the Scorecard includes 50 measures of health care access and affordability, prevention and treatment, avoidable hospital use and costs, health outcomes and healthy behaviors, and equity. (Learn more about the measures we use.)

By enabling states to see how they compare with their peers, we hope to inform and inspire action at the federal, state, and local levels to ensure all Americans have affordable access to high-quality health care and the opportunity to live a healthy life.

Leading our rankings for 2025 are Massachusetts, Hawaii, New Hampshire, Rhode Island, and the District of Columbia. These states outperformed others in health system performance overall. Still, even these states are not performing as well as other states in certain areas. Massachusetts, for example, ranks near the bottom on several measures of care for adults age 65 and older, including preventable hospitalizations and hospital readmissions.

The lowest-ranked states overall were Mississippi, Texas, Oklahoma, Arkansas, and West Virginia. But in specific areas, each of these states outperformed many of their peers. Mississippi, for example, ranks in the top quartile of state spending on primary care.

The 2025 edition of the Scorecard on State Health System Performance once again demonstrates that when it comes to having affordable health coverage, access to good-quality care, and the ability to lead a healthy life, where you live matters. In many cases, the wide variations in health and health care we see come down to the policy choices that state leaders make: for example, whether to expand Medicaid eligibility, whether to ensure women can access the full range of reproductive care services, or whether to boost investment in primary care.

But states cannot address these concerns on their own. Federal leadership and financial commitment are also critical. Medicaid is an example of how the federal government partners with states to respond to changing needs: for example, during a recession, federal funding rises at a time when state revenues typically decline. The Affordable Care Act’s marketplaces and insurance regulations offer another example. By establishing nationwide affordability standards, insurance subsidies, and rules prohibiting insurers from excluding coverage of preexisting conditions, the ACA leveled the playing field for Americans and narrowed wide state differences in coverage and access to care.

Similar federal and state efforts are needed to improve other areas of health system performance as well as to address the gaps in access and affordability that remain.

 

Key Scorecard Findings

Access and Affordability

Radley_2025_state_scorecard_Exhibit_02

In 2024, 44 million Americans were enrolled in the ACA’s health insurance coverage expansions: 21.4 million had coverage through a marketplace plan, 21.3 million were enrolled in Medicaid through the eligibility expansion, and 1.3 million were covered through the Basic Health Program that some states opted to provide.1 These expansions have led to historic declines in the uninsured rate across the country. The Medicaid expansion alone has saved an estimated 27,000 lives.2

Based on the latest available data, the uninsured rate for working-age adults fell from 20.4 percent in 2013 to 11 percent in 2023. The uninsured rate of the top performer, the District of Columbia, was down to just 3.4 percent for nonelderly adults. Still, too many Americans aren’t able to get the health care they need, and protection from the health expenses they might incur if they do get care, because they’re uninsured. In Texas, the worst-performing state on this measure, one in five nonelderly adults remained uninsured.

Radley_2025_state_scorecard_access_rankings

The states with high uninsured rates generally haven’t expanded Medicaid. In addition, millions of uninsured people are eligible for Medicaid, subsidies for marketplace plans, or employer health benefits but are not enrolled.

Recent policy developments, however, could lead to fewer people with health insurance in all states.3 These include proposed Medicaid enrollment requirements; potential reductions in marketplace premium tax credits, which helped more than double plan enrollment after they were made more generous in 2021; and recent regulatory and proposed legislative changes that will eliminate marketplace eligibility for many people and make it much harder for those who need health insurance to enroll in marketplace plans and keep their coverage over time.4

Why Do Uninsured Rates Vary So Much Across the U.S.?

People’s health insurance coverage is directly tied to the policy decisions their states have made, as well as decisions the federal government has made. The states with the lowest uninsured rates and the biggest improvement since 2013 are those that have fully implemented the Affordable Care Act, including its Medicaid eligibility expansion. Both Massachusetts and Hawaii also expanded health coverage prior to the ACA.

All states have the ability to expand eligibility for Medicaid, but 10 have not done so: Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming. States also have the choice of either running their own health insurance marketplace or letting their residents get covered through the federal online marketplace, HealthCare.gov. The marketplaces, which offer premium tax credits and cost-sharing subsidies to people with incomes above 100 percent of the federal poverty level ($15,060 for an individual and $31,200 for a family of four), have been a critical source of coverage for people in states that have not expanded Medicaid. In Texas, nearly 4.0 million people were enrolled in a marketplace plan by the end of this year’s open enrollment period.5 In Florida, 4.7 million had selected a plan.

About 1.4 million uninsured people in the 10 states that haven’t expanded Medicaid fall in the so-called coverage gap: they earn too little to be eligible for marketplace coverage but also are not eligible for their state’s existing Medicaid program, which is generally only for parents with very low income.6

When comparing states that neighbor one another, the impact of Medicaid expansion becomes very clear. In Kentucky, one of the first states to expand Medicaid eligibility, the uninsured rate for people with incomes under 200 percent of poverty ($30,120 for an individual and $62,400 for a family of four) fell by two-thirds between 2013 and 2023, from 38 percent to 12 percent.7 By contrast, in Tennessee, which has not expanded Medicaid, the uninsured rate for the same group of low-income adults declined by only one-third, from 37 percent to 24 percent.

States with larger numbers of residents without legal status, like Nevada and Texas, also have higher uninsured rates. This is because undocumented immigrants are not eligible for the ACA’s coverage expansions. About 5 million uninsured people in the U.S. are ineligible because of their immigration status.8

Radley_2025_state_scorecard_Exhibit_03

In 2023, 11.7 percent of U.S. adults did not get care because of cost, down from 15.9 percent in 2013. Improvement in this measure in nearly every state coincides with major drops in the uninsured rate. That’s because health insurance facilitates access to care and limits what people have to spend out of pocket on their care.9 By requiring most private health plans to cover certain preventive care without any cost sharing, the ACA made it easier for Americans to afford contraceptives, cancer screenings, and many other services. But pending litigation poses a major threat to free preventive care.10

In Texas, the state with the highest uninsured rate, more than 18 percent of adults reported going without care because of cost in 2023. The best-performing state on this measure, Hawaii, had a much lower rate, 6.7 percent, alongside a nonelderly adult uninsured rate of 3.9 percent.

Despite progress in making health care more affordable for people, challenges remain. People who have health coverage may still be underinsured, meaning their insurance doesn’t always enable them to access affordable care.11 Being underinsured also places people at risk of going into medical debt, even for emergency care.12

High premiums and deductibles also burden many middle-income households covered by employer-sponsored plans.13 For those with marketplace coverage, the potential loss of enhanced premium tax credits, which have helped drive enrollment to record highs, could increase the number of uninsured people by an estimated 4 million.14 Congress has yet to extend the tax credits at their higher level.

Under Threat: The Public Data Needed to Track Health System Performance

For two decades, the Commonwealth Fund’s health system scorecards have used public data to shine light on the state of U.S. health care. This endeavor requires performance measures sourced from federal surveys and data repositories to answer key questions about how well the health system is working, or not, for people in each state. The reports identify opportunities for improvement that can help people in every state access health care and live heathier lives.

But our scorecards, and similar efforts to assess the functioning of U.S. health care, face new challenges and an uncertain future. These include changes in the federal government, including a restructuring of the Department of Health and Human Services that shuffles programmatic responsibility and reduces staffing available to process and publish data, as well as the cancelation of key federal surveys and other data collection activities that threaten our nation’s public data infrastructure.

In these uncertain times, having reliable and complete public data could not be more critical.

 

Prevention and Treatment

Radley_2025_state_scorecard_Exhibit_04

In most states, the number of children who have received all doses of seven recommended early childhood vaccines is below 75 percent. To protect young children against serious illnesses like measles, polio, and tetanus, experts have long recommended they receive all doses of the combined seven-vaccine series. A handful of states, mostly in the Northeast, performed better than others on this measure. Massachusetts had the best rate, with about 90 percent of young children receiving all recommended doses in 2023; Montana had the lowest rate, around 60 percent (Appendix D1).

In some instances, children start the vaccine series but don’t receive all doses — sometimes because they lack health insurance coverage.15 Children living in poverty or in rural areas are less likely to complete the vaccination series, with access-related barriers and logistical challenges key contributors to their lower vaccination rates.16

Radley_2025_state_scorecard_prevention_rankings

High rates of vaccination are important for achieving herd immunity: when enough people are immune, disease spread can be limited, and people who can’t be vaccinated, like newborns and immunocompromised individuals, are better protected.17

A recent measles outbreak originating in Texas in January 2025 illustrates the importance of herd immunity.18 The disease has now spread to multiple states, infecting more than 1,000 children and adults, nearly all of whom are unvaccinated.19 There is no antiviral treatment for measles. Vaccination is the best method of protection, with the first dose of measles vaccine recommended for children between ages 12 and 15 months and a second dose between ages 4 and 6 years.20 For a highly contagious disease like measles, 95 percent of the population must be vaccinated to achieve herd immunity.21

Radley_2025_state_scorecard_Exhibit_05

Vaccination rates for the combined seven-vaccine series fell across most states between 2019 and 2023. In five states, the drop over this period exceeded 10 percent. Nebraska had the largest decrease, about 18 percent.

Vaccine hesitancy, a longstanding challenge in the U.S., worsened during the COVID-19 pandemic.22 This occurred despite the great success of previous vaccination efforts, including for measles, which in 2000 had been declared “eliminated” — defined as a lack of continuous disease spread — in the U.S.23 Also contributing to falling vaccination rates during the pandemic was the decline in well-child visits resulting from disruptions in care.24

Recent changes in recommendations from the federal government, including conflicting announcements about COVID-19 vaccinations for healthy children, pose an additional challenge to maintaining confidence in vaccines.25 COVID-19 vaccinations are no longer recommended for pregnant women on the Centers for Disease Control and Prevention’s adult immunization schedule despite evidence that pregnant women are at greater risk for severe complications from COVID-19.26

To maintain historical gains in the battle against infectious diseases and prevent further backsliding, clinicians and public health officials will need ongoing access to timely data about vaccination rates, better strategies to address families’ concerns, and clear messaging from federal, state, and local health agencies.27

Lifting Up Primary Care by Reforming Payment and Increasing Investment

Primary care is the foundation of a well-functioning health system. Having good primary care is associated with better health outcomes, fewer hospitalizations, and less frequent use of emergency departments.28

Despite strong evidence of its value, the U.S. doesn’t invest in primary care like other high-income nations do. Our primary care workforce has been shrinking as a result. Faced with increasing workloads, heavy administrative burdens, insurance restrictions, and lower compensation relative to specialist care, many clinicians are leaving primary care — and fewer medical school graduates are choosing to enter the field.29

More than 20 states are taking steps to address these challenges.30 For example, Oklahoma enacted legislation requiring Medicaid managed care programs to report how much they spend on primary care and to raise the share of total spending devoted to primary care from 5 percent to a targeted 11 percent over four years.31 In Virginia, a state task force tracked data on primary care investment and other primary care performance metrics and successfully advocated for $151 million in increased primary care spending within the state’s Medicaid program.32 Upon implementing its Patient Centered Primary Care Home program, Oregon found that a one-dollar increase in primary care spending was associated with $13 in savings for other health services, including emergency department use.33

The federal government has also taken steps to change how the U.S. pays for primary care. In 2023, the Centers for Medicare and Medicaid Services (CMS) announced that Making Care Primary (MCP) would be tested in eight states to help primary care practices shift away from a fee-for-service approach to a prospective, population-based one that ties physician payment to the quality of care provided rather than to just the volume of services rendered.34 The participating states are Colorado, Massachusetts, Minnesota, New Jersey, New Mexico, New York, North Carolina, and Washington.

In March 2025, however, CMS announced that the MCP model will end early — well before the 2034 target date — likely in response to the federal government’s cost-cutting imperative.35

 

Healthy Lives

Radley_2025_state_scorecard_Exhibit_06

The infant mortality rate, which indicates deaths occurring before one year of age, worsened in 20 states between 2018 and 2022. While infant deaths have generally declined over time, they increased between 2021 and 2022, and longstanding disparities between groups persist.36 The infant mortality rate for babies born to Black women in 2022 was 10.9, more than double the rate for babies born to white women (4.5).37 Disparities between states are considerable as well: in 2022, Massachusetts had a rate of 3.3 infant deaths per 1,000 live births; Mississippi’s rate was 9.1. Infant mortality rates in the U.S. are highest in rural counties.38

The leading causes of infant deaths in 2022 were congenital malformations, premature birth/low birth weight, sudden infant death syndrome (SIDS), accidents, and maternal complications of pregnancy.39

Radley_2025_state_scorecard_outcomes_rankings

What can help narrow the disparities we see in infant mortality? For one, timely prenatal care is important for healthy birth outcomes.40 So is parent or caregiver education about safe sleep practices that can reduce sleep-related infant deaths, the number of which rose between 2020 and 2022.41 (In a worrisome move, federal funding was recently cut for a longstanding National Institutes of Health campaign to educate parents and caregivers about safe sleep practices.42)

Expanding access to community-based models of maternity care, like group prenatal care and doula services, may also help improve outcomes for mothers and infants.43 Finally, ensuring that families have good health coverage is critical for addressing preconception health risks: states that have expanded Medicaid eligibility have seen greater reductions in infant mortality than states that have not.44

Maternal mortality also worsened between 2018 and 2022.45 Some of the increase in deaths can be attributed to the COVID-19 pandemic.46 Pregnancy-related deaths vary widely across states, with Alabama’s rate three times higher than California’s.47 More than half of maternal deaths occur following birth, emphasizing the importance of ongoing care during the postpartum period.48

Threatened access to reproductive and maternal health care may further worsen infant mortality and sharpen current disparities between states. Following the overturning of Roe v. Wade, which eliminated the constitutional right to abortion as of June 2022, there is evidence that ob/gyns and medical trainees are avoiding or leaving states with restrictive abortion policies in place, making it harder for women in those states to get the reproductive health care they need.49 A recent study found higher-than-expected infant mortality in 14 states after they implemented restrictive abortion policies.50

A further threat lies in uncertainty over the availability of information needed to monitor and address trends in infant and maternal mortality, including a key federal survey that collects data about maternal and infant health.51

Radley_2025_state_scorecard_Exhibit_07

Premature deaths from avoidable causes are common in the U.S., with rates highly variable across states. Not only are deaths from avoidable causes more common in the U.S. than in other high-income countries, but rates have been increasing in the U.S. while decreasing in peer countries.52 Avoidable mortality is a measure of deaths before age 75 from certain infections, injuries, and illnesses, including diabetes and certain cancers, that are generally considered to be avoidable through strong primary and preventive care, early disease detection, and effective care management and treatment. (See Scorecard Methods for additional detail on preventable and treatable conditions.) High mortality from these causes points to health system deficiencies that are highly correlated with lower life expectancy.53

In 2023, there were 278 premature avoidable deaths for every 100,000 people under age 75. Rates were highly variable across states, ranging from 201 per 100,000 in Massachusetts to 445 per 100,000 in West Virginia — a more than twofold difference.

Radley_2025_state_scorecard_Exhibit_08

Historically, Black Americans have been more likely to die early from avoidable causes compared to other groups.54 This held true in 2023: in every state, Black people had higher rates of avoidable death than people from other racial and ethnic groups.

Racial disparities in avoidable deaths are modest in some states: for example, the gap in Hawaii is about 20 percent. In 42 states and D.C., however, Black people are at least twice as likely to die early from avoidable causes than members of the racial and ethnic group with the lowest rate; in 32 states and D.C., they are at least three times as likely. These deeply rooted racial disparities are linked to health-related social challenges, lower rates of insurance coverage, and a history of racially discriminatory state and federal policies.55

Radley_2025_state_scorecard_Exhibit_09

Drug overdose deaths are down slightly in recent years but still well above historical norms. Drug overdose is among the most visible causes of avoidable mortality in recent years. Rates surged between 2019 and 2022, a period encompassing the COVID-19 pandemic and the growing prevalence of high-potency synthetic opioids. By 2023, the total number of drug overdose deaths had fallen for the first time since 2018, and overdose rates had nearly returned to prepandemic levels in many states. Between 2022 and 2023, overdose deaths fell in 37 states and the District of Columbia. In Nebraska and North Carolina, drug overdose mortality dropped by approximately 20 percent. Yet drug mortality rose significantly in certain states: Nevada, Oregon, Washington, and Alaska all saw drug overdose deaths spike by 25 percent or more.

While falling overdose deaths are a welcome development, the decline could be short lived. In 2022, 77 percent of adults with substance use disorder were not receiving treatment, which research shows is critical for reducing overdose deaths (Appendix D1). That rate may rise with the reduced footprint of the Substance Abuse and Mental Health Services Administration — a casualty of the Trump administration’s restructuring of the Department of Health and Human Services — and the loss of roughly $11 billion in grants that had been supporting state and local substance use treatment programs.56

What States Are Doing About Drug Overdose Deaths

While the national number of drug overdose deaths remains high — more than 100,000 deaths annually — the decrease in deaths observed between 2022 and 2023 is a sign that intervention efforts may be helping to turn the tide. Rates of drug overdose deaths, however, vary considerably across states. Maine has struggled in this area, ranking 43rd in overdose deaths in 2023 (Appendix F1). But the state experienced a 17 percent drop in such deaths between 2022 and 2023, one of the largest decreases in the U.S.

Maine’s opioid response plan features a multipronged approach involving prevention, harm reduction, and treatment for substance use disorder.57 Harm-reduction strategies, like the distribution of naloxone (an opioid-reversal medication) or fentanyl testing strips (to detect the potent synthetic opioid implicated in many deaths), can help reduce overdose deaths.58 Maine boosted funding for substance use disorder treatment programs, including treatment with medications like buprenorphine. The 2019 expansion of Maine’s Medicaid program, MaineCare, has also helped more people access treatment.

Under Maine’s OPTIONS program (Overdose Prevention Through Intensive Outreach, Naloxone, and Safety), behavioral health liaisons operating in the state’s 16 counties help connect residents with prevention, harm reduction, treatment, and recovery resources.59 First responders carry naloxone and are authorized to distribute naloxone kits when responding to calls for overdoses.60 And the online Maine Drug Data Hub makes detailed data available on drug overdose and substance use metrics in the state.61

Despite progress, the U.S. needs to continue to do better. Maine’s interventions show how other states can take a comprehensive approach to addressing drug overdose deaths in their communities.

 

How the U.S. Can Address Its Health Challenges

The 2025 Scorecard on State Health System Performance reveals the considerable geographic variations in Americans’ health insurance coverage, access to care, health outcomes, and ability to live a long and healthy life. The U.S. lags other economically advanced countries in most of these areas. This means that some states not only perform worse than other states, but they are even further behind many countries.62

We can and must do better.

When it comes to enacting large-scale reform, history shows that states cannot be expected to go it alone. They require federal leadership, commitment, and financial support. In the absence of a strong federal role, health outcomes and quality of care will worsen and disparities will grow, leaving Americans in states with fewer resources even further behind.63

Here’s what we as a nation can do to improve health and health care for everyone.

Health Care Access and Affordability

The importance of good health insurance coverage cannot be overstated. People who are uninsured get far less needed care and lead sicker, less productive, and shorter lives.64 A recent report found that the ACA’s Medicaid expansion significantly reduced mortality among adults with low incomes, saving an estimated 27,000 lives.65 We as a nation have a number of options to get more people insured and to improve health plans’ coverage and affordability.

Employer coverage. More than 160 million Americans get health insurance through a job, but this coverage is increasingly unaffordable for working-class individuals and families. Many plans also have high deductibles and other cost sharing. To help, more employers could adjust premiums and cost sharing based on their employees’ income. In 2022, just 10 percent of firms with 200 or more employees reduced premium contributions for lower-wage workers; only 5 percent had similar policies in place to reduce cost sharing.66

Medicaid. Medicaid covers more than 72 million people, from infants to older adults in nursing homes.67 Of those, more than 21 million people in 40 states and D.C. are enrolled because of the ACA’s eligibility expansion. This coverage is now at risk. Congressional Republicans are proposing to impose work requirements and substantially increase eligibility verification requirements for adults who are covered in this expansion, which could cause at least 7.8 million people to become uninsured.68

People wouldn’t lose their Medicaid coverage because they aren’t working, however: most Medicaid beneficiaries already have jobs. Others would be exempt from work requirements due to disability or other factors. But people would be dropped from the program because of the known difficulties associated with submitting documentation, filing paperwork, and securing internet access.

To improve Medicaid, policymakers could instead ease enrollment barriers for eligible people and fill the Medicaid coverage gap, which affects low-income people who don’t qualify for either their state’s Medicaid program or subsidized marketplace coverage.

Marketplaces and insurance market reforms. More than 21 million people have health insurance through the ACA marketplaces. As with Medicaid, this coverage is also at risk. First, Congress has yet to extend the extra tax credits set to expire at the end of this year; failing to do so could cause a spike in consumers’ annual premium costs of $387 to $2,914, depending on income.69 Second, the Trump administration has proposed regulatory changes that will likely increase insurance premium costs and out-of-pocket costs for care, in addition to making enrollment significantly more difficult. Congressional Republicans are proposing to codify the rule in their budget bill and make several additional changes that will make it harder for people to get and maintain marketplace coverage. The Congressional Budget Office estimates that these changes, along with the loss of the extra premium tax credits, will cause more than 8 million people to become uninsured by 2034.70

To preserve the affordability of marketplace plans and prevent potentially millions from losing their coverage next year, Congress and the administration could extend the premium tax credits and avoid erecting new enrollment and cost barriers.

Medical debt. An estimated 30 percent of working-age adults have medical debt.71 It’s a chronic problem for those who lack coverage as well as those who are enrolled in plans but are underinsured. To help solve the crisis, the Trump administration could let stand a new federal rule finalized in January that bans credit rating agencies from including most medical debt on most consumers’ credit reports.72 States also could strengthen enforcement of legislation to ensure patients have access to hospital financial assistance programs and ban aggressive collection activities.73 Other states could look to North Carolina’s innovative debt relief program as a model.74

Real relief for U.S. consumers, however, will come only when policymakers and the health care industry address the core drivers of medical debt: the rapid growth in health care costs and many health plans’ high patient cost-sharing requirements.

Prevention and Treatment

Increase accountability of health care systems. Federal policymakers could uncouple health care providers’ compensation from the volume of services they provide and instead tie payment to the quality of care they deliver to patients. Switching to a prospective payments system that incentivizes care quality and health outcomes would help make for a more equitable health care system across racial and ethnic groups, income levels, and geographic regions.75

Strengthen primary care. Primary care providers play a key role in coordinating their patients’ care, screening for illness, managing behavioral health concerns, and managing treatment for chronic disease.76 Federal and state policymakers and stakeholders can strengthen primary care by turning to tech-enabled, team-based approaches to care and expanding the workforce.

Address vaccine hesitancy. To control infectious disease spread, clinicians and public health officials will need ongoing access to timely data about vaccination rates, strategies to communicate with families about their concerns, and clear messages from leading health agencies on the importance of vaccinations.77

Avoidable Mortality and Healthy Behavior

Improve and expand reproductive health care. Federal and state policymakers and stakeholders can promote policies, innovative payment models, and digital tools that support the full range of reproductive health care services — from family planning and abortion services to maternity, postpartum, and well-woman care.78

Increase access to addiction care. Federal policymakers could codify regulatory changes made during the pandemic that gave providers and patients more flexibility to administer effective opioid addiction treatments.79 Some states are also taking action to remove administrative barriers.80 States can support and work with local jurisdictions to implement effective harm-reduction policies and programs, such as increased access to naloxone, supplies for safe drug use, and supervised consumption sites.81

Support the development of a national public health system. To counteract falling vaccination rates, rising infant and maternal mortality, and continued high rates of drug overdoses, the need for a strong public health system is more urgent than ever. The federal government should work to achieve a truly national public health system by leading coordination efforts across state, local, tribal, and territorial health departments, provide sufficient and reliable funding to support the public health workforce and infrastructure, prioritize tracking and sharing crucial health data, and more closely integrate public health agencies with health care delivery.82

Maintain a strong federal health data collection and reporting infrastructure. Recent deep reductions in the federal workforce and agencies dedicated to health are threatening the ability of the United States to maintain the data infrastructure and analytic capacity to track, understand, and rectify poor health system performance across the country. It is critical that the Department of Health and Human Services maintain the robust and reliable data that clinicians, health system leaders, state and federal policymakers, and the public have long relied on to keep all of us healthy.

Radley_2025_state_scorecard_overall_rankings
SCORECARD METHODS

The Commonwealth Fund’s 2025 Scorecard on State Health System Performance evaluates states and the District of Columbia on 50 performance indicators grouped into four dimensions.

The report generally reflects data from 2023.

Access and Affordability (8 indicators): includes rates of insurance coverage for children and adults, as well as individuals’ out-of-pocket expenses for health insurance and medical care, cost-related barriers to receiving care, rates of medical debt, and receipt of dental visits.

Prevention and Treatment (16 indicators): includes measures of receipt of preventive care (including COVID-19 booster vaccines) and mental health care, as well as measures of quality in ambulatory, hospital, postacute, and long-term care settings.

Potentially Avoidable Hospital Use and Cost (12 indicators; including several measures reported separately for distinct age groups): includes indicators of hospital and emergency department use that might be reduced with timely and effective care and follow-up care, successful discharges for skilled nursing home patients, estimates of per-person spending among Medicare beneficiaries and working-age adults with employer-sponsored insurance, and the share of Medicare and employer-sponsored insurance spending directed toward primary care.

Healthy Lives (14 indicators): includes measures of premature death from preventable and treatable causes, deaths from breast and colorectal cancer, deaths from drug overdose, suicide, alcohol, and firearms, infant mortality, health status, health risk behaviors and factors (including smoking and obesity), and tooth loss.

INCOME DISPARITY DIMENSION

This year, the State Scorecard reports on performance differences within states associated with individuals’ income level for 19 of the 50 indicators where data are available to support a population analysis by income; these indicators span the four dimensions. For most indicators, we measure the difference between rates for a state’s low-income population (generally under 200% of the federal poverty level) and higher-income population (generally more than 400% of the federal poverty level). For elderly adult indicators built from Medicare claims (e.g., potentially avoidable emergency department visits age 65 and older), we measure the difference between beneficiaries who are dually eligible for Medicaid and those who are not. States are ranked on the magnitude of the resulting disparities in performance.

The income disparity indicators are different than those used in previous versions of this scorecard; hence, these disparity rankings are not strictly comparable to those published previously. For some indicators, we combined multiple years of data to ensure adequate sample sizes for stratified analysis.

RACIAL HEALTH EQUITY DIMENSION

As in 2023, the State Scorecard ranks states based on racial and ethnic health equity. To do this, the report uses updated data metrics and employs the same scoring method used in the Commonwealth Fund April 2024 report, Advancing Racial Equity in U.S. Health Care: The Commonwealth Fund 2024 State Health Disparities Report, to produce summary state health system performance scores for each of four racial and ethnic groups.

That report and method aggregates data on 25 performance indicators (reflecting health outcomes, health care access, and health care quality), stratified by race and ethnicity for Black (non-Hispanic), white (non-Hispanic), Hispanic or Latino (any race), American Indian/Alaska Native (AIAN, non-Hispanic), and Asian American, Pacific Islander, and Native Hawaiian (AANHPI, non-Hispanic) populations.

Each population group in each state receives a percentile score from 1 (worst) to 100 (best) reflecting the state’s overall health system performance for that group relative to all other population groups in all states. This enables comparisons within and across states. For example, a state health system score of 45 for Hispanic or Latino individuals in California indicates that the health system is performing better for those residents than Hispanic or Latino people in Texas, who have a score of 6, but worse than white residents in California, who have a score of 87.

The updated overall percentile scores for AIAN, AANHPI, Black, and Hispanic or Latino people are used in this year’s State Scorecard to reflect each states’ performance for non-white racial and ethnic groups. States were evaluated and ranked on their health system performance for each of the four groups separately (contingent on data availability), and those scores were then combined for the state’s final overall composite score. Summary scores for each group can be found in Appendix H. State health system performance scores for white residents are included in the appendix for comparative purposes.

We also include performance data for each of the 25 metrics used in that equity report — updated to the most current year — in each state’s 2025 State Scorecard profile.

GUIDING PRINCIPLES

The following principles guided the development of the State Scorecard:

Performance Metrics. The 50 metrics selected for this report span health care system performance, representing important dimensions and measurable aspects of care delivery and population health. Where possible, indicators align with those used in previous scorecards. Several indicators used in previous versions of the State Scorecard have been dropped either because all states improved to the point where no meaningful variations existed (for example, measures that assessed hospitals on processes of care) or the data to construct the measures were no longer available (for example, adults with any mental illness who did not receive treatment). New indicators have been added to the State Scorecard series over time in response to evolving public health threats or data availability (e.g., measures of substance use disorder treatment and firearm deaths).

Measuring Change over Time. We were able to track performance over time for 45 of the 50 indicators. Not all indicators could be trended because of changes in the underlying data or measure definitions, and some reflect newly collected data (e.g., substance use disorder treatment).

For indicators where trends were possible, the baseline period generally reflects five years prior to the time of observation for the latest year of data available (often 2019). See Appendix A1 for baseline and current data years used in the report.

We considered a change in an indicator’s value between the baseline and current-year data points to be meaningful if it was at least one-half (0.5) of a standard deviation larger than the indicator’s combined distribution over the two time points — a common approach used in social science research. We did not formally evaluate change over time for indicators in the income or racial equity dimensions.

Data Sources. Indicators generally 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 whenever possible. Appendix A1 provides detail on the data sources and time frames.

Scoring and Ranking Methodology. For each indicator, a state’s standardized z-score is calculated by subtracting the 51-state average (including the District of Columbia as if it were a state) from the state’s observed rate, and then dividing by the standard deviation of all observed state rates. States’ standardized z-scores are averaged across all indicators within the performance dimension, and dimension scores are averaged into an overall score. Ranks are assigned based on the overall score. This approach gives each dimension equal weight and, within each dimension, it weights all indicators equally. This method accommodates the different scales used across State Scorecard indicators (for example, percentages, dollars, and population-based rates).

Several of the indicators in the Healthy Lives dimension are also nested in the definition of preventable and treatable deaths. We made an adjustment in our ranking method to account for this to avoid double-counting mortality from certain causes (e.g., deaths from breast cancer). Note that this adjustment is only reflected in the ranked values for preventable and treatable mortality; the values reported in charts and the report appendix are unadjusted.

As in previous scorecards, if historical data were not available for a particular indicator in the baseline period, the current-year data point was used as a substitute, thus ensuring that ranks in each time period were based on the same number of indicators.

REGIONAL COMPARISONS

The State Scorecard groups states into the eight regions used by the Bureau of Economic Analysis to measure and compare economic activity. The regions are: Great Lakes (Illinois, Indiana, Michigan, Ohio, Wisconsin); Mid-Atlantic (Delaware, District of Columbia, Maryland, New Jersey, New York, Pennsylvania); New England (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont); Plains (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota); Rocky Mountain (Colorado, Idaho, Montana, Utah, Wyoming); Southeast (Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, West Virginia); Southwest (Arizona, New Mexico, Oklahoma, Texas); and West (Alaska, California, Hawaii, Nevada, Oregon, Washington).

ACKNOWLEDGMENTS

We owe our sincere appreciation to all the researchers who developed indicators and conducted data analyses for this scorecard. These include: Michael E. Chernew and Andrew Hicks, Department of Health Care Policy, Harvard Medical School; Sherry Glied and Dong Ding, New York University Robert F. Wagner Graduate School of Public Service; and Caitlin Burbank, Gulcan Cil, and Shreya Roy from the Center for Evidence-based Policy at Oregon Health & Science University. We acknowledge Mental Health America for data reported in The State of Mental Health in America; and the Urban Institute for data reported in Debt in America.

We would like to thank the following Commonwealth Fund staff members: Joseph Betancourt, Tony Shih, Arnav Shah, and Neil Powe for providing constructive feedback and guidance; Celli Horstman for providing research assistance; and the Fund’s communications and support teams, including Barry Scholl, Chris Hollander, Bethanne Fox, Samantha Chase, Deborah Lorber, Josh Tallman, Jen Wilson, Paul Frame, Naomi Leibowitz, Aishu Balaji, Avni Gupta, Carson Richards, Arnav Shah, Sara Federman, Paige Huffman, Faith Leonard, Claire Coen, and Celli Horstman for their guidance, editorial and production support, and public dissemination efforts.

Finally, the authors wish to acknowledge Maya Brod of Burness for her assistance with media outreach, and the Center for Evidence-based Policy at Oregon Health & Science University for its support of the research unit, which enabled the analysis and development of the scorecard report.

NOTES
  1. Jennifer Tolbert et al., A Look at ACA Coverage Through the Marketplaces and Medicaid Expansion Ahead of Potential Policy Changes (KFF, Jan. 2025). ↩
  2. Angela Wyse and Bruce D. Meyer, Saved by Medicaid: New Evidence on Health Insurance and Mortality from the Universe of Low-Income Adults, NBER Working Paper No. 33719 (National Bureau of Economic Research, Apr. 2025). ↩
  3. Carson Richards and Sara R. Collins, “Enhanced Premium Tax Credits for ACA Health Plans: Who They Help, and Who Gets Hurt If They’re Not Extended“ (explainer), Commonwealth Fund, Feb. 18, 2025; Rachel Swindle, Jalisa Clark, and Justin Giovannelli, “New Administration Plans to Reinstate Cuts to Funding for ACA Outreach and Enrollment Assistance,” To the Point (blog), Commonwealth Fund, Mar. 27, 2025; Sabrina Corlette and Rachel Swindle, “A New Rule to Limit ACA Enrollment Periods May Deter Sign-Ups and Worsen Risk Pools,” To the Point (blog), Commonwealth Fund, Apr. 24, 2025; and Sara R. Collins, “Proposed Rule Will Make Consumers Pay More for Health Insurance and Care in the ACA Marketplaces,” To the Point (blog), Commonwealth Fund, May 7, 2025. ↩
  4. Sara R. Collins and Carson Richards, “House Budget Bill and Tax Credit Expiration Will Make It Harder to Get and Afford Marketplace Health Plans,” To the Point (blog), Commonwealth Fund, June 5, 2025; and “What the ACA Marketplaces Do for Your State,” Commonwealth Fund, June 5, 2025. ↩
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Publication Details

Date

Contact

David C. Radley, Senior Scientist, Tracking Health System Performance, The Commonwealth Fund

[email protected]

Citation

David C. Radley, Kristen Kolb, and Sara R. Collins, 2025 Scorecard on State Health System Performance: Fragile Progress, Continuing Disparities (Commonwealth Fund, June 2025). https://doi.org/10.26099/w0ns-ae34

Area of Focus

Topics

Affordability,
Behavioral Health,
Care Delivery,
Costs and Spending,
Coverage and Access,
Government Programs & Policies,
Health Disparities,
Maternal Health,
Medicaid Expansion,
Social Needs,
State Health Policy,
Quality of Care,
Affordable Care Act

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