2023 Scorecard on State Health System Performance

Scorecard Highlights

• Massachusetts, Hawaii, and New Hampshire top the 2023 State Scorecard rankings for health system performance, based on 58 measures of health care access, quality, use of services, costs, health disparities, reproductive care and women’s health, and health outcomes. The lowest-performing states were Oklahoma, West Virginia, and Mississippi.
• Deaths from COVID-19 — as well as premature, avoidable deaths from causes like drug overdoses, firearms, and certain treatable chronic conditions — rose dramatically during the first two years of the pandemic, lowering life expectancy across the United States.
• There was wide state variation on the Scorecard’s new measures of health outcomes and access to care for women, mothers, and infants. Maternal mortality and deaths related to substance use rose quickly among women of reproductive age during the pandemic — a particular concern given new state policies limiting reproductive care access.
• Temporary federal policies during the COVID-19 pandemic drove uninsured rates to record lows, with nearly all states realizing gains in health coverage. But some of those policies have ended, and high health costs still saddle millions of Americans with medical debt.
• There are ways the nation could improve health outcomes and lessen variation from state to state. Federal and state governments could: close the coverage gaps that remain and enroll uninsured people who are eligible for subsidized coverage; improve the cost protections of insurance plans; and lower barriers to reproductive health, preventive health, and behavioral health care, particularly for the most vulnerable.

Overview

Every year, the Commonwealth Fund’s Scorecard on State Health System Performance uses the most recent data to assess how well the health care system is working in every U.S. state. This year, Massachusetts achieved the best overall score, consistently placing among the top states on the seven dimensions of health system performance we evaluate. Hawaii, New Hampshire, Rhode Island, and Vermont round out the top five.

The lowest-ranked states overall are Arkansas, Texas, Oklahoma, West Virginia, and Mississippi.

All states face a number of daunting health challenges in the years ahead. In this report, we examine three of them:

• Historically high rates of premature death. Still reeling from the COVID-19 pandemic, states are trying to reverse a stunning rise in preventable deaths from multiple causes. These premature deaths have lowered the nation’s average life expectancy, with people of color experiencing the steepest declines. The 2023 Scorecard reports on avoidable premature mortality in each state and looks at inequalities in health outcomes for different racial and ethnic groups.
• Reproductive care and women’s health. Many states perform poorly when it comes to the health of women, mothers, and infants: high and increasing rates of maternal mortality, inequities in pregnancy-related outcomes for Black and American Indian/Alaska Native women, and rising rates of other avoidable deaths. In the coming years, states will face new challenges stemming from the end of pandemic-era policies that enabled people to maintain their insurance coverage after pregnancy and from new state restrictions on reproductive health care following the reversal of Roe v. Wade. This year’s Scorecard takes a deeper look at women’s and reproductive health care with 12 new measures that evaluate and rank states on maternal and pregnancy-related outcomes as well as women’s access to reproductive services and other care. Most of the data available to us reflect people’s experiences in 2021 — during the pandemic and before recent abortion restrictions took effect. These results offer a baseline for assessing future state performance.
• Health care access and affordability. Some pandemic-era insurance policies that drove uninsured rates to record lows have ended, raising concerns over people’s ability to stay covered. At the same time, growth in health care costs is making health services even less affordable and leaving many burdened with crushing medical debt.

Key Findings of the 2023 State Scorecard

Health Outcomes and Healthy Behaviors

Deaths from preventable and treatable causes increased rapidly with the arrival of COVID-19, leading to unprecedented declines in U.S. life expectancy.

Since 2020, states have had to grapple with rising population health risks and mortality. These have been driven not only by the COVID-19 virus itself but also by increased risk for substance use during the pandemic and barriers to timely care for treatable conditions.

All states experienced increases in avoidable, premature deaths. The Scorecard tracks the number of deaths from preventable causes as well as from causes treatable with health care. Preventable deaths before age 75 — such as those from certain preventable infections, injuries, or illnesses — can largely be avoided through effective public health measures and primary care. Deaths from health care–treatable causes before age 75 — such as chronic illness like diabetes and cancers like colon and breast cancer — can generally be avoided through timely and effective health care interventions. Added together, these two types of mortality are known as “avoidable” deaths.¹ (Refer to the Scorecard Methods for additional detail on preventable and health care–treatable conditions.)

Our measure of deaths from preventable causes includes deaths directly attributable to COVID-19 — the major reason for increased mortality rates between 2019 and 2021. The national variation in COVID deaths was influenced by a number of factors, including underlying health and socioeconomic characteristics of states’ populations, states’ pandemic responses, and the share of the population that got vaccinated.² Firearms-related mortality is another component of avoidable premature deaths: firearms claimed 48,830 lives in 2021, and gun-related deaths have risen 23 percent since 2019, in part because of an increase in mass shooting events and suicides.³

Deaths from health care–treatable conditions, particularly those associated with chronic diseases, rose after 2019. Delays in routine and preventive care amid the pandemic’s disruptions may have contributed to the increase.⁴

All states experienced large increases in avoidable deaths between 2019 and 2021, leading to substantial declines in life expectancy across the U.S.⁵ Arizona, Louisiana, Mississippi, New Mexico, and Texas stand apart: each experienced more than a 35 percent increase in avoidable mortality rates over this period. Arizona’s rate jumped the largest percentage, by 45 percent.

In many states, premature mortality for Black and American Indian/Alaska Native people has historically been much higher than that of other groups, and increased by a larger margin during the COVID-19 pandemic. Consequently, both groups of people, along with Hispanic Americans, experienced the largest drops in life expectancy between 2019 and 2021.⁶ To a great extent, this reflects higher age-adjusted rates of COVID-related deaths, particularly among Black, Hispanic, and American Indian/Alaska Native communities, as well as higher mortality from treatable conditions like cardiovascular disease and stroke.⁷

These disparities in outcomes have deep roots: the nation’s history of structural racism; generations of discriminatory state and federal policies around housing, education, and employment; health insurance policies that disproportionately disadvantage people of color; and well-documented variations in patient care quality by race and ethnicity. Together, these factors played a major role in many of the poor health outcomes seen across the U.S. both before and during the COVID-19 pandemic.⁸

Amid rising concerns over mental health and record-high deaths from suicide, alcohol use, and drug overdose, many Americans are struggling to get the behavioral health services they need. In addition to causing more than 1 million deaths, the COVID-19 pandemic also exacerbated mental and behavioral health issues for many Americans. The consequences have been dire: in 2021, for the first time, combined deaths from drug overdoses, alcohol, and suicide claimed upwards of 200,000 lives, some 50,000 more than the prepandemic high, in 2019.⁹

As we emerge from the worst of the pandemic, it’s become clear that Americans — especially teens — are not getting the mental health care they need.¹⁰ Recent data point to alarming increases in the shares of teens who have persistent feelings of sadness and who attempt or seriously consider suicide.¹¹ Yet nationally, 60 percent of adolescents ages 12 to 17 who had a major depressive episode did not get any treatment, according to a 2020 federal survey; in South Carolina, it was nearly 80 percent.

Similarly, 55 percent of adults with mental illness reported not receiving treatment. Among adults who did not receive needed care, 42 percent cited cost as the primary barrier.¹²

Reproductive Care and Women’s Health

State performance on reproductive care and women’s health varies widely across the country. Many of the states with the worst outcomes are now implementing or considering further restrictions on reproductive care, raising concerns about inequity in access and health outcomes.

This year’s Scorecard features a new domain of health system performance — Reproductive Care and Women’s Health — to rank states on health outcomes for women, mothers, and infants and access to important health care services. The 12 indicators it includes measure mortality, such as maternal and infant deaths; high-risk events, such as severe maternal morbidity and preterm births; and ability to get routine checkups, prenatal and postpartum care, and other vital services.

The results show significant variation across states in women’s health and health care. Given that the data for these measures were collected primarily in 2021 — prior to the Supreme Court’s June 2022 decision overturning the constitutional right to abortion — they provide a baseline for assessing reproductive and women’s health across states in the coming years.

Twenty-six states now have abortion restrictions in place following the Court’s ruling.¹³ These restrictions will not only reduce or eliminate access to abortion services, but they could also limit access to providers that offer important preventive health care like contraception and reproductive cancer screenings. Many of these reproductive health care providers are concerned they will no longer be able to deliver high-quality care, while others fear being criminalized for providing their patients with the full spectrum of reproductive services.¹⁴

Women with low income, women of color, and women in rural communities will be especially impacted by these changes in health care access. They disproportionately live in those states that have enacted additional abortion restrictions, and they are often the ones to experience the most acute effects of any systemic failure or shortcoming.¹⁵

Health system performance for women, mothers, and infants varies widely across states, with large differences in avoidable mortality and access to important health services.

Women faced particularly severe challenges during the COVID-19 pandemic. These included delays in getting health care and pregnancy complications stemming from the virus.¹⁶ Women of color were particularly affected, which further worsened racial and ethnic disparities in health outcomes.¹⁷

A key population health metric is the all-cause mortality rate for women of reproductive age (15 to 44). During the pandemic, deaths from all causes for women in this age group reached startling levels, jumping nearly 40 percent, from 89.4 deaths per 100,000 women in 2019 to 124.2 deaths per 100,000 in 2021. The increase included not only more maternal deaths but also other preventable deaths such as those from COVID-19, substance use, and additional conditions.¹⁸

The all-cause mortality rate in 2021 for women ages 15 to 44 shows wide variation across states, with the highest state (West Virginia) having a mortality rate triple that of the lowest state (Hawaii).

Many of these deaths could have been avoided through better, more equitable access to comprehensive health care. They could also have been avoided through greater efforts to address racial and ethnic disparities in quality of care. This is especially important given that racial inequities in quality of care persist, with pregnant women of color experiencing worse delivery-related outcomes even within the same hospitals.¹⁹

To improve these outcomes, it will be critical to integrate the continuum of reproductive health services before, during, and after pregnancy with primary care, including preventive services like cancer screenings and behavioral health services like substance use treatment.

Unfortunately, shortages of maternal care providers are commonplace across the U.S.; some communities are even considered to be “maternity care deserts.” Other women don’t have insurance coverage or can’t find providers who accept their coverage.²⁰

State variations in care become starkly apparent when looking at specific services. In Vermont, only 11 percent of women giving birth in 2021 did not receive early prenatal care during the first trimester. But in Texas and Florida, 29 percent of pregnant women did not receive this care. Prenatal care is critical to identifying risks early and supporting people throughout their pregnancy, and it can improve outcomes for mothers and their babies.²¹

Postpartum visits following birth are also a critical component of comprehensive reproductive and perinatal care. Experts say up to a year of postpartum care is key to better maternal health outcomes. Alaska, New Jersey, Missouri, and Arizona stand out for having lower access to both early prenatal care and postpartum care in the first four to six weeks after birth (see maps below).

We also find state-to-state variation in other measures of health care access that are essential to optimal health for women. Four of the states ranked among the lowest overall on reproductive care and women’s health — Alaska, New Mexico, Oklahoma, and Texas — also rank toward the bottom on two key measures for women of reproductive age: having a usual source of care and receiving a routine checkup visit (see Appendix Table G1).

Maternal deaths increased during the pandemic, particularly for women of color.

Inadequate access to health services during and after pregnancy, combined with disparities in socioeconomic status, underlying health, and quality of care, have helped drive a U.S. maternal mortality rate that is nearly twice as high as rates in other high-income countries. And for many people of color in the U.S., maternal death rates are even higher.²²

During the pandemic, maternal deaths rose considerably amid the severe disruptions in health care delivery. COVID-19 was an additional clinical risk factor and slow vaccine uptake raised the risk of death for those who were pregnant.²³ Maternal mortality jumped from 20.1 deaths per 100,000 live births in 2019 to 32.9 per 100,000 in 2021. A federal report found that COVID was a contributing factor in more than 30 percent of maternal deaths in 2021.²⁴

The maternal death rate for AIAN women jumped by nearly 70 deaths per 100,000 live births between 2019 and 2021, while the rate for Black women increased by more than 25 deaths per 100,000, putting them well above other racial and ethnic groups.²⁵ Among the likely causes were the greater burden of COVID-19 in Black and AIAN communities; higher rates of poverty, food insecurity, and other social risk factors; and disparities in insurance coverage and quality of care.²⁶

These outcomes differed depending on where women lived. Maternal death rates between 2019 and 2021 were as low as 9.6 per 100,000 live births in California, but higher than 40 deaths per 100,000 births in Arkansas, Alabama, Louisiana, Tennessee, and Mississippi. It’s important to note that California has made concerted efforts to address racial equity in maternal health over the past decade.²⁷

States must confront a confluence of emerging crises that are putting women’s health at risk.

The prolonged pandemic, coupled with the existing maternal mortality crisis and inequities in care delivery, has driven up avoidable deaths for women and presented unprecedented challenges to state leaders.

As states struggle to find ways to maintain access to coverage and care as pandemic-era policies expire, the overturning of Roe v. Wade has further fractured reproductive health care access. Which state you live in now determines whether you have access to a full range of reproductive health care services. And for low-income women and women of color, the stakes are even higher.

The data we’ve presented show that in many states that have imposed abortion restrictions, women had poor health outcomes even prior to the 2022 Supreme Court ruling. Twelve of the 15 states that rank lowest on our measures of reproductive care and women’s health have restrictive abortion laws as defined by the Guttmacher Institute.²⁸ The trends are particularly pronounced for all-cause mortality and for maternal and infant deaths (see Appendix Table G1). States with abortion restrictions also had fewer maternal care providers before 2022.²⁹ The additional limitations on reproductive care in states with these poor outcomes raise concern that existing gaps could widen in the coming years.

Health Coverage and Access to Care

Health insurance coverage rates reached record highs in 2021, but declines loom on the horizon, and concerns with the affordability of health care are growing.

The number and percentage of Americans lacking health insurance has fallen to historic lows. That’s because of temporary policies during the pandemic aimed at helping people get covered and stay covered, as well as recent decisions by several states to expand Medicaid eligibility under the Affordable Care Act (ACA). Still, many people in the United States remain uninsured or inadequately covered. As pandemic-era policies expire and health care costs continue to climb, the outlook is likely to worsen.

The national adult uninsured rate declined during the first two years of the pandemic, from nearly 13 percent in 2019 to 12.1 percent in 2021 (see Appendix Table C2). Across the nation, uninsured rates declined in all but seven states, falling even in most states that had not expanded their Medicaid programs. This nationwide improvement in coverage was attributable to record enrollment in Medicaid (93 million by 2023)³⁰ and in the ACA insurance marketplaces (16.4 million by 2023).³¹ Four policy changes accounted for these coverage gains:

• The 2020 federal requirement that states keep Medicaid beneficiaries continuously enrolled through the end of the public health emergency, in exchange for enhanced federal matching funds for state Medicaid programs.
• The decision by seven additional states between 2019 and 2021 — Idaho, Maine, Missouri, Nebraska, Oklahoma, Utah, and Virginia — to expand Medicaid eligibility.
• More generous marketplace premium subsidies that were put in place in 2021 and extended through 2025 under the Inflation Reduction Act.
• Increased federal funding for ACA marketplace outreach and enrollment.

The substantial gains achieved through Medicaid’s continuous coverage requirement may prove ephemeral, however. The requirement ended in April 2023, leaving states with the complex and difficult task of determining whether people enrolled are still eligible. An estimated 15 million people may lose Medicaid coverage over the next year, either from changes in eligibility or through administrative error. Of those, the Congressional Budget Office projects that 6.2 million will become uninsured.³²

Among those most at risk of losing coverage are people who have Medicaid because they were pregnant but are now out of the postpartum period, and young adults who aged out of Medicaid and the Children’s Health Insurance Program (CHIP). This will particularly affect those who live in states that have not expanded Medicaid or have not yet extended postpartum coverage as allowed during the pandemic.³³ Coverage losses could be exacerbated by the burdensome process of redetermining eligibility for so many people, since state Medicaid agencies are likely to fall behind in enrolling new applicants as a result.

In some states, medical debt is a crisis for the insured and uninsured alike. Despite the nation’s substantial gains in health insurance coverage, many Americans are struggling to pay off medical debt. There are two key reasons: 1) millions remain uninsured, and 2) many people with coverage are underinsured, meaning they may still face high costs when they get health care. In 2022, the Commonwealth Fund found that nearly a quarter of adults had coverage all year but were still underinsured.³⁴ Of those, 39 percent were paying off medical debt, slightly higher than the share of uninsured people with medical debt.

In 2021, there was an estimated $88 billion of medical debt on consumer credit records, accounting for 58 percent of all debt-collection entries on credit reports — by far the largest single source of debt.³⁵ This estimate is an undercount of U.S. households’ medical debt, since it does not include debt people owe directly to hospitals and other providers.

Of the estimated 230 million people in the U.S. who had credit reports in February 2022, nearly 13 percent had medical debt in collections. The share of people with medical debt in collections varied significantly across the country, from 2.4 percent in Minnesota to 24 percent in West Virginia (see Appendix Table C1). Southern states had the highest rates of medical debt in collections; the region not only has some of the highest state uninsured rates in the country, but out-of-pocket cost exposure in commercial health plans is also among the highest relative to people’s incomes.³⁶

How the U.S. Can Address Its Health Challenges

The 2023 Scorecard on State Health System Performance shows that all states face challenges in ensuring the health and well-being of their residents. How can state and federal legislators and agencies address these challenges and improve health outcomes?

Avoidable Mortality and Behavioral Health

• Expand the primary care workforce. Primary care providers play a key role in coordinating their patients’ care, screening for acute and chronic illness, managing treatment for chronic disease, and educating patients on issues related to public health.³⁷ Federal and state policymakers can bolster the primary care workforce by incentivizing the creation of training programs for primary care clinicians.
• Promote primary care and behavioral health integration. Federal policymakers could provide additional supports to states in designing and implementing waivers, demonstrations, and state plan amendments that scale integrated care in Medicaid and the Children’s Health Insurance Program; align payments to incentivize the integration of primary care and behavioral health; and ensure reimbursement levels are adequate to promote integrated primary care in small, rural, and underresourced practices.³⁸
• Increase treatment for behavioral health needs of children and adolescents. State policymakers could adopt and implement evidence-based models such as the collaborative care model which brings mental health services into pediatric settings. Adequate reimbursement rates, start-up costs, and technical assistance are essential elements to successful implementation of this model.³⁹
• 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.⁴⁰ Some states are also taking action to remove administrative barriers.⁴¹
• Expand comprehensive harm reduction policies. 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.⁴²
• Develop community-based health care workforces focused on team care. Offer financial assistance, such as loan repayment, to providers who serve in medically underserved communities. Expand community health worker programs to train individuals to provide basic health-related services and support within their communities.

Reproductive Care and Women’s Health

• Extend and provide support for evidence-based implementation of Medicaid’s postpartum coverage to 12 months. The American Rescue Plan Act gives states the option of extending Medicaid postpartum coverage to 12 months, although this option is available to states for only five years. So far, 36 states have taken the option, six are planning to, and three have opted for a more limited extension.⁴³ Congress could make the option permanent. In addition to eligibility extension, states can adopt changes that improve postpartum, preventive, and intensive health care services during the year following a Medicaid-financed pregnancy.
• Promote policies, innovative payment models, and digital tools that support the continuum of reproductive health care — from family planning, abortion services, and maternity care to postpartum and well-woman care. To address the maternal health crisis and wide racial disparities, federal and state policymakers could advance policies and approaches that further expand reproductive services in the delivery of comprehensive health care.⁴⁴
• Provide funding to community-based organizations focused on advancing maternal health outcomes and addressing racial equity. Change is needed at the community level, where women and birthing people live and seek services. The federal government could increase funding for reproductive and maternal health care, particularly through community-based organizations prioritizing birth equity.⁴⁵
• Expand and diversify the maternal and reproductive health workforce by investing in teams of physicians, midwives, doulas, community health workers, and maternity care coordinators. Across the continuum of maternal health, team-based care — and financial support for such care — is needed. State policymakers can take steps to increase the availability of birthing facilities, especially in high-need areas, and grow the maternal health workforce by incentivizing and diversifying educational programs for nurses, midwives, and doulas.⁴⁶ States that have restricted abortion can aid the retention of reproductive health care providers by eliminating the potential that these clinicians could face punitive actions or criminal punishment.
• Invest in care models that support mothers with maternal mental health conditions and substance use disorders.⁴⁷
• Increase financial investments in social determinants of health that influence maternal health outcomes. To increase economic and social service supports for children and women, Congress and states could expand paid family leave, tax credits, unemployment compensation, childcare, and affordable housing assistance for children and for women of reproductive age.⁴⁸ States can also use the Temporary Assistance for Needy Families (TANF) program to provide lower-income, single mothers of young infants with financial support similar to paid maternity leave.⁴⁹
• Continue to prioritize the elimination of racial inequities in maternal health. Adopt policies and quality improvement approaches that center health equity through Medicaid quality strategies, hospital regulations, community investments, improved data collection standards, and other approaches.

Insurance Coverage and Affordability of Care

• Fill the Medicaid coverage gap. Congress could create a federal fallback option for Medicaid-eligible people in the 10 states that have yet to expand Medicaid.⁵⁰
• Permanently extend enhanced marketplace premium subsidies set to expire in 2025. These larger subsidies led to record enrollment in marketplace plans. Congress could make these subsidies permanent to keep people enrolled in coverage and to encourage new enrollment.
• Create a longer period of continuous Medicaid eligibility. Disruption in Medicaid coverage because of eligibility changes, administrative errors, and other factors can leave people uninsured and unable to get care. Congress could apply the lessons of the pandemic and give states the option to maintain continuous enrollment eligibility for adults for 12 months without the need to apply for a waiver — just as has been done for children in Medicaid and the Children’s Health Insurance Program.⁵¹
• Create an autoenrollment mechanism. Research shows that many uninsured people are eligible for Medicaid or subsidized marketplace coverage. By allowing autoenrollment in comprehensive health coverage, Congress could move the nation closer to universal coverage.⁵²
• Lower deductibles and out-of-pocket costs in marketplace plans. Congress could extend cost-sharing reduction subsidies to middle-income people and change the benchmark plan in the ACA marketplaces from silver to gold, which offers better financial protection.⁵³ These policies would reduce the number of people who are underinsured and lower the number of uninsured by an estimated 1.5 million.⁵⁴
• Lower health care cost growth. Federal and state policymakers could take steps to address the high health care prices that are driving up commercial insurance premiums and deductibles, such as by creating new public plan options.⁵⁵
• Protect consumers from being financially ruined by medical debt. Many states have passed legislation banning aggressive collection activities by hospitals and collection agencies. And the Biden administration is taking steps to protect consumers from being financially damaged by medical debt, including scrutinizing provider bill collection behavior.⁵⁶ Congress could reinforce those actions by requiring providers to allow debt repayment grace periods following illness or during appeals processes; ending such hospital practices as suing patients, garnishing wages, or placing liens on homes; and banning or placing limits on the charging of interest.⁵⁷

In the coming years, women’s health and reproductive care will continue to be at the forefront of political and policy debates — particularly as additional legal challenges surrounding abortion move through the court system and the effects of judicial and legislative policy on women’s health and reproductive health access become clear.⁵⁸

At the same time, policymakers must contend with the behavioral health crisis, the lingering effects of COVID, and gaps in the health insurance system that are leaving millions without timely access to affordable care or protection from medical debt.

These challenges are considerable. The policies presented here show, however, that states and the federal government have a wide range of options for making progress in the near term and for improving the health of all U.S. residents over time.