States Not Making the Grade on Key Health Indicators Pre-ACA

Megan Brooks

April 30, 2014

States made little progress in improving healthcare access, quality, costs, and outcomes in the 5 years leading up to the major coverage reforms of the Affordable Care Act (ACA), according to a report released yesterday by the Commonwealth Fund.

"There is room for improvement in every state. Between 2007 and 2012, a majority of states did worse or did not improve on most of the indicators that we track," Commonwealth Fund President David Blumenthal, MD, said during a media briefing.

Access and affordability of healthcare declined for adults younger than 65 years in most states, the report notes.

"We certainly were hoping that we would see more substantial progress across states; of course, this was a period of recession," added Cathy Schoen, senior vice president for policy, research, and evaluation at the Commonwealth Fund.

Where You Live Matters

The report, "Aiming Higher: Results from a Scorecard on State Health System Performance, 2014," ranks the health systems of every state and the District of Columbia on the basis of 42 healthcare indicators, including 34 that show trends between 2007 and 2011-2012.

The majority of states failed to improve or declined on two thirds of the 34 scorecard indicators with time trends, the report shows.

In line with prior data, "where you live continues to matter," Schoen said, with top states sometimes performing 2 to 8 times better than the lowest-performing states.

States in the Northeast, Upper Midwest, and Hawaii continue to perform best overall, whereas states in the South and Southeast tend to perform below average, but there is also wide variation within states for vulnerable populations.

What is "heartening," Schoen said, is that the handful of indicators for which improvements did occur in most states (eg, safer drug prescribing in the elderly, reductions in avoidable hospital admissions and readmissions, higher childhood vaccination rates, and fewer cancer-related deaths) were often the targets of concerted and coordinated efforts on the federal and state level.

The scorecard has an interactive map that allows users to download individual state profiles and compare states.

The report notes that Vermont, in particular, which ranks near the top of the scorecard, along with Hawaii, Massachusetts, Minnesota, and New Hampshire, has been a national leader in guaranteeing access to care and investing in primary care.

In these top-ranking states, between 5% and 17% of working-age adults were uninsured in 2011-2012. The states at the bottom of the scorecard, Mississippi, Arkansas, Oklahoma, and Louisiana, had adult uninsured rates between 22% and 28% in 2011-2012.

Nationally, between 2007 and 2011-2012, the uninsured rate for working-age adults rose from 19% to 21%, increasing in 20 states, the report shows. The percentage of adults going without healthcare because of costs increased in 42 states over the 5 years that included the recession.

Improvement Possible, Millions Would Benefit

The ACA "has the potential to level the playing field, as all states have the opportunity to make substantial improvements to their healthcare systems if they take full advantage of the law, including Medicaid expansion," Blumenthal said.

The report predicts that if all states could do as well as the top-performing states, more than 35 million children and adults would gain health insurance, an additional 10 million older adults would receive preventive care, more than 1 million fewer Medicare enrollees would be exposed to an unsafe prescription drug, and some 84,000 fewer people would die prematurely annually from conditions that could have been prevented with timely and effective care.

"The scorecard shows us that improvement is possible," David Radley, PhD, scorecard project director and the report's lead author, from the Institute for Healthcare Improvement in Cambridge, Massachusetts, said in a news release that accompanied the report.

"We hope to see progress accelerate and spread in the future. But for that to happen, states and local healthcare systems must make concerted efforts to set goals, aim to achieve them, and learn what works from one another," he added.

The Commonwealth Fund is a private foundation supporting independent research on health policy reform and a high-performance health system.

"Aiming Higher: Results from a Scorecard on State Health System Performance, 2014." Commonwealth Fund. Full text

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