2022 Scorecard on State Health System Performance

Highlights

• COVID-19 took a huge toll on Americans’ health, directly and indirectly, but that toll varied dramatically by state.
• Hawaii and Massachusetts top the 2022 State Scorecard rankings, based on overall performance across 56 measures of health care access and quality, service use and cost, health disparities, and health outcomes during the COVID-19 pandemic in 2020. The lowest-performing states were Mississippi, Oklahoma, and West Virginia.
• The pandemic’s impact reverberated throughout the health system in every state, as health care use fell and deaths from drug overdoses and treatable causes rose.
• Federal pandemic relief policies helped stabilize insurance coverage.
• Opportunities exist to strengthen states’ insurance coverage and care delivery systems so they are better able to withstand future health emergencies.

Introduction

Every year, the Commonwealth Fund’s Scorecard on State Health System Performance uses the latest data available to assess how well the health care system is working in every state. We ask such questions as:

• Do Americans have good access to health care? Does their health insurance enable them to get the care they need to stay healthy? Are they protected from high out-of-pocket health costs?
• Are Americans getting the right health care, at the right time, and in the right setting? To what extent are they seeking care from emergency departments or other costly settings instead of visiting a primary care provider? Has health care use and spending gone up or down?
• How healthy is America? How prevalent are high-risk behaviors like smoking or health conditions like obesity that put people at higher risk for poor health? What are Americans’ chances of dying early in life from preventable or treatable causes?

For the 2022 State Scorecard, we added a new area of inquiry:

• How well has each state responded to and managed the COVID-19 pandemic? With data that generally reflect the nation’s experience since 2020, we were able to provide a window on how state health systems have performed as the pandemic was unfolding.

To be sure, COVID-19 has challenged the health care system in all states. Still, many states have been able to maintain a high level of performance in the face of crisis. Looking across all measures of performance — health care access, quality, and spending, as well as health outcomes and equity — we find that Hawaii and Massachusetts top this year’s rankings. These two states’ overall performance separates them from other states, even other top performers. Both were consistently among the top three states across each of the seven dimensions of performance the State Scorecard evaluates.

Connecticut, Washington, and Vermont rounded out the five top-performing states. Mississippi, Oklahoma, and West Virginia ranked lowest overall.

We found that states that have historically performed well on our State Scorecard also performed well as the pandemic unfolded, both on our usual set of health system measures and the new COVID-19-specific measures.

How COVID-19 Impacted State Health Care Systems

COVID-19 placed considerable stress on health care in every state. However, states experienced, and responded to, the pandemic differently, as shown by measures in key areas of performance: vaccination rates; hospital and intensive care unit (ICU) capacity; and what is known as “excess mortality,” or death rates that exceed historical norms for a given time and place.

All states have made progress in vaccinating their residents against COVID-19, but there are ample opportunities for improvement.

COVID-19 vaccines are effective at decreasing transmission of the SARS-CoV-2 virus and reducing hospitalizations and deaths among those infected. They are a crucial public health tool for combatting the pandemic.

The first vaccine became available to all states at the same time in late 2020. States took different approaches to distributing doses to people, especially early on when vaccine supplies were limited.¹ In the states that moved the fastest to get shots in arms — Vermont, Massachusetts, Connecticut, and Maine — 70 percent of the population age 12 and older had completed a full vaccine series (typically, two doses) within 200 days from when the vaccine became available. In contrast, 21 states still had not reached 70 percent by the end of March 2022 (see Appendix Table G1), and Alabama, Wyoming, and Mississippi had yet to reach 60 percent (data not shown).

With new COVID variants continuing to emerge, the Centers for Disease Control and Prevention (CDC) has also recommended booster shots for most individuals. Despite the renewed protection they offer, less than 40 percent of all U.S. adults age 18 and older had received a single booster dose, in addition to their initial vaccination series, by the end of March 2022 (see Appendix Table G1). This ranged from more than 50 percent of adults in Vermont, Rhode Island, and Maine to less than 25 percent in North Carolina, Alabama, and Mississippi.

COVID-19 pushed hospitals to the breaking point, as many operated close to capacity while being understaffed.

Millions of Americans across all states have become severely ill with COVID-19. With 4.6 million COVID-related hospitalizations from August 2020 through March 2022 — often for patients requiring intensive care — many hospitals were overwhelmed.² The State Scorecard measured the total number of days during the pandemic on which at least 80 percent of ICU beds in each state were occupied. More days at high ICU capacity suggests stress on the care delivery system, a reduced ability to respond when COVID cases surge, and less capacity to treat patients hospitalized with non-COVID illnesses.

Between August 2020 and March 2022, 16 states and the District of Columbia operated at high ICU capacity for at least 150 days. Texas and Alabama stand out, with 566 and 517 days at or above 80 percent ICU capacity, respectively. Rhode Island, Georgia, Mississippi, New Mexico, and Oklahoma also exceeded 300 days (see Appendix Table G1).

Many hospitals operating near capacity were doing so while short-staffed, in part because hospital workers who contracted COVID needed to isolate. Between August 2020 and March 2022, 18 states experienced at least 100 days in which a significant share (25%) of their hospitals reported critical staffing shortages. Alabama had 516 days of reported critical staffing shortages; South Carolina, New Mexico, and Rhode Island each experienced more than 400 days (see Appendix Table G1).

The death toll from COVID is high and extends beyond deaths directly attributed to the virus.

By the spring of 2022, over 1 million Americans had died of COVID-19.³ But the virus’s effect on health outcomes has extended well beyond deaths directly attributable to COVID. Because the pandemic disrupted their ability to get timely care for conditions other than COVID-19, many more people likely died sooner than they otherwise would have.

Every state has experienced higher-than-expected mortality from all causes — deaths from COVID-19 in addition to deaths from other causes, like heart disease, cancer, and drug overdose — since the pandemic began. The number of excess deaths varies fivefold across states, from 110 per 100,000 people in Hawaii to 596 per 100,000 in Mississippi.

While COVID has been the driving force behind high rates of excess deaths across the U.S., states with historically strong health systems — low uninsured rates, robust primary care capacity, and effective care management — generally had lower rates than states with weaker health systems. Hawaii, New Hampshire, and Washington recorded the lowest excess death rates, fewer than 200 deaths per 100,000 people. Mississippi, West Virginia, and Alabama had more than 500 deaths per 100,000.

Amid the pandemic’s disruptions, deaths from preventable causes such as drug overdoses and chronic conditions rose across the country.

As the coronavirus quickly spread, Americans suddenly had to navigate disruptions in their access to health care facilities and cope with prolonged periods of isolation and economic uncertainty. Premature deaths from preventable causes like drug overdoses, alcohol use, diabetes, and pregnancy rose alongside COVID deaths. The pandemic’s broad impact on population health will likely be felt for years to come.

Deaths related to substance use spiked after the arrival of COVID-19.

Drug overdoses are a public health crisis. After rising steadily through 2017, drug overdose deaths had leveled off by 2018–19. However, immediately after the pandemic began, deaths spiked, as people dealt with physical isolation, disrupted addiction treatment, and a supply of deadlier drugs like fentanyl.⁴ Overdoses claimed a record 91,799 lives in 2020, with rates increasing at least 20 percent in 35 states and the District of Columbia.

Previously hard-hit areas like West Virginia reported the greatest absolute increases in rates of overdose mortality in 2020. But many southern states, including Florida, South Carolina, Louisiana, and Tennessee, also endured large jumps in mortality. Provisional data now show that 2021 was even deadlier, with more than 105,000 overdose deaths projected and large increases in nearly every region.⁵

Deaths attributable to alcohol, which has been consumed at higher rates during the pandemic, also jumped right after COVID-19’s arrival.⁶ Alcohol-related mortality rose by an unprecedented 26 percent in 2020, to more than 49,000 total deaths (10,000 deaths higher than in 2019), with higher rates and increases in many parts of the western and Great Plains regions (see Appendix Table F1). New Mexico, Wyoming, and Alaska reported the highest age-adjusted mortality rates, all exceeding 32 deaths per 100,000 people.

Premature deaths from treatable causes grew at unprecedented rates in 2020.

As evidenced by steep declines in outpatient visits during 2020,⁷ many Americans were forced to delay routine health services such as checkups, screenings, and chronic care management because of COVID-19 lockdowns and overwhelmed health care facilities. Premature deaths from treatable conditions such as heart disease and diabetes, which can be managed through timely, high-quality care, jumped from 83.8 to 89.8 deaths per 100,000 population between 2019 and 2020.⁸ This measure had stayed nearly constant in the eight years leading up the pandemic. Particularly in the South and Midwest, preventable deaths remain elevated (see Appendix Table F1).

Another category of preventable deaths, maternal mortality, also increased in 2020, with the highest rates in southern states (see Appendix Table F1).⁹

Black, Indigenous, and Latinx/Hispanic people — groups that have been among the most affected by COVID-19 — experienced the most significant preventable mortality increases.¹⁰

Health Insurance Coverage Held Steady During 2020, But Losses Loom on the Horizon

Despite expectations that loss of employment, and employer-provided health benefits, during the pandemic would leave millions of people uninsured, the national uninsured rate held steady in 2020. More recent federal data show an actual decline in early 2021. But risks to people’s coverage and their ability to afford health care remain.     

The stability in insurance coverage in 2020 stemmed from three factors:¹¹

• lower-than-expected declines in employer insurance coverage, as job losses were concentrated in industries that are less likely to offer coverage to workers
• the insurance coverage expansions of the Affordable Care Act (ACA), which provided safety-net coverage for people who lost their insurance
• the Families First Coronavirus Response Act, a 2020 law that required states to keep people continuously enrolled in Medicaid in exchange for enhanced federal matching funds through the end of the federally declared public health emergency.

In 2021, the American Rescue Plan, as well as actions taken by the Biden administration, raised subsidies for marketplace plan premiums and made it easier for people to enroll in plans.

Most states with high uninsured rates in 2020 were those that had not expanded Medicaid eligibility, as the ACA allows. Lower-income residents of these states who lost their employer coverage thus lacked a critical fallback option that was available to residents of states that did expand Medicaid.

Still, the recent improvements in coverage may prove ephemeral. The temporary “continuous eligibility” requirement in Medicaid will end once the federal public health emergency is over. This will trigger a massive effort to redetermine people’s eligibility for Medicaid in all 50 states and the District of Columbia.¹² When all is said and done, as many as 15.8 million people could be disenrolled from Medicaid, and some will not be able to find other coverage.¹³

Moreover, the American Rescue Plan’s enhanced subsidies for marketplace plan coverage are set to expire at the end of 2022. If Congress does not extend these subsidies, the number of uninsured people could climb by 3 million.¹⁴ These potential coverage losses will coincide with the cessation of federal funds that have until now paid for COVID-19 testing, treatment, and vaccines for people without insurance.

While health coverage held steady, use of health services declined.

For people who fell ill with COVID, this stability in insurance coverage, along with federal funding of COVID-19 testing and treatment for the uninsured, was critical to ensuring timely access to care. It also ensured that the providers who cared for them would be paid. But there were massive declines in use of health care services unrelated to COVID treatment during 2020, as evidenced by several measures of access and health care use in the State Scorecard. For example, reports of cost-related access problems declined in nearly every state (see Appendix Table C2). Similarly, the share of people with high out-of-pocket costs relative to income also fell nationally between 2016–17 and 2019–20, with declines of 3 percentage points or more in Alabama, Arizona, Arkansas, Connecticut, Indiana, and Missouri (data not shown). And despite the fact that people age 65 and older were the hardest-hit age group in terms of contracting serious illness from COVID-19, Medicare spending per beneficiary declined in all regions of the country in 2020.

Policy Changes That Could Make a Difference

The COVID-19 pandemic, as well as state and federal responses to it, has had a profound impact on people’s health and on health care systems in every state. What are some of the ways that we could apply lessons learned from the past two years to improve the overall performance of U.S. health care in the years ahead?

Strengthening States’ Ability to Respond to Future Crises

The COVID-19 pandemic caught too many of us off guard. Public health funding cuts in 2018 only hampered federal and state responses in the early months of the pandemic.¹⁵ But there are actions we as a nation could take to strengthen our ability to prepare for the public health crises that are sure to come.

• Develop a long-term, evidence-based pandemic preparedness strategy, drawing on recent lessons learned, that delineates federal and state responsibilities and authorities. Build public trust in the plan through early education and outreach efforts.¹⁶
• Fight misinformation and its spread — particularly on social media — by strengthening content moderation policies related to matters of public health.¹⁷
• Require hospitals and other health facilities to develop a comprehensive disaster response strategy featuring detailed plans for reallocating resources to increase short-term capacity and for bringing on and training the additional staff that may be needed.¹⁸

Reducing Deaths from Preventable Causes

To reverse the continued rise in deaths from substance use and treatable health conditions, it will be important to prioritize policy solutions that center equity, safety, and health.

Addressing the overdose crisis:

• Increase access to effective addiction treatments by lowering insurance and administrative barriers and requiring treatment availability throughout the criminal justice system.¹⁹
• Increase investment in harm reduction by expanding availability of overdose reversal drugs and drug-testing services and establishing supervised consumption sites.

Lowering deaths from treatable conditions:

• Boost investment in good primary care — the foundation for a high-performing health care system — and fully integrate behavioral health services with primary care services.²⁰
• Lower financial barriers to care that are preventing many people from getting appropriate treatment for chronic conditions like diabetes.²¹
• Target maternal mortality, including the stark racial disparities associated with it, by growing and diversifying the perinatal workforce, funding community-based maternal care models, expanding telehealth services, promoting high-value payment models, and improving data collection efforts.²²
• Invest broadly in social services to address factors that are key determinants of health and well-being, such as housing and economic security.²³

Continuing to Make Coverage More Affordable and Care More Accessible

Four near-term solutions could help the nation maintain progress on health coverage and give uninsured Americans access to COVID-19 prevention and treatment:

• Make the American Rescue Plan’s marketplace premium subsidy enhancements permanent.
• Require states to conduct Medicaid eligibility redeterminations gradually and phase down — rather than immediately eliminate — the temporary increase in Medicaid matching funds that is set to expire once the public health emergency ends.
• Replenish federal funds for COVID-19 testing, treatment, and vaccination of uninsured people.
• Provide a federal fallback option for people with low income who live in states that have yet to expand eligibility for their Medicaid program.²⁴

Longer term, we can apply lessons from the pandemic by fully deploying, and building on, the ACA to get more people covered. Lawmakers could:

• Make it easier for adults to maintain their Medicaid eligibility by giving states the option to make eligibility continuous, without the need to apply for a federal waiver — much like we currently do for children in Medicaid and the Children’s Health Insurance Program.²⁵
• Maintain vigorous, targeted, and consistent outreach and enrollment efforts to cover people who remain uninsured and keep them covered.
• Enable people to autoenroll in the coverage for which they are eligible.²⁶