Report Paints Dark Picture of Healthcare Indicators Across the United States

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Some states are losing ground in healthcare coverage and most states are being rocked by rising deaths of despair, reports a national scorecard of the nation’s health.

What would health outcomes look like across the country nationally, if all states achieved the highest level of performance achieved so far in a specific indicator?

According to The Commonwealth Fund, which released its 2019 Scorecard on State Health System Performance, 14 million fewer adults would not skip healthcare services because of cost. There would be 90,000 fewer deaths before age 75 because of treatable diseases. Emergency departments would see 6.7 million fewer visits for nonemergency care. And 18 million more Americans would have health insurance, beyond those who already gained it through the Affordable Care Act (ACA).

Instead, the report said, the widespread gains in health coverage and access to care following the 2010 passage of the ACA are at a standstill since 2015. From 2016 to 2017, more than half of states managed to retain earlier gains, while in 16 states, these gains slightly eroded between 2016 and 2017.

Whether or not states chose to expand Medicaid had a direct impact on insurance rates, as seen by a 6-fold variation between the low end (Massachusetts, where 4% lack health insurance) and the high end (Texas, where 24% of residents go without health insurance).

Massachusetts belongs to the tier of top-ranked states, according to their performance on 47 measures of access to healthcare, quality of care, service use and costs of care, health outcomes, and income-based healthcare disparities. The others are Hawaii, Minnesota, Washington, Connecticut, and Vermont.


Texas, along with Arkansas, Nevada, Oklahoma, and Mississippi, ranks at the bottom of the Commonwealth Fund report.

Meanwhile, 17 states did not expand Medicaid, which is associated with a variety of health improvements, including fewer cardiovascular deaths, reduced maternal mortality, and more. Enrollment in both Medicaid and individual plans bought through the ACA has been trimmed due to various actions by both the Trump administration and Congress, the report noted.

Rising Deaths of Despair

Meanwhile, so-called “deaths of despair”—deaths from drug overdoses, suicides, and alcohol—continue to contribute to a decline in US life expectancy. While noting that each state is affected differently, the report called these increases “concerning and represent yet another marker of complex socioeconomic and behavioral health problems across the nation.”

In 11 states, including parts of the Midwest and New England, drug overdose deaths tripled between 2005 and 2017.

In other areas—Montana, Nebraska, the Dakotas, Oregon, and Wyoming— there were higher rates of death from suicide and alcohol than from drugs.

Nationally, suicide rates are up nearly 30% since 2005 and rose more sharply between 2016 and 2017 than during any other 1-year period in recent history. Alcohol death rates are also climbing, with average growth of 4% per year between 2013 and 2017, compared with 2% per year between 2005 and 2012.

Employer-Based Plans Still Put Healthcare Out of Reach

Healthcare costs in employer-based plans are outpacing any gains in income, with workers facing a larger share of out-of-pocket costs.

As of the end of last year, 30 million adults remained uninsured and an estimated 44 million people had insurance but had such high deductibles and OOP costs relative to income that they are considered to be underinsured.

States with the highest average employer premiums (from both the employer and employee) also tended to have the highest per-enrollee healthcare costs. The report also cited the work of the Health Care Cost Institute (HCCI), saying that there is growing evidence that prices paid by private payers, not utilization, is the primary driver of cost and premium growth.

In addition, per capita costs in private insurance are rising faster than those in Medicare, mainly because of prices. Medicare sets prices for providers, whereas prices in private plans are usually negotiated with providers or employers.

Growth in per-enrollee spending among working-age adults with employer coverage outpaced growth in per-enrollee Medicare spending between 2013 and 2016 in 5 of 8 regions. An analysis of cost trends at the state level found that per-enrollee spending growth in employer plans outpaced that in Medicare in 31 states.