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Our Scorecard ranks every state’s health care system based on how well it provides high-quality, accessible, and equitable health care. Read the report to see how your state ranks.

AREA OF FOCUS
Achieving Universal Coverage

SCORECARD
JUNE 22, 2023

2023 Scorecard on State

Health System
Performance
Americans’ Health Declines and Access to Reproductive Care
Shrinks, But States Have Options

Scorecard Highlights
Massachusetts, Hawaii, and New Hampshire top the 2023 State Scorecard
AUTHORS
rankings for health system performance, based on 58 measures of health
David C. Radley, care access, quality, use of services, costs, health disparities, reproductive
Jesse C. Baumgartner,
Sara R. Collins, Laurie C. Zephyrin care and women’s health, and health outcomes. The lowest-performing
states were Oklahoma, West Virginia, and Mississippi.
DOWNLOADS
Deaths from COVID-19 — as well as premature, avoidable deaths from
Appendices ↓
causes like drug overdoses, firearms, and certain treatable chronic
State Profiles, States A–M (pdf zip) ↓
conditions — rose dramatically during the first two years of the
State Profiles, States N–W (pdf zip) ↓
pandemic, lowering life expectancy across the United States.
News Release ↓

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.

Black residents 3/6


Avoidable deaths from preventable and treatable causes vary by
race and ethnicity, both across and within states; Black and
American Indian/Alaska Native people have the highest rates.
Avoidable deaths before age 75 per 100,000 population, by state and race/ethnicity (2020–21)

Race/Ethnicity Lowest rate in state Black residents

1400
1300
1200
1100
1000
900
800
700
600
500
400
300
200
100
0
Connecticut

South Carolina
Rhode Island

United States

Wisconsin
Idaho

Massachusetts

Maine

Indiana
Utah

Maryland

North Carolina
Florida

Arizona

Alabama

Montana
Ohio

Illinois

Oklahoma

Missouri
Michigan
Mississippi
Minnesota

Louisiana
Georgia

Oregon
South Dakota

Alaska

Arkansas
Hawaii

Wyoming

New Mexico
Kentucky
New Hampshire

Colorado

New Jersey

Iowa

Kansas
Delaware

California
North Dakota

Nevada
Virginia

Nebraska
Vermont

Washington

Pennsylvania

West Virginia
Tennessee
New York

Texas

D.C.

Note: Number of deaths before age 75 per 100,000 population that resulted from causes that can be mainly avoided through timely and effective prevention and
treatment. Methodology developed by the Organisation for Economic Co-operation and Development (OECD) and Eurostat, as published in Avoidable Mortality:
OECD/Eurostat Lists of Preventable and Treatable Causes of Death (January 2022 Version); Grey dots represent the lowest mortality rate in each state by any of the five
groups (if no grey dot is visible, the highlighted group has the low rate). Rates not available for all racial and ethnic groups in all states.

Data: 2020-21 National Vital Statistics System (NVSS), All-County Micro Data, Restricted Use Files. Rates shown are for American Indian/Alaska Native (AIAN, non-
Hispanic); Black (non-Hispanic); Asian American, Native Hawaiian, and Pacific Islander (AANHPI, non-Hispanic); white (non-Hispanic); and Hispanic (any race) people
based on information from decedent’s death certificate.

Source: David C. Radley et al., The Commonwealth Fund 2023 Scorecard on State Health System Performance: Americans’ Health Declines and Access to Reproductive
Care Shrinks, But States Have Options (Commonwealth Fund, June 2023). https://doi.org/10.26099/fcas-cd24

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

Click through to see each race/ethnicity group on its own. 1/6


Avoidable deaths from preventable and treatable causes vary by
race and ethnicity, both across and within states; Black and
American Indian/Alaska Native people have the highest rates.
Avoidable deaths before age 75 per 100,000 population, by state and race/ethnicity (2020–21)

All

Race/Ethnicity AIAN residents Black residents Hispanic residents AANHPI residents White residents

1400
1300
1200
1100
1000
900
800
700
600
500
400
300
200
100
0
Connecticut

South Carolina

Rhode Island
United States

Wisconsin
Massachusetts

Maryland
Illinois
Maine

Ohio

Alabama
Michigan

Indiana
North Carolina

Florida

Missouri

Idaho

Arizona

Mississippi

Montana
Utah
Oklahoma
Minnesota
Louisiana
Georgia

Oregon

Arkansas

Alaska

South Dakota
Wyoming
Kentucky

New Mexico

Hawaii
New Hampshire

New Jersey

Colorado

Kansas

Iowa
Delaware

California
North Dakota

Nevada
Virginia

Nebraska
Vermont
Pennsylvania

Washington
West Virginia

Tennessee
New York
Texas
D.C.

Note: Number of deaths before age 75 per 100,000 population that resulted from causes that can be mainly avoided through timely and effective prevention and
treatment. Methodology developed by the Organisation for Economic Co-operation and Development (OECD) and Eurostat, as published in Avoidable Mortality:
OECD/Eurostat Lists of Preventable and Treatable Causes of Death (January 2022 Version); Grey dots represent the lowest mortality rate in each state by any of the five
groups (if no grey dot is visible, the highlighted group has the low rate). Rates not available for all racial and ethnic groups in all states.

Data: 2020-21 National Vital Statistics System (NVSS), All-County Micro Data, Restricted Use Files. Rates shown are for American Indian/Alaska Native (AIAN, non-
Hispanic); Black (non-Hispanic); Asian American, Native Hawaiian, and Pacific Islander (AANHPI, non-Hispanic); white (non-Hispanic); and Hispanic (any race) people
based on information from decedent’s death certificate.

Source: David C. Radley et al., The Commonwealth Fund 2023 Scorecard on State Health System Performance: Americans’ Health Declines and Access to Reproductive
Care Shrinks, But States Have Options (Commonwealth Fund, June 2023). https://doi.org/10.26099/fcas-cd24

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

Drug overdose and alcohol-induced deaths increased rapidly after the arrival of
COVID-19 and reached record levels in 2021.
Drug overdose, alcohol-induced, and suicide deaths, United States (2010-2021)

120,000

106,699
100,000

80,000

Drug Overdose
60,000 70,630
54,258 Alcohol-Induced
47,511
Suicide
40,000 38,329 48,183

38,364 39,043

20,000 25,692

0
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Download data

Note: Categories are not mutually exclusive.

Data: 2010-2021 National Vital Statistics System (NVSS), via CDC WONDER.

Source: David C. Radley et al., The Commonwealth Fund 2023 Scorecard on State Health System Performance: Americans’ Health Declines and Access to Reproductive Care Shrinks, But
States Have Options (Commonwealth Fund, June 2023). https://doi.org/10.26099/fcas-cd24

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

U.S. adolescents and adults with mental health needs are often not able to access
treatment.
Youth ages 12–17 with a major depressive episode who Adults age 18 and older with any mental illness who
did not receive mental health services did not receive treatment
90 90

80 80

70 70

60 60

50 50

40 40

30 30

20 20

10 10

0 33 60 77 0 41 55 69
Lowest Rate State: US Average Highest Rate State: Lowest Rate State: US Average Highest Rate State:
D.C. SC MT HI
Download data Download data

Note: Exhibit shows the share of adolescents and adults who did not receive mental health care in the lowest- and highest-rate states, and the U.S. average.

Data: National Survey on Drug Use and Health (NSDUH), 2019-20, as reported by Mental Health America, “The State of Mental Health in America, 2023”

Source: David C. Radley et al., The Commonwealth Fund 2023 Scorecard on State Health System Performance: Americans’ Health Declines and Access to Reproductive Care Shrinks,
But States Have Options (Commonwealth Fund, June 2023). https://doi.org/10.26099/fcas-cd24

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

How States Rank on Reproductive Care and Women’s Health

The Scorecard’s new composite measure of
Click on the headers to sort the ranking.
reproductive care and women’s health includes Scroll to see all 50 states and D.C.
12 indicators of the quality and Rank State
comprehensiveness of care that women, 1 Massachusetts
mothers, and infants receive and the health 2 Rhode Island
outcomes they experience. The full list of 3 New Hampshire
measures, including data sources and definitions, 4 Maine
can be found in Appendix Table A1. 5 Connecticut
6 Iowa
Massachusetts performed best on this key aspect 7 Vermont
8 Wisconsin
of health system performance, with Rhode Island,
9 Oregon
New Hampshire, Maine, and Connecticut also
10 New York
placing among the top five states. The lowest-
11 Hawaii
ranked states are Oklahoma, Alaska, Texas,
12 California
Mississippi, and New Mexico.

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).

All-cause mortality rates for women of reproductive age vary widely across
states and increased significantly from 2019 to 2021.
Age-adjusted all-cause mortality rate per 100,000 females ages 15-44, by state (2019 and 2021)

2019 2021
250

200

150

100

50

0
Connecticut

Utah

Ohio
Idaho
Illinois

Maine

Florida

Arizona
Indiana
Wisconsin

Missouri

South Carolina
Maryland

Michigan

Montana

Alabama
Rhode Island

Oregon

Georgia

Oklahoma

Alaska
Hawaii

Iowa

Mississippi
Minnesota

United States

Louisiana
Arkansas
Colorado

Kansas

Wyoming

Kentucky
North Carolina
Massachusetts

New Jersey

South Dakota

New Mexico
California

Virginia

Delaware
Nevada
New Hampshire
Nebraska

North Dakota
Vermont
Washington

Pennsylvania

West Virginia
Tennessee
New York

Texas
D.C.

Download data

Data: 2019 and 2021 National Vital Statistics System (NVSS), via CDC WONDER.

Source: David C. Radley et al., The Commonwealth Fund 2023 Scorecard on State Health System Performance: Americans’ Health Declines and Access to Reproductive Care Shrinks,
But States Have Options (Commonwealth Fund, June 2023). https://doi.org/10.26099/fcas-cd24

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).

No early prenatal care 1/2


Twenty-nine percent of women in Texas and Florida did not receive
early prenatal care, compared to 11 percent in Vermont.
Percentage of live births for which prenatal care did not begin in the first trimester, by state (2021)

10.8%–16.7% 16.8%–20.7% 21.4%–23.4% 23.9%–29.3%

Notes: PRAMS respondents are surveyed 2 to 6 months after birth, and PRAMS defines a postpartum checkup visit as “the regular checkup a woman has about 4-6
weeks after she gives birth.” Indiana, Nevada, North Carolina, Oklahoma, Rhode Island, South Carolina, and Texas participated in the 2020 PRAMS but did not meet the
CDC’s 50% response rate requirement. California and Idaho do not participate in PRAMS, while Ohio conducts its own survey using the PRAMS core questionnaire and
is included.

Data: CDC WONDER Natality File, 2021.

Source: David C. Radley et al., The Commonwealth Fund 2023 Scorecard on State Health System Performance: Americans’ Health Declines and Access to Reproductive
Care Shrinks, But States Have Options (Commonwealth Fund, June 2023). https://doi.org/10.26099/fcas-cd24

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

The U.S. maternal mortality rate nearly doubled between 2018 and 2021, and
rates for American Indian/Alaska Native and Black women increased the most
during the COVID-19 pandemic.
Maternal mortality rate per 100,000 live births, United States (2018-2021)

120

100

80 Total
Black

60 AIAN
AANHPI

40 Hispanic
White

20

0
2018 2019 2020 2021
Download data

Note: Maternal deaths include those assigned to ICD-10 codes A34, O00–O95, and O98–O99 and occur while pregnant or within 42 days of being pregnant. Rates shown are for
American Indian/Alaska Native (AIAN; non-Hispanic); Asian American, Native Hawaiian and Pacific Islander (AANHPI; non-Hispanic); Black (non-Hispanic); white (non-Hispanic); and
Hispanic (any race) people, based on information from decedent’s death certificate. 2018 AIAN rate is not available because of CDC data suppression standards for small numbers of
deaths.

Data: 2018–2021 National Vital Statistics System (NVSS), Natality and Mortality; and Donna L. Hoyert, Maternal Mortality Rates in the United States, 2021 (National Center for Health
Statistics, March 2023).

Source: David C. Radley et al., The Commonwealth Fund 2023 Scorecard on State Health System Performance: Americans’ Health Declines and Access to Reproductive Care Shrinks,
But States Have Options (Commonwealth Fund, June 2023). https://doi.org/10.26099/fcas-cd24

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

Maternal mortality between 2019 and 2021 varied widely across states, with
rates above 40 deaths per 100,000 live births in Arkansas, Alabama, Louisiana,
Tennessee, and Mississippi.
Maternal mortality rate per 100,000 live births, by state (2019-21)

60

50 50.3

40

30

20

10 9.6

0
Connecticut

Utah

Ohio
Idaho
Illinois

Florida

Indiana

Arizona
Wisconsin

Missouri

South Carolina
Michigan

Maryland

Montana

Alabama
Oregon

Oklahoma

Georgia
Hawaii
Iowa

Mississippi
Minnesota

Louisiana
Arkansas
Colorado

Kansas

Kentucky
North Carolina
Massachusetts

New Jersey

South Dakota

New Mexico
California

Virginia
Nevada
Nebraska

North Dakota
Washington
Pennsylvania

West Virginia

Tennessee
New York

Texas

Download data

Note: Calculated by authors. Maternal deaths include those assigned to ICD-10 codes A34, O00–O95, and O98–O99 and occur while pregnant or within 42 days of being pregnant.
Maternal mortality rates for Alaska, Delaware, D.C., Maine, New Hampshire, Rhode Island, Vermont, and Wyoming could not be calculated because of CDC suppression standards for
small numbers of deaths (<10).

Data 2019-2021 National Vital Statistics System (NVSS), Natality and Mortality, via CDC WONDER.

Source: David C. Radley et al., The Commonwealth Fund 2023 Scorecard on State Health System Performance: Americans’ Health Declines and Access to Reproductive Care Shrinks,
But States Have Options (Commonwealth Fund, June 2023). https://doi.org/10.26099/fcas-cd24

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.

How States Rank on Health Care Access and Affordability

When it comes to health insurance
Click on the headers to sort the ranking.
coverage and access to care, the top- Scroll to see all 50 states and D.C.
performing states in 2023 were Rank State
Massachusetts, Hawaii, Rhode Island, New 1 Massachusetts
Hampshire, and the District of Columbia. 2 Hawaii
Massachusetts reported the nation’s 3 Rhode Island
lowest adult uninsured rate, 3.4 percent. 4 New Hampshire
5 District of Columbia
The lowest-performing states were among 5 Vermont
7 Minnesota
those that had not yet expanded Medicaid
8 Connecticut
eligibility under the Affordable Care Act as
9 Pennsylvania
of 2021: Mississippi, Georgia, Wyoming,
10 Washington
Oklahoma, and Texas. Texas’s adult
11 Iowa
uninsured rate, 24.3 percent, was the 11 Michigan
nation’s highest in 2021. 13 New York

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.

Adult uninsured rates have fallen since 2019 but remain highest in states that
have not expanded their Medicaid programs.
Percentage of adults ages 19-64 who are uninsured, by state (2021)

Expanded Medicaid Had not expanded Medicaid

25 24.3

20

15

12.1

10

5
3.4

0
District of Columbia

South Carolina
Connecticut
Massachusetts

Rhode Island

United States

North Carolina
New Hampshire

South Dakota
Wisconsin

Mississippi
New Mexico

Oklahoma
Minnesota

Michigan

Maryland

New Jersey
North Dakota

Montana

Alabama
Louisiana

Missouri
Arkansas
Kentucky

Indiana

Arizona
Colorado

Wyoming

Georgia
Florida
Oregon
Maine

Illinois
Delaware

California

Idaho

Alaska
Hawaii

Ohio

Utah
Pennsylvania

Kansas
Nebraska
Washington
West Virginia

Nevada
Virginia
Iowa
Vermont

Tennessee
New York

Texas

Download data

Note: States with orange shading had not fully expanded their Medicaid program under the Affordable Care Act by January 1, 2021.

Data: U.S. Census Bureau, 2021 One-Year American Community Survey, Public Use Microdata Sample (ACS PUMS).

Source: David C. Radley et al., The Commonwealth Fund 2023 Scorecard on State Health System Performance: Americans’ Health Declines and Access to Reproductive Care Shrinks,
But States Have Options (Commonwealth Fund, June 2023). https://doi.org/10.26099/fcas-cd24

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

In some states, particularly in the South, as many as a quarter of residents have

medical debt; a symptom of coverage gaps and inadequate insurance.
Share of people with a credit bureau record who have medical debt in collections, by state (2021)

2.4% – 9.5%
10.4% – 15.9%
16.0% – 24.0%

Download data

Note: Urban Institute analysis is based on a 4 percent nationally representative sample of consumer records from a major credit bureau as of February 2022.

Data: Alexander Carther, et al., Debt in America (Urban Institute, June 2022). Accessible from https://datacatalog.urban.org/dataset/debt-america-2022

Source: David C. Radley et al., The Commonwealth Fund 2023 Scorecard on State Health System Performance: Americans’ Health Declines and Access to Reproductive Care Shrinks,
But States Have Options (Commonwealth Fund, June 2023). https://doi.org/10.26099/fcas-cd24

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.

SCORECARD METHODS The Commonwealth Fund’s 2023 Scorecard on State Health System
Performance evaluates states on 58 performance indicators grouped into five
dimensions, including a new dimension focused on Reproductive Care and
Women’s Health.

The report generally reflects data from 2021.

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 (15 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 (13 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 (10 indicators): includes measures of premature death, health

status, health risk behaviors and factors (including smoking and obesity), and
tooth loss.

Reproductive Care and Women’s Health (12 indicators): includes measures

to reflect health outcomes and access to important health services for
women, mothers, and infants, including mortality, such as maternal and
infant deaths; high-risk events, such as severe maternal morbidity and
preterm births; and access to important health services, like routine checkups
and prenatal or postpartum care. Certain measures in this domain have
appeared in the Healthy Lives dimension (e.g. infant mortality, cancer deaths,
maternal mortality) in previous scorecards. We include performance data for
each of the 12 metrics in each state’s 2023 State Scorecard profile, along with
data for different racial and ethnic groups on six of the metrics.

The development of this new dimension was made possible through

collaboration with Dr. Laurie Zephryin of the Commonwealth Fund, along
with helpful feedback from Dr. Eugene Declercq of Boston University and
Kay Johnson of Dartmouth Medical School.

INCOME DISPARITY DIMENSION

This year, the State Scorecard reports on performance differences within

states associated with individuals’ income level for 19 of the 49 indicators
where data are available to support a population analysis by income; these
indicators span four of the five dimensions. For most indicators, we measure
the difference between rates for a state’s low-income population (generally
less than 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
scorecards; 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 AND ETHNIC HEALTH EQUITY DIMENSION

As in 2022, 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 November 2021
report, Achieving Racial and Ethnic Equity in U.S. Health Care: A Scorecard of
State Performance, 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 (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 50 for Hispanic individuals in California indicates that the
health system is performing better for those residents than Hispanic people
in Texas, who have a score of 8, but worse than white residents in California,
who have a score of 89.

The updated overall percentile scores for AIAN, AANHPI, Black, and
Hispanic people are used in this year’s State Scorecard to reflect each state’s
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 Table I1. 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 2023 State
Scorecard profile.

GUIDING PRINCIPLES

The following principles guided the development of the State Scorecard:

Performance Metrics. The 58 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,
hospitalizations for children with asthma). New indicators have been added
to the State Scorecard series over time in response to evolving priorities or
data availability (e.g., measures of COVID-19 vaccination status and medical
debt).

Measuring Change over Time. We were able to track performance over time
for 50 of the 58 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., COVID-19 vaccination).

For indicators where trends were possible, the baseline period generally
reflects two to three years prior to the time of observation for the latest year
of data available (often 2019), with the intent to use a baseline period prior to
the emergence of COVID-19 in 2020. See Appendix Table 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 Table 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 available indicators within the
performance dimension. States with missing values for a specific indicator
are not assigned a z-score for that indicator, but are still assigned a dimension
score based on their values for other indicators within the dimension.
Dimension scores are averaged into an overall score, and 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).

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).

ACKNOWLEDGEMENTS We owe our sincere appreciation to all of 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; Emily Gadbois and
Vincent Mor, Brown University; and Caitlin Burbank, Gulcan Cil, Snehapriya
Yeddala, 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 also thank Dr. Eugene
Declercq of Boston University and Kay Johnson of Dartmouth Medical
School for their feedback on data indicators for the new Reproductive Care
and Women’s Health dimension and the report draft.

We would like to thank the following Commonwealth Fund staff members:

Joseph Betancourt, Melinda Abrams, Rachel Nuzum, and Neil Powe for
providing constructive feedback and guidance; and the Fund’s
communications and support teams, including Barry Scholl, Chris Hollander,
Deborah Lorber, Bethanne Fox, Josh Tallman, Jen Wilson, Paul Frame, Naomi
Leibowitz, Aishu Balaji, Sam Chase, Jack Schiff, Relebohile Masitha, Arnav
Shah, Evan Gumas, Alexandra Bryan, Sara Federman, Celli Horstman, Faith
Leonard, and Munira Gunja for their guidance, editorial and production
support, and public dissemination efforts.

Finally, the authors wish to acknowledge Maya Brod of Burness

Communications 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. Preventable mortality includes deaths before age 75 from causes that can generally be avoided through
effective public health and primary prevention interventions. Examples of causes include measles,
HIV/AIDS, and other infectious diseases; certain preventable cancers; personal injuries; and alcohol- and
drug-related mortality. Treatable mortality includes deaths before age 75 from causes that can generally
be avoided through timely and effective health care interventions. Examples of causes include diabetes
(50%), heart disease (50%), appendicitis, certain types of cancer, and maternal mortality. Based on the
methodology and categories developed by the Organisation for Economic Co-operation and
Development: Avoidable Mortality: OECD/Eurostat Lists of Preventable and Treatable Causes of Death
(Jan. 2022 version) (OECD, Jan. 2022).

2. Thomas J. Bollyky et al., “Assessing COVID-19 Pandemic Policies and Behaviours and Their Economic
and Educational Trade-Offs Across U.S. States from Jan. 1, 2020, to July 31, 2022: An Observational
Analysis,” The Lancet 401, no. 10385 (Apr. 22, 2023): 1341–60.

3. John Gramlich, What the Data Says About Gun Deaths in the U.S. (Pew Research Center, Apr. 26, 2023);
Janie Boschma, Curt Merrill, and John Murphy-Teixidor, “Mass Shootings in the US: Fast Facts,” CNN,
May 4, 2023; and Evan D. Gumas, Munira Z. Gunja, and Reginald D. Williams II, “The Health Costs of Gun
Violence: How the U.S. Compares to Other Countries,” chartpack, Commonwealth Fund, Apr. 2023.

4. Chad Terhune and Robin Respaut, “U.S. Diabetes Deaths Top 100,000 for Second Straight Year,” Reuters,
Jan. 31, 2022; and Alexander Tin, “Heart-Related Deaths Rose Sharply During First Year of COVID-19
Pandemic, Report Shows,” CBS News, Jan. 25, 2023.

5. Elizabeth Arias et al., “U.S. State Life Tables, 2020,” National Vital Statistics Reports 71, no. 2 (Aug. 23,
2022).

6. Elizabeth Arias et al., “Provisional Life Expectancy Estimates for 2021,” National Vital Statistics Rapid
Release, no. 23 (Aug. 2022).

7. Benedict I. Truman, Man-Huei Chang, and Ramal Moonesinghe, “Provisional COVID-19 Age-Adjusted
Death Rates, by Race and Ethnicity — United States, 2020–2021,” Morbidity and Mortality Weekly Report
71, no. 17 (Apr. 29, 2022): 601–5; Quanhe Yang et al., “Stroke Mortality Among Black and White Adults
Aged ≥35 Years Before and During the COVID-19 Pandemic — United States, 2015–2021,” Morbidity and
Mortality Weekly Report 72, no. 16 (Apr. 21, 2023): 431–36; and Stephen Sidney et al., “Age-Adjusted
Mortality Rates and Age and Risk–Associated Contributions to Change in Heart Disease and Stroke
Mortality, 2011–2019 and 2019–2020,” JAMA Network Open 5, no. 3 (Mar. 2022): e223872.

8. Courtnee Melton-Fant, “Health Equity and the Dynamism of Structural Racism and Public Policy,”
Milbank Quarterly 100, no. 3 (Sept. 2022): 628–49.

9. Authors’ analysis of CDC WONDER Database (Wide-Ranging Online Data for Epidemiologic Research).

10. Matt Richtel, “The Surgeon General’s New Mission: Adolescent Mental Health,” New York Times, Mar. 21,
2023.

11. Centers for Disease Control and Prevention, “CDC Report Shows Concerning Increases in Sadness and
Exposure to Violence Among Teen Girls and LGBQ+ Youth,” news release, Mar. 9, 2023.

12. Mental Health America, The State of Mental Health in America: 2023.

13. Guttmacher Institute, “Interactive Map: U.S. Abortion Policies and Access After Roe,” updated June 13,
2023; and “Tracking the States Where Abortion Is Now Banned,” New York Times, updated June 5, 2023.

14. Sarah Varney, “After Idaho’s Strict Abortion Ban, OB-GYNs Stage a Quick Exodus,” KFF Health News, May
2, 2023; Eric Boodman, “Legal at One Clinic, Illegal at Another: How Abortion Bans Make Gestational Age
Even Less Precise,” STAT, Nov. 10, 2022; and Arielle Dreher and Oriana González, “New Doctors Avoid
Residencies in States with Abortion Bans,” Axios, Apr. 18, 2023.

15. Laurie C. Zephyrin and David Blumenthal, “The Loss of Abortion Rights Will Send Shockwaves Through
the U.S. Health Care System,” To the Point (blog), Commonwealth Fund, June 24, 2022; and Fabiola
Cineas, “Black Women Will Suffer the Most Without Roe,” Vox, June 29, 2022.

16. Marie E. Thoma and Eugene R. Declercq, “All-Cause Maternal Mortality in the US Before vs During the
COVID-19 Pandemic,” JAMA Network Open 5, no. 6 (June 2022): e2219133.

17. Marie E. Thoma and Eugene R. Declercq, “Changes in Pregnancy-Related Mortality Associated with the
Coronavirus Disease 2019 (COVID-19) Pandemic in the United States,” Obstetrics & Gynecology 141, no. 5
(May 1, 2023): 911–17.

18. Karen Wang, Derek Kravitz, and Dillon Bergin, “New CDC and State Data Shows How the COVID-19
Pandemic Led to a Startling Rise in Maternal Deaths,” MuckRock, Mar. 8, 2023; Jodie G. Katon et al.,
Policies for Reducing Maternal Morbidity and Mortality and Enhancing Equity in Maternal Health: A
Review of the Evidence (Commonwealth Fund, Nov. 2021); and authors’ analysis of CDC WONDER.

19. Elizabeth A. Howell et al., “Race and Ethnicity, Medical Insurance, and Within-Hospital Severe Maternal
Morbidity Disparities,” Obstetrics and Gynecology 135, no. 2 (Feb. 2020): 285–93; and Elizabeth A. Howell
and Jennifer Zeitlin, “Improving Hospital Quality to Reduce Disparities in Severe Maternal Morbidity
and Mortality,” Seminars in Perinatology 41, no. 5 (Aug. 2017): 266–72.

20. Meghan Bellerose, Mariela Rodriguez, and Patrick Vivier, “A Systematic Review of the Qualitative
Literature on Barriers to High-Quality Prenatal and Postpartum Care Among Low-Income Women,”
Health Services Research 57, no. 4 (Aug. 2022): 775–85; Denisse S. Holcomb et al., “Geographic Barriers to
Prenatal Care Access and Their Consequences,” American Journal of Obstetrics & Gynecology MFM 3, no.
5 (Sept. 2021): 100442; and Nowhere to Go: Maternity Care Deserts Across the U.S. (March of Dimes, Oct.
2022).

21. Strong Start for Mothers and Newborns Initiative: Evaluation of Full Performance Period (2018) (CMS
Center for Medicare and Medicaid Innovation); and Arden Handler and Kay Johnson, “A Call to Revisit
the Prenatal Period as a Focus for Action Within the Reproductive and Perinatal Care Continuum,”
Maternal and Child Health Journal 20, no. 11 (Sept. 2016): 2217–27.

22. Eugene Declercq and Laurie C. Zephyrin, Maternal Mortality in the United States: A Primer
(Commonwealth Fund, Dec. 2020); Munira Z. Gunja et al., Health and Health Care for Women of
Reproductive Age: How the United States Compares with Other High-Income Countries (Commonwealth
Fund, Apr. 2022); Munira Z. Gunja, Evan D. Gumas, and Reginald D. Williams II, “The U.S. Maternal
Mortality Crisis Continues to Worsen: An International Comparison,” To the Point (blog),
Commonwealth Fund, Dec. 1, 2022; and Donna L. Hoyert, Maternal Mortality Rates in the United States,
2021 (National Center for Health Statistics, Mar. 2023).

23. Martha Hostetter, Sarah Klein, and Laurie C. Zephyrin, Maternity Care, Interrupted: As the U.S. Is Jolted by
COVID-19, So Too Is the Traditional Model of Delivering Maternity Care (Commonwealth Fund, May
2020).

24. Maternal Health: Outcomes Worsened and Disparities Persisted During the Pandemic (U.S. Government
Accountability Office, Oct. 2022).

25. Hoyert, Maternal Mortality Rates, 2023; authors’ calculations using CDC natality and mortality files;
Thoma and Declercq, “Changes in Pregnancy-Related Mortality,” 2023.

26. GAO, Maternal Health: Outcomes Worsened, 2022.

27. Diana Crumley, How California’s Medi-Cal Program Aims to Advance Health Equity for Pregnant People
(Center for Health Care Strategies, July 2022).

28. Guttmacher Institute, “Interactive Map,” 2023.

29. Eugene Declercq et al., The U.S. Maternal Health Divide: The Limited Maternal Health Services and Worse
Outcomes of States Proposing New Abortion Restrictions (Commonwealth Fund, Dec. 2022).

30. Centers for Medicare and Medicaid Services, January 2023 Medicaid and CHIP Enrollment Trends
Snapshot.

31. Centers for Medicare and Medicaid Services, “Access to Health Coverage.”

32. Office of the Assistant Secretary for Planning and Evaluation, Unwinding the Medicaid Continuous
Enrollment Provision: Projected Enrollment Effects and Policy Approaches (U.S. Department of Health and
Human Services, Aug. 19, 2022); and Caroline Hanson et al., “Health Insurance for People Younger Than
Age 65: Expiration of Temporary Policies Projected to Reshuffle Coverage, 2023–33,” Health Affairs 42,
no. 6 (June 2023): 742–52.

33. Sara Rosenbaum et al., “Unwinding Continuous Medicaid Enrollment,” New England Journal of Medicine
388, no. 12 (Mar. 23, 2023): 1061–63; and Usha Ranji, Jennifer Tolbert, and Ivette Gomez, “Postpartum
Individuals Are at Risk of Losing Medicaid During the Unwinding of the Medicaid Continuous
Enrollment Provision, Especially in Certain States,” Henry J. Kaiser Family Foundation, May 30, 2023.

34. Sara R. Collins, Lauren A. Haynes, and Relebohile Masitha, The State of U.S. Health Insurance in 2022:
Findings from the Commonwealth Fund Biennial Health Insurance Survey (Commonwealth Fund, Sept.
2022).

35. Consumer Financial Protection Bureau, Medical Debt Burden in the United States (CFPB, Feb. 2022).

36. Sara R. Collins, David C. Radley, and Jesse C. Baumgartner, State Trends in Employer Premiums and
Deductibles, 2010–2020 (Commonwealth Fund, Jan. 2022).

37. Yalda Jabbarpour et al., The Health of US Primary Care: A Baseline Scorecard Tracking Support for High-
Quality Primary Care (Milbank Memorial Fund, Feb. 2023); and Atul Gawande, “The Aftermath of a
Pandemic Requires as Much Focus as the Start,” New York Times, Mar. 16, 2023.

38. Nathaniel Counts and Rachel Nuzum, “What Policymakers Can Do to Address Our Behavioral Health
Crisis,” To the Point (blog), Commonwealth Fund, Sept. 21, 2022.

39. Improving Behavioral Health Care for Youth Through Collaborative Care Expansion (Meadows Mental
Health Policy Institute, May 2023).

40. Jesse C. Baumgartner and Celli Horstman, “Changing the Way Opioid Addiction Treatment Is Delivered
Could Reduce Death and Suffering,” To the Point (blog), Commonwealth Fund, Oct. 24, 2022.

41. Charlie Severance-Medaris, “As Opioid Overdoses Surge, States Expand Treatment,” National Conference
of State Legislatures, May 17, 2022.

42. Jesse C. Baumgartner and David C. Radley, “Overdose Deaths Declined but Remained Near Record Levels
During the First Nine Months of 2022 as States Cope with Synthetic Opioids,” To the Point (blog),
Commonwealth Fund, Mar. 13, 2023.

43. “Medicaid Postpartum Coverage Extension Tracker,” Henry J. Kaiser Family Foundation, June 15, 2023.

44. Sara Rosenbaum et al., “The Road to Maternal Health Runs Through Medicaid Managed Care,” To the
Point (blog), Commonwealth Fund, May 22, 2023; and Shanoor Seervai et al., “Limiting Abortion Access
for American Women Impacts Health, Economic Security: An International Comparison,” To the Point
(blog), Commonwealth Fund, Jan. 12, 2023.

45. Declercq et al., The U.S. Maternal Health Divide, 2022; and Katon et al., Policies for Reducing Maternal
Morbidity and Mortality, 2021.

46. Gunja et al., Health and Health Care for Women of Reproductive Age, 2022; and Katon et al., Policies for
Reducing Maternal Morbidity and Mortality, 2021.

47. “Chapter 6: Substance Use Disorder and Maternal and Infant Health,” in Report to Congress on Medicaid
and CHIP (Medicaid and CHIP Payment and Access Commission, June 2020); “Substance Use Disorder
Treatment in Pregnant and Parenting Women: Integrated Care Models,” CLOUD Library, Center for
Evidence-based Policy, May 12, 2020; and Maggie Clark, “Maternal Mental Health Month Shines Light on
Need for Policy Solutions,” Say Ahhh! (blog), Georgetown University Health Policy Institute, Center for
Children and Families, May 25, 2023.

48. Eileen Wang et al., “Social Determinants of Pregnancy-Related Mortality and Morbidity in the United
States: A Systematic Review,” Obstetrics and Gynecology 135, no. 4 (Apr. 2020): 896–915.

49. Elizabeth Lower-Basch and Stephanie Schmit, TANF and the First Year of Life: Making a Difference at a
Pivotal Moment (Center for Law and Social Policy, Oct. 2015); and Heather D. Hill, “Welfare as Maternity
Leave? Exemptions from Welfare Work Requirements and Maternal Employment,” Social Service Review
86, no. 1 (Mar. 2012): 37–67.

50. Sara Rosenbaum, “Expanding Health Coverage to the Poorest Residents of States That Have Not
Expanded Medicaid,” To the Point (blog), Commonwealth Fund, Feb. 1, 2022.

51. Sara R. Collins and Lauren A. Haynes, “Congress Can Give States the Option to Keep Adults Covered in
Medicaid,” To the Point (blog), Commonwealth Fund, Nov. 14, 2022.

52. The approach would treat all legal residents as insured 12 months a year regardless of enrollment in a
health plan. Income-related premiums would be collected through the tax system. See Linda J.
Blumberg, John Holahan, and Jason Levitis, How Auto-Enrollment Can Achieve Near-Universal Coverage:
Policy and Implementation Issues (Commonwealth Fund, June 2021).

53. A bill introduced by Senator Jeanne Shaheen (D–N.H.) would raise the cost-protection of the
marketplace benchmark plan and make more people eligible for cost-sharing subsidies (Improving
Health Insurance Affordability Act of 2021, S. 499, 117th Cong. (2021), S. Doc. 1–6). This could eliminate
deductibles for some people and reduce them for others by as much as $1,650 a year. See Linda J.
Blumberg et al., From Incremental to Comprehensive Health Insurance Reform: How Various Reform
Options Compare on Coverage and Costs (Urban Institute, Oct. 2019); and Jesse C. Baumgartner, Munira
Z. Gunja, and Sara R. Collins, The New Gold Standard: How Changing the Marketplace Coverage
Benchmark Could Impact Affordability (Commonwealth Fund, Sept. 2022).

54. John Holahan and Michael Simpson, Next Steps in Expanding Health Coverage and Affordability: What
Policymakers Can Do Beyond the Inflation Reduction Act (Commonwealth Fund, Sept. 2022); Rosenbaum,
“Expanding Health Coverage,” 2022; and John Holahan et al., Filling the Gap in States That Have Not
Expanded Medicaid Eligibility (Commonwealth Fund, June 2021, updated Oct. 5, 2021).

55. Choose Medicare Act, H.R.5011, 117th Cong. (2021), H.R. Doc. 1–32; Medicare-X Choice Act of 2021,
H.R.1227, 117th Cong. (2021), H.R. Doc. 1–24; Medicare-X Choice Act of 2021, S.386, 117th Cong. (2021),
S. Doc. 1–25; State Public Option Act, H.R.4974, 117th Cong. (2021), H.R. Doc. 1–27; State Public Option
Act, S.2639, 117th Cong. (2021), S. Doc. 1–27; Public Option Deficit Reduction Act, H.R.2010, 117th Cong.
(2021), H.R. Doc. 1–17; CHOICE Act, S.983, 117th Cong. (2021), S. Doc. 1–12; Health Care Improvement
Act of 2021, S.352, 117th Cong. (2021), S. Doc. 1–75; State-Based Universal Health Care Act of 2021,
H.R.3775, 117th Cong. (2021), H.R. Doc. 1–30; Christine H. Monahan, Justin Giovannelli, and Kevin Lucia,
“HHS Approves Nation’s First Section 1332 Waiver for a Public Option Plan in Colorado,” To the Point
(blog), Commonwealth Fund, July 12, 2022; Christine H. Monahan, Justin Giovannelli, and Kevin Lucia,
“Update on State Public Option-Style Laws: Getting to More Affordable Coverage,” To the Point (blog),
Commonwealth Fund, Mar. 29, 2022; and Ann Hwang et al., State Strategies for Slowing Health Care Cost
Growth in the Commercial Market (Commonwealth Fund, Feb. 2022).

56. The Biden Administration Announces New Actions to Lesson the Burden of Medical Debt and Increase
Consumer Protection, fact sheet, The White House, Apr. 11, 2022.

57. Chi Chi Wu, Jenifer Bosco, and April Kuehnhoff, Model Medical Debt Protection Act (National Consumer
Law Center, Sept. 2019); and Christopher T. Robertson, Mark Rukavina, and Erin C. Fuse Brown, “New
State Consumer Protections Against Medical Debt,” JAMA 327, no. 2 (Jan. 11, 2022): 121–22.

58. Adam Liptak, “In Abortion Pill Ruling, the Supreme Court Trades Ambition for Prudence,” New York
Times, Apr. 22, 2023.

PUBLICATION DETAILS DATE AREA OF FOCUS

June 22, 2023 Achieving Universal Coverage

CONTACT
TOPICS
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COVID-19,
CITATION Government Programs & Policies,
David C. Radley et al., The Commonwealth Fund 2023 Health Disparities,
Maternal Health,
Scorecard on State Health System Performance: Americans’
Medicaid Expansion,
Health Declines and Access to Reproductive Care Shrinks, But Social Needs,
States Have Options (Commonwealth Fund, June 2023). State Health Policy,
https://doi.org/10.26099/fcas-cd24 Quality of Care

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