2018 Scorecard on David C. Radley Senior Scientist State Health System The Commonwealth Fund Douglas McCarthy Performance Senior Research Director The Commonwealth Fund Susan L. Hayes Senior Researcher The Commonwealth Fund MAY 2018 2018 Scorecard on State Health System Performance OVERVIEW Hawaii, Massachusetts, Minnesota, Vermont, Overall, four major trends emerge from and Utah are the top-ranked states according our analysis of the Scorecard results: to the Commonwealth Fund’s 2018 Scorecard on State Health System Performance, which Rising death rates, high assesses all 50 states and the District of levels of obesity, and gaps in Columbia on more than 40 measures of access care are pressing challenges to health care, quality of care, efficiency in care for states delivery, health outcomes, and income-based health care disparities. Regional differences in The 2018 Scorecard reveals that states are performance persist, as do losing ground on key measures related to within-state disparities life expectancy. On most other measures, performance continues to vary widely across Many states are not getting states; even within individual states, large good value for their health disparities are common. care dollars Still, on balance, the Scorecard finds more improvement than decline between 2013 and States made progress in 2016 in the functioning of state health care areas that were the target of systems. This represents a reversal of sorts from efforts to improve the first decade of the century, when stagnating or worsening performance was the norm. 2018 Scorecard on State Health System Performance 3 SCORECARD HIGHLIGHTS Which states lead the rankings? Hawaii, Did the Medicaid expansion make a difference? Massachusetts, Minnesota, Vermont, and Utah. In 47 states, the uninsured rate for adults ages 19 to 64 was at least five percentage points Which states are ranked at the bottom? lower in 2016 than it had been in 2013. Eleven Louisiana, Oklahoma, and Mississippi. of the 13 states with at least a 10-point drop Which states moved up the most in the had expanded Medicaid by January 2016. rankings between 2013 and 2016? California During this time, there was also a drop in the and Oregon rose the highest, jumping 9 and percentage of people reporting they had not 10 spots, respectively. Both states expanded gone to the doctor when needed because of eligibility for Medicaid. the cost. States that expanded Medicaid saw greater improvement, on average, than states Which states improved on the most indicators? that did not. New York improved on 18 of the 37 indicators we track over time — the most of any state. How does performance vary regionally? Arkansas, Louisiana, Oklahoma, and West New England, the Upper Midwest, and several Virginia each improved on 17 indicators. states in the West are at the top of our overall Exhibit 1 INTERACTIVE Overall health system performance variesstates Overall health system performance varies greatly among greatly among states Better performance HI MA MN VT UT IA WA WI CT CO NH OR RI CA ID ME SD MT NY MD NE DE ND PA NJ IL U.S. average MI VA AZ DC NM KS WY AK NC OH IN SC NV GA TN KY AL MO TX AR WV FL LA OK MS Worse performance States are arranged in rank order from left (best) to right (worst), based on their overall 2018 Scorecard rank. States are arranged in rank order from left (best) to right (worst), based on their overall 2018 Scorecard rank. commonwealthfund.org May 2018 Source: David C. Radley, Douglas McCarthy, and Susan L. Hayes, 2018 Scorecard on State Health System Performance (The Commonwealth Fund, May 2018). 2018 Scorecard on State Health System Performance 4 Exhibit 2 More improvement than decline decline More improvement than New York Greatly improved MOST IMPROVED Improved Worsened Greatly worsened INDICATORS IMPROVED INDICATORS WORSENED Notes: Based on trends for 37 of 43 total indicators (Disparity dimension not included); trend data are not available for all indicators. Bar length equals the total number of indicators with any improvement or worsening with an absolute value greater than 0.5 standard deviations (StDev) of the state distribution. Lighter portion of bars represents the number of indicators with a change of 0.5–0.9 StDevs between baseline and current time periods, darker portions represent indicators with 1.0 or greater StDev change. Notes: Based on trends for 37 of 43 total indicators (Disparity dimension not included); trend data are not available for all indicators. Bar length equals the total number of indicators with any improvement or worsening with an absolute value greater than 0.5 standard deviations (StDev) of the state distribution. Lighter portion of bars Exhibit 3B represents the number of indicators with a change of 0.5–0.9 StDevs between baseline and current time periods, darker portions represent indicators with 1.0 or greater rankings. Southern states StDev change. State health system performance varies within regions State health system performance varies within re generally rank at the bottom. The Scorecard shows how Source: David C. Radley, Douglas2018). and Susan L. Hayes, 2018 Scorecard on State Health System Performance (The Commonwealth Fund, May McCarthy, states perform relative to their geographic neighbors. Northeast West What’s the trend? Following a long period of decline, premature Midwest death rates are flattening or trending upward in many states. Nonetheless, across all dimensions of South performance there was more Top 3 states in each region improvement than decline Better-than-average states in each region between 2013 and 2016 — a Worse-than-average states in each region reversal of what happened during the 2000s, when Note: Regions are U.S. Census regions. Regional shading is based on performance among states within the region progress stalled or worsened. only. See Scorecard Methods for additional detail. Note: Regions are U.S. Census regions. Regional shading is based on performance among states within the region only. See Scor Source: David C. Radley, Douglas McCarthy, and Susan L. Hayes, 2018 Scorecard on commonwealthfund.org (The Commonwealth Fund, May 2018). May 2018 2018 Scorecard on State Health System Performance 5 KEY TRENDS Premature deaths are on the rise. After trending downward for most of the past decade, rates of premature death from preventable or treatable causes (a measure called Rising death rates, high levels of “mortality amenable to health care”3) ticked upward obesity, and gaps in care are pressing nationally. Two-thirds of states experienced an increase challenges for states. in 2014–15. In six states — Colorado, Maine, Nebraska, Oklahoma, Vermont, and Wyoming — the increase was Deaths from suicide, alcohol, and drug use are at an all-time greater than 5 percent. Compared to mortality rates in high. In 2016, average life expectancy at birth in the United 2012–13, the higher rates in 2014–15 represented a sobering States declined for a second year in a row, driven in large number of additional premature deaths: 351 in Colorado, part by a spike in deaths from opioid and other substance 643 in Oklahoma, and 988 in Texas, for example. abuse as well as suicide.1 The combined rate of deaths from suicide, alcohol, and drug use — sometimes referred to as Obesity represents a rising public health threat. In “deaths of despair” — increased 50 percent from 2005 to 2 Mississippi and West Virginia, the proportion of obese 2016. Rates rose in all states, doubling or more in Delaware, adults reached 39 percent in 2016. Even in states with the New Hampshire, New York, Ohio, and West Virginia. lowest rates, a quarter of adults are obese. Exhibit 4 Deaths from suicide, alcohol, and drug overdose on theoverdose on the rise and Deaths from suicide, alcohol, and drug rise and differences between states widening differences between states widening Deaths per 100,000 population U.S. average State rates Data: 2004–2016 National Vital Statistics System (NVSS), via CDC WONDER. Data: 2004–2016 National Vital Statistics System (NVSS), via CDC WONDER. Source: David C. Radley, Douglas McCarthy, and Susan L. Hayes, 2018 Scorecard on State Health System Performance (The Commonwealth Fund, May 2018). commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 6 Exhibit 5 Premature death rates from treatable medical conditions rose Premature death rates from treatable medical conditions rose slightly following decade- slightly following decade-long decline long decline Mortality amenable to health care: deaths per 100,000 population U.S. average State rates U.S. average if historical trend had continued Notes: Y-axis starts at 50 deaths per 100,000. Dashed line represents the expected premature death rate if the historical trend from 2004–05 to 2012–13 had continued in Notes: Y-axis starts at 50 deaths per 100,000.do not include deaths from expected premature death rate if the historical trend from 2004–05 to 2012–13 had continued in 2014–15. Premature deaths reported here Dashed line represents the suicide, alcohol, or drug use; see Appendix H for a complete list of health care–amenable deaths. 2014–15. Premature deaths Vital Statistics do not include deaths from suicide, alcohol, or drug use; see Appendix H for a complete list of health care–amenable deaths. Data: 2004–2015 National reported here System (NVSS) Mortality All-County Micro Data Files. Data: 2004–2015 National Vital Statistics System (NVSS) Mortality All-County Micro Data Files. Source: David C. Radley, Douglas McCarthy, and Susan L. Hayes, 2018 Scorecard on State Health System Performance (The Commonwealth Fund, May 2018). 56 % Gaps in mental health care are pervasive. Up to one-quarter of In the worst- adults with a mental illness reported performing states: a need for care that wasn’t met during the 2013–15 period. Meanwhile, up to one-third of children needing mental of adults with mental illness received 66% of adults in health treatment in 2016 did not no treatment Nevada received receive it, according to their parents. no treatment Across states, 41 percent to 66 percent of adults with symptoms of a mental illness (some of whom may not have been diagnosed) received no treatment in 2013–15. 18 % 34% of children with of children in mental health Georgia received What Can Be Done? Reversing these no treatment needs received trends and closing gaps in care will no treatment likely require cooperation across sectors as well as greater integration Data: 2013–15 National Survey of Drug Use and Health, as reported in The State of Mental Health Care in of medical, behavioral, public health, America, 2017; 2016 National Survey of Children’s Health, as reported by the Child and Adolescent Health Measurement Initiative. and social services.4 commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 7 Exhibit 8 Income-related disparities in health care access differ a What Are States Doing? Some states and Medicaid The magnitude of health care disparities within states managed care organizations are realizing the importance Alabama varies widely when comparing low- and high-income Pennsylvania of investing in, and fostering linkages to, social services in residents. In Alabama, for example, low-income adults are the community that can address the “social determinants nearly seven times more likely than high-income residents 33% of health,” such as stable housing and access to nutritious to report skipping needed care because of the cost (33% food.5 Medicaid programs are starting to integrate 27% vs. 5%). In Pennsylvania, the disparity is much narrower behavioral and physical health care, for example, by (17% vs. 9%). This pattern of disparities in access to care establishing “health homes” where teams of health is mirrored in uninsured rates, which reflect differences professionals deliver coordinated care for patients with in state policies such as Medicaid eligibility.7 Income- 17% 15% chronic illnesses and provide screenings, referrals to related disparities are evident across all the Scorecard’s substance abuse treatment, and other services.6 dimensions of health system performance. 4% 5% 3% Regional differences in performance adults care because ofdisparitiesUninsured adults Uninsured Income-related Adults who skipped in health care Adults wh access differ acrosscost states Exhibit 8 care becau persist, as do within-state disparities. Income-related disparities in health care Less than 200% 400% federal poverty Geographic disparities persist. As previous Commonwealth federal poverty level level or higher Fund scorecards have documented, the highest-ranked Data: Uninsured (ages 19–64): U.S. Census Bureau, 2016 One-Year American Community Surveys. Public Use Micro Sample (ACS PUMS); Cost b state generally performs two to three times betterRisk Factor Surveillance System (BRFSS). 2016 Behavioral overall than the lowest-ranked state. It’s a stark reminder that Alabama where you live can affect both your ability to access Source: David C. Radley, Douglas McCarthy, and Susan L. Hayes, 2018 Scorecard on State Health Sy high-quality health care and your prospects for a healthy (The Commonwealth Fund, May 2018). 33% life. Differences between states are most pronounced for 27% hospital admission rates among children with asthma: Exhibit 8 Vermont had 11 times fewer admissions per 100,000 Income-related disparities in health care access differ across states children than New York did (22 vs. 243). 15% Exhibit 7 America’s health care Alabama divide America’s health care divide Exhibit 8 Pennsylvania 4% 5% Income-related disparities in health Uninsured adults differwho skippedstates Uninsur care access Adults across 33% care because of cost 27% Alabama Pennsylvaniapoverty level Less than 200% federal 400% federa level or high 17% Data: Uninsured (ages 19–64): U.S. Census Bureau, 2016 One-Year American Community Surveys. Public U 33% 15% 2016 Behavioral Risk Factor Surveillance System (BRFSS). 27% 9% Source: David C. Radley, Douglas McCarthy, and Susan L. Haye (The Commonwealth Fund, May 2018). 4% 5% 3% Uninsured adults Adults who skipped Uninsured adults Adults who skipped care because of cost 17% 15% care because of cost 9% Data: Uninsured (ages 19–64): U.S. Census Bureau, 2016 One-Year American Better-than-average than 200% Community Surveys. Public Use Micro Sample (ACS PUMS); Cost barriers (age 18 Less states 400% federal poverty federal poverty level level or higher 4% Worse-than-average states5% 3% and older): 2016 Behavioral Risk Factor Surveillance System (BRFSS). Data: UninsuredUninsured adults Bureau, 2016 One-Year American Community Surveys. Public Use Micro Sample (ACS PUMS); Cost barriers (age 18 and older): (ages 19–64): U.S. Census Adults who skipped Uninsured adults Adults who skipped 2016 Behavioral Risk Factor Surveillance System (BRFSS). care because of cost care because of cost commonwealthfund.org Source: David C. Radley, Douglas McCarthy, and Susan L. Hayes, 2018 Scorecard on State Health System Performance 2018 May Less than 200% (The Commonwealth Fund, May 2018). 400% federal poverty federal poverty level level or higher 2018 Scorecard on State Health System Performance 8 What Can Be Done? Socioeconomic disadvantages are a many as 40 percent of adults in Idaho, New Mexico, major contributor to disparities in health care and health Oklahoma, and Wyoming did not get these screenings. outcomes across the country.8 In general, people of color • Even when they have insurance coverage, Americans are disproportionately more likely than whites to have visit the emergency department (ED) for nonemergency lower incomes and to be at risk for health care disparities.9 care at high rates. Similarly high rates among Medicare- Measuring disparities in health care can help to raise and employer-insured adults suggest there may be awareness of the need for action, but this is only a first step factors other than coverage or age, such as inadequate toward achieving equal opportunity for health.10 access to primary care, driving the behavior. What Are States Doing? Many states are promoting 29 % health equity by expanding Medicaid eligibility, engaging in multisector partnerships, increasing health care workforce diversity, promoting standards for culturally appropriate services, and addressing the social of adults received determinants of health.11 Oregon’s Medicaid Coordinated potentially Care Organizations, for example, demonstrate how state inappropriate policy can help narrow disparities in access to care by lower back imaging improving how health services are delivered to patients.12 at diagnosis In the worst-performing state: Many states are not getting good value 41 % of adults in Alabama received for their health care dollars. potentially inappropriate imaging at diagnosis Quality of care is not in line with the level of state health spending. Health care spending in the United States is much greater than in other wealthy countries, but U.S. 32 % health outcomes are not better.13 Our analysis finds that for every state, health spending exceeds median per capita spending in each of 10 other high-income countries.14 In general, research shows that higher spending in the U.S. is of adults failed attributable to higher prices.15 to receive all Here are just a few examples of gaps in quality across the U.S.: recommended cancer screenings • Among working-age adults with employer-sponsored insurance, nearly one in three (29%) who were newly diagnosed with lower back pain in 2015 received In the worst-performing states: 40 % potentially inappropriate medical imaging. That of adults in Idaho, means the scans these patients received are not New Mexico, Oklahoma, associated with improved outcomes when there is no and Wyoming failed underlying condition; some tests would expose them to get recommended to unnecessary radiation.16 In Alabama, the worst- cancer screenings performing state on this measure, the rate is 41 percent. Note: Lower back pain imaging is measured among newly diagnosed working-age patients ages 18–50 with employer-sponsored insurance. • One in three adults were not up to date on Data: Lower back imaging, 2015 Truven MarketScan Database, analysis by recommended cancer screenings in 2016. Even in the M. Chernew, Harvard University; Cancer screenings, 2016 Behavioral Risk best-performing state, the shortfall was 24 percent. As Factor Surveillance System (BRFSS). commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 9 Mixed findings on health care spending. The average amount What Are States Doing? Several states participate in Medicare spends on care for each beneficiary has leveled initiatives involving both public and private insurers to off in recent years across all states. Spending per enrollee foster the transformation of primary care practices into in employer-sponsored insurance plans was nearly flat patient-centered medical homes, which can improve nationally from 2013 to 2015. However, 18 states saw patient care and reduce costs.23 State and federal increases of at least $300 per enrollee during this time, or 5 partnerships to integrate care for Medicare and Medicaid percent on average — more than twice the rate of general beneficiaries aim to reduce hospitalizations and ED use inflation.17 These data do not include prescription drug among patients with complex care needs while improving costs, which have been rising rapidly in recent years. Both their quality of life.24 In Rhode Island, health plans are across states and within individual states, there is often no required to measure and increase the proportion of health consistent relationship between health care spending by care spending devoted to primary care, without increasing Medicare and by employer-sponsored insurance.18 medical costs or premiums.25 What Can Be Done? Efforts to control health care costs must be tailored to reflect the unique characteristics of each market.19 Greater pricing transparency, coupled with States made progress in areas that value-based benefit design and payment approaches, were the target of efforts to improve. could encourage better-informed choices and movement toward higher-value health services and providers.20 There have been widespread gains in health care access. Evidence from states and from countries around the During the first three years of the Affordable Care Act’s major world show that health systems with a strong primary insurance coverage expansions, the adult uninsured rate care orientation generally achieve better health outcomes declined by at least five percentage points in 47 states. And at lower cost. Making primary care more accessible and 21 in nearly three-quarters of states, substantially fewer adults patient-centered also can help reduce use of the ED for Exhibit 10 skipped needed care because of costs. States that expanded INTERACTIVE Cost barriers to receiving care fell as uninsured rates fell largest gains. conditions that could be treated in primary care settings.22 their Medicaid programs have made the 26 following ACA coverage expansions Cost barriers to receiving care fell as uninsured rates fell following ACA coverage expansions Less than 10% 10%–14% 15% or more Uninsured adults Adults who went without care because of costs 2013 2014 2015 2016 Notes: Data: Uninsured (ages 19–64): U.S. Census Bureau, 2011–2016 One-Year American Community Surveys. Public Use Micro Sample (ACS PUMS). Cost barriers (age 18 and older): 2011–2016 Behavioral Risk Factor Surveillance System (BRFSS). American Community Surveys. Public Use Micro Sample (ACS PUMS); Cost barriers (age 18 and Data: Uninsured (ages 19–64): U.S. Census Bureau, 2011–2016 One-Year older): 2011–2016 Behavioral Risk Factor Surveillance System (BRFSS). commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 10 NEW HAMPSHIRE AND MAINE: TWO STATES WHERE MEDICAID EXPANSION IS IN FLUX Before the Affordable Care Act expanded coverage, New Number of people skipping care Hampshire greatly lagged Maine in terms of access to because of costs drops in New health care for low-income adults. But in August 2014, New Hampshire, increases in Maine Hampshire expanded its Medicaid program and has since New Hampshire saw a 9 percentage caught up to its New England neighbor, matching Maine on point reduction in the share of low- its uninsured rate among low-income adults and nearly income adults age 18 and older who closing the gap on several other key Scorecard measures reported not going to the doctor when needed because of health care access. Maine has not only failed to take advan- costs were too high. In Maine, the share of adults with low tage of its early lead, it has lost ground on some measures. incomes who said they skipped needed care because they couldn’t afford it increased 4 percentage points In November 2017, Maine residents voted to expand between 2013 and 2016. Medicaid under a citizen-initiated ballot referendum. Share of low-income adults without a usual The expansion is estimated to extend Medicaid coverage source of care drops in New Hampshire, stays the to 70,000 to 80,000 Mainers45 with incomes up to same in Maine 138 percent of the federal poverty level ($16,753 for a New Hampshire also nearly caught up with Maine on single person in 2018), although implementation has another key measure of health care access: having a been stalled because of funding conditions set by the regular doctor or health care provider. The share of low- governor. New Hampshire is facing the expiration of its income adults age 18 and older who did not have a usual Medicaid expansion in December 2018, and it’s not clear source of care decreased 6 percentage points in New whether the state legislature will reauthorize it. The result Hampshire between 2013 and 2016; the rate remained could be a loss of coverage for an estimated 50,000 unchanged in Maine. Granite State adults.46 Premature death rates rise in Maine, decrease in The Scorecard offers an inkling of what New Hampshire New Hampshire could lose by dropping Medicaid expansion and what In Maine, the rate of premature death from preventable Maine might gain by adding it. or treatable causes — a measure called “mortality amenable to health care” in the Scorecard — increased Adult uninsured rates drop more in New from 62.3 to 66.2 per 100,000 people between 2012– Hampshire than in Maine 2013 and 2014–2015. This represented a 6.3 percent Although the low-income adult uninsured rate fell to 20 increase — one of the highest in the nation. Only three percent in both states in 2016, in New Hampshire, this states saw larger relative increases. New Hampshire, represented a 14 percentage point drop from its 2013 on the other hand, was one of only 14 states that saw rate. Maine saw a 6 percentage point decline in the same a decline in this rate, with a drop from 58.4 to 57.7 per time period of Two States: New Hampshire and Mainea 1.1 percent decline. A Tale (see chart). 100,000 people, about Notes: Low-income is < 200% of the New Hampshire Maine federal poverty level. The difference between the 2013 and 2016 rates in New Percentage of low-income adults 2013 2016 2013 2016 Hampshire on all three access indicators among low-income adults meet the Scorecard’s threshold for improvement Uninsured (ages 19–64) 34% 20% 26% 20% for these indicators, as does the does the difference in Maine in uninsured rates. Went without needed care The increase in low-income adults who because of costs in past year 28% 19% 13% 17% went without care because of costs in (age 18 and older) Maine meets the Scorecard’s threshold for worsening on this measure. See Scorecard Without a usual source of care Methods and Appendix H for more detail. 19% 13% 12% 12% (age 18 and older) Data: Uninsured, U.S. Census Bureau, 2013 and 2016 One-Year American Total population Community Surveys. Public Use Micro Sample (ACS PUMS); Cost barriers, 2013 and 2016 Behavioral Risk Factor Rate of premature death from 2012–2013 2014–2015 2012–2013 2014–2015 Surveillance System (BRFSS); Premature preventable or treatable conditions, 57.7 62.3 66.2 58.4 death, 2012–2015 National Vital Statistics per 100,000 people System (NVSS) Mortality All-County Micro Data Files. commonwealthfund.org May 2018 Notes: Low-income is < 200% of the federal poverty level. The difference between the 2013 and 2016 rates in New Hampshire on all three access indicators among low- income adults meet the Scorecard’s threshold for improvement for these indicators, as does the does the difference in Maine in uninsured rates. The increase in low- income adults who went without care because of costs in Maine meets the Scorecard’s threshold for worsening on this measure. See Scorecard Methods and Appendix H 2018 Scorecard on State Health System Performance 11 Nursing home care has improved, and home health 50 STATES patients have gained physical mobility. The percentage of home health patients who got better at walking or moving around — a key measure of quality of care — AND D.C. increased the number of rose substantially in every state. In nursing homes, home health patients the potentially harmful use of antipsychotic drugs as who got better at walking “chemical restraints” has fallen in nearly all states. This or moving around change likely reflects the goals of the National Partnership to Improve Dementia Care in Nursing Homes, which supports state-based coalitions in efforts to reduce inappropriate antipsychotic drug use and improve care for residents with dementia.27 Tobacco use continues to wane. Adult smoking rates fell by at 48 STATES AND D.C. decreased the use of least three percentage points in all but four states between chemical restraints 2011 and 2016. States with some of the highest rates, such in nursing homes as Nevada and Oklahoma, saw the largest declines.28 States like California with long-standing comprehensive tobacco control policies have seen substantial reductions in health Note: Chemical restraints means use of antipsychotic medication. care spending because of lower smoking rates.29 Limiting Data: OASIS (via CMS Home Health Compare); MDS (via CMS Nursing Home tobacco use continues to represent a major opportunity for Compare). states to improve public health.30 Exhibit 12 Tobacco useuse continues to decline: Nevada and Oklahoma had among Tobacco continues to decline: Nevada and Oklahoma had among the largest reductions in adult smoking between 2011 and 2016 the largest reductions in adult smoking between 2011 and 2016 Percent of adults who smoke 2011 2013 2016 26% 23% 24% 20% 19% 19% 18% 16% 16% U.S. average Nevada Oklahoma Data: 2011, 2013, and 2016 Behavioral Risk Factor Surveillance System (BRFSS). commonwealthfund.org Behavioral Risk Factor Surveillance System (BRFSS). Data: 2011, 2013, and 2016 May 2018 2018 Scorecard on State Health System Performance 12 Avoidable hospital use has declined. Hospital readmission At the same time, recognition that performance rates for elderly Medicare beneficiaries continued to fall in incentives can sometimes be gamed, or can unfairly nearly half the states (particularly those with the highest penalize providers treating a large share of vulnerable or rates) during the 2012–15 period. This reduction was the high-need patients, is prompting discussions of how to goal of federal financial penalties, as well as initiatives that improve these incentives. 33 brought hospitals and postacute care providers together to improve patients’ transitions in care.31 There was also a CONCLUSION continuing reduction in potentially preventable hospital All states can improve their health care performance, admissions in several states, possibly because of better ambulatory care management. including those that topped the Scorecard rankings. On certain health system indicators, states ranked What Is Being Done? States’ gains likely reflect the lower overall performed better than the overall leaders. influence of government policies, regulatory actions, and This suggests that even the lower-ranking states have collaborative improvement efforts, all of which may be something to teach. reinforced by the public reporting of performance data by the federal government, states, and other groups. If every state achieved the performance of the top-ranked With federal assistance, many states also are working state on each Scorecard indicator, the gains in health with health plans, care providers, and other stakeholders care access, quality, efficiency, and outcomes would be to promote quality measurement and improvement in dramatic. At current rates of improvement, however, it Medicaid and to spread payment and delivery system may take many years or decades for states and the nation transformation more broadly.32 to see such progress. Exhibit 13 National gains if allachieved top rates* of performance of performance National gains if all states states achieved top rates* 18 million more adults and children insured, beyond those who already gained coverage through the ACA 14 million fewer adults skipping care because of its cost 26 million more adults with a usual source of care 11 million more adults receiving recommended cancer screenings 837,000 more young children receiving all recommended vaccines 1 million fewer Medicare beneficiaries receiving a high-risk prescription drug a 440,000 fewer hospital readmissions a 5.7 million fewer emergency room visits for nonemergency care or conditions treatable with primary care 89,000 fewer deaths before age 75 from treatable diseases * Performance benchmarks set at the level achieved by the top-performing state with available data for this indicator. * Performance benchmarks set at the level achieved by the top-performing state with available data for this indicator. a Estimate based on working-age population ages 18–64 with employer-sponsored insurance and Medicare beneficiaries age 65 and older. a Estimate based on working-age population, ages 18–64, with employer-sponsored insurance, and Medicare beneficiaries age 65 and older. Source: David C. Radley, Douglas McCarthy, and Susan L. Hayes, 2018 Scorecard on State Health System Performance commonwealthfund.org (The Commonwealth Fund, May 2018). May 2018 2018 Scorecard on State Health System Performance 13 States have many opportunities to lead and to collaborate with other stakeholders to promote health system A CLOSER LOOK AT HOSPITAL MORTALITY improvement.34 Many states are already doing so by: The Scorecard measures deaths within 30 days of • expanding Medicaid eligibility under the Affordable hospital discharge among Medicare beneficiaries Care Act (ACA)35 who were treated for four common conditions: heart attack, stroke, congestive heart failure, • establishing rules to ensure well-functioning insurance and pneumonia. Hospital 30-day mortality markets36 rates rose in nearly all states between the two • using “value-based purchasing” in Medicaid and state measurement periods reported in the Scorecard, employee benefits programs in order to promote driving the national average from 13.2 percent higher-quality, lower-cost care37 to 14.1 percent.47 The increase in this rate, which • promoting secure and efficient methods for care represents a reversal in an earlier improvement providers, health plans, and state programs to trend, appears to be driven by a sharp uptick in share electronic health information for quality mortality among pneumonia patients. improvement38 Hospital mortality has risen amongrisen among admit Hospital mortality has patients • supporting sustainable efforts to address the social patients admitted for pneumonia pneumonia determinants of health39 • ensuring an adequate primary care workforce, Average 30-day mortality among patients especially in underserved areas.40 discharged for heart attack, stroke, congestive heart failure, or pneumonia (%) Some states are in better economic shape than others and have more resources to support improvement. But Total 13.2 the gains in access to care and narrowing of disparities associated with the ACA’s coverage expansions highlight 14.1 the role that public programs can play in equalizing opportunity across and within states.41 (For example, see Average 30-day hospital mortality by condition (%) box on New York’s improvement on next page.) 14.9 Heart attack These gains in access to care may be compromised, 13.6 however, by the repeal of the ACA’s individual mandate 15.3 penalty and by regulatory changes to state insurance Stroke 14.6 markets currently under way.42 Although states have tools to strengthen their individual insurance markets, Congestive 11.9 such as reinsurance mechanisms that can help moderate heart failure 11.9 premium increases,43 there are limits to what the health 11.9 law can do. Insurance coverage is a necessary but not Pneumonia 15.9 sufficient condition for improving health care and outcomes. Urgent concerns such as the opioid crisis may 2010–2013 call for new initiatives.44 2013–2016 With states assuming ever greater responsibility for the Data: CMS Hospital Compare, 2014 and 2017 4th Quarter, National-Level future of health policy, it will be Hospital Compare, 2014 and 2017 4th Quarter, National-Level Summary Estimates. Data: CMS more important than ever Summary Estimates. to continue tracking the performance of the health system throughout the country. Source: D. Radley, D. McCarthy, and S. Hayes, Aiming Higher: Results from the Commonw Health System Performance 2018 Edition, The Commonwealth Fund, TK 2018. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 14 NEW YORK MOVES TO IMPROVE Total New York states If the Scorecard What other steps has New York Indicator improved improved gave out awards, taken? Even before the Affordable ACCESS & AFFORDABILITY New York would Care Act’s coverage expansions, New Adults ages 19–64 uninsured ü 47 walk home York extended Medicaid coverage to Adults who went without with the trophy for “Most Improved.” parents at higher income levels and to care because of cost in the past year ü 37 The Empire State, home to about 20 some childless adults. It also prohibited Individuals with high million people, met or exceeded the insurers selling plans in the individual out-of-pocket medical ü 26 spending Scorecard’s threshold for improvement market from denying coverage to people Employee health on nearly half the indicators that could with preexisting conditions or from insurance contributions be tracked over time (18 of 37) — more charging them higher premiums. Under as a share of median ü 6 income than any other state. the ACA, New York expanded Medicaid PREVENTION & TREATMENT New York made strides in four areas of eligibility still further and created a state- Home health patients health system performance tracked run insurance marketplace. Between who did not get better at walking or moving around ü 51 by the Scorecard. This included a few 2013 and 2016, New York’s adult Nursing home residents indicators where the state was among uninsured rate dropped 6 percentage with an antipsychotic medication ü 49 only a handful to make notable progress points while the share of adults who Medicare beneficiaries (see chart). skipped needed care because of costs who received a high-risk ü 46 prescription drug fell 4 points. Some improvements suggest that Adults with mental illness older New Yorkers may be receiving Shortly after expanding Medicaid in who did not receive treatment ü 28 better care. Fewer elderly patients 2014, the state received federal approval Hospital patients received a high-risk drug. In addition, to reinvest savings generated through discharged without  ü 27 instructions for home hospital admissions for ambulatory its Medicaid redesign initiative to recovery care–sensitive (ACS) conditions, which implement a Delivery System Reform Adults without all age- Incentive Program (DSRIP). The program, appropriate vaccines ü 7 are generally regarded as potentially which just wrapped up its third year, aims AVOIDABLE HOSPITAL USE & COST preventable with good primary 30-day hospital care, were down among Medicare to improve the way care is delivered readmissions, age 65 ü 23 beneficiaries. New York also improved and paid for — initially for Medicaid and older on all three of the Scorecard’s indicators beneficiaries but ultimately for all state Short-stay nursing home residents with a 30-day related to nursing home care. This residents.49 One of the program’s main readmission to the ü 20 hospital included lowering the percentage of goals is to reduce avoidable hospital Admissions for ACS long-stay nursing home residents with use by 25 percent within five years. A conditions, ages 65–74, per 100,000 Medicare ü 12 a hospital admission, an indicator where program within DSRIP called Medicaid beneficiaries only a few states measurably improved. Accelerated Exchange, or the MAX Admissions for ACS conditions, age 75 “New York has undertaken significant project, which deploys multidisciplinary and older, per 100,000 ü 10 “action teams” to improve care for Medicare beneficiaries reforms to create a high-performing high utilizers and has shown promising Long-stay nursing home long-term services and supports system, residents with a hospital ü 5 results, may be key to helping the state admission implementing strategies to improve care transitions, support community living, achieve that goal.50 HEALTHY LIVES and reduce long nursing home stays In addition to DSRIP, New York also Colorectal cancer deaths per 100,000 population ü 39 and avoidable hospitalizations,” noted is implementing a State Innovation the SCAN Foundation in awarding New Models grant and a Medicaid Health Adults who smoke ü 32 Adults who report fair/ York a “Pacesetter Prize” last year for Home program.51 Given all these poor health ü 4 progress made in improving the lives of initiatives, the state may be positioning Note: For the purposes of the Scorecard,  we count the older adults, people with disabilities, and itself to improve on even more District of Columbia as a state, and it may be included in tally of number of states that improved. family caregivers.48 indicators in the next Scorecard. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 15 SCORECARD METHODS The 2018 Scorecard on State Health System Performance, evaluates 43 performance indicators grouped into four dimensions: • Access and Affordability (7 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, and dental visits. • Prevention and Treatment (16 indicators): includes measures of receiving preventive care and needed mental health care, as well as measures of quality in ambulatory, hospital, postacute, and long-term care settings. • Potentially Avoidable Hospital Use and Cost (10 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, as well as estimates of per-person spending among Medicare beneficiaries and working-age adults with employer-sponsored insurance. • Healthy Lives (10 indicators): includes measures of premature death, health status, health risk behaviors including smoking and obesity, and tooth loss. DISPARITY DIMENSION. The 2018 Scorecard The following principles guided the evaluates performance differences within development of the Scorecard: states associated with individuals’ income level for a subset of 19 indicators that span the other PERFORMANCE METRICS. The 43 metrics four dimensions of performance. For each selected for this report span health care state and indicator, we evaluate the difference system performance, representing important in rates for the state’s low-income population dimensions and measurable aspects of care. (generally under 200% of the federal poverty Where possible, indicators align with those level) and higher-income population (generally used in previous state scorecards. Several over 400% of the federal poverty level). States indicators used in previous versions of the are ranked on the relative magnitude of the scorecard have been dropped either because resulting disparities in performance. This all states improved to the point where no method represents a change from that used in meaningful variations existed (e.g., hospital previous scorecard editions. Racial and ethnic quality process-of-care measures) or the data disparities in state health system performance to construct the measures were no longer will be evaluated separately in a forthcoming available. New indicators have been added report. to the scorecard series over time, ensuring the Scorecard reflects current and evolving priorities. See below for more detail on changes in indicators. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 16 MEASURING CHANGE OVER TIME. We were SCORING AND RANKING METHODS. For the able to construct a time series for 37 indicators. 2018 Scorecard, we introduce a new method Not all indicators could be trended over time of ranking states based on a standardized because of changes in the underlying data or measure of variation known as the “z-score.” measure definitions. For each indicator, a state’s standardized There were generally two to three years between z-score is calculated by subtracting the 51-state indicators’ baseline and current year data average (including the District of Columbia observation, though the starting and ending as if it were a state) from the state’s observed points depended on data availability. We chose rate, and dividing by the standard deviation this short time horizon to capture the immediate of all observed state rates. States’ standardized effects of changes relative to the policy and z-scores are averaged across all performance delivery system environment, such as recent indicators within the performance dimension, coverage expansions under the Affordable Care and dimension scores are averaged into Act, and other reforms as they are or may be an overall score. Ranks are assigned based enacted and implemented in the future. on the overall score. This approach gives each dimension equal weight, and within We considered a change in an indicator’s value dimensions weights the indicators equally. between the baseline and current year data points to be meaningful if it was at least one- The z-score more precisely portrays differences half (0.5) of a standard deviation larger than in performance across states (as shown in the indictor’s combined distribution over the Exhibit 1) than our prior simple ranking two time points — a common approach used approach used in prior scorecards. It is also in social science research. better suited to accommodate the different scales used across Scorecard indicators (e.g., To assess change over time in the Disparity percentages, dollars, and population-based dimension, we counted how often the within- rates). This method also aligns with methods state disparity narrowed, so long as there was used in Commonwealth Fund international also an improvement in observed rate for the health system ranking reports. state’s low-income population. As in previous state scorecards, if historical DATA SOURCES. Indicators draw from publicly data were not available for a particular available data sources, including government- indicator in the baseline period, the current sponsored surveys, registries, publicly reported year data point was used as a substitute, thus quality indicators, vital statistics, mortality ensuring that ranks in each time period were data, and administrative databases. The most based on the same number of indicators. current data available were used in this report Three indicators in the Avoidable Hospital whenever possible. Appendix B provides detail Use and Cost dimension are stratified by on the data sources and time frames. age: preventable hospitalizations, 30-day commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 17 readmissions, and avoidable emergency –– potentially avoidable emergency room visits. For these indicators, states’ department use for nonemergency z-scores are averaged across age groups into conditions a single, measure-specific composite before determining the state’s dimension score. –– 30-day hospital readmissions. We expanded our previously reported measure of suicide deaths to also include death Because of changes in indicators and methods, from alcohol and drug use — collectively the 2018 Scorecard rankings are not comparable called “deaths of despair.” to those reported in previous scorecard reports. Finally, we dropped several performance measures that no longer differentiated state- CHANGES IN SCORECARD INDICATORS level performance or for methodological The 2018 Scorecard includes several changes reasons, including: to the set of performance measures on which each state is evaluated. New performance • At-risk adults without a routine doctor visit indicators were added, including: in past two years • two new measures of access to and use of • Medicare beneficiaries with dementia, hip/ mental health services by adults pelvic fracture, or chronic renal failure who received a prescription drug that is • a new measure of employee contributions contraindicated for that condition to the cost of their employer-sponsored health insurance costs • Medicare fee-for-service patients whose health provider always listens, explains, • several new quality and utilization shows respect, and spends enough time measures to better capture the health care with them experience of working-age adults with employer-sponsored insurance: • Home health patients whose wounds improved or healed after an operation –– adult diabetics with an annual hemoglobin A1c test • High-risk nursing home residents with pressure sores –– potentially inappropriate medical imaging for low-back pain • Years of potential life lost before age 75. –– potentially avoidable hospital admissions Additional information regarding the rationale for ambulatory care–sensitive conditions for these changes is available upon request. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 18 NOTES 1 David Blumenthal, “Drop in U.S. Life Expectancy Interventions Addressing Nonmedical Health Is an ‘Indictment of the American Health Care Determinants in Medicaid Managed Care,” American System,’” STAT, Jan. 4, 2018, https://www.statnews. Journal of Managed Care 22, no. 5 (May 2016): 370–76, com/2018/01/04/life-expectancy-us-health-care/; and http://www.commonwealthfund.org/publications/ Kenneth D. Kochanek et al., Mortality in the United in-brief/2016/jun/addressing-nonmedical-health- States, 2016, NCHS Data Brief No. 293 (National Center determinants-medicaid; and Deborah Bachrach et al., for Health Statistics, Dec. 2017), https://www.cdc.gov/ Enabling Sustainable Investment in Social Interventions: nchs/data/databriefs/db293.pdf. A Review of Medicaid Managed Care Rate-Setting Tools (The Commonwealth Fund, Jan. 2018), http:// 2 Anne Case and Angus Deaton, “Rising Morbidity and www.commonwealthfund.org/publications/fund- Mortality in Midlife Among White Non-Hispanic reports/2018/jan/social-inteventions-medicaid- Americans in the 21st Century,” Proceedings of the managed-care-rate-setting. National Academy of Sciences of the United States of America 112, no. 49 (Dec. 8, 2015): 15078–83, http://www. 6 Deborah Bachrach, Stephanie Anthony, and Andrew pnas.org/content/112/49/15078. Detty, State Strategies for Integrating Physical and Behavioral Health Services in a Changing Medicaid 3 Ellen Nolte and Martin McKee, “Variations in Amenable Environment (The Commonwealth Fund, Aug. 2014), Mortality — Trends in 16 High-Income Nations,” http://www.commonwealthfund.org/publications/ Health Policy 103, no. 1 (Nov. 2011): 47–52, http:// fund-reports/2014/aug/state-strategies-behavioral- www.commonwealthfund.org/publications/in-the- health; Deborah Bachrach, Patricia M. Boozang, and literature/2011/sep/variations-in-amenable-mortality. Hailey E. Davis, How Arizona Medicaid Accelerated the Integration of Physical and Behavioral Health Services 4 Melinda K. Abrams and Donald Moulds, “Integrating (The Commonwealth Fund, May 2017), http://www. Medical and Social Services: A Pressing Priority for commonwealthfund.org/publications/issue-briefs/2017/ Health Systems and Payers,” Health Affairs Blog, July may/arizona-medicaid-integration-behavioral-health; 5, 2016, https://www.healthaffairs.org/do/10.1377/ Hannah Dorr, State Strategies for Integrating Substance hblog20160705.055717/full/; KPMG Government Use Disorder Treatment and Primary Care (National Institute, Investing in Social Services as a Core Strategy Academy for State Health Policy, Mar. 2017), https:// for Healthcare Organizations (The Commonwealth nashp.org/state-strategies-for-integrating-substance- Fund, Mar. 2018), http://www.commonwealthfund.org/ use-disorder-treatment-and-primary-care; and Lisa publications/other/2018/investing-in-social-services; Clemans-Cope et al., “Experiences of Three States and Institute of Medicine, Primary Care and Public Implementing the Medicaid Health Home Model Health: Exploring Integration to Improve Population to Address Opioid Use Disorder — Case Studies in Health (National Academies Press, 2012), http://www. Maryland, Rhode Island, and Vermont,” Journal of nationalacademies.org/hmd/Reports/2012/Primary- Substance Abuse Treatment 83 (Dec. 2017): 27–35, http:// Care-and-Public-Health.aspx. www.journalofsubstanceabusetreatment.com/article/ S0740-5472(17)30195-2/fulltext. Anna Spencer et al., Measuring Social Determinants 5 of Health Among Medicaid Beneficiaries: Early State Henry J. Kaiser Family Foundation, Where Are States 7 Lessons (Center for Health Care Strategies, Dec. 2016), Today? Medicaid and CHIP Eligibility Levels for Children, https://www.chcs.org/resource/measuring-social- Pregnant Women, and Adults (KFF, Mar. 2018), https:// determinants-health-among-medicaid-beneficiaries- www.kff.org/medicaid/fact-sheet/where-are-states- early-state-lessons; Laura M. Gottlieb et al., “Clinical today-medicaid-and-chip. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 19 8 Nancy Adler et al., Reaching for a Healthier Life: Facts on 12 . John McConnell et al., “Oregon’s Emphasis on Equity K Socioeconomic Status and Health in the U.S. (John D. and Shows Signs of Early Success for Black and American Catherine T. MacArthur Foundation Research Network Indian Medicaid Enrollees,” Health Affairs 37, no. 3 on Socioeconomic Status and Health, n.d.), http://www. (Mar. 2018): 386–93, https://www.healthaffairs.org/doi/ macses.ucsf.edu/downloads/Reaching_for_a_Healthier_ abs/10.1377/hlthaff.2017.1282. Life.pdf. 13 ric C. Schneider et al., Mirror, Mirror 2017: International E 9 Jessica L. Semega, Kayla R. Fontenot, and Melissa A. Comparison Reflects Flaws and Opportunities for Better Kollar, Income and Poverty in the United States: 2016 U.S. Health Care (The Commonwealth Fund, July 2017), (Current Population Reports, U.S. Government Printing http://www.commonwealthfund.org/interactives/2017/ Office, Sept. 2017), https://census.gov/content/dam/ july/mirror-mirror/. Census/library/publications/2017/demo/P60-259.pdf; and Agency for Healthcare Research and Quality, 2016 enters for Medicare and Medicaid Services, Health 14 C National Healthcare Quality and Disparities Report: Expenditures by State of Residence, 1991–2014 (CMS, Executive Summary (U.S. Department of Health and n.d.), https://www.cms.gov/Research-Statistics- Human Services, July 2017), http://www.ahrq.gov/ Data-and-Systems/Statistics-Trends-and-Reports/ research/findings/nhqrdr/nhqdr16/summary.html. NationalHealthExpendData/NationalHealth AccountsStateHealthAccountsResidence.html. 10 ohn E. McDonough et al., A State Policy Agenda J to Eliminate Racial and Ethnic Disparities (The 15 ustin Frakt and Aaron E. Carroll, “Why the U.S. Spends A Commonwealth Fund, June 2004), http://www. So Much More Than Other Nations on Health Care,” commonwealthfund.org/programs/minority/ The Upshot (blog), New York Times, Jan. 2, 2018, https:// mcdonough_statepolicyagenda_746.pdf; and National www.nytimes.com/2018/01/02/upshot/us-health-care- Partnership for Action to End Health Disparities, expensive-country-comparison.html; and Joseph L. National Stakeholder Strategy for Achieving Health Dieleman et al., “Factors Associated with Increases in Equity (U.S. Department of Health and Human Services, U.S. Health Care Spending, 1996–2013,” JAMA 318, no. Office of Minority Health, n.d.), https://minorityhealth. 17 (Nov. 7, 2017): 1668–78, https://jamanetwork.com/ hhs.gov/npa/files/Plans/NSS/CompleteNSS.pdf. journals/jama/article-abstract/2661579. 11 ational Conference of State Legislatures, State N 16 he measure specification excludes patients with T Approaches to Reducing Health Disparities (NCSL, underlying conditions for which imaging may be June 2017), http://www.ncsl.org/research/health/ appropriate, to the degree these conditions are state-approaches-to-reducing-health-disparities.aspx; captured in claims data; see National Quality Measures Association of State and Territorial Health Officials, Clearinghouse, Measure Summary: Use of Imaging Health Equity Snapshots (ASTHO, 2014), http://www. Studies for Low Back Pain: Percentage of Members with a astho.org/Programs/Health-Equity/Minority-Health- Primary Diagnosis of Low Back Pain Who Did Not Have Survey/2014/State-Snapshots/Map/; and Office of an Imaging Study (Plain X-ray, MRI, CT Scan) Within 28 Minority Health, National Standards for Culturally Days of the Diagnosis (Agency for Healthcare Research and Linguistically Appropriate Services in Health and Quality, 2016), https://www.qualitymeasures.ahrq. and Health Care: Compendium of State-Sponsored gov/summaries/summary/49748 (site discontinued as of National CLAS Standards Implementation Activities July 17, 2018). (U.S. Department of Health and Human Services, 2016), 17 ureau of Labor Statistics, Consumer Price Index (U.S. B https://www.thinkculturalhealth.hhs.gov/assets/pdfs/ Department of Labor, 2018), https://data.bls.gov. CLASCompendium.pdf. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 20 18 evin Quealy and Margot Sanger-Katz, “The Experts K of the Evidence on Quality and Costs of Health Care,” Were Wrong About the Best Places for Better and Health Affairs 29, no. 5 (May 2010): 766–72, https://www. Cheaper Health Care,” The Upshot (blog), New York healthaffairs.org/doi/abs/10.1377/hlthaff.2010.0025. Times, Dec. 15, 2015, https://www.nytimes.com/ interactive/2015/12/15/upshot/the-best-places-for- 22 athy Schoen et al., “Access, Affordability, and C better-cheaper-health-care-arent-what-experts-thought. Insurance Complexity Are Often Worse in the html; and Zack Cooper et al., The Price Ain’t Right? United States Compared to Ten Other Countries,” Hospital Prices and Health Spending on the Privately Health Affairs 32, no. 12 (Dec. 2013): 2205–15, http:// Insured, NBER Working Paper No. 21815 (National www.commonwealthfund.org/publications/in-the- Bureau of Economic Research, Dec. 2015), https://www. literature/2013/nov/access-affordability-and-insurance; nber.org/papers/w21815. and John Billings, Nina Parikh, and Tod Mijanovich, Emergency Department Use in New York City: A 19 ominique Hall and Mark A. Zezza, “McAllen, Texas: D Substitute for Primary Care? (The Commonwealth Tailored Solutions to High Spending Are Needed,” To Fund, March 2000), http://www.commonwealthfund. the Point (blog), The Commonwealth Fund, May 5, 2015, org/publications/issue-briefs/2000/mar/emergency- http://www.commonwealthfund.org/publications/ department-use-in-new-york-city--a-substitute-for- blog/2015/may/mcallen-texas-health-spending. primary-care. 20 nna D. Sinaiko, Karen E. Joynt, and Meredith B. A 23 arci Nielsen et al., The Patient-Centered Medical M Rosenthal, “Association Between Viewing Health Home’s Impact on Cost and Quality: Annual Review of Care Price Information and Choice of Health Care Evidence, 2014–2015 (Patient-Centered Primary Care Facility,” JAMA Internal Medicine 176, no. 12 (Dec. 1, Collaborative, Feb. 2016), https://www.pcpcc.org/ 2016): 1868–70, https://jamanetwork.com/journals/ resource/patient-centered-medical-homes-impact-cost- jamainternalmedicine/fullarticle/2571612; Suzanne F. and-quality-2014-2015; and Amanda R. Markovitz et al., Delbanco et al., Benefit Designs: How They Work (Urban “Patient-Centered Medical Home Implementation and Institute and the Catalyst for Payment Reform, Apr. Use of Preventive Services,” JAMA Internal Medicine 175, 2016), https://www.urban.org/research/publication/ no. 4 (Apr. 2015): 598–606, https://jamanetwork.com/ benefit-designs-how-they-work; Mark B. McClellan journals/jamainternalmedicine/fullarticle/2110999. et al., Payment Reform for Better Value and Medical Innovation: A Vital Direction for Health and Health Care arah Klein, Martha Hostetter, and Douglas McCarthy, 24 S (National Academy of Medicine, Mar. 2017), https:// The “One Care” Program at Commonwealth Care nam.edu/wp-content/uploads/2017/03/Payment- Alliance: Partnering with Medicare and Medicaid Reform-for-Better-Value-and-Medical-Innovation.pdf; to Improve Care for Nonelderly Dual Eligibles (The and Zirui Song et al., “Changes in Health Care Spending Commonwealth Fund, Dec. 2016), http://www. and Quality 4 Years into Global Payment,” New England commonwealthfund.org/publications/case- Journal of Medicine 371, no. 18 (Oct. 30, 2014): 1704–14, studies/2016/dec/commonwealth-care-alliance; and http://www.nejm.org/doi/10.1056/NEJMsa1404026. Alexandra Kruse, Stephanie Gibbs, and Leah Smith, Advancing Medicare and Medicaid Integration: Key 21 arbara Starfield, Leiyu Shi, and James Macinko, B Program Features and Factors Driving State Investment “Contribution of Primary Care to Health Systems and (Center for Health Care Strategies, Nov. 2017), https:// Health,” Milbank Quarterly 83, no. 3 (2005): 457–502, www.chcs.org/resource/advancing-medicare-medicaid- http://www.commonwealthfund.org/usr_doc/Starfield_ integration-key-program-features-factors-driving-state- Milbank.pdf; and Mark W. Friedberg, Peter S. Hussey, investment. and Eric C. Schneider, “Primary Care: A Critical Review commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 21 25 hristopher F. Koller and Dhruv Khullar, “Primary C 30 ational Center for Chronic Disease Prevention and N Care Spending Rate — A Lever for Encouraging Health Promotion, Best Practices for Comprehensive Investment in Primary Care,” New England Journal Tobacco Control Programs — 2014 (Centers for Disease of Medicine 377, no. 18 (Nov. 2, 2017): 1709–11, http:// Control and Prevention, 2014), https://www.cdc. www.nejm.org/doi/10.1056/NEJMp1709538; and Office gov/tobacco/stateandcommunity/best_practices/ of the Health Insurance Commissioner, Primary Care index.htm?s_cid=cs_3281; and National Governors Spending in Rhode Island: Commercial Health Insurer Association, Health Investments That Pay Off: Taking Compliance (State of Rhode Island, Jan. 2014), http:// a Comprehensive Approach to Tobacco Control (NGA www.ohic.ri.gov/documents/Primary-Care-Spending- Center for Best Practices, Aug. 16, 2016), https://www. generalprimary-care-Jan-2014.pdf. nga.org/files/live/sites/NGA/files/pdf/2016/1608HealthI nvestmentsTobacco.pdf. 26 usan L. Hayes et al., What’s at Stake: States’ Progress S on Health Coverage and Access to Care, 2013–2016 obert Fornango et al., Project Evaluation Activity in 31 R (The Commonwealth Fund, Dec. 2017), http://www. Support of Partnership for Patients Interim Evaluation commonwealthfund.org/publications/issue-briefs/2017/ Report, Final September 2015 (Centers for Medicare dec/states-progress-health-coverage-and-access. and Medicaid Services, revised Dec. 29, 2015), https:// downloads.cms.gov/files/cmmi/pfp-interimevalrpt. 27 enters for Medicare and Medicaid Services, C pdf; and David Ruiz et al., Evaluation of the Community- National Partnership to Improve Dementia Care in Based Care Transitions Program: Final Evaluation Report Nursing Homes (CMS, n.d.), https://www.cms.gov/ (Centers for Medicare and Medicaid Services, Nov. 2017), Medicare/Provider-Enrollment-and-Certification/ https://downloads.cms.gov/files/cmmi/cctp-final-eval- SurveyCertificationGenInfo/National-Partnership- rpt.pdf. to-Improve-Dementia-Care-in-Nursing-Homes.html. The Partnership built on the Advancing Excellence 32 auren S. Hughes, Alon Peltz, and Patrick H. Conway, L in America’s Nursing Homes Campaign, launched in “State Innovation Model Initiative: A State-Led 2007 with support from the Commonwealth Fund; Approach to Accelerating Health Care System see: National Nursing Home Quality Improvement Transformation,” JAMA 313, no. 13 (Apr. 7, 2015): 1317–18, Campaign, Campaign History (NNHQIC, n.d.), https:// https://jamanetwork.com/journals/jama/article- www.nhqualitycampaign.org/history.aspx. abstract/2190630; Julia C. Martinez, Martha P. King, and Richard Cauchi, Improving the Health Care System: 28 ebekah R. Rhoades and Laura A. Beebe, “Tobacco R Seven State Strategies (National Conference of State Control and Prevention in Oklahoma: Best Practices Legislatures, July 2016), http://www.ncsl.org/Portals/1/ in a Preemptive State,” American Journal of Preventive Documents/Health/ImprovingHealthSystemsBrief16. Medicine 48, no. 1, Suppl. 1 (Jan. 2015): S6–S12, http:// pdf; Martha Hostetter, Sarah Klein, and Douglas www.ajpmonline.org/article/S0749-3797(14)00497-8/ McCarthy, Hennepin Health: A Care Delivery Paradigm fulltext. for New Medicaid Beneficiaries (The Commonwealth Fund, Oct. 2016), http://www.commonwealthfund.org/ 29 ames Lightwood and Stanton A. Glantz, “The Effect of J publications/case-studies/2016/oct/hennepin-health; the California Tobacco Control Program on Smoking and Sara Rosenbaum et al., Medicaid Payment and Prevalence, Cigarette Consumption and Healthcare Delivery System Reform: Early Insights from 10 Medicaid Costs: 1989–2008,” PLoS ONE 8, no. 2 (Feb. 2013), https:// Expansion States (The Commonwealth Fund, Oct. 2017), doi.org/10.1371/journal.pone.0047145. http://www.commonwealthfund.org/publications/ issue-briefs/2017/oct/medicaid-payment-reform-10- expansion-states. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 22 33 ian Gu et al., “The Medicare Hospital Readmissions Q Ashley Williams, “Regulation of Narrow Networks: Reduction Program: Potential Unintended With Federal Protections in Jeopardy, State Approaches Consequences for Hospitals Serving Vulnerable Take on Added Significance,” To the Point (blog), The Populations,” Health Services Research 49, no. 3 (June Commonwealth Fund, Jan. 31, 2017, http://www. 2014): 818–37, https://onlinelibrary.wiley.com/doi/ commonwealthfund.org/publications/blog/2017/feb/ abs/10.1111/1475-6773.12150; Andrew M. Ibrahim et regulation-of-narrow-networks. al., “Association of Coded Severity with Readmission Reduction After the Hospital Readmissions Reduction 37 ailit Health and National Association of Medicaid B Program,” JAMA Internal Medicine 178, no. 2 (Feb. 1, Directors, The Role of State Medicaid Programs in 2018): 290–92, https://jamanetwork.com/journals/ Improving the Health Care System (NAMD, Mar. 22, jamainternalmedicine/article-abstract/2663252; and 2016), http://medicaiddirectors.org/wp-content/ Ashish K. Jha, “To Fix the Hospital Readmissions uploads/2016/03/NAMD_Bailit-Health_Value-Based- Program, Prioritize What Matters,” JAMA 319, no. 5 (Feb. Purchasing-in-Medicaid.pdf; and Michael Bailit, Megan 6, 2018): 431–33, https://jamanetwork.com/journals/ Burns, and Mary Beth Dyer, Value-Based-Innovation jama/fullarticle/2671454. by State Public Employee Health Benefits Programs (State Health and Value Strategies, Princeton University 34 haron Silow-Carroll and Greg Moody, Lessons from S Woodrow Wilson School of Public and International High- and Low-Performing States for Raising Overall Affairs, Nov. 2017), https://www.shvs.org/resource/ Health System Performance (The Commonwealth value-based-innovation-by-state-public-employee- Fund, May 2011), http://www.commonwealthfund. health-benefits-programs. org/publications/issue-briefs/2011/may/high-and-low- performing-states. 38 ate Johnson et al., Getting the Right Information to the K Right Health Care Providers at the Right Time: A Road enjamin D. Sommers et al., “Changes in Utilization 35 B Map for States to Improve Health Information Flow and Health Among Low-Income Adults After Medicaid Between Providers (National Governors Association Expansion or Expanded Private Insurance,” JAMA Center for Best Practices, Dec. 2016), https://www. Internal Medicine, published online Aug. 8, 2016, http:// nga.org/cms/center/publications/health/health- www.commonwealthfund.org/publications/in-the- information-flow. literature/2016/aug/changes-utilization-health-low- income; and Benjamin D. Sommers et al., “Three-Year 39 eborah Bachrach, Jocelyn Guyer, and Ariel Levin, D Impacts of the Affordable Care Act: Improved Medical Medicaid Coverage of Social Interventions: A Road Map Care and Health Among Low-Income Adults,” Health for States (Milbank Memorial Fund, July 2016), https:// Affairs Web First, published online May 17, 2017; http:// www.milbank.org/publications/medicaid-coverage- www.commonwealthfund.org/publications/in-the- social-interventions-road-map-states. literature/2017/may/aca-improved-medical-care-and- 40 ational Conference of State Legislatures, Primary N health. Care Workforce: A Health Care Safety-Net Toolkit for 36 abrina Corlette, Kevin Lucia, and Maanasa Kona, S State Legislators (NCSL, 2013), http://www.ncsl.org/ “States Step Up to Protect Consumers in Wake of Cuts documents/health/PCWorkforceTK13.pdf. to ACA Cost-Sharing Reduction Payments,” To the ichelle M. Doty, Munira Z. Gunja, and Sara R. 41 M Point (blog), The Commonwealth Fund, Oct. 27, 2017, Collins, “Coverage Gains Among Lower-Income http://www.commonwealthfund.org/publications/ Blacks and Latinos Highlight ACA’s Successes and blog/2017/oct/states-protect-consumers-in-wake-of- Areas for Improvement,” To the Point (blog), The aca-cost-sharing-payment-cuts; Justin Giovannelli and commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 23 Commonwealth Fund, Aug. 15, 2017, http://www. Yes on 2, Mainers for Health Care, “Get the Facts on commonwealthfund.org/publications/blog/2017/aug/ Question 2: Medicaid Expansion Will Help Maine,” (see coverage-gains-blacks-and-latinos; and Susan L. Hayes question 14 in document), http://mejp.org/sites/default/ et al., Reducing Racial and Ethnic Disparities in Access files/Medicaid-Expansion-Get-the-Facts-10-5-17.pdf. to Care: Has the Affordable Care Act Made a Difference? (The Commonwealth Fund, Aug. 2017), http://www. 46 ew Hampshire Fiscal Policy Institute, “Medicaid N commonwealthfund.org/publications/issue-briefs/2017/ Expansion in New Hampshire and the State Senate’s aug/racial-ethnic-disparities-care. Proposed Changes,” Mar. 30, 2018, http://nhfpi.org/ research/health-policy/medicaid-expansion-in-new- 42 avid Blumenthal, “The ACA at Eight: Resilient But Still D hampshire-and-the-state-senates-proposed-changes. at Risk,” To the Point (blog), The Commonwealth Fund, html. Mar. 23, 2018, http://www.commonwealthfund.org/ publications/blog/2018/mar/aca-at-eight. 47 he Centers for Medicare and Medicaid Services reports T hospital mortality over a three-year time frame. 43 evin Lucia et al., State Regulation of Coverage Options K Outside of the Affordable Care Act: Limiting the Risk 48 CAN Foundation Pacesetter Prize winners are selected S to the Individual Market (The Commonwealth Fund, based on data in the AARP LTSS State Scorecard, Mar. 2018), http://www.commonwealthfund.org/ published with support from the Commonwealth Fund, publications/fund-reports/2018/mar/state-regulation- http://www.thescanfoundation.org/new-york-wins- coverage-options-outside-aca; and Michael Ollove, “To pacesetter-prize-effective-transitions. Curb Rising Health Insurance Costs, Some States Try 49 eborah Bachrach et al., Implementing New York’s D ‘Reinsurance Pools’,” Stateline (blog), Pew Charitable DSRIP Program: Implications for Medicaid Payment Trusts, Apr. 9, 2018, http://www.pewtrusts.org/en/ and Delivery System Reform (The Commonwealth research-and-analysis/blogs/stateline/2018/04/09/ Fund, Apr. 2016), http://www.commonwealthfund.org/ to-curb-rising-health-insurance-costs-some-states-try- publications/fund-reports/2016/apr/new-york-dsrip- reinsurance-pools. medicaid. 44 elly Murphy et al., Finding Solutions to the Prescription K 50 MAX: Achieving Large-Scale Transformation By “ Opioid and Heroin Crisis: A Road Map for States Engaging Front-Line Action Teams,” Health Affairs Blog, (National Governors Association Center for Best Mar. 30, 2018, https://www.healthaffairs.org/do/10.1377/ Practices, July 2016), https://www.nga.org/cms/finding- hblog20180327.761736/full/. solutions-to-the-prescription-opioid-and-heroin-crisis- a-road-map-for-states. ew York State Department of Health, The New York 51 N State Health Innovation Plan (NYSDOH, n.d.), https:// pril Grady, Patricia M. Boozang, and Cindy Mann, 45 A www.health.ny.gov/technology/innovation_plan_ Estimated Budget Impacts of Expanding MaineCare, initiative/; and New York State Department of Health, Prepared for the Maine Health Access Foundation Medicaid Health Homes — Comprehensive Care (Manatt Health, Feb. 28, 2018), https://www.manatt. Management (NYSDOH, n.d.), https://www.health. com/Insights/White-Papers/2018/Estimated-Budget- ny.gov/health_care/medicaid/program/medicaid_ Impacts-of-Expanding-MaineCare; Elizabeth H. health_homes/. Kilbreth, The Real Impact of Medicaid Expansion in Maine (Maine Equal Justice Partners, Sept. 26, 2017), http://www.mejp.org/sites/default/files/Medicaid- Expansion-The-Real-Impact-Kilbreth-Sep2017.pdf; and commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 24 ABOUT THE AUTHORS distinguished career in journalism, working as an editorial David C. Radley, Ph.D., M.P.H., is senior scientist for assistant at PC Magazine and a senior editor at National the Commonwealth Fund’s Tracking Health System Geographic Kids and later at Woman’s Day magazine. Performance initiative, working on the Scorecard Following that period, Ms. Hayes was a freelance health project. Dr. Radley and his team develop national, state, writer and a contributing editor to Parent & Child magazine and substate regional analyses on health care system and cowrote a book on raising bilingual children with a performance and related insurance and care system pediatrician at Tufts Medical Center. market structure analyses. He is also a senior study director at Westat, a research firm that supports the ACKNOWLEDGMENTS Scorecard project. Previously, he was associate in domestic We owe our sincere appreciation to all of the researchers health policy for Abt Associates, with responsibility for a who developed indicators and conducted data analyses number of projects related to measuring long-term care for this Scorecard. These include: Michael E. Chernew, quality and evaluating health information technology Ph.D., and Andrew Hicks, M.S., Department of Health Care initiatives. Dr. Radley received his Ph.D. in health Policy, Harvard Medical School; Sherry Glied, Ph.D., and policy from the Dartmouth Institute for Health Policy Ougni Chakraborty, New York University Robert F. Wagner and Clinical Practice, and holds a B.A. from Syracuse Graduate School of Public Service; Ashish Jha, M.D., M.P.H., University and an M.P.H. from Yale University. and Jie Zheng, Ph.D., Harvard School of Public Health; Douglas McCarthy, M.B.A., is senior research director Vincent Mor, Ph.D., Julie Lima, Ph.D., Zhanlian Feng, Ph.D., for the Commonwealth Fund. He leads a team that has Brown University; and Yuting Zhang, Ph.D., University of conducted more than 100 case studies of promising Pittsburgh. We acknowledge Mental Health America for practices and innovations in health care delivery. He data reported in The State of Mental Health Care in America. helped develop the Fund’s Scorecards on State Health We also would like to thank the following Commonwealth System Performance and led their production from 2014 to Fund staff: David Blumenthal, Donald Moulds, Eric 2018. His 30-year career has spanned roles in government, Schneider, Sara Collins, Melinda Abrams, and Rachel corporate, and nonprofit organizations, including the Nuzum for providing constructive guidance throughout; Institute for Healthcare Improvement and UnitedHealth and the Fund’s communications and support teams, Group’s Center for Health Care Policy and Evaluation. He including Barry Scholl, Chris Hollander, Deborah Lorber, was a public policy fellow at the University of Minnesota’s Mary Mahon, Christine Haran, Josh Tallman, Jen Wilson, Humphrey School of Public Affairs and a leadership fellow Paul Frame, and Jeanne Moore, for their guidance, editorial of the Denver-based Regional Institute for Health and and production support, and public dissemination efforts. Environmental Leadership. He serves on the board of We also thank Bethanne Fox and Maya Brod of Burness for Colorado’s Center for Improving Value in Health Care. their assistance with media outreach. We are grateful to the members of the Advisory Group who provided advice Susan L. Hayes, M.P.A., is senior researcher for the on improvements to the scorecard series: Joel C. Cantor, Commonwealth Fund’s Tracking Health System Sc.D., Rebekah Gee, M.D., Sherry Glied, Ph.D., Christopher F. Performance initiative. In this role she supports the Koller, David Lansky, Ph.D., Noam N. Levey, Karen Minyard, Scorecard project, actively participating in the selection/ Ph.D., Elizabeth Mitchell, and Ernest Moy, M.D., M.P.H. development, research, and analysis of national, state, local, and special-population-level health system performance Finally, the authors wish to acknowledge Westat for its measures, and coauthoring Scorecard reports and related support of the research unit, which enabled the analysis publications. Ms. Hayes holds an M.P.A. from New York and development of the Scorecard report, as well as Helen University’s Wagner School of Public Service, where she Liu for her analytic support of the project. won the Martin Dworkis Memorial Award for academic achievement and public service. She graduated from Editorial support was provided by Christopher Hollander Dartmouth College with an A.B. in English and began a and Deborah Lorber. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 25 APPENDIX A1. State ScorecardYears and Databases Appendix A1. State Scorecard Data Data Years and Databases Indicator Past year Current year Database Access and Affordability 1 Adults ages 19–64 uninsured 2013 2016 ACS PUMS 2 Children ages 0–18 uninsured 2013 2016 ACS PUMS 3 Adults without a usual source of care 2013 2016 BRFSS 4 Adults who went without care because of cost in past year 2013 2016 BRFSS 5 Individuals with high out-of-pocket medical spending 2013-14 2015-16 CPS ASEC 6 Employee insurance costs as a share of median income 2013 2016 MEPS-IC 7 Adults without a dental visit in past year 2012 2016 BRFSS Prevention and Treatment 8 Adults without all age- and gender-appropriate cancer screenings 2012 2016 BRFSS 9 Adults without all age-appropriate recommended vaccines 2013 2016 BRFSS 10 Diabetic adults ages 18–64 without a hemoglobin A1c test — 2015 Truven MarketScan 11 Medicare beneficiaries received a high-risk drug 2012 2014 5% Medicare enrolled in Part D 12 Children without all components of a medical home — 2016 NSCH 13 Children without both a medical and dental preventive care visit in past year — 2016 NSCH 14 Children who did not receive needed mental health treatment — 2016 NSCH 15 Children ages 19–35 months without all recommended vaccines 2013 2016 NIS 16 Hospital 30-day mortality 07/2010 - 06/2013 07/2013 - 06/2016 CMS Hospital Compare 17 Central line-associated bloodstream infection (CLABSI) — 2015 CDC HAI Progress Report 18 Hospital patients discharged without instructions for home recovery 2013 2016 HCAHPS (via CMS Hospital Compare) 19 Hospital patients who did not receive patient-centered care 2013 2016 HCAHPS (via CMS Hospital Compare) 20 Home health patients who did not get better at walking or moving around 2013 2016 OASIS (via CMS Home Health Compare) 21 Nursing home residents with an antipsychotic medication 2013 2016 MDS (via CMS Nursing Home Compare) 22 Adults with any mental illness reporting unmet need 2009-2011 2013-2015 NSDUH (via State of Mental Health in America report) 23 Adults with any mental illness who did not receive treatment 2009-2011 2013-2015 NSDUH (via State of Mental Health in America report) Avoidable Hospital Use and Cost 24 Hospital admissions for pediatric asthma, per 100,000 children 2012 2014 HCUP (via AHRQ National Healthcare Quality Report) 25 Potentially avoidable emergency department visits Ages 18–64, per 1,000 employer-insured enrollees — 2015 Truven MarketScan Age 65 and older, per 1,000 Medicare beneficiaries 2012 2015 Medicare SAF 26 Admissions for ambulatory care–sensitive conditions Ages 18–64, per 1,000 employer-insured enrollees — 2015 Truven MarketScan Ages 65–74, per 1,000 Medicare beneficiaries 2012 2015 CCW (via CMS Geographic Variation Public Use File) Age 75 and older, per 1,000 Medicare beneficiaries 2012 2015 CCW (via CMS Geographic Variation Public Use File) 27 30-day hospital readmissions Ages 18–64, per 1,000 employer-insured enrollees 2015 2015 Truven MarketScan Age 65 and older, per 1,000 Medicare beneficiaries 2012 2015 CCW (via CMS Geographic Variation Public Use File) 28 Short-stay nursing home residents with a 30-day readmission to the hospital 2012 2014 MedPAR, MDS 29 Long-stay nursing home residents with a hospital admission 2012 2014 MedPAR, MDS 30 Home health patients also enrolled in Medicare with a hospital admission 2013 2016 OASIS (via CMS Home Health Compare) 31 Adults ages 18–50 with low back pain who had an imaging study at diagnosis — 2015 Truven MarketScan 32 Total reimbursements per enrollee (ages 18–64) with employer-sponsored insurance 2013 2015 Truven MarketScan 33 Total Medicare (Parts A & B) reimbursements per enrollee 2012 2015 CCW (via CMS Geographic Variation Public Use File) Healthy Lives 34 Mortality amenable to health care, deaths per 100,000 population 2012-13 2014-15 CDC NVSS: Mortality Restricted Use File 35 Breast cancer deaths per 100,000 female population 2013 2016 CDC NVSS: WONDER 36 Colorectal cancer deaths per 100,000 population 2013 2016 CDC NVSS: WONDER 37 Deaths from suicide, alcohol, and drug use per 100,000 population 2013 2016 CDC NVSS: WONDER 38 Infant mortality, deaths per 1,000 live births 2012 2015 CDC NVSS: WONDER 39 Adults ages 18–64 who report fair/poor health 2013 2016 BRFSS 40 Adults who smoke 2013 2016 BRFSS 41 Adults who are obese 2013 2016 BRFSS 42 Children who are overweight or obese — 2016 NSCH 43 Adults who have lost six or more teeth 2012 2016 BRFSS Note: (—) Previous data not available or its definition is not comparable over time. Note: — Previous data not available or its definition is not comparable over time. See Appendix H for definitions. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 26 APPENDIX A2. List of 43 Indicators the 2018 Scorecard on State Health System Performance Appendix A2. List of 43 Indicators in in the 2018 Scorecard on State Health System Performance Data years represented U.S. average rate Range of state performance 2018 2018 Indicator Baseline Scorecard Baseline Scorecard Baseline 2018 Scorecard Access and Affordability 1 Adults ages 19–64 uninsured 2013 2016 20 12 ** 5 - 30 4 - 23 2 Children ages 0–18 uninsured 2013 2016 8 5 ** 2 - 14 1 - 11 3 Adults without a usual source of care 2013 2016 24 22 12 - 35 11 - 32 4 Adults who went without care because of cost 2013 2016 16 13 * 7 - 22 7 - 19 5 Individuals with high out-of-pocket medical spending 2013-14 2015-16 15 14 10 - 22 9 - 19 6 Employee insurance costs as a share of median income 2013 2016 6 6 3-8 4-9 7 Adults without a dental visit in past year 2012 2016 15 16 10 - 20 10 - 20 Prevention and Treatment 8 Adults without all age- and gender-appropriate cancer screenings 2012 2016 31 32 21 - 40 24 - 40 9 Adults without all age-appropriate recommended vaccines 2013 2016 64 63 53 - 72 54 - 70 10 Diabetic adults ages 18–64 without a hemoglobin A1c test — 2015 — 17 — 11 - 24 11 Medicare beneficiaries received a high-risk drug 2012 2014 17 13 ** 9 - 24 7 - 21 12 Children without all components of a medical home — 2016 — 51 — 40 - 66 13 Children without both a medical and dental preventive care visit — 2016 — 32 — 20 - 41 14 Children who did not receive needed mental health treatment — 2016 — 18 — 5 - 34 15 Children ages 19–35 months without all recommended vaccines 2013 2016 30 29 18 - 43 15 - 42 16 Hospital 30-day mortality 2010-13 2013-16 13.2 14.1 ** 12.2 - 14.1 13 - 15.4 17 Central line-associated bloodstream infection (CLABSI) — 2015 — 0.99 — 0.32 - 1.43 18 Hospital patients discharged without instructions 2013 2016 14 13 10 - 22 9 - 18 19 Hospital patients who did not receive patient-centered care 2013 2016 32 32 28 - 42 27 - 43 20 Home health patients without improved mobility 2013 2016 39 29 ** 34 - 51 23 - 40 21 Nursing home residents with an antipsychotic medication 2013 2016 21 16 ** 11 - 27 8 - 20 22 Adults with any mental illness reporting unmet need 2009-2011 2013-2015 21 20 14 - 30 14 - 25 23 Adults with any mental illness who did not receive treatment 2009-2011 2013-2015 59 56 * 45 - 73 41 - 66 Avoidable Hospital Use and Cost 24 Hospital admissions for pediatric asthma, per 100,000 children 2012 2014 143 106 * 28 - 231 22 - 243 25 Potentially avoidable emergency department visits a Ages 18–64, per 1,000 employer-insured enrollees — 2015 — 159 — 130 - 203 Age 65 and older, per 1,000 Medicare beneficiaries 2012 2015 188 197 131 - 248 138 - 251 26 Admissions for ambulatory care–sensitive conditionsa Ages 18–64, per 1,000 employer-insured enrollees — 2015 — 5 — 3-6 Ages 65–74, per 1,000 Medicare beneficiaries 2012 2015 29 26 13 - 51 14 - 45 Age 75 and older, per 1,000 Medicare beneficiaries 2012 2015 70 66 41 - 100 33 - 93 27 30-day hospital readmissions a Ages 18–64, per 1,000 employer-insured enrollees — 2015 — 2.9 — 1.2 - 5.46 Age 65 and older, per 1,000 Medicare beneficiaries 2012 2015 49 42 * 26 - 65 21 - 55 28 Skilled nursing facility patients with a hospital readmission 2012 2014 20 19 13 - 26 11 - 25 29 Long-stay nursing home residents with a hospital admission 2012 2014 17 16 7 - 30 5 - 28 30 Home health patients with a hospital admission 2013 2016 16 16.4 14 - 18 14 - 18.4 31 Adults with inappropriate lower back imaging — 2015 29 29 16 - 41 16 - 41 32 Total employer-sponsored insurance spending per enrollee 2013 2015 $4,697 $4,736 $3,117 - $7,186 $3,347 - $8,902 33 Total Medicare (Parts A & B) reimbursements per enrollee 2012 2015 $8,854 $9,025 $5,399 - $10,868 $5,586 - $10,851 Healthy Lives 34 Mortality amenable to health care, deaths per 100,000 population 2012-13 2014-15 83.7 84.3 55.6 - 136.7 54.7 - 142.4 35 Breast cancer deaths per 100,000 female population 2013 2016 21 20 15.5 - 29.8 13.6 - 23.7 36 Colorectal cancer deaths per 100,000 population 2013 2016 14.6 13.1 * 10.9 - 19.8 10.1 - 17.4 37 Deaths from suicide, alcohol, and drug use per 100,000 population 2013 2016 35.6 43.2 * 25.7 - 61.8 28.5 - 83.1 38 Infant mortality, deaths per 1,000 live births 2012 2015 6.0 5.9 4.2 - 8.9 4.1 - 9.5 39 Adults who report fair/poor health 2013 2016 16 16 10 - 22 10 - 24 40 Adults who smoke 2013 2016 18 16 * 10 - 27 9 - 25 41 Adults who are obese 2013 2016 29 30 22 - 37 22 - 39 42 Children who are overweight or obese — 2016 — 31 — 19 - 38 43 Adults who have lost six or more teeth 2012 2016 10 10 6 - 23 6 - 21 Notes: (a) State rates are averaged across age cohorts for purposes of scoring, but indicators are counted separately for evaluating change over time. (—) Previous data are not shown because of changes in the indicators' definitions or data were not available. Notes: (a) State rates are averaged across age cohorts for purposes of scoring, but indicators are counted separately for evaluating change over time. * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. — Previous data are not shown because of changes in the indicators’ definitions or data were not available. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 27 APPENDIX A3. National and Regional Performance Benchmarks Appendix A3. National and Regional Performance Benchmarks National Midwest Northeast South West Indicator Rate Best state(s)a Rate Best state(s)a Rate Best state(s)a Rate Best state(s)a Rate Best state(s)a Access and Affordability 1 Adults ages 19–64 uninsured 4 MA 6 IA, MN 4 MA 5 DC 5 HI 2 Children ages 0–18 uninsured 1 MA 2 IA 1 MA 2 WV 2 HI 3 Adults without a usual source of care 11 MA 15 MI 11 MA 15 MD 15 HI 4 Adults who went without care because of cost 7 HI 8 IA, ND 8 VT 9 DC 7 HI 5 Individuals with high out-of-pocket medical spending 9 DC, RI 10 MN 9 RI 9 DC 11 HI CT, MA, NH, NJ, 6 Employee insurance costs as a share of median income 4 HI, MI 4 MI 5 5 DC, MD 4 HI NY, PA, VT 7 Adults without a dental visit in past year 10 CT 12 IA, MN, WI 10 CT 14 DC, DE, VA 12 HI Prevention and Treatment 8 Adults without all age- and gender-appropriate cancer screenings 24 CT 28 WI 24 CT 25 DC 26 HI 9 Adults without all age-appropriate recommended vaccines 54 SD 54 SD 56 RI 58 MD, NC, WV 59 CO 10 Diabetic adults ages 18–64 without a hemoglobin A1c test 11 MN 11 MN 16 MA 13 NC, TN 13 WA 11 Medicare beneficiaries received a high-risk drug 7 MN 7 MN 9 MA, NY, RI, VT 11 DE 9 HI 12 Children without all components of a medical home 40 VT 42 IA 40 VT 42 MD 43 UT 13 Children without both a medical and dental preventive care visit 20 VT 28 IL 20 VT 25 SC 27 WA 14 Children who did not receive needed mental health treatment 5 NH 7 IA, MI 5 NH 9 DE 7 WY 15 Children ages 19–35 months without all recommended vaccines 15 MA 19 NE 15 MA 22 DE, NC 24 CO, WA 16 Hospital 30-day mortality 13 DE, MA 13.6 OH 13 MA 13 DE 13.7 CA 17 Central line-associated bloodstream infection (CLABSI) 0.32 HI 0.65 SD 0.75 MA 0.74 WV 0.32 HI 18 Hospital patients discharged without instructions 9 VT 10 NE, WI 9 VT 12 NC, SC, VA 10 ID, UT 19 Hospital patients who did not receive patient-centered care 27 LA, SD 27 SD 29 ME 27 LA 29 ID, MT, WY 20 Home health patients without improved mobility 23 MS 28 MO, ND 27 PA 23 MS 25 UT 21 Nursing home residents with an antipsychotic medication 8 HI 13 MI, WI 12 NJ 12 DC 8 HI 22 Adults with any mental illness reporting unmet need 14 HI 19 NE, WI 16 MA 17 DE, TX 14 HI 23 Adults with any mental illness who did not receive treatment 41 ME 44 MN 41 ME 50 NC 48 MT Avoidable Hospital Use and Cost 24 Hospital admissions for pediatric asthma, per 100,000 children 22 VT 61 ND 22 VT 74 TN 48 OR 25 Potentially avoidable emergency department visits a Ages 18–64, per 1,000 employer-insured enrollees 130 CA 139 MN 142 MA 148 MD 130 CA Age 65 and older, per 1,000 Medicare beneficiaries 138 HI 155 SD 174 VT 179 DE 138 HI 26 Admissions for ambulatory care–sensitive conditionsa IA, MN, ND, SD, CT, MA, ME, NH, Ages 18–64, per 1,000 employer-insured enrollees 3 WA 4 4 4 NC 3 WA WI RI, VT Ages 65–74, per 1,000 Medicare beneficiaries 14 CO, UT 19 MN 20 VT 23 VA 14 CO, UT Age 75 and older, per 1,000 Medicare beneficiaries 33 HI 52 MN 58 VT 62 SC, VA 33 HI 27 30-day hospital readmissions a Ages 18–64, per 1,000 employer-insured enrollees 1.2 AL 2.68 IA 2.14 ME 1.2 AL 1.37 UT Age 65 and older, per 1,000 Medicare beneficiaries 21 HI 31 SD 32 VT 37 SC 21 HI 28 Skilled nursing facility patients with a hospital readmission 11 AK 14 ND, SD 15 VT 18 NC 11 AK 29 Nursing home residents with a hospital admission 5 HI 7 MN 9 RI 16 DE, MD, NC 5 HI 30 Home health patients with a hospital admission 14 UT 16.2 WI 16.3 RI 15.9 FL, TX 14 UT 31 Adults with inappropriate lower back imaging 16 ND 16 ND 23 ME, VT 28 DE 20 OR 32 Total employer-sponsored insurance spending per enrollee $3,347 MS $3,818 MI $4,333 RI $3,347 MS $3,667 HI 33 Total Medicare (Parts A & B) reimbursements per enrollee $5,586 HI $7,682 SD $7,231 VT $8,172 VA $5,586 HI Healthy Lives 34 Mortality amenable to health care, deaths per 100,000 population 54.7 MN 54.7 MN 57.7 NH 80.2 VA 60.7 UT 35 Breast cancer deaths per 100,000 female population 13.6 VT 17 MN 14 VT 19 FL 15 HI 36 Colorectal cancer deaths per 100,000 population 10.1 UT 11.9 MN 10.4 CT 12.4 NC 10.1 UT 37 Deaths from suicide, alcohol, and drug use per 100,000 population 28.5 NE 28.5 NE 32.8 NY 35.1 GA 31.2 HI 38 Infant mortality, deaths per 1,000 live births 4.1 NH 4.2 IA 4.1 NH 5.7 TX 4.4 CA 39 Adults who report fair/poor health 10 DC 11 MN, SD 12 VT 10 DC 11 UT 40 Adults who smoke 9 UT 15 MN 13 CT 14 MD, TX 9 UT 41 Adults who are obese 22 DC 28 MN 23 MA 22 DC 23 CO 42 Children who are overweight or obese 19 UT 27 IL 22 VT 27 VA 19 UT 43 Adults who have lost six or more teeth 6 CA, DC, HI, UT 7 MN, NE 7 CT 6 DC 6 CA, HI, UT Note: (a) State rates are averaged across age cohorts for purposes of scoring, but indicators are counted separately for evaluating change over time. Note: (a) State rates are averaged across age cohorts for purposes of scoring, but indicators are counted separately for evaluating change over time. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 28 Appendix A4. Change in State Health System Performance by Indicator APPENDIX A4. Change in State Health System Performance by Indicator Indicator Number of states that: (arranged by number of states with improvement within dimension) • Improved a • No Change b • Worsened a Access and Affordability 0 Adults ages 19–64 uninsured 47 4 Adults who went without care because of cost 37 14 Children ages 0–18 uninsured 33 17 1 Individuals with high out-of-pocket medical spending 26 23 2 Adults without a usual source of care 11 39 1 Adults without a dental visit in past year 7 35 9 Employee health insurance contributions as a share of median income 6 28 17 Prevention and Treatment Home health patients who did not get better at walking or moving around 51 Nursing home residents with an antipsychotic medication 49 2 Medicare beneficiaries received a high-risk drug 46 5 Adults with any mental illness who did not receive treatment 28 17 6 Hospital patients discharged without instructions for home recovery 27 24 Children ages 19–35 months without all recommended vaccines 21 16 14 Adults with any mental illness reporting unmet need 19 17 15 Adults without all age-appropriate recommended vaccines 7 37 7 Hospital patients who did not receive patient-centered care 4 46 1 Adults without all age- and gender-appropriate cancer screenings 2 41 8 Hospital 30-day mortality 1 50 Avoidable Hospital Use and Cost 30-day readmissions, Medicare, age 65+ 23 28 Skilled nursing facility patients with a hospital readmission 20 31 Preventable hospitalizations, Medicare, ages 65–74 12 39 Preventable hospitalizations, Medicare, age 75+ 10 41 Hospital admissions for pediatric asthma 6 44 1 Nursing home residents with a hospital admission 5 45 1 Avoidable emergency department visits, Medicare, age 65+ 4 32 15 Home health patients with a hospital admission 3 19 29 Employer-sponsored insurance spending per enrollee 2 43 6 Medicare spending per beneficiary 49 2 Healthy Lives Colorectal cancer deaths per 100,000 population 39 10 2 Adults who smoke 32 18 1 Breast cancer deaths per 100,000 female population 16 30 5 Adults who have lost six or more teeth 8 42 1 Infant mortality, deaths per 1,000 live births 6 38 7 Adults who report fair/poor health 4 40 7 Adults who are obese 1 32 18 Mortality amenable to health care, deaths per 100,000 population 51 Deaths from suicide, alcohol, and drug use per 100,000 population 18 33 Notes: Only Scorecard indicators with trends are shown. Trend data generally reflect the two- to three-year period ending in 2015 or 2016; refer to Appendix A1 for additional detail (trend data were not available for all indicators). For purposes of this analysis we count the District of Columbia as a state. (a) Improvement or worsening refers to a change between the baseline and current time periods of at least 0.5 standard deviations. (b) Includes the number of states with no change or without sufficient data for this subpopulation to assess change over time. Notes: Only Scorecard indicators with trends are shown. Trend data generally reflect the two- to three-year period ending in 2015 or 2016; refer to Appendix A1 for additional detail (trend data were not available for all indicators). For purposes of this analysis we count the District of Columbia as a state. (a) Improvement or worsening refers to a change between the baseline and current time periods of at least 0.5 standard deviations. (b) Includes the number of states with no change or without sufficient data for this subpopulation to assess change over time. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 29 APPENDIX A5. National Cumulative Impact All States Achieved Top State Rate Appendix A5. National Cumulative Impact if if All States Achieved Top State Rate Indicator If all states improved their performance to the level of the best-performing state* for this indicator, then: more adults (ages 19–64) would be covered by health insurance (public or private), and therefore Insured adults 15,435,831 would be more likely to receive health care when needed. more children (ages 0–18) would be covered by health insurance (public or private), and therefore Insured children 3,126,010 would be more likely to receive health care when needed. Went without care because of cost 14,779,499 fewer adults (age 18 and older) would go without needed health care because of cost. High out-of-pocket medical spending 13,554,907 fewer individuals would be burdened by high out-of-pocket spending on medical care. more adults (age 18 and older) would have a usual source of care to help ensure that care is Adult usual source of care 26,451,243 coordinated and accessible when needed. more adults would receive age- and gender-appropriate recommended cancer screenings, including Adult cancer screening 11,063,985 tests for colon, breast, and cervical cancers. Adult vaccines 24,308,576 more adults would receive age- appropriate recommended vaccines. more children (ages 0–17) would have a medical home to help ensure that care is coordinated and Children with a medical home 8,470,792 accessible when needed. Children vaccines 837,144 more children (ages 19–35 months) would receive all recommended vaccines. Children with preventive medical and 9,332,953 more children (ages 0–17) would receive annual preventive medical and dental care visits each year. dental visits Medicare received a high-risk drug 1,066,097 fewer Medicare beneficiaries would receive an inappropriately prescribed medication. Preventable hospital admissions among 62,199 fewer children (ages 2–17) would be hospitalized for asthma exacerbations. children Hospital readmissions 440,000 fewer hospital readmissions would occur.a Potentially avoidable emergency fewer emergency department visits for nonemergent or primary care–treatable conditions would 5.7 million department visits occur.a fewer premature deaths (before age 75) might occur from causes that are potentially treatable or Mortality amenable to health care 89,462 preventable with timely and appropriate health care. Breast cancer deaths 10,623 fewer women would die from breast cancer. Colon cancer deaths 9,611 fewer individuals would die from colon cancer. Deaths of despair 47,095 fewer deaths from alcohol, suicide, alcohol, and drug use. Infant mortality 7,161 more infants would live to see their first birthday. Adults who smoke 17,242,749 fewer adults would smoke, reducing their risk of lung and heart disease. fewer adults would be obese, with body weights that increase their risk for disease and long-term Adults who are obese 15,764,091 complications. fewer children (ages 10–17) would be overweight or obese, thus reducing the potential for poor health Children who are overweight or obese 4,049,354 as they transition into adulthood. Adults with tooth loss 7,882,045 fewer adults (ages 18–64) would have lost six or more teeth to decay, infection, or gum disease. * Performance benchmarks set at the level achieved by the top-performing state with available data for this indicator. (a) Estimate based on working-age population ages 18–64 with employer-sponsored insurance and Medicare beneficiaries age 65 and older. * Performance benchmarks set at the level achieved by the top-performing state with available data for this indicator. (a) Estimate based on working-age population ages 18–64 with employer-sponsored insurance and Medicare beneficiaries age 65 and older. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 30 APPENDIX B1. State Scorecard Summary of Health System Performance Across Dimensions Overall performance Top quartile Second quartile Appendixquartile Third B1. State Scorecard Summary of Health System Performance Across Dimensions Bottom quartile st ital st ital Data not available Co sp Co sp en nd en nd es es nd Ho nd Ho ty ty tm n a tm n a rd d rd d iv iv ili ili t t e a le e a le fo an fo an Baseline Ranking ea io ea io yL yL ity ity ab ab Us dab Us dab Current Ranking Tr ent Tr ent Af ss Af ss ar ar th th ce ce oi oi sp sp ev ev al al Av Av He He Ac Ac Pr Pr Di Di 1 Hawaii 1 1 1 1 1 1 Hawaii 1 2 1 1 1 2 Massachusetts 1 1 3 1 1 2 Massachusetts 1 1 3 1 1 3 Minnesota 1 1 1 1 1 3 Minnesota 1 1 1 1 1 4 Vermont 1 1 2 1 2 4 Vermont 1 1 2 1 1 5 Utah 3 2 1 1 1 5 Utah 3 2 1 1 1 6 Iowa 1 1 2 1 2 6 New Hampshire 1 1 1 2 2 7 Washington 2 2 1 1 1 7 Iowa 1 3 1 1 3 8 Wisconsin 1 1 2 2 1 8 Maine 1 1 2 2 2 9 Connecticut 1 2 3 1 2 9 Connecticut 1 2 3 1 1 10 Colorado 3 2 1 1 2 10 Colorado 3 2 1 1 2 11 New Hampshire 1 1 2 2 3 10 South Dakota 2 1 2 1 3 11 Oregon 2 3 1 2 2 12 Wisconsin 1 3 1 1 3 11 Rhode Island 1 1 3 2 2 13 Washington 2 1 2 2 2 14 California 2 4 1 1 2 14 Nebraska 2 4 2 1 2 15 Idaho 4 2 1 1 1 14 North Dakota 2 2 1 2 2 16 Maine 2 1 2 3 2 16 Rhode Island 2 1 2 2 1 16 South Dakota 2 1 1 3 1 17 Maryland 1 1 1 3 1 18 Montana 3 2 1 2 2 18 Delaware 2 3 1 2 2 18 New York 2 3 4 1 1 19 Idaho 3 3 4 2 1 20 Maryland 1 2 3 3 3 20 Pennsylvania 1 1 3 2 2 21 Nebraska 2 2 2 2 3 21 Montana 4 2 2 1 3 22 Delaware 2 1 2 3 3 21 Oregon 3 1 2 3 1 22 North Dakota 2 2 1 3 3 23 California 3 2 1 3 2 24 Pennsylvania 2 1 3 3 1 24 New York 2 1 3 3 1 25 New Jersey 2 3 3 2 2 25 Wyoming 3 3 3 2 3 26 Illinois 2 3 3 2 1 26 Virginia 2 3 3 3 2 27 Michigan 1 2 4 3 3 27 Kansas 2 2 3 4 3 28 Virginia 3 2 2 2 4 27 New Jersey 2 2 3 2 4 29 Arizona 4 4 2 2 2 29 Illinois 2 4 2 2 3 30 District of Columbia 1 3 4 3 3 29 Michigan 2 3 4 3 2 31 New Mexico 4 4 2 3 1 31 New Mexico 4 4 1 3 1 32 Kansas 3 3 3 2 4 32 Alaska 3 2 3 2 3 33 Wyoming 4 3 2 2 3 33 District of Columbia 1 2 2 2 2 34 Alaska 4 4 1 3 3 34 Arizona 4 4 2 3 2 35 North Carolina 3 2 2 3 4 34 Ohio 2 2 2 3 4 36 Ohio 2 2 4 4 4 36 North Carolina 3 3 4 4 4 37 Indiana 3 3 3 4 3 37 South Carolina 3 3 4 4 4 38 South Carolina 4 3 2 4 3 38 Missouri 3 3 2 4 4 39 Nevada 4 4 3 3 2 39 Indiana 3 4 3 3 2 40 Georgia 4 4 3 4 4 40 Alabama 3 4 3 3 4 40 Tennessee 3 3 3 4 4 41 Georgia 4 2 3 4 4 42 Kentucky 3 3 4 4 4 42 Texas 4 3 4 4 4 43 Alabama 3 3 4 4 3 43 Florida 4 3 4 4 4 44 Missouri 3 4 4 4 4 43 Nevada 4 4 4 4 4 44 Texas 4 4 4 2 4 45 Tennessee 4 4 4 3 3 46 Arkansas 3 4 3 4 4 46 Kentucky 3 4 3 4 3 46 West Virginia 3 3 4 4 3 47 West Virginia 3 3 4 4 3 48 Florida 4 4 4 3 4 48 Arkansas 4 4 4 3 4 49 Louisiana 4 4 4 4 2 48 Oklahoma 4 4 4 4 3 50 Oklahoma 4 4 4 4 4 50 Louisiana 4 4 4 4 4 51 Mississippi 4 4 4 4 4 51 Mississippi 4 4 4 4 3 commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 31 APPENDIX B2. Summary of State Rankings in 2018 Scorecard Appendix B2. Summary of State Rankings in 2018 Scorecard 2018 Scorecard rankings Avoidable Overall ranking Overall Access and Prevention and Hospital Use Healthy in the baseline a State ranking Affordability Treatment and Cost Lives Disparity time period Alabama 43 38 34 42 44 34 40 Alaska* 34 39 48 10 30 33 32 Arizona* 29 42 39 17 17 13 34 Arkansas* 46 35 43 38 49 39 48 California* 14 23 40 11 5 22 23 Colorado* 10 26 17 7 9 21 10 Connecticut* 9 5 14 32 6 14 9 Delaware* 22 16 6 22 36 27 18 District of Columbia* 30 8 38 43 38 28 33 Florida 48 49 49 49 31 49 43 Georgia 40 46 41 31 40 47 41 Hawaii* Hawaii* 1 1 9 1 2 1 1 Idaho Idaho 15 39 24 5 11 5 19 Illinois* Illinois* 26 21 26 34 23 8 29 Indiana* Indiana* 37 28 35 37 41 38 39 Iowa* Iowa* 6 6 4 14 12 19 7 Kansas Kansas 32 27 30 30 25 44 27 Kentucky* Kentucky* 42 30 30 47 48 41 46 Louisiana Louisiana 49 47 47 50 47 19 50 Maine Maine 16 17 5 19 32 18 8 Maryland* Maryland* 20 10 13 26 27 31 17 Massachusetts*Massachusetts* 2 2 1 29 3 2 2 Michigan* Michigan* 27 12 15 39 37 32 29 Minnesota* Minnesota* 3 9 2 8 4 7 3 Mississippi Mississippi 51 50 50 51 50 43 51 Missouri Missouri 44 34 44 44 39 51 38 Montana* Montana* 18 33 22 6 15 25 21 Nebraska Nebraska 21 22 19 16 16 35 14 Nevada* Nevada* 39 45 51 28 35 17 43 New Hampshire* Hampshire* New 11 7 7 21 14 35 6 New Jersey*New Jersey* 25 14 26 36 19 24 27 New Mexico* New Mexico* 31 44 42 15 29 8 31 New York* New York* 18 13 29 46 10 4 24 North CarolinaNorth Carolina 35 37 16 24 33 44 36 North Dakota* North Dakota* 22 24 23 9 27 26 14 Ohio* Ohio* 36 18 19 39 43 47 34 Oklahoma Oklahoma 50 48 44 45 46 50 48 Oregon* Oregon* 11 19 36 4 13 15 21 Pennsylvania* Pennsylvania* 24 15 12 33 34 11 20 Rhode Island* Rhode Island* 11 4 11 27 18 22 16 South CarolinaSouth Carolina 38 41 32 23 42 35 37 South Dakota South Dakota 16 25 10 12 26 12 10 Tennessee Tennessee 40 36 33 35 44 42 45 Texas Texas 44 51 46 39 24 40 42 Utah Utah 5 32 21 2 1 3 5 Vermont* Vermont* 4 3 8 13 6 15 4 Virginia Virginia 28 29 18 25 19 44 26 Washington* Washington* 7 20 25 3 8 6 13 West Virginia*West Virginia* 46 31 28 48 51 29 47 Wisconsin Wisconsin 8 11 3 18 21 10 12 Wyoming Wyoming 33 42 36 20 22 29 25 Notes: (*) Indicates state implemented Medicaid expansion under the Affordable Care Act as of January 1, 2016. Louisiana subsequently implemented Medicaid expansion, in July 2016. (a) The baseline period generally reflects two to three years prior to the time of observation for the latest year of data available. This is not the same ranking as reported in our 2017 State Scorecard and should not be compared to the 2017 ranking because of changes in the underlying set of performance indicators evaluated in the two reports. Notes: * Indicates state implemented Medicaid expansion under the Affordable Care Act as of January 1, 2016. Louisiana subsequently implemented Medicaid expansion, in July 2016. (a) The baseline period generally reflects two to three years prior to the time of observation for the latest year of data available. This is not the same ranking as reported in our 2017 State Scorecard and should not be compared to the 2017 ranking because of changes in the underlying set of performance indicators evaluated in the two reports. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 32 APPENDIXB3. Summary of Indicator Rankings by State Appendix B3. State B o No. of indicators t No. of ind scored t with t Overall ranking State (of 43) Top 5 states Top quartile 2nd quartile 3rd quartile o Bottom 5 states (of 3 43 Alabama 42 3 7 6 13 12 36 34 Alaska* 42 5 12 9 7 8 33 29 Arizona* 43 2 7 15 12 3 37 46 Arkansas* 43 2 3 8 13 13 37 14 California* 43 9 16 11 9 5 37 10 Colorado* 43 8 18 15 8 1 37 9 Connecticut* 43 10 21 10 5 2 37 22 Delaware* 42 3 10 17 13 2 36 30 District of Columbia* 38 9 13 5 9 10 30 48 Florida 43 0 5 5 11 13 37 40 Georgia 43 0 5 4 19 8 37 1 Hawaii* 43 23 31 7 2 2 34 15 Idaho 42 6 18 7 11 4 36 26 Illinois* 43 1 6 14 19 1 37 37 Indiana* 43 1 2 9 23 1 37 6 Iowa* 43 13 22 18 1 1 37 32 Kansas 43 1 4 18 15 3 37 42 Kentucky* 43 2 8 5 12 11 37 49 Louisiana 43 1 2 6 11 17 37 16 Maine 42 3 16 13 10 0 36 20 Maryland* 43 7 17 11 11 1 37 2 Massachusetts* 42 20 26 9 6 0 36 27 Michigan* 43 4 9 11 18 1 37 3 Minnesota* 43 16 31 5 4 0 37 51 Mississippi 42 2 5 1 4 25 36 44 Missouri 43 0 2 6 23 5 37 18 Montana* 43 4 16 12 10 6 36 21 Nebraska 43 8 16 14 10 3 37 39 Nevada* 43 0 1 11 11 12 37 11 New Hampshire* 42 12 21 12 4 2 36 25 New Jersey* 43 6 14 7 13 4 37 31 New Mexico* 43 1 6 14 11 8 36 18 New York* 43 7 11 17 9 5 37 35 North Carolina 43 2 8 15 12 2 37 22 North Dakota* 43 7 15 14 8 4 36 36 Ohio* 42 1 5 16 12 2 36 50 Oklahoma 43 0 2 6 12 12 37 11 Oregon* 43 7 17 15 5 4 37 24 Pennsylvania* 43 1 11 15 12 1 36 11 Rhode Island* 42 10 20 8 9 2 36 38 South Carolina 40 0 3 12 16 5 36 16 South Dakota 43 10 14 14 9 1 36 40 Tennessee 43 1 5 9 13 6 37 44 Texas 43 3 6 6 13 10 37 5 Utah 42 15 20 8 11 1 36 4 Vermont* 42 15 24 9 4 1 35 28 Virginia 43 0 5 21 14 0 37 7 Washington* 43 8 21 14 4 1 37 46 West Virginia* 43 3 5 8 11 11 37 8 Wisconsin 43 7 19 17 6 1 37 33 Wyoming 43 4 10 15 6 10 35 Notes: (*) Indicates state implemented Medicaid expansion under the Affordable Care Act as of January 1, 2016. Louisiana subsequently implemented Medicaid expansion, in July 2016. Improv time periods of at least 0.5 standard deviations. Notes: * Indicates state implemented Medicaid expansion under the Affordable Care Act as of January 1, 2016. Louisiana subsequently implemented Medicaid expansion, in July 2016. (a) The baseline period generally reflects two to three years prior to the time of observation for the latest year of data available. This is not the same ranking as reported in our 2017 State Scorecard and should not be compared to the 2017 ranking because of changes in the underlying set of performance indicators evaluated in the two reports. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 33 APPENDIXB3. Summary of Indicator Rankings by State (continued) Appendix B3. State B B o o t No. of indicators No. of indicators t No. of ind t with trend scored No. of indicators No. of indicators t with t d quartile Overallquartile 3rd ranking o Bottom 5 states State (of 43) (of 37) Top 5 states improved Top quartile worsened 2nd quartile Net change 3rd quartile o Bottom 5 states (of 3 6 43 13 Alabama 12 42 36 10 3 77 6 3 13 12 36 9 347 Alaska* 8 42 33 59 12 6 9 3 7 8 33 15 29 12 Arizona* 3 43 37 15 2 73 15 12 12 3 37 8 46 13 Arkansas*13 43 37 17 2 36 11 8 13 13 37 11 149 California* 5 43 37 15 9 16 2 11 13 9 5 37 15 108 Colorado* 1 43 37 10 8 18 4 156 8 1 37 10 95 Connecticut*2 43 37 10 12 21 5 107 5 2 37 17 22 13 Delaware* 2 42 36 13 3 10 9 174 13 2 36 5 309 District of 10 Columbia* 38 30 11 9 13 5 5 6 9 10 30 5 48 11 Florida 13 43 37 11 0 55 5 6 11 13 37 4 40 19 Georgia 8 43 37 10 0 54 4 6 19 8 37 7 12 Hawaii* 2 43 34 23 13 31 5 7 8 2 2 34 7 15 11 Idaho 4 42 36 13 6 18 5 7 8 11 4 36 14 26 19 Illinois* 1 43 37 14 1 64 14 10 19 1 37 9 37 23 Indiana* 1 43 37 14 1 24 10 9 23 1 37 18 61 Iowa* 1 43 37 13 11 22 4 187 1 1 37 18 32 15 Kansas 3 43 37 12 1 46 186 15 3 37 5 42 12 Kentucky* 11 43 37 15 2 85 10 5 12 11 37 6 49 11 Louisiana 17 43 37 17 1 26 11 6 11 17 37 13 16 10 Maine 0 42 36 37 16 5 132 10 0 36 11 20 11 Maryland* 1 43 37 12 7 17 5 117 11 1 37 9 26 Massachusetts* 0 42 36 20 9 26 5 9 4 6 0 36 11 27 18 Michigan* 1 43 37 14 4 93 11 11 18 1 37 5 34 Minnesota* 0 43 37 16 9 31 4 5 5 4 0 37 1 514 Mississippi 25 42 36 14 2 57 1 7 4 25 36 6 44 23 Missouri 5 43 37 11 0 26 6 5 23 5 37 12 18 10 Montana* 6 43 36 13 4 16 2 12 11 10 6 36 14 21 10 Nebraska 3 43 37 86 16 8 14 -2 10 3 37 11 39 11 Nevada* 12 43 37 10 0 13 117 11 12 37 12 114 New Hampshire* 2 42 36 12 8 21 5 123 4 2 36 7 25 13 New Jersey* 4 43 37 16 6 14 5 11 7 13 4 37 14 31 11 New Mexico* 8 43 36 13 1 67 146 11 8 36 17 189 New York* 5 43 37 18 7 11 5 17 13 9 5 37 15 35 12 North Carolina 2 43 37 11 2 85 156 12 2 37 14 228 North Dakota* 4 43 36 10 7 15 8 142 8 4 36 16 36 12 Ohio* 2 42 36 12 1 53 169 12 2 36 6 50 12 Oklahoma12 43 37 17 0 25 12 6 12 12 37 15 115 Oregon* 4 43 37 12 7 17 6 156 5 4 37 15 24 12 Pennsylvania* 1 43 36 11 1 11 3 158 12 1 36 8 119 Rhode Island* 2 42 36 10 10 20 5 8 5 9 2 36 12 38 16 South Carolina 5 40 36 12 0 37 125 16 5 36 14 169 South Dakota1 43 36 10 10 14 5 145 9 1 36 9 40 13 Tennessee 6 43 37 14 1 55 9 9 13 6 37 6 44 13 Texas 10 43 37 11 3 65 6 6 13 10 37 8 511 Utah 1 42 36 15 8 20 4 8 4 11 1 36 9 44 Vermont* 1 42 35 15 10 24 6 9 4 4 1 35 21 28 14 Virginia 0 43 37 11 0 57 214 14 0 37 14 74 Washington* 1 43 37 14 8 21 5 149 4 1 37 8 46 11 West Virginia* 11 43 37 17 3 57 10 8 11 11 37 17 86 Wisconsin 1 43 37 13 7 19 2 17 11 6 1 37 15 336 Wyoming 10 43 35 47 10 6 151 6 10 35 a subsequently implemented Medicaid expansion, in Medicaid expansion under the Affordable Care Actchange between the baseline and current Notes: (*) Indicates state implemented July 2016. Improvement or worsening refers to a as of January 1, 2016. Louisiana subsequently implemented Medicaid expansion, in July 2016. Improv time periods of at least 0.5 standard deviations. Notes: * Indicates state implemented Medicaid expansion under the Affordable Care Act as of January 1, 2016. Louisiana subsequently implemented Medicaid expansion, in July 2016. Improvement or worsening refers to a change between the baseline and current time periods of at least 0.5 standard deviations. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 34 APPENDIX C1. Access & Affordability: Dimension and Indicator Ranking Appendix C1. Access & Affordability: Dimension and Indicator Ranking Overall performance Top quartile e n en ket ar Second quartile ng re f c are lts fc rc a si t a sp c ts ild t di o u ut os u eo tc al po Third quartile eo vi u os ch ad l s ho al ho us u ic f- A d ce c ca tho t Bottom quartile ed ed ed t-o ua it nt it su ee us lts w de lts w ur ur oy be i m ou n Data not available tw ra s s pl in in gh en u u Em Un Un Ad Hi in W 1 Hawaii 1 1 1 1 1 1 1 2 Massachusetts 1 1 1 1 1 1 1 3 Vermont 1 0 1 1 1 1 1 4 Rhode Island 1 0 1 1 1 2 1 5 Connecticut 1 1 1 1 1 1 1 6 Iowa 1 1 1 1 2 1 1 7 New Hampshire 2 1 1 1 1 1 1 8 District of Columbia 1 0 3 1 1 1 2 9 Minnesota 1 1 4 1 1 1 1 10 Maryland 1 1 1 2 1 1 2 11 Wisconsin 1 1 1 1 3 1 1 12 Michigan 1 1 1 3 2 1 2 13 New York 2 1 1 2 1 1 2 14 New Jersey 2 1 2 3 1 1 1 15 Pennsylvania 1 3 1 2 1 1 2 16 Delaware 1 2 1 2 1 2 2 17 Maine 2 3 1 2 2 2 1 18 Ohio 1 2 1 2 2 1 2 19 Oregon 2 1 2 2 3 1 2 20 Washington 2 1 3 1 2 2 2 21 Illinois 2 1 2 2 2 2 3 22 Nebraska 3 3 2 2 2 1 2 23 California 2 1 3 2 1 2 3 24 North Dakota 2 4 3 1 2 1 2 25 South Dakota 3 3 3 1 3 2 1 26 Colorado 2 2 3 2 2 1 3 27 Kansas 3 3 3 2 2 2 2 28 Indiana 2 3 2 3 3 1 3 29 Virginia 3 3 2 3 2 2 2 30 Kentucky 1 1 2 2 3 3 4 31 West Virginia 1 1 2 4 4 2 3 32 Utah 3 3 4 2 4 1 2 33 Montana 3 3 3 2 4 3 2 34 Missouri 3 3 2 3 3 3 3 35 Arkansas 3 2 2 4 4 3 3 36 Tennessee 3 2 2 2 4 3 4 37 North Carolina 4 3 2 4 4 2 2 38 Alabama 3 1 2 4 4 3 3 39 Alaska 4 4 4 3 1 1 2 39 Idaho 4 3 4 3 3 3 3 41 South Carolina 4 2 2 4 4 3 4 42 Arizona 3 4 4 3 3 3 3 42 Wyoming 4 4 4 3 4 2 2 44 New Mexico 3 3 4 3 2 4 4 45 Nevada 4 3 4 4 2 3 4 46 Georgia 4 4 4 4 2 3 3 47 Louisiana 4 2 3 4 3 4 4 48 Oklahoma 4 4 3 4 3 3 4 49 Florida 4 4 4 4 3 4 3 50 Mississippi 4 3 3 4 4 4 4 51 Texas 4 4 4 4 2 3 4 commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 35 APPENDIX C2. Access & Affordability: Dimension Ranking Ranking and Indicator Rates Appendix C2. Access & Affordability: Dimension and Indicator Rates Emp in Adults who went Individuals with high contr Adults ages 19–64 Children ages 0–18 Adults without a without care because out-of-pocket shar uninsured uninsured usual source of care of cost medical spending 2013 2016 2013 2016 2013 2016 2013 2016 2013-14 2015-16 201 United States 20% 12% ** 8% 5% ** 24% 22% 16% 13% * 15% 14% 6 Alabama 20 14 * 5 3 * 22 21 16 16 16 19 ** Alaska 24 18 * 12 11 33 32 14 13 18 12 ** Arizona 24 14 ** 13 8 ** 32 27 * 17 14 * 16 15 Arkansas 24 12 ** 6 4 * 23 20 * 21 15 ** 21 18 ** California 24 10 ** 8 3 ** 29 24 * 16 11 ** 13 12 Colorado 19 10 ** 9 4 ** 24 26 15 12 * 15 14 Connecticut 13 7 * 4 3 15 15 12 10 * 13 12 Delaware 14 8 * 5 4 14 17 * 12 11 13 11 * District of Columbia 8 5 — — 24 25 11 9 * 11 9 * Florida 29 18 ** 12 7 ** 27 28 21 17 ** 15 16 Georgia 26 18 ** 10 7 ** 28 27 20 17 * 15 14 Hawaii 10 5 * 3 2 15 15 9 7 * 14 11 ** Idaho 23 15 ** 9 5 ** 28 28 16 14 * 22 16 ** Illinois 18 9 ** 5 3 * 20 18 14 11 * 13 13 Indiana 19 11 ** 9 6 ** 20 18 16 13 * 16 15 Iowa 12 6 * 5 2 ** 19 17 10 8 * 15 13 * Kansas 18 12 * 7 5 * 22 23 14 12 * 15 14 Kentucky 21 7 ** 6 3 ** 22 20 19 12 ** 18 15 ** Louisiana 25 15 ** 6 4 * 26 25 20 18 * 19 16 ** Maine 16 11 * 5 5 13 12 10 11 15 13 * Maryland 14 8 * 5 3 * 21 15 ** 13 11 * 10 10 Massachusetts 5 4 2 1 12 11 9 9 11 11 Michigan 16 8 ** 5 3 * 17 15 15 13 * 15 13 * Minnesota 11 6 * 6 3 ** 27 27 10 9 12 10 * Mississippi 25 18 ** 8 5 ** 23 23 22 19 * 20 17 ** Missouri 18 13 * 7 5 * 21 22 16 13 * 17 15 * Montana 23 12 ** 11 5 ** 30 26 * 14 11 * 19 17 * Nebraska 15 12 6 6 21 19 13 12 15 13 * Nevada 27 15 ** 14 6 ** 35 31 * 17 16 18 13 ** New Hampshire 16 9 ** 4 3 12 12 12 10 * 12 12 New Jersey 19 11 ** 6 3 ** 19 18 15 13 * 13 11 * New Mexico 28 13 ** 9 6 ** 31 30 18 13 ** 16 14 * New York 15 9 * 4 3 19 17 15 11 ** 12 10 * North Carolina 23 15 ** 6 5 27 21 ** 18 16 * 18 18 North Dakota 14 9 * 8 10 * 27 26 7 8 17 13 ** Ohio 16 8 ** 5 4 19 17 15 11 ** 15 14 Oklahoma 25 20 * 11 8 ** 26 25 17 15 * 19 16 ** Oregon 21 9 ** 7 3 ** 26 22 * 18 11 ** 20 15 ** Pennsylvania 14 8 * 5 5 14 14 12 11 12 12 Rhode Island 17 6 ** 6 — 16 13 * 14 10 ** 13 9 ** South Carolina 23 15 ** 7 4 ** 24 22 19 16 * 17 17 South Dakota 17 12 * 7 5 * 24 24 10 9 16 16 Tennessee 20 14 * 6 4 * 23 22 18 12 ** 22 17 ** Texas 30 23 ** 13 10 ** 33 31 19 18 17 14 ** Utah 18 12 * 9 6 ** 28 27 15 12 * 16 17 Vermont 10 5 * — — 13 12 9 8 12 11 Virginia 17 12 * 6 5 24 22 15 13 * 12 14 * Washington 20 9 ** 7 3 ** 28 24 * 15 10 ** 13 13 West Virginia 20 8 ** 5 2 ** 23 20 * 18 15 * 17 17 Wisconsin 13 7 * 5 3 * 19 17 12 10 * 16 15 Wyoming 18 15 7 8 31 31 14 14 18 17 Change States Improved 47 33 11 37 26 States Worsened 0 1 1 0 2 Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. — Indicates that estimates are not available. Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. — Indicates that estimates are not available. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 36 Indicator Rates C2. Access & Affordability: Dimension Ranking Ranking and Indicator Rates APPENDIX C2. Access & Affordability: Dimension and Indicator Rates (continued) Appendix Employee health Emp insurance in Adults who went Individuals with high contributions as a Adults without a Adults who went Individuals with high contr out a out-of-pocket without care because Adults ages 19–64 Children ages 0–18 share of median dental visit in past without care because Adults without a out-of-pocket shar of care of cost medical spending uninsured uninsured income usual source of care year of cost medical spending 016 2013 2016 2013-14 2015-16 2013 2016 2013 2016 2012 2013 2016 2013 2016 2013-14 2015-16 201 22% United States 13% * 16% 15% 20% 14% ** 12% 6% 8% 6% ** 5% 15% 24% 16% 22% 16% 13% * 15% 14% 6 21 Alabama 16 16 16 20 19 14 ** * 6 5 7 3 * 18 22 16 21 * 16 16 16 19 ** 32 Alaska14 13 18 24 12 18 ** * 12 5 11 5 14 33 15 32 14 13 18 12 ** 27 * Arizona 17 14 * 16 24 15 14 ** 13 7 7 8 ** 17 32 17 27 * 17 14 * 16 15 20 * Arkansas 21 15 ** 21 24 18 12 ** 7 6 7 4 * 19 23 16 20 ** * 21 15 ** 21 18 ** 24 * California 16 11 ** 13 24 12 10 ** 6 8 6 3 ** 16 29 16 24 * 16 11 ** 13 12 26 Colorado 15 12 * 15 19 14 10 ** 5 9 5 4 ** 16 24 16 26 15 12 * 15 14 15 Connecticut 12 10 * 13 12 7 * 5 4 5 3 11 15 10 15 12 10 * 13 12 17 * Delaware 12 11 13 14 11 8 * 7 5 6 4 * 12 14 14 17 * 12 11 13 11 * 25 District of Columbia 9 11 * 11 8 9 5 * —5 —5 16 24 14 25 * 11 9 * 11 9 * 28 Florida21 17 ** 15 29 16 18 ** 12 8 8 7 ** 18 27 17 28 21 17 ** 15 16 27 Georgia 20 17 * 15 26 14 18 ** 10 7 7 ** 16 28 17 27 20 17 * 15 14 15 Hawaii 9 7 * 14 10 11 5 ** * 3 4 2 * 15 12 15 ** 9 7 * 14 11 ** 28 Idaho 16 14 * 22 23 16 15 ** 5 9 7 5 ** 13 28 16 28 ** 16 14 * 22 16 ** 18 Illinois 14 11 * 13 18 13 9 ** 6 5 6 3 * 15 20 17 18 * 14 11 * 13 13 18 Indiana 16 13 * 16 19 15 11 ** 6 9 5 6 * ** 15 20 16 18 16 13 * 16 15 17 Iowa 10 8 * 15 12 13 6 * 5 5 2 ** 12 19 12 17 10 8 * 15 13 * 23 Kansas 14 12 * 15 18 14 12 * 6 7 6 5 * 13 22 14 23 14 12 * 15 14 20 Kentucky 19 12 ** 18 21 15 7 ** 7 6 7 3 ** 16 22 18 20 * 19 12 ** 18 15 ** 25 Louisiana20 18 * 19 25 16 15 ** 7 6 8 4 * 20 26 20 25 20 18 * 19 16 ** 12 Maine 10 11 15 16 13 11 * 6 5 6 5 13 13 12 10 11 15 13 * 15 ** Maryland 13 11 * 10 14 10 8 * 5 5 3 * 13 21 15 * ** 13 11 * 10 10 11 Massachusetts 9 9 11 5 11 4 5 2 5 1 11 12 12 11 9 9 11 11 15 Michigan 15 13 * 15 16 13 8 * ** 5 4 3 * 14 17 14 15 15 13 * 15 13 * 27 Minnesota10 9 12 11 10 6 * 4 6 5 3 * ** 11 27 12 27 10 9 12 10 * 23 Mississippi 22 19 * 20 25 17 18 ** 7 8 9 5 ** 19 23 18 23 22 19 * 20 17 ** 22 Missouri 16 13 * 17 18 15 13 * 6 7 7 5 * 15 21 17 22 * 16 13 * 17 15 * 26 * Montana 14 11 * 19 23 17 12 * ** 11 5 7 5 ** 17 30 15 26 * 14 11 * 19 17 * 19 Nebraska 13 12 15 13 12 * 5 6 5 6 15 21 14 19 13 12 15 13 * 31 * Nevada 17 16 18 27 13 15 ** 14 7 7 6 ** 20 35 19 31 * 17 16 18 13 ** 12 New Hampshire 10 12 * 12 16 12 9 ** 5 4 5 3 10 12 11 12 12 10 * 12 12 18 New Jersey 15 13 * 13 19 11 * ** 5 6 5 3 ** 15 19 13 18 * 15 13 * 13 11 * 30 New Mexico 18 13 ** 16 28 14 13 * ** 7 9 8 6 * ** 18 31 19 30 18 13 ** 16 14 * 17 New York 15 11 ** 12 15 10 9 * 6 4 5 3 * 15 19 15 17 15 11 ** 12 10 * 21 ** North Carolina 18 16 * 18 23 18 15 ** 7 6 6 5 * 15 27 15 21 ** 18 16 * 18 18 26 North Dakota 7 8 17 14 13 9 ** * 4 8 10 5 * 15 27 14 26 7 8 17 13 ** 17 Ohio 15 11 ** 15 16 14 8 ** 5 5 4 14 19 15 17 15 11 ** 15 14 25 Oklahoma 17 15 * 19 25 16 20 ** * 11 7 7 8 ** 18 26 18 25 17 15 * 19 16 ** 22 * Oregon 18 11 ** 20 21 15 9 ** 6 7 5 3 * ** 15 26 14 22 * 18 11 ** 20 15 ** 14 Pennsylvania 12 11 12 14 12 8 * 5 5 13 14 15 14 * 12 11 12 12 13 * Rhode14 Island 10 ** 13 17 9 6 ** 5 6 —6 * 12 16 11 13 * 14 10 ** 13 9 ** 22 South Carolina 19 16 * 17 23 17 15 ** 6 7 7 4 * ** 18 24 18 22 19 16 * 17 17 24 South Dakota 10 9 16 17 16 12 * 6 7 6 5 * 11 24 13 24 * 10 9 16 16 22 Tennessee18 12 ** 22 20 17 14 ** * 7 6 7 4 * 17 23 18 22 18 12 ** 22 17 ** 31 Texas 19 18 17 30 14 23 ** 13 7 10 7 ** 18 33 19 31 19 18 17 14 ** 27 Utah 15 12 * 16 18 17 12 * 4 9 5 6 * ** 16 28 14 27 * 15 12 * 16 17 12 Vermont 9 8 12 10 11 5 * —5 —5 11 13 12 9 8 12 11 22 Virginia 15 13 * 12 17 14 12 * 5 6 6 5 * 12 24 14 22 * 15 13 * 12 14 * 24 * Washington 15 10 ** 13 20 13 9 ** 4 7 6 3 ** 14 28 15 24 * 15 10 ** 13 13 20 * West Virginia 18 15 * 17 20 17 8 ** 5 6 2 * ** 18 23 17 20 * 18 15 * 17 17 17 Wisconsin12 10 * 16 13 15 7 * 5 5 3 * 12 19 12 17 12 10 * 16 15 31 Wyoming 14 14 18 17 15 5 7 6 8 * 15 31 15 31 14 14 18 17 Change 11 States Improved 37 26 47 33 6 11 7 37 26 1 States Worsened 0 2 0 17 1 9 1 0 2 n or more. — Indicates that estimates are notleast 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. — Indicates that estimates are not available. Notes: * Denotes a change of at available. Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 37 APPENDIX D1. Prevention & Treatment: Dimension and Indicator Ranking Appendix D1. Prevention & Treatment: Dimension and Indicator Ranking Overall performance Top quartile e d d a e v al c m de de I) it d A1 ar ic BS ho ve is en en e c ed ca ve Hb Second quartile de s LA ei en h al m m re tiv a m lth ei ec d m nt y ta ic (C gs o m m ea rec lit sr ed m o Third quartile fe d ou co n en h ta s co m in ate in ec ie io uc i s m ev o t lh t re th or t a no Ho ine l re – 35 ug iar en ll r ct tr s d tb ta m ci Bottom quartile ym ll wi en id d r fic ea so re a ta ns t 9 ou al u t i ien lts cc a 1 sc u t m d nt ho sk ne da as es u va o ut ges th pr ed ho Data not available er ho i n ho du o u at d s e- de it 0- -ri b e wi d nw ed n w oo lin th l p l3 a nc i t cc wit l st c a gh e tr ca t s w n n ita wi ita hi icar re an re ne r e wi re te eti b l ral ts ild ild ild ild sp sp nt ul ul ab th ed s Ho Ho Ch Ch Ch Ch Ad Ad Ce va Di M 1 Massachusetts 1 2 2 1 1 1 2 1 1 1 1 2 Minnesota 1 1 1 1 1 3 1 2 2 1 1 3 Wisconsin 1 3 1 1 2 2 1 1 3 1 1 4 Iowa 2 1 1 1 1 2 1 2 4 2 1 5 Maine 1 2 3 2 1 1 3 2 2 1 1 6 Delaware 1 2 4 2 2 2 1 1 1 3 3 7 New Hampshire 1 2 4 2 1 1 1 1 2 3 1 8 Vermont 2 2 3 1 1 1 2 1 3 4 1 9 Hawaii 1 2 1 1 3 2 4 2 2 1 3 10 South Dakota 3 1 1 1 1 4 3 3 3 1 1 11 Rhode Island 1 1 4 1 3 2 2 1 1 3 3 12 Pennsylvania 2 1 3 1 1 1 2 2 1 2 2 13 Maryland 1 1 2 2 1 1 1 2 1 4 3 14 Connecticut 1 1 4 1 1 1 2 1 1 4 2 15 Michigan 2 4 1 2 3 3 1 3 2 2 1 16 North Carolina 1 1 1 4 1 1 4 1 3 3 2 17 Colorado 2 1 3 2 3 2 4 1 2 2 1 18 Virginia 1 1 1 3 3 2 2 4 2 2 2 19 Nebraska 3 1 3 1 1 3 3 1 4 4 1 19 Ohio 2 2 3 2 2 3 2 3 1 2 1 21 Utah 2 3 1 3 1 3 3 2 3 2 1 22 Montana 4 2 2 1 2 3 1 4 4 2 3 23 North Dakota 4 1 1 1 2 4 1 3 3 1 4 24 Idaho 4 4 2 3 3 3 2 2 3 1 1 25 Washington 2 2 1 2 4 1 3 1 4 2 2 26 Illinois 3 4 3 1 3 2 2 2 1 2 3 26 New Jersey 2 2 3 1 3 1 4 3 1 4 4 28 West Virginia 3 1 4 3 2 2 4 4 2 1 3 29 New York 2 2 4 1 2 2 3 2 2 3 3 30 Kansas 3 3 2 2 2 4 2 1 4 1 2 30 Kentucky 2 2 1 4 1 3 3 2 3 3 3 32 South Carolina 2 3 0 4 2 1 3 3 3 3 2 33 Tennessee 2 3 1 4 1 3 2 4 3 2 3 34 Alabama 2 3 1 4 2 3 3 1 3 4 3 35 Indiana 4 3 3 3 2 3 3 3 2 4 1 36 Oregon 3 4 2 2 2 3 1 4 4 1 1 36 Wyoming 4 4 4 2 2 3 1 4 4 1 2 38 District of Columbia 1 3 0 2 3 1 2 3 1 4 4 39 Arizona 3 4 2 3 4 2 4 3 2 2 3 40 California 1 4 3 2 4 4 2 4 1 3 4 41 Georgia 3 4 1 4 3 2 4 1 3 4 3 42 New Mexico 4 2 4 3 4 2 1 3 3 3 4 43 Arkansas 4 2 3 4 4 4 2 3 4 3 4 44 Missouri 3 1 3 3 3 4 4 4 2 3 3 44 Oklahoma 4 2 2 4 4 4 1 4 3 2 3 46 Texas 4 3 1 4 4 4 4 3 2 3 3 47 Louisiana 2 4 3 4 3 3 4 4 1 4 3 48 Alaska 4 4 2 2 4 4 4 3 4 3 2 49 Florida 2 4 3 3 4 4 3 4 2 3 4 50 Mississippi 4 4 1 4 2 4 4 3 4 4 4 51 Nevada 4 4 4 3 4 4 4 2 3 2 4 Notes: * SIR = Standardized Infection Ratio. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 38 APPENDIX D1. Prevention & Treatment: Dimension and Indicator Ranking (continued) anking Appendix D1. Prevention & Treatment: Dimension and Indicator Ranking Overall performance e e Top quartile L A ed ed ve a e v al e v al c m amn I) I) it it td ei1 ar ic ar ic (C d nd ca neo t BS BS ho ho cA ue is is n en d iv e c ed e c ned ca ve Hb de s de s Second quartile g ceo LA ge re t re alt th div en h en h al io m ns m wi h re re tiv a m iv m lth ei d d al ce m nt m nt y y ar i ca ntoa ic ic ri t (C di ty we es edm io ohm nt at ea rec lit lit ug eds r he t oe ed m o m o t ve ho fe d Third quartile d ou fg tco n ili es en h nt r ta ta ct i sc s co m d r en s co m in ate s etp c ale wh re hd io c c is am ic adm ev o t lh t nit nin lirae ru re or or t a no re bro o a i fe ru c i Ho ine l re – 35 Ho e e 35 gb r ct ct ld sid sd ntm t n te t tb ruo c a m ci m itie i ee olc lp l s eat ds ym ym st asl Bottom quartile o t uets in ll r 9– I n st s o en tw en id aed ut ea so ram a i n nt in as t 9 al u re uil efa s e ts -c tilen n ch e r ts n du cc a 1 cc a 1 et m d tm d nt ho o nte ho sed np da da trc s as amt e-ie au ets iu od va o ut ges va o ut ges sy t h pr ed ho oim riv lteh e eo ao Data not available d e lita ee llha nt d u onu tht reou inat drs h- d s e- de t 0- 0- a wi hr-o ab ed n w tip nhw d nw edi y w kd oo lin oo lin m y il th lip te p Stth al Lp l3 l3 a a nc t l sti cl a ce n i igp hre tr c l ra w vi tw n n n l an dirneg ita wa tis a pe itia ita wi tr ta un dael re el an re ne r e wi re wi re ba ltsl b l ral vd ihm iea a rl ne l et lda tr c npi be ild ild ild ild sp up asp sp lt i irls em nt nt sl cc th th ein ein d Ce s s u d Nu Ho Ho Ho Ho Ho Ch Ch Ch Ch Ch Ch Ch Ad Ad Ce Ce ta Di M M M 1 1 2 Massachusetts 1 1 1 1 2 3 2 2 1 3 1 1 1 2 1 1 1 1 3 2 1 2 Minnesota2 1 1 1 4 1 1 4 3 1 2 2 1 1 2 3 1 1 Wisconsin3 1 1 3 1 3 1 1 2 1 2 2 1 1 3 1 1 2 4 1 2 Iowa4 2 1 1 2 1 2 1 2 1 2 4 2 1 1 5 3 2 Maine 2 1 1 2 1 3 3 2 3 1 1 1 3 2 2 1 1 2 6 1 1 Delaware 1 3 1 3 2 3 4 2 1 2 1 2 1 1 1 3 3 1 7 1 New Hampshire 2 1 3 1 1 2 1 4 3 2 3 1 4 1 1 1 2 3 1 1 8 2 1 Vermont 3 4 2 1 2 1 3 4 1 3 1 2 1 1 2 1 3 4 1 2 9 4 2 Hawaii2 1 3 2 2 1 4 1 1 3 1 2 4 2 2 1 3 4 10 3 South Dakota3 3 1 3 1 1 4 1 2 1 2 4 2 3 3 3 1 1 2 11 2 Rhode Island 1 1 3 1 3 1 3 4 2 1 3 1 2 1 2 1 1 3 3 1 12 2 Pennsylvania1 2 2 2 1 3 1 2 1 2 1 2 2 1 2 2 1 13 1 2 Maryland 1 4 1 3 1 4 2 1 2 1 2 1 4 1 2 1 4 3 1 14 2 Connecticut 1 1 4 1 2 1 4 4 1 2 1 3 1 2 1 1 4 2 3 15 1 3 Michigan2 2 1 4 2 1 3 2 1 3 2 3 2 1 3 2 2 1 1 16 4 North Carolina3 1 3 1 2 1 3 1 2 4 1 4 1 1 4 1 3 3 2 2 17 4 1 Colorado2 2 1 1 3 2 2 3 3 2 3 4 1 2 2 1 2 18 2 4 Virginia2 2 1 2 1 4 1 3 2 3 3 2 2 4 2 2 2 3 19 3 1 Nebraska4 4 3 1 1 3 2 1 4 1 1 3 3 1 4 4 1 3 19 2 3 Ohio1 2 1 2 2 3 2 3 2 2 3 2 3 1 2 1 3 21 3 2 Utah3 2 1 3 3 1 1 3 3 1 4 3 3 2 3 2 1 3 22 1 4 Montana4 2 4 3 2 1 2 4 1 2 1 3 1 4 4 2 3 4 23 1 North Dakota3 3 1 4 4 1 1 2 1 3 2 2 4 3 1 3 3 1 4 3 24 2 2 Idaho3 1 4 1 4 1 2 1 3 3 4 3 2 2 3 1 1 1 25 3 Washington4 1 2 2 4 1 3 2 2 4 4 1 3 1 4 2 2 2 26 2 2 Illinois 1 2 3 3 4 3 3 1 4 3 2 2 2 1 2 3 1 26 4 3New Jersey1 4 2 4 2 4 3 2 1 1 3 1 3 4 3 1 4 4 2 28 4 West Virginia2 4 1 3 3 1 3 4 1 3 2 3 2 2 4 4 2 1 3 2 29 3 2 New York2 3 2 3 2 4 2 1 1 2 1 2 3 2 2 3 3 4 30 2 1 Kansas 4 1 3 2 3 1 2 3 2 4 2 4 2 1 4 1 2 3 30 3 2 Kentucky3 3 2 3 2 1 1 4 4 1 4 3 1 3 2 3 3 3 1 32 3 South Carolina3 3 3 2 2 3 2 0 1 4 1 2 2 1 3 3 3 3 2 3 33 2 4Tennessee 3 2 3 3 1 1 4 3 1 2 3 3 2 4 3 2 3 3 34 3 1 Alabama3 4 2 3 1 1 4 4 2 2 3 2 3 1 3 4 3 3 35 3 3 Indiana2 4 1 3 2 3 3 2 4 3 3 3 2 4 1 3 36 1 4 Oregon4 1 3 1 4 2 4 2 2 4 3 1 4 4 1 1 3 36 1 4 Wyoming 4 1 4 2 4 1 4 4 2 1 2 2 3 2 1 4 4 1 2 1 38 2 District 3 Columbia1 of 4 1 4 3 4 0 1 2 1 3 4 1 4 2 3 1 4 4 2 39 4 3 Arizona2 2 3 3 4 4 2 4 3 2 4 2 4 3 2 2 3 4 40 2 4 California1 3 1 4 4 3 3 2 1 4 1 4 4 2 4 1 3 4 2 41 4 1 Georgia3 4 3 3 4 3 1 1 4 4 3 1 2 3 4 1 3 4 3 2 42 1 New Mexico3 3 3 4 4 2 4 4 3 3 4 1 2 3 1 3 3 3 4 4 43 2 3 Arkansas 4 3 4 4 2 2 3 1 4 2 4 1 4 3 2 3 4 3 4 4 44 4 4 Missouri2 3 3 1 3 2 3 4 3 4 2 4 4 2 3 3 4 44 1 4 Oklahoma3 2 4 3 2 1 2 2 4 4 3 4 3 1 4 3 2 3 4 46 4 3 Texas 2 3 4 3 2 1 4 3 4 1 4 4 3 2 3 3 3 47 4 4 Louisiana1 4 2 3 4 1 3 2 4 4 3 2 3 3 4 4 1 4 3 4 48 4 3 Alaska4 3 4 2 4 2 4 2 1 4 1 4 4 3 4 3 2 4 49 3 4 Florida2 3 2 4 4 3 1 3 2 4 1 4 4 3 4 2 3 4 4 50 4 3 Mississippi4 4 4 1 1 4 4 2 4 3 4 3 4 4 4 4 51 4 2 Nevada3 2 4 4 4 4 3 2 4 3 4 4 2 3 2 4 Notes: * SIR = Standardized Infection Ratio. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 39 APPENDIX D2. Prevention & Treatment: Dimension Ranking and Indicator Rates Appendix D2. Prevention & Treatment: Dimension Ranking and Indicator Rates Children Children without both a Adults without all Adults without all without all medical and Children wh age- and gender- age-appropriate Diabetic adults ages components dental not rece appropriate cancer recommended 18–64 without a Medicare beneficiaries of a medical preventive care needed m screenings vaccines hemoglobin A1c test received a high-risk drug home visit health trea 2012 2016 2013 2016 2015 2012 2014 2016 2016 2016 United States 31% 32% 64% 63% 17% 17% 13% ** 51% 32% 18% Alabama 32 32 62 65 * 15 24 18 ** 49 32 19 Alaska 37 36 67 67 16 17 12 ** 52 37 24 Arizona 37 35 69 66 * 16 17 13 ** 55 31 22 Arkansas 39 36 * 63 63 18 17 16 52 41 15 California 27 28 66 66 19 16 11 ** 58 39 16 Colorado 31 32 58 59 17 16 12 ** 51 29 27 Connecticut 25 24 63 59 * 21 13 10 * 46 23 15 Delaware 25 28 * 57 61 * 21 16 11 ** 48 28 9 District of Columbia 25 25 64 64 — 13 12 51 26 16 Florida 32 33 72 68 * 19 16 14 * 58 38 18 Georgia 28 34 ** 68 66 15 21 16 ** 51 28 34 Hawaii 30 26 * 57 63 ** 15 21 9 ** 50 31 23 Idaho 39 40 68 67 16 16 13 * 50 33 13 Illinois 33 34 66 66 18 13 10 * 50 28 15 Indiana 37 37 67 64 * 18 17 13 ** 47 32 18 Iowa 29 31 56 55 15 12 9 * 42 30 7 Kansas 32 34 60 64 * 16 15 12 * 49 36 14 Kentucky 35 33 62 63 14 23 17 ** 46 33 18 Louisiana 33 32 61 69 ** 17 24 21 * 51 32 25 Maine 27 29 59 60 17 12 12 46 22 17 Maryland 25 29 * 58 58 16 15 12 * 42 26 11 Massachusetts 21 26 ** 53 60 ** 16 9 9 42 22 13 Michigan 29 31 67 66 15 14 12 * 50 33 7 Minnesota 27 29 56 57 11 10 7 * 45 35 9 Mississippi 37 36 65 66 15 22 19 * 49 41 22 Missouri 34 35 60 59 18 16 14 * 51 38 22 Montana 40 38 63 62 16 13 10 * 47 32 8 Nebraska 34 35 57 57 19 13 10 * 45 35 20 Nevada 37 36 71 70 20 17 13 ** 66 38 26 New Hampshire 25 27 61 60 21 13 11 * 42 21 5 New Jersey 31 31 66 63 * 19 15 10 ** 50 26 23 New Mexico 37 40 * 64 62 20 18 13 ** 55 28 9 New York 28 31 * 65 62 * 21 12 9 * 48 31 17 North Carolina 29 28 56 58 13 20 15 ** 46 27 30 North Dakota 36 36 61 59 15 11 8 * 49 41 10 Ohio 33 33 62 63 18 17 12 ** 48 32 15 Oklahoma 39 40 59 61 16 22 18 ** 55 36 11 Oregon 33 34 67 66 16 16 11 ** 49 33 10 Pennsylvania 31 33 63 59 * 19 13 10 * 45 26 13 Rhode Island 24 26 58 56 24 11 9 * 50 28 16 South Carolina 32 33 63 64 — 20 17 * 49 25 19 South Dakota 32 34 53 54 13 10 8 * 46 39 17 Tennessee 33 33 58 65 ** 13 21 16 ** 46 34 15 Texas 34 37 * 66 65 15 19 16 * 59 36 24 Utah 32 33 65 65 15 18 13 ** 43 34 18 Vermont 27 30 * 58 60 19 11 9 * 40 20 16 Virginia 28 29 59 59 14 17 13 ** 51 28 14 Washington 31 32 61 62 13 16 12 ** 52 27 20 West Virginia 34 35 58 58 20 17 14 * 48 28 24 Wisconsin 29 28 65 65 14 11 9 * 48 31 9 Wyoming 39 40 68 67 22 13 12 48 34 7 Change States Improved 2 7 46 States Worsened 8 7 0 Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. — Indicates that estimates are not available. q001a_0 q001a_1 q001b_0 q001b_1 q026_1 q014_0 q014_1 q003_1 q004_0 q005_0 Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. — Indicates that estimates are not available. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 40 APPENDIX D2. Prevention & Treatment: Dimension Ranking and Indicator Rates (continued) Appendix D2. Prevention & Treatment: Dimension Ranking and Indicator Rates Children Children Children without both a Children ages 19–35 Central line- Children without both a without all medical and Children without all months who did not Adults who did Adults without all associated Hospital patients all without medical and Children wh Home components dental age- and gender- not receive receive all age-appropriate Diabetic adults ages bloodstream discharged without Hospital patients whonot rece components dental who d of a medical preventive care appropriate cancer recommended needed mental recommended Hospital 30-daya 18–64 without Medicare beneficiaries infection instructions for home did not receive patient- at wa of a medical preventive care needed m home visit health treatment screenings vaccines vaccines hemoglobin A1c test mortality received a high-risk drug (CLABSI) recovery home centered care health trea visit 2010- 2013- 2016 2016 2012 2016 2016 2013 2013 2016 2016 2013 2015 2016 2012 2015 2014 2013 2016 2016 2013 2016 2016 2016 20 51% United States 32% 31% 18% 32% 30% 64% 29% 63% 13.2% 17% 14.1% ** 17% 0.99 13%14% ** 51% 13% 32% 32% 32% 18%3 49 Alabama 32 32 19 32 23 62 23 * 65 13.7 15 14.6 ** 1.41 24 18 ** 15 4914 3132 30 19 52 Alaska 37 37 24 36 36 67 31 * 67 13.7 16 14.9 ** 1.09 17 12 ** 12 5212 3037 31 24 55 Arizona 31 37 22 35 35 69 30 * * 66 13.1 16 13.9 ** 0.85 17 13 ** 14 5513 3431 34 22 52 Arkansas 41 39 15 36 * 43 63 32 ** 63 14.1 18 15.2 ** 1.1 17 16 17 5215 * 3241 31 15 58 California 39 27 16 28 31 66 35 * 66 13 19 13.7 * 0.97 16 11 ** 16 5815 3639 36 16 51 Colorado 29 31 27 32 31 58 24 ** 59 12.9 17 14.2 ** 0.9 16 12 ** 12 5111 3029 30 27 46 Connecticut 23 25 15 24 22 63 24 * 59 13 21 13.5 * 1.16 13 10 *15 4612 ** 3523 35 15 48 Delaware 28 259 28 * 28 57 22 ** 61 * 12.2 21 13 ** 1.05 16 11 ** 15 4813 * 3428 32 * 9 51 District of Columbia 26 25 16 25 23 64 32 ** 64 12.4 — 13.6 ** 1.16 13 12 22 5118 ** 4226 43 16 58 Florida 38 32 18 33 30 72 33 * * 68 13.1 19 13.9 ** 1.1 16 14 *17 5815 * 3738 36 18 51 Georgia 28 28 34 34 ** 30 68 23 ** 66 13.4 15 14.4 ** 1.17 21 16 ** 16 5114 * 3428 33 34 50 Hawaii 31 30 23 26 * 34 57 25 ** 63 ** 13.4 15 14.3 ** 0.32 21 9 ** 15 5014 3131 31 23 50 Idaho 33 39 13 40 30 68 26 * 67 13.6 16 14.6 ** 0.64 16 13 *12 5010 * 3033 29 13 50 Illinois 28 33 15 34 33 66 29 * 66 12.9 18 13.8 ** 0.82 13 10 *14 5013 3328 32 15 47 Indiana 32 37 18 37 31 67 31 * 64 13.4 18 14.3 ** 1.12 17 13 ** 13 4711 * 3132 31 18 42 Iowa 30 297 31 22 56 27 * 55 13.4 15 15 ** 0.93 12 9 *12 4211 3130 30 7 49 Kansas 36 32 14 34 31 60 24 ** 64 * 13 16 14.7 ** 0.8 15 12 *14 4912 * 3036 28 * 14 46 Kentucky 33 35 18 33 27 62 25 63 13.3 14 14.4 ** 1.07 23 17 ** 14 4613 3133 30 18 51 Louisiana 32 33 25 32 31 61 33 ** 69 13.3 17 13.8 * 1.43 24 21 *14 5113 2832 27 25 46 Maine 22 27 17 29 32 59 29 * 60 13.4 17 14.2 ** 0.8 12 12 11 4611 2822 29 17 42 Maryland 26 25 11 29 * 24 58 26 58 12.8 16 13.7 ** 1.12 15 12 *15 4214 3926 38 11 42 Massachusetts22 21 13 26 ** 21 53 15 ** 60 ** 12.4 16 13 * 0.75 9 9 13 4211 * 3322 33 13 50 Michigan 33 297 31 30 67 30 66 13 15 13.9 ** 0.94 14 12 *13 5011 * 3233 31 7 45 Minnesota 35 279 29 26 56 26 57 12.8 11 13.9 ** 0.78 10 7 *12 4511 2935 29 9 49 Mississippi 41 37 22 36 25 65 30 * 66 13.4 15 14.8 ** 1.11 22 19 *17 4915 * 3041 30 22 51 Missouri 38 34 22 35 32 60 33 59 13.2 18 14.2 ** 1.06 16 14 *13 5113 3338 33 22 47 Montana 32 408 38 35 63 36 62 13.2 16 14.9 ** 0.93 13 10 *15 4713 * 3332 29 ** 8 45 Nebraska 35 34 20 35 21 57 19 57 13.3 19 14.9 ** 1.16 13 10 *12 4510 * 2835 28 20 66 Nevada 38 37 26 36 39 71 28 ** 70 13.8 20 14.5 * 0.95 17 13 ** 16 6615 3638 37 26 42 New Hampshire 21 255 27 25 61 22 * 60 13.3 21 14 * 1.04 13 11 *12 4210 * 3121 30 5 50 New Jersey 26 31 23 31 27 66 30 * * 63 12.7 19 13.3 * 1.13 15 10 ** 18 5016 * 3726 37 23 55 New Mexico 28 379 40 * 34 64 32 62 13.3 20 14.5 ** 18 1 13 ** 16 5515 3428 34 9 48 New York 31 28 17 31 * 28 65 28 * 62 13.1 21 13.9 ** 1.07 12 9 *16 4814 * 3731 37 17 46 North Carolina27 29 30 28 28 56 22 ** 58 13.7 13 14.5 ** 1.06 20 15 ** 13 4612 3127 32 30 49 North Dakota 41 36 10 36 28 61 32 * 59 12.7 15 14.6 ** 0.79 11 8 *18 4915 ** 3041 29 10 48 Ohio 32 33 15 33 38 62 32 ** 63 12.9 18 13.6 * 0.88 17 12 ** 13 4811 * 3232 31 15 55 Oklahoma 36 39 11 40 37 59 33 * 61 13.2 16 14.5 ** 0.95 22 18 ** 15 5513 * 3036 30 11 49 Oregon 33 33 10 34 33 67 42 ** 66 13.9 16 14.9 ** 0.8 16 11 ** 14 4911 ** 3233 31 10 45 Pennsylvania 26 31 13 33 24 63 26 * 59 12.9 19 13.7 ** 0.94 13 10 *14 4512 * 3326 32 13 50 Rhode Island 28 24 16 26 18 58 24 ** 56 13.2 24 13.1 1.07 11 9 *14 5013 3328 32 16 49 South Carolina25 32 19 33 33 63 30 * 64 13.5 — 14.4 ** 1.1 20 17 *14 4912 * 3125 31 19 46 South Dakota 39 32 17 34 26 53 30 * 54 13.1 13 14.6 ** 0.65 10 8 *13 4611 * 2839 27 17 46 Tennessee 34 33 15 33 32 58 33 ** 65 13.5 13 14.6 ** 0.9 21 16 ** 15 4614 3234 32 15 59 Texas 36 34 24 37 * 28 66 31 * 65 13 15 13.9 ** 0.97 19 16 *14 5913 3136 31 24 43 Utah 34 32 18 33 25 65 28 * 65 13.5 15 14.6 ** 0.82 18 13 ** 10 4310 3034 32 * 18 40 Vermont 20 27 16 30 * 33 58 23 ** 60 13.8 19 14.6 ** 1.13 11 9 *12 40 9 ** 3120 30 16 51 Virginia 28 28 14 29 31 59 34 * 59 13.5 14 14.1 * 0.92 17 13 ** 14 5112 * 3428 34 14 52 Washington 27 31 20 32 29 61 24 * 62 13.9 13 14.9 ** 0.87 16 12 ** 13 5212 3427 34 20 48 West Virginia 28 34 24 35 34 58 35 58 13.2 20 14.2 ** 0.74 17 14 *15 4813 * 3328 32 24 48 Wisconsin 31 299 28 27 65 21 ** 65 13.5 14 14.4 ** 0.77 11 9 *11 4810 2931 28 9 48 Wyoming 34 397 40 30 68 37 ** 67 13 22 15.4 ** 0.67 13 12 12 4812 3134 29 * 7 Change States Improved 2 21 7 0 0 46 27 4 States Worsened 8 14 7 50 0 0 0 1 vailable. Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. — Indicates that estimates are not available. q003_1 q004_0 q001a_0 q001a_1 q006_0 q005_0 q001b_0q006_1 q001b_1 q009_0 q026_1 q009_1 q022_1 q014_0 q014_1 q010_0 q010_1q003_1 q011_0 q004_0 q011_1 q017_0 q005_0 Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. — Indicates that estimates are not available. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 41 APPENDIX D2. Prevention & Treatment: Dimension Ranking and Indicator Rates (continued) Appendix D2. Prevention & Treatment: Dimension Ranking and Indicator Rates Children ine- Children without both a ated Hospital patients Adults without all Adults without all Home health patients Nursing home without all medical and Children wh ream discharged without Hospital patients who who did not get better age- and gender- age-appropriate Diabetic adults ages an residents with Adults with any mentalcomponentsany mental Adults with dental not rece on instructions for home did not receive patient- at walking or moving 18–64antipsychotic Medicare beneficiaries appropriate cancer recommended without a illness reporting of illness who did not a medical preventive care needed m SI) recovery centered care screenings vaccines around hemoglobin A1c test received a high-risk drug medication unmet need home treatmentvisit receive health trea 2009- 2013- 2009- 2013- 2013 2016 2012 2013 2016 2016 2013 2013 20162016 2015 2013 2016 20122011 2014 2015 2016 2011 2015 2016 2016 United States 13% 14% 31% 32% 32% 32% 64% 39% 63% 29% ** 17% 21% 16% ** 17% 21% 13% ** 20% 51% 59% 56% 32% * 18% Alabama 15 14 32 31 3230 62 35 65 * 24 ** 15 22 19 * 24 21 1820 ** 49 59 54 *32 19 Alaska 12 12 37 30 3631 67 51 67 40 ** 16 13 12 17 22 1219 * ** 52 67 64 *37 24 Arizona 14 13 37 34 3534 69 42 66 * 32 ** 16 20 16 ** 17 30 1321 ** ** 55 59 59 31 22 Arkansas17 15 * 39 32 36 * 31 63 39 63 24 ** 18 24 16 ** 17 28 1619 ** 52 58 55 *41 15 California 16 15 27 36 2836 66 41 66 31 ** 19 17 12 ** 16 21 1118 * ** 58 64 61 *39 16 Colorado12 11 31 30 3230 58 38 59 28 ** 17 17 15 * 16 23 1222 ** 51 55 57 29 27 Connecticut 15 12 ** 25 35 2435 63 41 59 * 32 ** 21 21 16 ** 13 25 1022 * * 46 58 53 *23 15 Delaware15 13 * 25 34 28 * * 32 57 42 61 * 28 ** 21 17 13 ** 16 16 1117 ** 48 58 51 ** 28 9 District of Columbia18 22 ** 25 42 2543 64 40 64 26 ** —16 12 ** 13 24 1225 51 65 59 ** 26 16 Florida 17 15 * 32 37 3336 72 35 68 * 26 ** 19 22 16 ** 16 20 1418 * * 58 63 62 38 18 Georgia 16 14 * 28 34 34 ** 33 68 39 66 27 ** 15 22 19 * 21 20 1619 ** 51 59 57 28 34 Hawaii 15 14 30 31 26 * 31 57 45 63 **34 ** 15 11 8 * 21 14 914 ** 50 73 64 ** 31 23 Idaho 12 10 * 39 30 4029 68 37 67 27 ** 16 20 17 * 16 23 1325 * * 50 54 52 33 13 Illinois14 13 33 33 3432 66 39 66 30 ** 18 25 19 ** 13 22 1021 * 50 58 53 *28 15 Indiana 13 11 * 37 31 3731 67 41 64 * 30 ** 18 21 16 ** 17 23 1325 * ** 47 57 55 32 18 Iowa 12 11 29 31 3130 56 38 55 29 ** 15 20 15 ** 12 18 921 * * 42 55 46 ** 30 7 Kansas 14 12 * 32 30 34 * 28 60 39 64 * 30 ** 16 22 20 * 15 30 1223 ** * 49 49 54 *36 14 Kentucky14 13 35 31 3330 62 36 63 25 ** 14 22 20 * 23 19 1723 ** ** 46 55 51 *33 18 Louisiana 14 13 33 28 3227 61 40 69 **29 ** 17 27 19 ** 24 23 2120 * * 51 65 58 ** 32 25 Maine11 11 27 28 2929 59 38 60 30 ** 17 21 17 ** 12 16 1219 * 46 47 41 ** 22 17 Maryland15 14 25 39 29 * 38 58 37 58 25 ** 16 16 14 * 15 20 1220 * 42 57 60 *26 11 Massachusetts 13 11 * 21 33 26 ** 33 53 37 60 **28 ** 16 22 18 ** 9 21 916 ** 42 49 46 *22 13 Michigan13 11 * 29 32 3131 67 39 66 30 ** 15 15 13 * 14 23 1220 * * 50 60 54 ** 33 7 Minnesota 12 11 27 29 2929 56 43 57 33 ** 11 16 14 * 10 25 724 * 45 57 44 ** 35 9 Mississippi 17 15 * 37 30 3630 65 36 66 23 ** 15 25 20 ** 22 21 1923 * * 49 67 58 ** 41 22 Missouri13 13 34 33 3533 60 38 59 28 ** 18 24 19 ** 16 27 1425 * * 51 56 52 *38 22 Montana 15 13 * 40 33 38 ** 29 63 44 62 34 ** 16 18 15 * 13 24 1018 ** * 47 51 48 *32 8 Nebraska12 10 * 34 28 3528 57 41 57 29 ** 19 23 19 ** 13 16 1019 * * 45 53 58 *35 20 Nevada 16 15 37 36 3637 71 40 70 32 ** 20 21 16 ** 17 22 1322 ** 66 68 66 38 26 New Hampshire 10 12 * 25 31 2730 61 41 60 30 ** 21 21 17 ** 13 24 1124 * 42 57 49 ** 21 5 New Jersey 18 16 * 31 37 3137 66 37 63 * 28 ** 19 16 12 ** 15 15 1017 * ** 50 68 58 ** 26 23 New Mexico 16 15 37 34 40 * 34 64 41 62 32 ** 20 19 17 * 18 25 1318 ** ** 55 55 57 28 9 New York16 14 * 28 37 31 * 37 65 41 62 * 29 ** 21 19 14 ** 12 17 919 * * 48 61 56 *31 17 North13 Carolina 12 29 31 2832 56 39 58 28 ** 13 16 14 * 20 22 1524 * ** 46 59 50 ** 27 30 North18 Dakota 15 ** 36 30 3629 61 44 59 28 ** 15 19 17 * 11 17 821 ** * 49 55 56 41 10 Ohio 13 11 * 33 32 3331 62 39 63 29 ** 18 23 18 ** 17 20 1220 ** 48 54 53 32 15 Oklahoma15 13 * 39 30 4030 59 40 61 28 ** 16 23 20 * 22 18 1822 ** ** 55 60 56 *36 11 Oregon 14 11 ** 33 32 3431 67 44 66 35 ** 16 18 16 * 16 26 1125 ** 49 56 51 *33 10 Pennsylvania 14 12 * 31 33 3332 63 37 59 * 27 ** 19 19 16 * 13 21 1021 * 45 54 53 26 13 Rhode Island 14 13 24 33 2632 58 37 56 28 ** 24 18 18 11 27 918 ** * 50 47 49 28 16 South14 Carolina 12 * 32 31 3331 63 36 64 27 ** —17 14 * 20 22 1721 * 49 54 58 *25 19 South13 Dakota 11 * 32 28 3427 53 42 54 32 ** 13 19 16 * 10 17 820 * * 46 53 54 39 17 Tennessee 15 14 33 32 3332 58 37 65 **26 ** 13 24 18 ** 21 16 1620 ** ** 46 57 58 34 15 Texas14 13 34 31 37 * 31 66 44 65 34 ** 15 27 18 ** 19 20 1617 * * 59 65 60 *36 24 Utah 10 10 32 30 33 * 32 65 34 65 25 ** 15 25 17 ** 18 23 1323 ** 43 57 56 34 18 Vermont 12 9 ** 27 31 30 * 30 58 40 60 32 ** 19 20 17 * 11 24 921 * * 40 45 44 20 16 Virginia14 12 * 28 34 2934 59 37 59 30 ** 14 20 16 ** 17 22 1322 ** 51 53 53 28 14 Washington 13 12 31 34 3234 61 44 62 30 ** 13 19 15 ** 16 26 1224 * ** 52 53 56 *27 20 West Virginia 15 13 * 34 33 3532 58 37 58 24 ** 20 18 16 * 17 26 1422 ** * 48 48 54 ** 28 24 Wisconsin 11 10 29 29 2828 65 41 65 30 ** 14 16 13 * 11 22 919 * * 48 60 52 ** 31 9 Wyoming 12 12 39 31 40 * 29 68 42 67 34 ** 22 18 13 ** 13 17 1221 ** 48 61 52 ** 34 7 Change States Improved 27 24 7 51 49 4619 28 States Worsened 0 81 7 0 0 015 6 Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. — Indicates that estimates are not available. q010_0 q010_1 q011_0 q001a_0 q001a_1q011_1 q001b_0 q001b_1 q017_0 q017_1 q020_0 q026_1 q020_1 q014_0q024_0q014_1 q024_1 q025_0 q003_1 q025_1 q004_0 q005_0 Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. — Indicates that estimates are not available. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 42 APPENDIX E1. Avoidable Hospital Use & Cost: Dimension and Indicator Ranking Appendix E1. Avoidable Hospital Use & Cost: Dimension and Indicator Ranking Overall performance si t s e, 64 , s, , ar is ien Top quartile ns ns e, 4 ion on ic 8– ar io io d m at es ed s1 ic at – 7 at at Second quartile r ea p ag M a fo ed liz 65 liz 5+ liz l r ity ge i s cy si y s, s, m s ,M ita ita e 7 ita vi nc ,a Third quartile th o n ta il on on t v en p i fac i its ts nt ge d m es 4 sp ag p ag p as ssi si si en erg e, o s e, o s e 6 e er l a er ng is is Bottom quartile – 6 ho es ri c i ar h ar h at d m rt em ag rtm em 4 dm dm ita m ah i 18 le ic le ic le rs sp h o Data not available di l a os es ab ed ab ed ab pa le pa le – 6 ea e 6 ea t h nu m de b de b ho i ng p e ita 18 r ag ay r ag ent M ent M ent Pr 5+ 5+ da da ed ay sp rs ev ev ev oi oi ill -d -d Nu Ho Av Av Sk 30 30 Pr Pr wi H 1 Hawaii 1 1 1 1 1 1 1 1 1 1 2 Utah 0 1 1 1 1 1 1 1 1 1 3 Washington 1 1 1 1 1 1 1 1 1 1 4 Oregon 1 1 1 1 1 1 1 1 1 1 5 Idaho 0 1 1 1 1 1 1 1 1 1 6 Montana 1 1 1 1 1 1 2 2 1 1 7 Colorado 4 1 1 1 1 1 1 1 1 1 8 Minnesota 1 1 1 1 1 1 3 3 1 1 9 North Dakota 1 2 2 2 2 2 1 1 1 2 10 Alaska 0 4 4 1 1 1 1 1 1 1 11 California 2 1 1 1 1 1 2 2 3 3 12 South Dakota 2 1 1 2 2 2 2 2 1 2 13 Vermont 1 2 2 1 1 1 2 2 1 2 14 Iowa 1 2 2 2 2 2 2 2 1 2 15 New Mexico 4 2 2 1 1 1 2 2 2 2 16 Nebraska 1 1 1 2 2 2 2 2 1 2 17 Arizona 2 3 3 2 2 2 2 2 2 1 18 Wisconsin 2 3 3 1 1 1 3 3 1 1 19 Maine 0 4 4 2 2 2 1 1 1 1 20 Wyoming 3 2 2 2 2 2 1 1 1 2 21 New Hampshire 0 2 2 2 2 2 1 1 2 2 22 Delaware 0 2 2 3 3 3 2 2 3 2 23 South Carolina 3 2 2 2 2 2 2 2 3 3 24 North Carolina 3 3 3 2 2 2 2 2 2 2 25 Virginia 2 3 3 3 3 3 2 2 3 3 26 Maryland 3 2 2 3 3 3 3 3 3 2 27 Rhode Island 4 3 3 2 2 2 4 4 3 1 28 Nevada 3 3 3 2 2 2 3 3 4 3 29 Massachusetts 0 2 2 3 3 3 3 3 2 2 30 Kansas 4 2 2 3 3 3 3 3 2 3 31 Georgia 2 3 3 3 3 3 3 3 3 3 32 Connecticut 3 3 3 2 2 2 3 3 2 2 33 Pennsylvania 4 3 3 3 3 3 3 3 2 2 34 Illinois 3 2 2 3 3 3 4 4 3 4 35 Tennessee 1 3 3 4 4 4 2 2 2 3 36 New Jersey 4 1 1 3 3 3 4 4 4 4 37 Indiana 2 4 4 4 4 4 3 3 2 3 38 Arkansas 2 3 3 4 4 4 3 3 4 4 39 Michigan 3 3 3 4 4 4 4 4 4 3 39 Ohio 0 4 4 4 4 4 4 4 3 2 39 Texas 2 4 4 3 3 3 3 3 3 4 42 Alabama 0 3 3 4 4 4 1 1 3 3 43 District of Columbia 0 4 4 3 3 3 4 4 2 3 44 Missouri 4 4 4 4 4 4 4 4 3 3 45 Oklahoma 4 4 4 4 4 4 3 3 4 4 46 New York 4 2 2 3 3 3 4 4 4 2 47 Kentucky 3 4 4 4 4 4 4 4 3 4 48 West Virginia 2 4 4 4 4 4 4 4 3 3 49 Florida 4 4 4 4 4 4 4 4 4 4 50 Louisiana 3 4 4 4 4 4 3 3 4 4 51 Mississippi 0 4 4 4 4 4 4 4 4 4 commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 43 APPENDIX E1. Avoidable Hospital Use & Cost: Dimension and Indicator Ranking (continued) nsionAppendix E1. Avoidable Hospital Use & Cost: Dimension and Indicator Ranking and Indicator Ranking Overall performance s si t s si t s , e, re ic a 4 , s, , , , , ar geis en is ien Top quartile ns ns ns ns r ns ed th ca –6 e, e, io a 4 ion 18 n on ic ar ar , am ti i atth io io o 74 io p e tio r i ts n s w d m at –g atte es es a fo ed ed ad p a ic at – 7 at at Second quartile on iz i ea p 65n lirzia ag ag si als w + ng za m s, M M si i o y t ed liz 65 liz 5+ liz s, r isre cyy l r ity viiss cen np e 75 i ali si cy t 30ed e geen p irted itap s, s, ,M ,M th o ns is itnt t tva enili ita es ita e 7 ita agm p ro Third quartile ta il Ho 5+ ntm rgsid on as siio n on en iog 4 m spe en i rgac p i fac i ts its lle e, a p s o d m es y ssin e,k o s p sp ag p ag p i si si e 6 e d ere s – 6 d hoat i d p gf e, o s e, o s ic iss es g ar i d on l a er ng arac h a is tr mis is Bottom quartile – 6 ho ro arce ho a l ms e 1t8al leh p 4 i mn ag rtm eme in icb lein ar h ar h rtho em 4 dm ia + dm dm ic d e ta m ita m en ic n lep ah i le ic le ic le p aa e s rs – 6 f easp i ed r tab-s s eder taib h es i ablt p ad p i leo sp h o h nl r 4 Data not available d 65 l a os t es ab ed ab ed ab – 6 ea la p a a e 6 ea d et ab u t h nu d e s ab h u r 18 n y r e p ee itae ag s te ns n e lM es w ho idng ho i ng b e d iacar iM veo y ho enh 18 ay r ag sp y r ag ay r ag ent M ent M ent 18 5+ ow n wi dd ed a ev e ollie evlt o si a ep l e pa rs Pr m ev ev ev ill -d Ho-d -d Pr u Av r Em Avi - Nu Nu Ad Sk Sk 30 30 30 Pr Pr Pr wi M H 1 11 1 Hawaii 1 11 11 11 11 11 11 11 1 1 1 1 12 1 Utah1 10 11 11 11 21 21 21 1 1 1 1 13 1Washington 1 11 11 11 11 11 21 11 1 1 1 1 14 1 Oregon 1 11 11 11 11 11 31 11 1 1 1 1 15 1 Idaho 1 10 11 11 11 11 41 11 1 1 1 1 16 1 Montana 2 21 11 11 11 11 31 12 2 1 1 1 17 1 Colorado 1 14 11 11 11 21 31 11 1 1 1 1 18 1 Minnesota 3 31 11 11 31 11 31 13 3 1 1 2 29 North Dakota 2 1 11 12 22 32 12 22 21 1 1 2 1 10 1 1 Alaska 1 10 14 14 11 21 41 11 1 1 1 1 11 1 1 California 2 22 31 31 11 21 31 22 2 3 3 2 12 2 South Dakota 2 2 22 11 21 42 12 42 12 2 1 2 1 13 1 1 Vermont 2 21 12 22 41 11 41 12 2 1 2 2 14 2 2 Iowa2 21 12 22 42 12 12 22 2 1 2 1 15 1 1 New Mexico 2 24 22 22 11 21 31 12 2 2 2 2 16 2 2 Nebraska 2 21 11 21 22 12 32 22 2 1 2 2 17 2 2 Arizona 2 22 23 13 12 32 22 22 2 2 1 1 18 1 1 Wisconsin 3 32 13 13 21 21 41 23 3 1 1 2 19 2 2 Maine 1 10 14 14 32 12 32 21 1 1 1 2 20 2 2 Wyoming 1 13 12 22 32 22 42 11 1 1 2 2 21 2 New Hampshire 2 1 10 22 22 42 22 42 21 1 2 2 3 22 3 3 Delaware 2 20 32 22 23 23 23 32 2 3 2 2 23 2 South Carolina 2 2 23 32 32 32 02 02 22 2 3 3 2 24 2 North Carolina 2 2 23 23 23 22 42 32 22 2 2 2 3 25 3 3 Virginia2 22 33 33 33 43 23 22 2 3 3 3 26 3 3 Maryland 3 33 32 22 23 43 13 33 3 3 2 2 27 2 Rhode Island 2 4 44 33 13 22 32 12 34 4 3 1 2 28 2 2 Nevada 3 33 43 33 22 32 22 23 3 4 3 3 29 3 Massachusetts 3 3 30 22 22 43 23 23 33 3 2 2 3 30 3 3 Kansas 3 34 22 32 43 23 23 33 3 2 3 3 31 3 3 Georgia 3 32 33 33 33 43 23 33 3 3 3 2 32 2 2Connecticut 3 33 23 23 42 32 42 43 3 2 2 3 33 3 Pennsylvania 3 3 34 23 23 43 23 13 43 3 2 2 3 34 3 3 Illinois 4 43 32 42 23 33 33 34 4 3 4 4 35 4 4 Tennessee 2 21 23 33 44 44 14 42 2 2 3 3 36 3 3 New Jersey 4 44 41 41 33 33 33 44 4 4 4 4 37 4 4 Indiana 3 32 24 34 24 34 44 43 3 2 3 4 38 4 4 Arkansas 3 32 43 43 44 34 14 33 3 4 4 4 39 4 4 Michigan 4 43 43 33 24 34 14 44 4 4 3 4 39 4 4 Ohio4 40 34 24 24 34 34 34 4 3 2 3 39 3 3 Texas 3 32 34 44 13 43 43 43 3 3 4 4 42 4 4 Alabama 1 10 33 33 44 44 14 41 1 3 3 3 43 3 District of Columbia 3 4 40 24 34 23 03 03 34 4 2 3 4 44 4 4 Missouri 4 44 34 34 34 24 14 34 4 3 3 4 45 4 4 Oklahoma 3 34 44 44 24 34 24 43 3 4 4 3 46 3 3 New York 4 44 42 22 33 33 43 34 4 4 2 4 47 4 4 Kentucky 4 43 34 44 44 34 14 44 4 3 4 4 48 4 West Virginia 4 4 42 34 34 34 44 44 34 4 3 3 4 49 4 4 Florida4 44 44 44 14 44 34 44 4 4 4 4 50 4 4 Louisiana 3 33 44 44 34 44 24 43 3 4 4 4 51 4 4 Mississippi 4 40 44 44 44 44 14 44 4 4 4 commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 44 APPENDIX E2. Avoidable Hospital Use & Cost: & Cost: Dimension Ranking and Indicator Rates Appendix E2. Avoidable Hospital Use Dimension Ranking and Indicator Rates Avoidable emergency department Avoidable emergency Preventable Preventable Preventable Hospital admissions visits, ages department visits, hospitalizations, hospitalizations, hospitalization for pediatric asthma, 18–64 (rate per Medicare, age 65+ ages 18–64 (rate Medicare, ages 65–74 Medicare, age 75 per 100,000 children 1,000) (rate per 1,000) per 1,000) (rate per 1,000) (rate per 1,000 2012 2014 2015 2012 2015 2015 2012 2015 2012 2015 United States 143 106 * 159 188 197 5 29 26 70 66 Alabama — — 171 192 200 6 38 35 82 76 Alaska 62 — 166 205 213 4 — — 52 48 Arizona 125 90 * 176 178 191 * 5 20 17 51 47 Arkansas 81 95 157 185 200 * 5 35 32 83 78 California 96 96 130 167 174 4 21 18 55 52 Colorado 129 141 147 173 177 4 16 14 50 45 Connecticut 136 130 163 189 208 * 4 26 24 75 70 Delaware — — 151 159 179 * 5 27 27 68 65 District of Columbia — — — 248 242 — 37 — — 65 Florida 143 141 178 179 199 * 6 28 28 68 71 Georgia 97 81 164 201 197 5 31 28 73 68 Hawaii 69 63 138 131 138 4 13 — 41 33 Idaho — — 134 162 173 4 17 15 45 42 Illinois 119 116 154 192 199 5 31 27 * 73 73 Indiana 102 89 171 200 210 6 35 31 * 77 72 Iowa 71 70 151 184 186 4 24 22 64 60 Kansas 160 159 161 173 189 * 5 27 24 71 67 Kentucky 152 115 * 151 219 236 * 5 51 45 * 100 93 Louisiana 203 129 ** 174 236 238 6 44 38 * 97 88 Maine 76 — 172 233 219 * 4 26 25 65 64 Maryland 137 129 148 193 194 5 29 28 69 65 Massachusetts 141 — 142 209 208 4 30 29 80 79 Michigan 94 122 * 159 214 223 5 34 32 73 74 Minnesota 82 70 139 181 186 4 20 19 55 52 Mississippi — — 183 231 246 * 6 42 41 91 91 Missouri 161 172 203 197 209 5 31 30 73 69 Montana 77 78 145 158 163 4 21 18 — 53 Nebraska 82 69 140 153 157 5 24 21 63 61 Nevada 112 102 187 165 164 5 25 21 * 60 55 New Hampshire — — 156 192 183 4 23 24 64 67 New Jersey 163 155 145 170 180 5 27 26 73 70 New Mexico — 166 149 170 193 * 4 23 19 * 59 51 New York 231 243 155 173 179 5 29 24 * 73 65 North Carolina 113 109 159 197 217 * 4 29 28 67 65 North Dakota — 61 162 187 168 * 4 24 22 65 63 Ohio 128 — 177 219 230 5 38 31 * 82 74 Oklahoma 189 156 * 172 211 236 * 5 38 34 * 80 73 Oregon 41 48 137 162 167 4 17 17 48 47 Pennsylvania — 157 159 187 194 5 31 28 74 70 Rhode Island 149 140 158 188 212 * 4 27 29 66 65 South Carolina 133 108 * — 176 189 * — 27 25 65 62 South Dakota 76 89 143 168 155 * 4 22 22 — 61 Tennessee 73 74 168 200 205 6 37 32 * 84 79 Texas 114 97 176 186 198 5 31 28 76 70 Utah 93 — 132 147 151 4 17 14 42 38 Vermont 28 22 163 187 174 * 4 — 20 65 58 Virginia 100 80 168 193 195 5 27 23 * 71 62 Washington 84 60 * 138 157 175 * 3 18 17 49 47 West Virginia 98 84 182 226 251 * 5 50 41 ** 98 88 Wisconsin 86 86 164 182 194 4 22 21 60 56 Wyoming 123 106 166 169 178 5 — 20 — — Change States Improved 6 4 12 10 States Worsened 1 15 0 0 Notes: * Denotes a change of atof at least 0.5 standard deviations. ** Denotes of change of 1.0 standardmore. Medicare estimates reflect only the age 65+ Medicare fee-for-service Notes: * Denotes a change least 0.5 standard deviations. ** Denotes a change a 1.0 standard deviation or deviation or more. Spending estimates exclude prescription drug costs and are adjus population. — Indicates that estimates are not available. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 45 d Indicator Rates E2. Avoidable Hospital Cost: & Cost: Dimension Ranking and Indicator Rates APPENDIX E2. Avoidable Hospital Use & Use Dimension Ranking and Indicator Rates (continued) Appendix Avoidable emergency able Preventable Preventable department Avoidable emergency 30-day Short-stay nursing Preventable Preventable Preventable ations, hospitalizations, Hospital admissions readmissions, 30-day readmissions, home residents with a hospitalizations, hospitalizations, visits, ages department visits, hospitalizations, Long-stay nursing hospitalization Home health p 4 (rate Medicare, ages 65–74 for pediatric asthma, ages 18–64 (rate Medicare, age 65+ Medicare, age 75+ 18–64 (rate per Medicare, age 65+ 30-day readmission to home residents with a Medicare,a hosp ages 18–64 (rate Medicare, ages 65–74 with age 75 00) (rate per 1,000) per 100,000 children (rate per 1,000) per 1,000) 1,000) (rate per 1,000) (rate per 1,000) per 1,000) the hospital (rate per 1,000) hospital admission (rate per 1,000 admissio 5 2012 2015 2012 2012 2015 2014 2015 2012 2012 2015 2015 2012 2015 2014 2012 2012 2015 2014 2012 2013 2015 2 United States 26 29 143 70 106 * 66 159 2.9 188 49 197 * 42 20%5 19% 29 17% 26 16% 16.0% 70 16 66 Alabama 38 35 — 82 — 76 171 1.2 192 50 200 45 226 20 * 38 21 35 19 8217.0 76 Alaska— — 52 62 — 48 166 2.6 205 29 213 25 —4 11 — — — 11 5214.0 48 Arizona 20 17 125 51 47 * 90 3.32 176 178 38 191 ** 32 205 19 20 9 17 8 5115.0 47 Arkansas 35 32 83 81 78 95 2.99 157 185 51 200 ** 44 255 23 * 35 26 32 24 8317.0 78 California 21 18 55 96 52 96 2.39 130 167 43 174 * 37 224 20 * 21 20 18 19 5515.0 52 Colorado 16 14 129 50 141 45 2.29 147 173 31 177 27 164 14 * 16 10 14 9 5014.0 45 Connecticut 26 24 136 75 130 70 163 2.4 189 52 208 ** 46 204 19 26 16 24 14 7516.0 70 Delaware 27 27 — 68 — 65 2.68 151 159 42 179 * 39 205 20 27 19 27 16 * 6816.0 65 — District37 Columbia of —— — 65 — 248 65 242 ** 50 —— 19 37 — — 19 —18.0 65 Florida 28 28 143 68 141 71 3.87 178 179 54 199 * 51 226 22 28 23 28 22 6815.0 71 Georgia 31 28 73 97 68 81 2.94 164 201 46 197 * 40 215 20 31 19 28 17 7316.0 68 Hawaii13 — 41 69 33 * 63 2.81 138 131 26 138 21 —4 12 13 — — 5 4114.0 33 Idaho 17 15 — 45 — 42 2.49 134 162 26 173 24 144 14 17 11 15 12 4514.0 42 Illinois 31 27 * 119 73 116 73 3.22 154 192 59 199 ** 48 235 20 * 31 22 27 * 20 7316.0 73 Indiana35 31 * 102 77 72 89 3.13 171 200 51 210 * 43 206 18 * 35 19 31 * 17 7716.0 72 Iowa 24 22 64 71 60 70 2.68 151 184 39 186 35 174 16 24 15 22 15 6416.0 60 Kansas27 24 160 71 159 67 2.85 161 173 43 189 * 39 195 18 27 20 24 19 7117.0 67 Kentucky 51 45 * 100 152 115 ** 93 3.02 151 219 63 236 ** 54 225 20 * 51 24 45 * 21 * 10018.0 93 Louisiana44 38 * 203 97 129 *** 88 2.98 174 236 56 238 * 47 266 25 44 30 38 * 27 * 9716.0 88 Maine 26 25 65 76 — 64 2.14 172 233 39 219 * 37 174 16 26 12 25 12 6516.0 64 Maryland 29 28 137 69 129 65 2.63 148 193 54 194 ** 43 225 20 * 29 17 28 16 6917.0 65 Massachusetts 30 29 141 80 — 79 2.75 142 209 54 208 50 194 19 30 14 29 13 8016.0 79 Michigan 34 32 73 94 122 * 74 3.36 159 214 61 223 * 55 235 21 * 34 18 32 17 7316.0 74 Minnesota20 19 55 82 52 70 3.13 139 181 41 186 37 174 16 20 7 19 7 5516.0 52 Mississippi 42 41 — 91 — 91 2.88 183 231 56 246 ** 50 246 22 * 42 29 41 28 9117.0 91 Missouri 31 30 161 73 172 69 3.47 203 197 51 209 46 225 20 * 31 20 30 19 7316.0 69 Montana 21 18 —77 53 78 3.28 145 158 30 163 27 134 13 21 12 18 12 —15.0 53 Nebraska 24 21 63 82 61 69 2.98 140 153 39 157 35 165 15 24 16 21 16 6316.0 61 Nevada 25 21 * 112 60 102 55 3.63 187 165 41 164 37 235 22 25 20 21 * 19 6015.0 55 New Hampshire 24 23 — 64 — 67 156 2.3 192 36 183 36 164 17 23 14 24 14 6417.0 67 New Jersey 27 26 163 73 155 70 3.21 145 170 57 180 * 48 245 22 * 27 21 26 20 7316.0 70 New Mexico 23 19 * — 59 166 * 51 2.92 149 170 33 193 * 30 184 18 23 13 19 * 15 5915.0 51 New York 29 24 * 231 73 243 * 65 5.46 155 173 59 179 ** 47 235 21 * 29 17 24 * 14 * 7317.0 65 North Carolina 29 28 113 67 109 65 2.59 159 197 45 217 * 40 204 18 * 29 18 28 16 6716.0 65 North Dakota 24 22 — 65 63 61 162 2.7 187 42 168 ** 32 164 14 * 24 15 22 14 6515.0 63 Ohio 38 31 * 128 82 — 74 * 3.36 177 219 59 230 ** 47 215 20 38 15 31 * 13 8216.0 74 Oklahoma 38 34 * 189 80 156 ** 73 3.19 172 211 49 236 ** 42 235 21 * 38 24 34 * 23 8016.0 73 Oregon 17 17 48 41 47 48 2.65 137 162 28 167 28 174 16 17 8 17 9 4814.0 47 Pennsylvania 31 28 — 74 157 70 3.09 159 187 54 194 * 46 215 19 * 31 16 28 14 7417.0 70 Rhode 27 Island 29 149 66 140 65 3.36 158 188 50 212 * 48 214 20 27 10 29 9 6615.0 65 South Carolina 27 25 133 65 108 * 62 — 176 41 189 * 37 — 20 20 27 20 25 19 6516.0 62 South Dakota 22 22 —76 61 89 3.38 143 168 36 155 * 31 154 14 22 15 22 16 —17.0 61 Tennessee37 32 * 84 73 79 74 1.94 168 200 53 205 * 45 216 19 * 37 22 32 * 19 * 8417.0 79 Texas 31 28 114 76 70 97 3.45 176 186 46 198 41 225 20 * 31 23 28 21 7615.0 70 Utah 17 14 42 93 — 38 1.37 132 147 28 151 23 144 14 17 11 14 11 4214.0 38 Vermont — 20 65 28 58 * 22 3.21 163 187 33 174 * 32 164 15 — 15 20 14 6516.0 58 Virginia 27 23 * 100 71 62 * 80 168 2.5 193 48 195 * 39 215 20 27 20 23 * 18 7117.0 62 Washington 18 17 49 84 47 * 60 2.21 138 157 35 175 * 30 173 16 18 13 17 11 4915.0 47 West Virginia 50 41 ** 98 98 88 * 84 182 3 226 64 251 ** 54 235 20 * 50 19 41 ** 17 9818.0 88 Wisconsin22 21 60 86 56 86 3.24 164 182 41 194 * 35 174 16 22 12 21 12 6016.0 56 Wyoming — 20 — 123 — 106 2.86 166 169 34 178 30 155 14 — 13 20 16 * —17.0 — Change States Improved 12 10 6 23 4 20 12 5 10 States Worsened 0 0 1 15 0 0 0 1 0 ending estimates exclude prescription drugat least 0.5aredeviations.forDenotes Denotes of change of 1.0 standardmore. Medicareonly the age 65+ Medicare fee-for-service population. — Indicates tha Notes: * Denotes a change of atof costsstandard adjusted ** regional wage differences; Medicare estimates reflectmore. Spending estimates exclude prescription drug costs and are adjus Notes: * Denotes a change least 0.5 and standard deviations. ** a change a 1.0 standard deviation or deviation or estimates reflect only the age 65+ Medicare fee-for-service population. — Indicates that estimates are not available. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 46 APPENDIX E2. Avoidable Hospital Use & Cost: Dimension Ranking and Indicator and Indicator Rates Appendix E2. Avoidable Hospital Use & Cost: Dimension Ranking Rates (continued) Avoidable emergency ursing Adults with department Avoidable emergency Total Medicare Preventable Preventable Preventable s with a Long-stay nursing Home health patients inappropriate Hospital admissions visits, ages department visits, Total employer- hospitalizations, (Parts A & B) hospitalizations, hospitalization ssion to home residents with a for pediatric asthma, 18–64 (rate per sponsored insurance reimbursements with a hospital lower back Medicare, age 65+ ages 18–64 (rate Medicare, ages 65–74 Medicare, age 7 tal hospital admission per 100,000 children admission imaging 1,000) spendingper 1,000) (rate per enrollee per enrollee per 1,000) (rate per 1,000) (rate per 1,000 2014 2012 2014 2013 2012 2016 2014 2015 2015 2013 2012 2015 2015 201220152015 2012 2015 2012 201 19% United States 17% 16% 16.0% 143 16.4% * 106 29% 159 $4,697 188 $4,736 197 $8,854 5 $9,025 29 26 70 6 20 * Alabama 21 19 — 17.0 — 18.0 * 41 171 3,706 192 3,706 200 9,344 6 9,623 38 35 82 7 11 Alaska — 11 14.0 62 — 14.4 25 166 7,186 205 8,902 ** 213 5,399 4 6,318 * — — 52 4 19 Arizona9 8 15.0 125 14.6 * 90 32 176 4,453 178 4,509 * 191 7,998 5 8,168 20 17 51 4 23 * Arkansas 26 24 17.0 81 18.4 ** 95 32 157 3,117 185 3,609 ** 200 8,619 5 9,022 35 32 83 7 20 * California 20 19 15.0 96 14.9 96 25 130 4,915 167 5,151 174 8,310 4 8,295 21 18 55 5 14 * Colorado 10 9 14.0 129 15.3 ** 141 26 147 4,625 173 4,811 177 7,460 4 7,635 16 14 50 4 19 Connecticut 16 14 16.0 136 17.4 ** 130 33 163 5,067 189 5,358 * 208 8,936 4 9,335 26 24 75 7 20 Delaware 19 16 * — 16.0 — 16.5 * 28 151 4,509 159 4,643 * 179 8,514 5 8,980 27 27 68 6 19 — District of Columbia 19 — 18.0 — 16.0 ** —— 3,548 248 — 242 8,887 — 8,838 37 — — 6 22 Florida23 22 15.0 143 15.9 * 141 35 178 4,748 179 5,050 * 199 10,597 6 10,638 28 28 68 7 20 Georgia 19 17 16.0 97 16.9 * 81 35 164 4,951 201 4,507 * 197 8,743 5 8,974 31 28 73 6 12 Hawaii — 5 14.0 69 14.4 63 23 138 3,460 131 3,667 138 5,408 4 5,586 13 — 41 3 14 Idaho 11 12 — 14.0 — 15.2 ** 22 134 4,906 162 5,243 173 7,198 4 7,589 17 15 45 4 20 * Illinois 22 20 16.0 119 16.3 116 30 154 4,575 192 4,847 199 9,219 5 9,211 31 27 * 73 7 18 * Indiana 19 17 16.0 102 16.6 * 89 32 171 4,955 200 5,317 210 9,045 6 9,291 35 31 * 77 7 16 Iowa 15 15 16.0 71 17.2 ** 70 23 151 3,784 184 4,118 186 7,496 4 7,905 24 22 64 6 18 Kansas 20 19 17.0 160 17.7 * 159 25 161 4,079 173 4,362 * 189 8,586 5 9,034 27 24 71 6 20 * Kentucky 24 21 * 18.0 152 17.7 * 115 33 151 4,393 219 4,033 * 236 9,167 5 9,351 51 45 * 100 9 25 Louisiana30 27 * 16.0 203 16.9 *** 129 39 174 4,404 236 4,452 238 10,868 6 10,851 44 38 * 97 8 16 Maine 12 12 16.0 76 — 17.1 ** 23 172 4,661 233 4,868 * 219 7,606 4 8,083 26 25 65 6 20 * Maryland 17 16 17.0 137 16.3 * 129 34 148 3,683 193 3,848 194 8,472 5 8,927 29 28 69 6 19 Massachusetts 13 14 16.0 141 — 17.6 ** 27 142 4,659 209 4,648 208 9,041 4 9,158 30 29 80 7 21 * Michigan 18 17 16.0 94 16.4 * 122 33 159 3,903 214 3,818 223 9,565 5 9,714 34 32 73 7 16 Minnesota 7 7 16.0 82 16.9 * 70 21 139 4,483 181 4,726 186 7,225 4 7,791 20 19 55 5 22 * Mississippi 29 28 — 17.0 — 18.2 ** 37 183 3,982 231 3,347 ** 246 10,046 6 10,352 42 41 91 9 20 * Missouri 20 19 16.0 161 17.0 * 172 29 203 4,266 197 4,187 209 8,698 5 8,976 31 30 73 6 13 Montana 12 12 15.0 77 15.4 78 23 145 4,553 158 4,858 163 6,585 4 7,004 21 18 — 5 15 Nebraska 16 16 16.0 82 16.5 * 69 24 140 4,507 153 4,972 * 157 8,062 5 8,654 * 24 21 63 6 22 Nevada 20 19 15.0 112 16.1 ** 102 32 187 4,022 165 4,400 164 8,328 5 8,488 25 21 * 60 5 17 New Hampshire 14 14 — 17.0 — 17.6 * 29 156 5,245 192 5,487 183 7,618 4 7,839 23 24 64 6 22 * New Jersey 21 20 16.0 163 16.7 * 155 32 145 4,771 170 5,101 180 9,556 5 9,757 27 26 73 7 18 New Mexico 13 15 — 15.0 15.3 166 26 149 4,407 170 4,716 * 193 6,791 4 7,183 23 19 * 59 5 21 * New York 17 14 * 17.0 231 17.0 243 30 155 5,279 173 5,866 * 179 8,977 5 9,191 29 24 * 73 6 18 * North Carolina 18 16 16.0 113 16.1 109 34 159 4,497 197 4,852 * 217 8,158 4 8,590 29 28 67 6 14 * North Dakota 15 14 — 15.0 16.8 ** 61 16 162 4,306 187 4,438 * 168 7,529 4 7,867 24 22 65 6 20 Ohio 15 13 16.0 128 — 16.6 * 32 177 4,464 219 4,770 230 9,492 5 9,254 38 31 * 82 7 21 * Oklahoma 24 23 16.0 189 16.5 ** 156 32 172 4,312 211 4,356 * 236 9,182 5 9,721 38 34 * 80 7 16 Oregon8 9 14.0 41 15.5 ** 48 20 137 4,300 162 4,721 * 167 6,300 4 6,827 17 17 48 4 19 * Pennsylvania 16 14 — 17.0 17.4 157 27 159 4,185 187 4,344 194 9,391 5 9,432 31 28 74 7 20 Rhode10 Island 9 15.0 149 16.3 ** 140 30 158 4,018 188 4,333 * 212 8,557 4 8,803 27 29 66 6 20 South Carolina 20 19 16.0 133 16.7 ** 108 —— — 176 — 189 * 8,529 — 8,671 27 25 65 6 14 South Dakota 15 16 17.0 76 17.3 89 18 143 5,042 168 5,278 * 155 7,204 4 7,682 22 22 — 6 19 * Tennessee22 19 * 17.0 73 17.4 74 36 168 4,081 200 4,134 205 9,197 6 9,316 37 32 * 84 7 20 * Texas 23 21 15.0 114 15.9 * 97 35 176 5,110 186 5,424 198 10,135 5 10,364 31 28 76 7 14 Utah 11 11 14.0 93 — 14.0 26 132 4,322 147 4,508 151 8,011 4 8,207 17 14 42 3 15 Vermont 15 14 16.0 28 17.2 ** 22 23 163 5,384 187 5,660 * 174 6,816 4 7,231 — 20 65 5 20 Virginia 20 18 17.0 100 16.7 80 34 168 4,203 193 4,498 195 8,000 5 8,172 27 23 * 71 6 16 Washington 13 11 15.0 84 15.0 * 60 22 138 4,545 157 4,596 * 175 7,106 3 7,361 18 17 49 4 20 * West Virginia 19 17 18.0 98 16.9 ** 84 35 182 5,345 226 5,389 * 251 8,637 5 8,904 50 41 ** 98 8 16 Wisconsin12 12 16.0 86 16.2 86 27 164 5,871 182 6,149 194 7,615 4 7,905 22 21 60 5 14 Wyoming 13 16 * 17.0 123 16.8 106 27 166 5,779 169 6,312 * 178 ## 6,818 5 7,269 — 20 — — Change 20 States Improved 5 36 2 4 0 12 1 0 States Worsened 1 291 15 6 2 0 65+ Medicare fee-for-service population. — 0.5 standard deviations. ** Denotes a change of 1.0 standard1.0 standard deviation or more. Spending estimates excludecosts and are adjusted for and are adju Notes: * Denotes a change of at least Indicates standard deviations. ** available.a change of deviation or more. Spending estimates exclude prescription drug prescription drug costs Notes: * Denotes a change of at least 0.5 that estimates are not Denotes regional wage differences; Medicare estimates reflect only the age 65+ Medicare fee-for-service population. — Indicates that estimates are not available. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 47 APPENDIX F1. Healthy Lives: Dimension and Indicator Ranking Appendix F1. Healthy Lives: Dimension and Indicator Ranking Overall performance e n Top quartile th us re or r al ld xo ug po he hs Second quartile hi dr i r/ si at to ec se hs st nd de fa le Third quartile es be lo e at rt l, a ab er ok ob eo de th ve po y nc en ho sm lit Bottom quartile ee ha or re ar er ca am ta h s co nc ht th o o o et o or al at , al al h wh wh or h Data not available re ty ig ca he t s w m ts w ct m de ide we ca ali re ts ts st nt t er ul ul ul ul lo ea ic or fa Ov Su Co Ad Ad Ad Ad Br In M 1 Utah 1 1 1 3 1 1 1 1 1 1 2 Hawaii 2 1 1 1 2 1 1 1 1 1 3 Massachusetts 1 1 1 3 1 1 1 1 1 1 4 Minnesota 1 1 1 1 2 1 1 2 2 1 5 California 2 1 1 1 1 3 1 1 2 1 6 Connecticut 1 1 1 2 2 1 1 1 2 1 6 Vermont 1 1 4 3 1 1 2 1 1 2 8 Washington 1 2 1 2 1 1 1 2 1 1 9 Colorado 1 2 1 3 1 2 2 1 1 1 10 New York 2 2 2 1 1 2 1 1 3 2 11 Idaho 1 3 1 2 1 2 1 2 1 1 12 Iowa 2 2 2 1 1 1 2 3 2 1 13 Oregon 1 4 2 2 2 3 2 2 1 2 14 New Hampshire 1 1 2 4 1 1 3 1 1 2 15 Montana 2 2 2 3 2 1 3 1 1 3 16 Nebraska 1 2 3 1 2 1 2 3 2 1 17 Arizona 2 1 1 4 2 3 1 2 1 1 18 Rhode Island 1 1 1 4 2 2 1 1 4 1 19 New Jersey 2 3 3 1 1 3 1 1 3 2 19 Virginia 3 3 2 2 2 2 1 2 1 2 21 Wisconsin 2 2 2 2 2 2 2 2 2 2 22 Wyoming 2 2 1 4 1 2 3 2 1 3 23 Illinois 3 3 3 1 3 3 2 3 1 1 24 Texas 3 2 3 1 2 3 1 4 3 1 25 Kansas 3 3 3 1 3 2 2 3 2 2 26 South Dakota 2 2 4 2 4 1 3 2 2 2 27 Maryland 3 3 2 3 3 1 1 2 3 1 27 North Dakota 2 1 2 2 4 1 3 3 4 1 29 New Mexico 3 2 2 4 2 4 2 2 1 2 30 Alaska 2 2 3 4 3 1 3 3 1 2 31 Florida 3 1 2 3 3 4 1 2 4 3 32 Maine 1 1 2 4 3 3 3 2 2 4 33 North Carolina 3 2 2 2 4 3 3 3 2 3 34 Pennsylvania 3 4 3 4 3 2 3 2 3 3 35 Nevada 4 4 4 4 2 4 2 1 2 3 36 Delaware 3 3 2 3 4 3 3 3 2 3 37 Michigan 3 3 2 3 3 3 3 3 3 3 38 District of Columbia 4 4 4 3 4 1 1 1 3 1 39 Missouri 4 3 3 3 3 3 4 3 2 4 40 Georgia 4 4 3 1 4 4 3 3 3 4 41 Indiana 3 3 3 3 4 3 4 3 3 3 42 South Carolina 4 4 3 2 3 4 3 3 3 4 43 Ohio 3 4 4 4 4 3 4 3 3 4 44 Alabama 4 3 3 2 4 4 4 4 4 4 44 Tennessee 4 4 4 3 3 4 4 4 4 4 46 Oklahoma 4 4 4 4 4 4 3 3 3 4 47 Louisiana 4 4 4 2 4 4 4 4 3 4 48 Kentucky 4 4 4 4 3 4 4 4 3 4 49 Arkansas 4 3 4 2 4 4 4 4 3 4 50 Mississippi 4 4 4 1 4 4 4 4 4 4 51 West Virginia 4 4 4 4 3 4 4 4 4 4 commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 48 APPENDIX F2. Healthy Lives: Dimension Ranking andand Indicator Rates Appendix F2. Healthy Lives: Dimension Ranking Indicator Rates Mortality amenable to Breast cancer deaths per Deaths from suicide, health care, deaths per 100,000 female Colorectal cancer deaths alcohol, and drug use per Infant mortality, deaths Adults who 100,000 population population per 100,000 population 100,000 population per 1,000 live births fair/poor h 2012-13 2014-15 2013 2016 2013 2016 2013 2016 2012 2015 2013 United States 83.7 84.3 20.8 20.1 14.6 13.1 * 35.6 43.2 * 6.0 5.9 16% Alabama 111.3 110.4 21.4 21.1 17.7 14.3 ** 36.7 44.7 * 8.9 8.3 20 Alaska 71.6 73.2 19.3 20.0 16.4 14.0 ** 51.4 60.2 * 5.1 6.9 ** 14 Arizona 72.4 73.5 20.6 18.9 * 13.3 11.6 * 50.1 52.9 5.8 5.5 16 Arkansas 118.9 123.6 21.4 20.6 17.7 15.7 ** 36.9 43.2 * 7.1 7.5 22 California 72.0 70.8 20.1 18.5 * 13.2 11.8 * 32.3 33.3 4.5 4.4 18 Colorado 59.2 62.7 18.1 19.5 * 12.3 11.2 * 44.2 48.0 4.6 4.7 12 Connecticut 61.3 59.1 18.7 18.3 11.9 10.4 * 32.0 45.3 ** 5.3 5.7 11 Delaware 85.0 83.4 21.3 21.1 13.8 12.6 * 38.2 49.0 ** 7.6 9.1 ** 16 District of Columbia 123.9 127.9 29.8 23.7 ** 14.3 16.4 ** 27.7 51.8 ** 7.9 8.8 * 11 Florida 80.0 80.9 19.6 18.8 13.7 12.6 * 35.5 48.3 ** 6.1 6.2 18 Georgia 100.4 103.5 22.5 21.7 14.9 14.3 30.6 35.1 6.2 7.8 ** 17 Hawaii 75.3 76.1 15.5 14.5 * 14.2 11.5 ** 28.4 31.2 4.9 5.7 * 12 Idaho 66.7 64.9 22.1 21.4 13.4 11.7 * 42.5 44.6 5.4 4.7 * 13 Illinois 87.1 87.7 22.2 21.0 * 15.9 13.8 ** 30.1 38.3 * 6.5 6.0 15 Indiana 91.0 92.2 21.8 20.7 * 15.4 13.6 * 40.2 50.1 * 6.7 7.3 16 Iowa 71.8 70.6 18.7 19.2 15.6 13.4 ** 31.6 33.7 5.3 4.2 * 12 Kansas 78.1 80.1 18.5 21.4 ** 15.4 13.6 * 33.7 37.3 6.3 6.0 14 Kentucky 105.8 108.6 21.1 21.7 17.1 15.9 * 48.9 61.7 ** 7.2 6.7 21 Louisiana 123.5 124.9 23.9 22.2 * 18.4 15.5 ** 39.5 45.3 * 8.1 7.6 20 Maine 62.3 66.2 18.8 18.8 12.5 13.4 38.0 53.9 ** 7.0 6.6 13 Maryland 88.7 90.3 21.5 21.3 14.3 13.4 30.0 48.8 ** 6.4 6.6 13 Massachusetts 60.4 59.9 18.4 16.9 * 13.1 11.0 ** 30.8 50.2 ** 4.2 4.3 12 Michigan 91.3 92.2 21.2 20.5 14.8 13.1 * 37.7 47.1 * 6.9 6.5 16 Minnesota 55.6 54.7 19.6 17.0 ** 12.8 11.9 29.3 34.4 5.0 5.2 11 Mississippi 136.7 142.4 23.3 23.3 18.8 17.2 * 33.2 35.5 8.9 9.5 21 Missouri 95.1 95.7 22.0 21.1 15.7 13.8 * 40.0 49.5 * 6.6 6.5 17 Montana 70.3 71.2 19.9 19.4 12.4 12.2 48.8 50.2 5.9 5.8 14 Nebraska 64.9 68.2 21.0 20.1 15.2 13.6 * 26.6 28.5 4.7 5.7 * 12 Nevada 91.7 95.5 22.5 21.6 16.8 16.4 49.4 52.3 4.9 5.2 16 New Hampshire 58.4 57.7 19.8 19.0 12.8 12.6 34.7 64.3 ** 4.2 4.1 11 New Jersey 75.1 73.1 23.2 21.2 ** 14.9 13.7 * 29.7 37.7 * 4.4 4.7 15 New Mexico 78.6 80.0 17.3 20.3 ** 14.5 12.2 ** 61.8 72.2 * 6.8 5.1 ** 19 New York 79.0 77.1 20.6 19.9 14.0 12.1 * 25.7 32.8 * 5.0 4.6 16 North Carolina 92.5 93.6 20.4 20.1 13.3 12.4 34.5 41.8 * 7.4 7.4 17 North Dakota 70.5 73.3 17.9 17.9 15.9 12.8 ** 32.1 41.7 * 6.3 7.2 * 12 Ohio 94.5 94.5 22.9 21.6 * 16.3 15.0 * 42.6 63.0 ** 7.5 7.2 16 Oklahoma 117.5 126.3 22.9 22.2 17.5 16.3 * 51.1 56.8 * 7.5 7.3 19 Oregon 61.9 62.6 19.9 21.5 * 14.4 12.7 * 39.2 41.3 5.4 5.2 16 Pennsylvania 82.0 82.6 21.8 21.5 15.9 14.1 * 39.4 59.5 ** 7.1 6.2 * 15 Rhode Island 68.5 68.2 19.4 18.4 * 13.2 11.9 * 43.3 54.3 ** 6.5 5.9 14 South Carolina 99.2 99.2 21.3 22.4 * 15.0 13.7 * 38.3 45.4 * 7.5 6.9 17 South Dakota 74.5 75.8 19.9 19.8 16.7 14.6 ** 38.0 44.8 * 8.3 7.3 * 10 Tennessee 110.0 113.3 22.4 22.0 16.6 14.4 ** 44.1 51.9 * 7.2 7.0 21 Texas 93.4 95.3 20.2 19.7 14.7 13.5 * 33.1 35.7 5.8 5.7 17 Utah 61.4 60.7 20.3 19.0 * 10.9 10.1 48.7 50.7 4.8 5.0 11 Vermont 57.2 61.4 18.5 13.6 ** 14.3 15.7 * 39.3 46.1 * 4.3 4.6 11 Virginia 81.3 80.2 21.1 20.9 13.8 13.0 30.4 38.4 * 6.5 5.9 14 Washington 62.2 62.4 20.5 19.4 * 12.8 11.6 * 38.6 39.3 5.3 4.9 15 West Virginia 103.5 106.9 21.6 21.9 19.8 17.4 ** 60.5 83.1 ** 7.2 7.1 22 Wisconsin 69.4 69.4 20.4 19.3 * 14.1 12.3 * 37.3 42.9 * 5.7 5.8 14 Wyoming 68.0 73.8 20.5 20.3 12.6 11.0 * 51.5 55.9 5.6 4.9 * 14 Change States Improved 0 16 39 0 6 States Worsened 0 5 2 33 7 Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 49 APPENDIX F2. Healthy Lives: Dimension Ranking andand Indicator Rates Appendix F2. Healthy Lives: Dimension Ranking Indicator Rates (continued) Children who cide, Mortality amenable to Breast cancer deaths per are Deaths from suicide, use per Infant mortality, deaths health care, report per Adults who deaths 100,000 female Colorectal canceroverweight or Adults who have lost deaths alcohol, and drug use per Infant mortality, deaths Adults who ation per 1,000 live births 100,000 population Adults who smoke fair/poor health population Adults who100,000 population per are obese obese 100,000 population six or more teeth per 1,000 live births fair/poor h 016 2012 2015 2012-13 2013 2016 2014-15 2013 2013 2016 2016 2013 2013 2016 2016 2016 2013 2012 2016 2016 2012 2015 2013 43.2 * United States 5.9 6.0 16% 83.7 16% 84.3 18% 20.816% * 20.1 29% 14.6 30% 13.1 31% * 35.6 10% 43.210% * 6.0 5.9 16% 44.7 * Alabama8.9 8.3 111.3 20 20 110.4 21 21.4 21 21.1 33 17.737 ** 14.3 ** 35 36.7 17 44.7 *15 * 8.9 8.3 20 60.2 * Alaska 5.1 6.9 ** 14 71.6 1373.2 23 19.3 19 **20.0 28 16.431 * 14.0 ** 26 51.4 9 60.2 *10 5.1 6.9 ** 14 52.9 Arizona5.8 5.5 16 72.4 1773.5 16 20.6 15 18.9 * 28 13.330 * 11.6 *27 50.1 10 52.9 8 * 5.8 5.5 16 43.2 * Arkansas 7.1 7.5 118.9 22 24 * 123.6 26 21.4 24 * 20.6 37 17.738 15.7 ** 34 36.9 17 43.2 *16 7.1 7.5 22 33.3 California 4.5 4.4 18 72.0 16 * 70.8 12 20.1 10 * 18.5 * 25 13.225 11.8 *31 32.3 7 33.3 6 4.5 4.4 18 48.0 Colorado 4.6 4.7 12 59.2 14 * 62.7 18 18.1 16 * 19.5 * 22 12.323 11.2 *27 44.2 7 48.0 7 4.6 4.7 12 45.3 ** Connecticut 5.3 5.7 11 61.3 13 * 59.1 16 18.7 13 * 18.3 25 11.926 10.4 *30 32.0 8 45.3 **7 5.3 5.7 11 49.0 ** Delaware 7.6 9.1 ** 16 85.0 1583.4 20 21.3 18 * 21.1 31 13.831 12.6 *31 38.2 10 49.0 ** 11 7.6 9.1 ** 16 51.8 ** District of Columbia8.8 7.9 * 123.9 11 10 127.9 19 29.8 15 **23.7 ** 23 14.322 16.4 ** 34 27.7 7 51.8 **6 7.9 8.8 * 11 48.3 ** Florida6.1 6.2 18 80.0 1880.9 17 19.6 15 * 18.8 27 13.728 12.6 *37 35.5 11 48.3 ** 12 6.1 6.2 18 35.1 Georgia6.2 7.8 ** 100.4 17 18 103.5 19 22.5 18 21.7 31 14.932 14.3 32 30.6 13 35.1 13 6.2 7.8 ** 17 31.2 Hawaii 4.9 5.7 * 12 75.3 1376.1 13 15.5 13 14.5 * 23 14.226 * 11.5 ** 25 28.4 6 31.2 6 4.9 5.7 * 12 44.6 Idaho5.4 4.7 * 13 66.7 1464.9 17 22.1 15 * 21.4 30 13.428 * 11.7 *26 42.5 9 44.6 8 5.4 4.7 * 13 38.3 * Illinois 6.5 6.0 15 87.1 1687.7 18 22.2 16 * 21.0 * 30 15.932 * 13.8 ** 27 30.1 9 38.3 *8 6.5 6.0 15 50.1 * Indiana6.7 7.3 16 91.0 1792.2 22 21.8 21 20.7 * 32 15.433 13.6 *34 40.2 13 50.1 *12 6.7 7.3 16 33.7 Iowa 5.3 4.2 * 12 71.8 1270.6 19 18.7 17 * 19.2 32 15.632 13.4 ** 30 31.6 9 33.7 8 5.3 4.2 * 12 37.3 Kansas 6.3 6.0 14 78.1 1480.1 20 18.5 17 * 21.4 ** 31 15.432 13.6 *31 33.7 10 37.3 9 6.3 6.0 14 61.7 ** Kentucky 7.2 6.7 105.8 21 20 108.6 26 21.1 25 21.7 34 17.135 15.9 *34 48.9 16 61.7 ** 17 7.2 6.7 21 45.3 * Louisiana 8.1 7.6 123.5 20 19 124.9 24 23.9 23 22.2 * 33 18.436 * 15.5 ** 34 39.5 17 45.3 *14 * 8.1 7.6 20 53.9 ** Maine 7.0 6.6 13 62.3 15 * 66.2 20 18.8 20 18.8 29 12.530 13.4 28 38.0 14 53.9 ** 14 7.0 6.6 13 48.8 ** Maryland 6.4 6.6 13 88.7 1390.3 16 21.5 14 * 21.3 29 14.330 13.4 34 30.0 9 48.8 **7 * 6.4 6.6 13 50.2 ** Massachusetts 4.3 4.2 12 60.4 1359.9 17 18.4 14 * 16.9 * 24 13.123 11.0 ** 27 30.8 9 50.2 **8 4.2 4.3 12 47.1 * Michigan 6.9 6.5 16 91.3 1792.2 21 21.2 20 20.5 32 14.833 13.1 *32 37.7 11 47.1 *11 6.9 6.5 16 34.4 Minnesota 5.0 5.2 11 55.6 1154.7 18 19.6 15 * 17.0 ** 26 12.828 * 11.9 28 29.3 7 34.4 7 5.0 5.2 11 35.5 Mississippi 8.9 9.5 136.7 21 20 142.4 25 23.3 23 * 23.3 37 18.839 * 17.2 *37 33.2 18 35.5 18 8.9 9.5 21 49.5 * Missouri 6.6 6.5 17 95.1 1795.7 22 22.0 22 21.1 31 15.732 13.8 *29 40.0 12 49.5 *14 * 6.6 6.5 17 50.2 Montana5.9 5.8 14 70.3 1371.2 19 19.9 18 19.4 25 12.426 12.2 23 48.8 11 50.2 11 5.9 5.8 14 28.5 Nebraska 4.7 5.7 * 12 64.9 1368.2 18 21.0 17 20.1 30 15.233 * 13.6 *29 26.6 8 28.5 7 4.7 5.7 * 12 52.3 Nevada 4.9 5.2 16 91.7 20 ** 95.5 19 22.5 16 * 21.6 27 16.826 16.4 30 49.4 11 52.3 11 4.9 5.2 16 64.3 ** New Hampshire 4.1 4.2 11 58.4 13 * 57.7 16 19.8 18 * 19.0 27 12.827 12.6 24 34.7 10 64.3 ** 10 4.2 4.1 11 37.7 * New Jersey 4.4 4.7 15 75.1 1673.1 16 23.2 14 * 21.2 ** 27 14.927 13.7 *32 29.7 9 37.7 *9 4.4 4.7 15 72.2 * New Mexico 6.8 5.1 ** 19 78.6 1980.0 19 17.3 16 * 20.3 ** 28 14.530 * 12.2 ** 25 61.8 10 72.2 *10 6.8 5.1 ** 19 32.8 * New York 5.0 4.6 16 79.0 14 * 77.1 17 20.6 14 * 19.9 25 14.026 12.1 *32 25.7 10 32.8 *9 5.0 4.6 16 41.8 * North7.4Carolina 7.4 17 92.5 1793.6 20 20.4 18 * 20.1 30 13.333 * 12.4 31 34.5 13 41.8 *12 7.4 7.4 17 41.7 * North6.3Dakota 7.2 * 12 70.5 1373.3 21 17.9 20 17.9 31 15.932 12.8 ** 37 32.1 9 41.7 *8 6.3 7.2 * 12 63.0 ** Ohio 7.5 7.2 16 94.5 1694.5 23 22.9 23 21.6 * 31 16.332 15.0 *33 42.6 13 63.0 ** 14 7.5 7.2 16 56.8 * Oklahoma 7.5 7.3 117.5 19 18 126.3 24 22.9 19 **22.2 34 17.533 16.3 *34 51.1 14 56.8 *14 7.5 7.3 19 41.3 Oregon 5.4 5.2 16 61.9 1562.6 17 19.9 16 21.5 * 27 14.429 * 12.7 *20 39.2 10 41.3 10 5.4 5.2 16 59.5 ** Pennsylvania 7.1 6.2 * 15 82.0 1482.6 21 21.8 18 * 21.5 30 15.930 14.1 *32 39.4 11 59.5 ** 11 7.1 6.2 * 15 54.3 ** Rhode Island 6.5 5.9 14 68.5 1468.2 17 19.4 14 * 18.4 * 27 13.227 11.9 *36 43.3 9 54.3 **8 6.5 5.9 14 45.4 * South7.5 Carolina 6.9 17 99.2 1899.2 22 21.3 20 * 22.4 * 33 15.033 13.7 *33 38.3 15 45.4 *13 * 7.5 6.9 17 44.8 * South8.3 Dakota 7.3 * 10 74.5 1175.8 20 19.9 18 * 19.8 30 16.730 14.6 ** 31 38.0 9 44.8 *9 8.3 7.3 * 10 51.9 * Tennessee 7.2 7.0 110.0 21 18 * 113.3 23 22.4 22 22.0 35 16.637 * 14.4 ** 38 44.1 18 51.9 *13 ** 7.2 7.0 21 35.7 Texas5.8 5.7 17 93.4 1695.3 16 20.2 14 * 19.7 32 14.734 * 13.5 *33 33.1 8 35.7 7 5.8 5.7 17 50.7 Utah 4.8 5.0 11 61.4 1160.7 10 20.3 9 19.0 * 24 10.925 10.1 19 48.7 6 50.7 6 4.8 5.0 11 46.1 * Vermont4.3 4.6 11 57.2 1261.4 17 18.5 17 13.6 ** 25 14.327 * 15.7 *22 39.3 11 46.1 *10 4.3 4.6 11 38.4 * Virginia 6.5 5.9 14 81.3 1480.2 19 21.1 15 **20.9 27 13.830 * 13.0 27 30.4 11 38.4 *9 * 6.5 5.9 14 39.3 Washington 5.3 4.9 15 62.2 13 * 62.4 16 20.5 14 * 19.4 * 27 12.829 * 11.6 *25 38.6 8 39.3 7 5.3 4.9 15 83.1 ** West 7.2Virginia 7.1 103.5 22 24 * 106.9 27 21.6 25 * 21.9 37 19.839 * 17.4 ** 35 60.5 23 83.1 ** 21 * 7.2 7.1 22 42.9 * Wisconsin 5.7 5.8 14 69.4 1469.4 19 20.4 17 * 19.3 * 29 14.130 12.3 *30 37.3 11 42.9 *10 5.7 5.8 14 55.9 Wyoming5.6 4.9 * 14 68.0 1473.8 21 20.5 19 * 20.3 29 12.628 11.0 *27 51.5 11 55.9 12 5.6 4.9 * 14 Change 0 States Improved 6 4 0 32 16 1 39 0 8 6 33 States Worsened 7 7 0 1 5 18 2 33 1 7 Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 50 APPENDIX F3. Mortality Amenable toCare by Race, Deaths per 100,000 population, 2012–13 & 2014–15 Appendix F3. Mortality Amenable to Health Health Care by Race, Deaths per 100,000 population, 2012–13 & 2014–15 Total White Black Hispanic Change in % change Change in % change Change in % change Change in % change 2012-13 2014-15 rate in rate 2012-13 2014-15 rate in rate 2012-13 2014-15 rate in rate 2012-13 2014-15 rate in rate United States 83.7 84.3 0.6 1% 77.4 78.4 1.0 1% 155.2 154.7 -0.6 0% 66.6 66.2 -0.4 -1% Alabama 111.3 110.4 -0.9 -1% 97.2 95.9 -1.3 -1% 165.5 165.3 -0.2 0% 43.3 42.5 -0.8 -2% Alaska 71.6 73.2 1.6 2% 64.2 61.8 -2.4 -4% 97.5 96.5 -1.1 -1% — 43.8 — — Arizona 72.4 73.5 1.1 2% 69.2 71.4 2.2 3% 126.5 126.2 -0.3 0% 68.7 68.1 -0.5 -1% Arkansas 118.9 123.6 4.6 4% 110.8 116.2 5.4 5% 197.3 195.8 -1.5 -1% 50.2 47.4 -2.9 -6% California 72.0 70.8 -1.2 -2% 71.8 70.4 -1.4 -2% 147.6 148.1 0.6 0% 65.8 64.5 -1.3 -2% Colorado 59.2 62.7 3.4 6% 55.9 59.3 3.4 6% 105.8 116.9 11.1 11% 70.2 73.1 2.8 4% Connecticut 61.3 59.1 -2.1 -3% 57.0 54.8 -2.1 -4% 109.3 102.2 -7.1 -7% 61.4 59.7 -1.6 -3% Delaware 85.0 83.4 -1.6 -2% 75.2 77.5 2.3 3% 132.6 122.7 -10.0 -8% 57.0 50.5 -6.5 -11% District of Columbia 123.9 127.9 4.0 3% 41.4 43.2 1.8 4% 186.4 193.4 7.0 4% 49.0 49.7 0.6 1% Florida 80.0 80.9 0.9 1% 77.0 79.0 1.9 3% 138.7 136.9 -1.9 -1% 56.2 55.5 -0.7 -1% Georgia 100.4 103.5 3.2 3% 86.4 88.5 2.1 2% 151.4 155.7 4.3 3% 38.0 43.9 5.8 15% Hawaii 75.3 76.1 0.8 1% 59.3 66.2 6.9 12% 106.4 98.2 -8.2 -8% 84.5 91.1 6.6 8% Idaho 66.7 64.9 -1.7 -3% 67.5 66.1 -1.5 -2% — — — — 52.9 51.0 -1.9 -4% Illinois 87.1 87.7 0.6 1% 76.4 78.6 2.2 3% 178.4 176.1 -2.3 -1% 59.6 58.7 -1.0 -2% Indiana 91.0 92.2 1.2 1% 86.6 88.2 1.7 2% 159.3 155.5 -3.8 -2% 61.9 58.9 -3.0 -5% Iowa 71.8 70.6 -1.2 -2% 70.5 70.5 0.0 0% 151.4 129.1 -22.3 -15% 47.4 36.4 -11.0 -23% Kansas 78.1 80.1 2.0 3% 75.0 77.2 2.2 3% 146.9 155.3 8.4 6% 63.7 60.9 -2.8 -4% Kentucky 105.8 108.6 2.8 3% 104.0 107.0 3.0 3% 155.4 155.7 0.4 0% 36.8 43.8 7.0 19% Louisiana 123.5 124.9 1.4 1% 100.8 101.5 0.7 1% 188.7 190.3 1.6 1% 43.2 52.1 9.0 21% Maine 62.3 66.2 3.9 6% 62.5 66.2 3.6 6% 98.9 83.8 -15.1 -15% — — — — Maryland 88.7 90.3 1.6 2% 76.0 78.5 2.5 3% 135.2 135.1 -0.1 0% 39.2 41.9 2.7 7% Massachusetts 60.4 59.9 -0.5 -1% 60.0 59.9 -0.1 0% 89.5 85.0 -4.5 -5% 54.4 55.3 0.8 2% Michigan 91.3 92.2 0.9 1% 77.5 79.8 2.3 3% 190.3 186.8 -3.5 -2% 77.3 74.7 -2.6 -3% Minnesota 55.6 54.7 -0.9 -2% 53.0 51.0 -2.0 -4% 99.6 105.5 5.9 6% 45.6 47.7 2.1 5% Mississippi 136.7 142.4 5.6 4% 109.1 114.9 5.8 5% 198.4 201.6 3.2 2% 46.9 42.8 -4.1 -9% Missouri 95.1 95.7 0.7 1% 88.6 89.1 0.5 1% 165.7 168.6 2.8 2% 55.8 56.2 0.5 1% Montana 70.3 71.2 0.9 1% 66.1 66.4 0.3 0% — — — — 49.4 — — — Nebraska 64.9 68.2 3.3 5% 62.3 67.3 4.9 8% 140.7 126.4 -14.3 -10% 44.4 51.8 7.4 17% Nevada 91.7 95.5 3.9 4% 97.0 99.3 2.3 2% 144.7 157.1 12.4 9% 61.9 65.0 3.2 5% New Hampshire 58.4 57.7 -0.6 -1% 59.7 59.0 -0.6 -1% — 74.4 — — — — — — New Jersey 75.1 73.1 -2.0 -3% 71.1 68.7 -2.4 -3% 143.6 140.8 -2.8 -2% 55.5 55.2 -0.4 -1% New Mexico 78.6 80.0 1.3 2% 71.6 77.5 5.9 8% 105.6 130.0 24.4 23% 84.0 78.5 -5.5 -7% New York 79.0 77.1 -1.9 -2% 71.1 70.2 -0.9 -1% 139.8 135.3 -4.6 -3% 73.6 68.8 -4.8 -7% North Carolina 92.5 93.6 1.0 1% 80.8 81.9 1.1 1% 151.0 150.2 -0.8 -1% 34.7 41.7 7.0 20% North Dakota 70.5 73.3 2.8 4% 65.9 68.4 2.6 4% — — — — — 68.6 — — Ohio 94.5 94.5 0.1 0% 87.3 87.2 -0.1 0% 163.5 164.9 1.4 1% 58.9 55.8 -3.1 -5% Oklahoma 117.5 126.3 8.8 7% 112.9 120.0 7.1 6% 189.2 200.5 11.3 6% 75.7 77.7 2.0 3% Oregon 61.9 62.6 0.7 1% 62.6 63.5 0.8 1% 112.5 104.2 -8.2 -7% 50.7 46.0 -4.7 -9% Pennsylvania 82.0 82.6 0.5 1% 74.6 75.7 1.1 1% 161.9 157.3 -4.6 -3% 67.2 75.5 8.4 12% Rhode Island 68.5 68.2 -0.2 0% 70.1 67.6 -2.5 -4% 102.2 102.4 0.1 0% 46.9 48.8 1.9 4% South Carolina 99.2 99.2 0.0 0% 83.1 82.5 -0.6 -1% 156.3 155.7 -0.6 0% 40.0 45.6 5.6 14% South Dakota 74.5 75.8 1.3 2% 66.3 66.4 0.1 0% — — — — — 55.3 — — Tennessee 110.0 113.3 3.3 3% 101.1 105.5 4.3 4% 179.1 177.1 -2.0 -1% 42.6 48.0 5.4 13% Texas 93.4 95.3 1.9 2% 87.9 90.0 2.1 2% 164.2 167.2 3.0 2% 85.3 86.9 1.6 2% Utah 61.4 60.7 -0.7 -1% 59.8 60.3 0.4 1% 160.9 122.6 -38.3 -24% 62.0 50.7 -11.3 -18% Vermont 57.2 61.4 4.2 7% 57.5 61.7 4.3 7% — — — — — — — — Virginia 81.3 80.2 -1.0 -1% 72.1 72.8 0.8 1% 140.4 135.0 -5.4 -4% 35.4 38.5 3.1 9% Washington 62.2 62.4 0.2 0% 61.8 62.2 0.4 1% 99.3 110.0 10.7 11% 45.7 51.3 5.6 12% West Virginia 103.5 106.9 3.4 3% 103.3 106.5 3.3 3% 154.2 153.5 -0.6 0% — — — — Wisconsin 69.4 69.4 0.0 0% 63.9 63.6 -0.3 0% 159.9 171.7 11.8 7% 51.9 55.6 3.7 7% Wyoming 68.0 73.8 5.8 9% 67.3 73.7 6.4 9% — — — — 61.5 52.4 -9.1 -15% Notes: — Indicates that estimates are not available. Notes: — Indicates that estimates are not available. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 51 APPENDIX G1. Disparity: Dimension and Indicator Ranking Appendix G1. Disparity: Dimension and Indicator Ranking Overall performance e Top quartile d d f m de de eo i s nd ho f en en rc ev l a eo t de s Second quartile si en h it al ou m m ar ca d us m nt vi ic gs o m m ls e c ed i al ed m o ca Third quartile co ed s co m ua nt in ec be m m re M ine re 35 de us n ug iar en r ta en a re re ll ll Bottom quartile lts ll 9– ev ut d r fic ta ta re a ta tiv ca ou ild cc t a s 1 sc u t u p r ho sk ne ou ou es u ch th ut ad er ho i n ho Data not available o u ge al it -ri b e h th wi o nt n w d d th n a re i t nc i t cc i t st t h re re wi gh e ca t s w ca t s w va ts w n hi icar co t wi re d e re wi re su su lts ild ild ild in in ul ul ul en u Un Un Ch Ch Ch Ad Ad Ad Ad va W H 1 Hawaii 1 1 2 2 1 4 2 1 2 2 3 2 Massachusetts 1 1 1 1 1 3 1 2 1 2 2 3 Utah 3 4 3 2 2 2 3 1 3 2 1 4 New York 1 1 2 1 1 1 1 2 2 2 1 5 Idaho 3 1 3 3 4 1 4 1 1 1 1 6 Washington 2 2 2 2 4 2 3 2 1 2 1 7 Minnesota 1 1 2 1 1 2 2 2 4 3 2 8 Illinois 2 1 2 2 1 1 1 3 2 2 1 8 New Mexico 2 2 4 2 2 1 3 3 3 3 1 10 Wisconsin 2 2 2 2 2 1 1 2 4 1 1 11 Pennsylvania 2 3 1 1 2 1 1 3 3 1 1 12 South Dakota 3 3 1 2 2 4 2 1 2 3 3 13 Arizona 3 4 4 3 3 1 3 3 2 1 1 14 Connecticut 1 1 3 1 1 3 2 3 3 3 1 15 Oregon 1 2 1 2 2 4 1 2 4 2 3 15 Vermont 1 1 1 1 4 4 3 1 3 3 3 17 Nevada 3 4 4 3 3 2 1 3 2 3 1 18 Maine 2 2 1 1 3 3 2 2 1 1 3 19 Iowa 1 1 1 1 3 2 2 3 3 2 3 19 Louisiana 3 1 3 4 3 1 1 4 1 1 1 21 Colorado 2 3 3 2 2 1 4 4 4 1 1 22 California 2 2 4 1 4 1 2 4 4 2 1 22 Rhode Island 1 1 2 3 2 1 1 4 2 4 2 24 New Jersey 3 3 3 3 2 1 1 3 3 4 3 25 Montana 3 3 3 2 1 4 4 1 2 1 3 26 North Dakota 3 4 1 1 4 4 2 1 2 3 4 27 Delaware 2 3 3 3 4 4 2 3 1 1 1 28 District of Columbia 1 3 1 3 1 2 4 2 1 3 1 29 West Virginia 1 1 1 1 4 2 1 1 4 4 1 29 Wyoming 3 2 4 3 2 1 3 1 1 4 2 31 Maryland 2 2 3 3 4 2 3 1 2 3 1 32 Michigan 1 2 2 1 1 3 2 2 4 4 3 33 Alaska 4 4 1 3 1 1 4 3 4 4 1 34 Alabama 4 2 3 4 2 3 3 1 1 3 3 35 Nebraska 4 4 3 3 4 3 3 4 4 3 4 35 New Hampshire 2 3 1 2 1 4 1 1 3 3 3 35 South Carolina 3 2 2 4 4 4 2 2 1 2 1 38 Indiana 3 4 3 3 4 4 3 3 3 2 3 39 Arkansas 2 2 3 3 3 2 4 2 4 4 3 40 Texas 4 4 4 4 4 4 4 4 2 2 1 41 Kentucky 1 3 1 2 2 4 2 2 1 1 4 42 Tennessee 3 2 1 3 3 2 1 4 2 4 4 43 Mississippi 4 3 3 4 2 2 2 4 1 3 2 44 Kansas 4 4 4 3 3 3 4 4 4 3 3 44 North Carolina 4 3 3 4 1 3 3 1 2 3 3 44 Virginia 4 4 4 4 2 2 3 2 2 2 2 47 Georgia 4 4 4 4 3 3 4 3 1 1 1 47 Ohio 1 2 2 1 2 2 3 2 3 4 3 49 Florida 4 3 4 4 2 2 3 2 2 3 3 50 Oklahoma 4 3 4 4 2 3 3 4 2 1 4 51 Missouri 3 3 1 4 4 4 4 4 4 4 4 commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 52 APPENDIX G1. Disparity: Dimension and Indicator Ranking (continued) Appendix G1. Disparity: Dimension and Indicator Ranking Overall performance rfic 65 nt e e Top quartile d d d d a it e m om de de de ato ge me is nodr i s nd d re d ho ve cie + f, en en , a tn en ev lm 5+ enos lh ev l a ca a it it urd de s hs ls mre Second quartile de r ei e en h it al en to is d is m m m ar icar a e 6 auso ar ca ca ec d rp o d m nt vi m op o so ua ep ic ti lv gs o m m s dm m n ae e c ix e c ed i di sr Ml ed m o sd ag l za flo m i r/ ta Third quartile co n g cy o co ee te s, eic eid s co 5 m ed s co 5am sa s,t in ec e d ec ie m tiv m em tiv m en n nu re re ia as as etb de os ug rien 5+ aio n ar ug iar M e e r 3f en ll r cn lnr en lo r e t s3 ta en a lle iu in ll r 9–t ll otb gle Bottom quartile ll 19– sp oak d u ar ev ut ev et d r lfdc d r fic re a ta sa de a ts cc a 1o e 6 i ss ou eu ovu i er tr cc t a d u l tc sc u t t mt re uho ep ho ho M mue sk ne sk ne ari p r ha es u ag u es u hi a mui al ar es va ut rs th s, td m al oith hs er ho i n ho m do ho e,r eo in o o Data not available ie ge o u dga bc al it ot de ca l e -ri b e th cs th wi wi dti abo ltoh ao nt n w nth w th nea th lia nc i t cc i t cc iht nt lie al eia es th wh et nh tah nh sc gh e gh e pr ca t s w va ts w ca t w d u ay rw ci t a w va ts w te trsew he trsew n n er va ds b as tis a hi isur hi icar M tewti Mn e re d e re trse wi su a co n ts -ri in dr nc ild ild ulld iuld ulld up iln ul ul sl dl uil ul l ev re en -u do si i i Un Ao Ho Ch Ch Ch Ch Ah Ch Ad Ad Hd Ad Ad Ad Cd Ad Av de 30 va Pr wi W U 4 1 2 1 Hawaii 2 2 1 3 1 0 2 1 2 1 1 4 1 2 1 1 2 1 2 3 3 2 1 Massachusetts 1 2 2 1 2 1 1 2 1 2 1 1 3 1 3 2 2 1 1 2 2 2 3 3 1 Utah 3 2 3 1 4 3 1 2 2 1 2 1 3 1 1 3 1 2 1 1 4 1 2 New York 2 2 1 1 4 2 1 2 1 1 1 2 1 2 1 2 1 1 5 4 1 Idaho 1 1 3 1 3 1 3 1 4 1 3 4 1 2 1 2 1 1 2 6 3 Washington 1 2 2 1 2 1 2 1 2 1 4 2 2 3 3 2 2 1 2 1 2 7 2 2 Minnesota 4 3 1 2 1 3 2 1 1 1 2 2 4 2 2 4 1 3 2 1 8 1 3 Illinois 2 2 1 3 2 4 2 3 1 3 1 1 1 3 1 2 2 1 1 8 3 New Mexico 3 3 3 2 1 2 2 4 1 2 1 2 2 1 1 3 1 3 1 3 2 3 1 1 10 1 2 Wisconsin 4 1 2 1 2 4 2 2 2 2 1 3 1 1 2 3 4 4 1 1 1 11 1 Pennsylvania 3 3 1 2 1 3 4 1 2 1 2 1 2 1 1 3 3 1 1 4 12 2 South Dakota 2 1 3 3 1 2 1 2 1 4 4 2 1 2 1 3 3 1 13 3 3 Arizona 2 1 3 1 4 1 4 1 3 2 3 4 1 1 3 3 1 2 3 1 1 3 14 2 Connecticut 3 3 3 1 1 3 2 1 3 1 3 1 2 4 3 2 3 2 3 1 4 15 1 2 Oregon 4 2 1 3 2 1 1 2 1 2 1 4 3 1 3 2 3 4 4 2 3 4 15 3 1 Vermont 3 3 1 3 1 0 1 1 1 4 2 4 4 3 1 4 3 3 3 2 17 1 3 Nevada 2 3 1 4 2 4 2 3 3 1 2 1 2 3 2 2 3 1 3 18 2 2 Maine 1 1 2 3 2 1 3 1 2 3 2 3 4 2 1 2 4 1 2 1 3 2 19 2 3 Iowa 3 2 1 3 1 3 1 2 1 2 3 2 3 2 2 3 2 3 4 2 3 1 19 1 4 Louisiana 1 1 3 1 2 3 3 4 3 4 1 1 1 4 3 1 2 1 1 1 21 4 4 Colorado 4 1 2 1 3 2 3 1 2 1 2 2 1 2 4 2 4 2 4 2 1 1 1 22 2 4 California 4 2 1 2 2 4 1 2 4 1 1 2 3 4 1 4 3 2 1 1 22 1 Rhode Island 2 4 4 1 2 1 4 2 3 2 4 1 1 4 1 2 1 4 2 1 24 1 3New Jersey 3 4 3 3 4 3 2 3 4 2 1 1 2 3 1 3 2 4 3 4 25 4 1 Montana 2 1 3 3 3 2 1 4 4 2 1 4 2 1 3 4 26 2 North Dakota 2 1 3 4 0 1 1 1 4 3 4 3 2 3 1 3 2 1 3 4 4 27 2 3 Delaware 1 1 2 1 3 3 4 3 4 3 4 2 1 3 2 1 2 1 1 2 28 4 District 2 Columbia 1 of 3 1 1 3 1 4 3 3 1 4 2 2 4 4 2 1 3 1 2 29 1 West Virginia 4 1 4 1 1 0 1 4 1 3 4 4 2 4 1 1 4 4 1 1 29 3 1 Wyoming 1 4 3 2 0 4 3 3 2 2 1 4 3 3 1 2 1 3 4 2 2 31 3 1 Maryland 2 3 2 1 2 4 3 2 3 3 4 2 2 3 3 1 2 3 1 3 32 2 2 Michigan 4 4 1 3 2 3 2 3 1 3 1 2 3 4 2 2 4 2 4 3 1 33 4 3 Alaska 4 4 1 4 1 2 3 1 4 1 4 1 3 4 1 4 1 3 34 3 1 Alabama 1 3 4 3 2 3 3 4 3 2 3 3 2 1 3 1 4 3 3 3 35 3 4 Nebraska 4 3 4 4 2 3 3 2 4 2 3 3 1 4 1 4 2 3 4 4 35 1 New Hampshire 3 1 3 2 3 1 4 2 2 1 3 4 4 1 4 1 4 3 4 3 3 4 35 2 South Carolina 1 2 2 3 1 2 2 3 4 4 4 3 2 4 2 3 1 3 2 1 4 38 3 3 Indiana 3 2 3 3 4 4 3 3 4 3 4 3 1 3 3 2 3 2 39 4 2 Arkansas 4 4 2 3 2 0 3 4 3 4 3 3 2 4 1 2 3 4 3 4 3 4 40 4 4 Texas 2 2 4 1 4 1 4 3 4 3 4 2 4 1 4 2 4 1 2 1 2 1 4 41 2 2 Kentucky 1 1 4 3 3 1 4 2 4 2 3 4 4 2 3 2 4 1 4 1 4 2 42 1 Tennessee 2 4 4 3 4 2 1 4 3 4 3 4 2 3 1 3 4 4 2 3 4 4 2 43 2 4 Mississippi 1 3 4 2 3 3 4 4 2 4 2 1 2 3 4 3 1 2 3 2 3 44 4 4 Kansas 4 3 4 3 4 1 4 2 3 2 3 2 3 3 4 3 4 2 4 2 3 3 3 44 3 North Carolina 2 1 3 4 3 2 3 3 4 4 1 4 3 2 3 4 1 2 4 3 3 2 44 3 2 Virginia 2 2 4 2 4 3 4 4 4 2 4 2 2 3 3 2 3 2 2 2 3 47 4 3 Georgia 1 1 4 1 4 1 4 3 4 3 3 1 4 4 3 3 1 4 1 1 2 47 3 2 Ohio 3 4 1 3 2 2 4 1 4 2 3 2 4 3 4 2 4 3 3 4 3 2 49 3 2 Florida 2 3 4 3 3 4 4 4 2 3 2 1 3 3 2 3 2 4 3 3 3 50 3 4 Oklahoma 2 1 4 4 3 3 4 4 3 2 4 3 3 4 4 2 4 1 4 4 51 4 4 Missouri 4 4 3 4 3 4 1 3 4 3 4 3 4 4 1 4 4 4 4 commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 53 APPENDIX G2. Disparity: Indicator Rates for Low-Income Population and Difference from Higher-Income Population Appendix G2. Disparity: Indicator Rates for Low-Income Population and Difference from Higher-Income Population Adults without all Adults without all Adults who went Adults without a age- and gender- age-appropriate Children with Adults ages 19–64 Children ages 0–18 Adults without a without care dental visit in past appropriate cancer recommended component uninsured uninsured usual source of care because of cost year screenings vaccines medical ho 2016 2016 2016 2016 2016 2016 2016 2016 Rate Disparity Rate Disparity Rate Disparity Rate Disparity Rate Disparity Rate Disparity Rate Disparity Rate Dis United States 23% -19 6% -4 27% -12 23% -16 24% -13 35% -10 67% -8 63% Alabama 27 * -23 4 * -3 26 -11 33 * -28 25 * -13 37 * -13 71 * -9 51 Alaska 34 * -24 14 * -10 34 * -6 28 * -20 14 * -5 34 * 1 77 * -16 65 Arizona 22 * -17 10 * -7 32 * -14 23 * -16 26 * -14 34 * -6 70 * -9 65 Arkansas 18 * -13 5 -3 23 * -11 23 * -16 23 * -14 38 * -10 70 * -13 59 California 19 * -15 4 * -3 35 * -19 18 * -11 25 * -15 29 * -6 70 -8 70 Colorado 19 * -15 7 * -5 31 -13 21 * -14 24 * -13 34 * -7 65 -12 66 Connecticut 14 * -11 2 * 0 19 * -10 15 * -9 17 * -10 31 * -11 61 * -7 61 Delaware 15 * -12 6 -4 21 * -10 21 * -17 24 * -16 35 * -16 65 * -8 60 District of Columbia 8 * -6 5 * -4 20 * -3 20 * -16 14 * -4 28 * -8 72 * -17 62 Florida 31 * -24 8 * -5 36 -15 29 * -22 26 -12 36 * -8 73 -10 67 Georgia 35 * -29 9 * -6 33 * -15 31 * -25 25 -14 36 -12 73 * -13 62 Hawaii 10 * -8 3 * -1 17 * -7 16 -12 18 -8 36 * -18 66 -7 59 Idaho 27 * -21 6 * -2 33 -11 27 * -18 25 * -15 39 * -5 74 * -12 55 Illinois 19 * -16 3 * -2 19 * -8 17 * -12 21 * -8 33 * -6 68 * -5 62 Indiana 21 * -17 8 * -6 24 * -11 23 * -17 25 * -15 42 * -14 69 -9 60 Iowa 11 * -9 3 * -2 18 * -4 15 * -11 22 * -14 33 * -8 59 * -7 53 Kansas 27 * -23 8 * -6 30 * -15 25 * -20 23 * -14 38 -11 70 -12 65 Kentucky 11 * -9 5 * -4 17 * 0 19 * -13 24 * -13 38 -14 66 * -8 52 Louisiana 26 * -21 4 -2 28 * -10 31 * -23 29 * -14 33 * -7 70 * -4 65 Maine 20 * -16 7 * -3 12 * -3 17 * -11 21 * -14 35 * -13 62 -7 57 Maryland 18 * -15 5 * -3 22 * -13 21 * -16 26 * -16 33 -8 63 * -11 55 Massachusetts 6 * -4 2 -1 11 * -4 12 * -6 17 * -9 33 * -11 61 -6 56 Michigan 14 * -11 4 * -3 16 * -7 18 * -10 19 * -10 35 -12 69 * -8 63 Minnesota 11 * -9 4 * -2 30 * -7 16 * -10 18 * -10 33 * -9 61 * -8 57 Mississippi 31 * -26 6 * -4 26 -10 32 * -21 24 * -11 34 * -10 68 -8 59 Missouri 26 * -22 7 * -4 22 * -6 28 * -22 29 * -16 43 * -19 67 * -14 63 Montana 23 * -19 7 -4 32 * -10 18 * -13 20 * -6 47 * -15 69 * -15 55 Nebraska 29 * -26 10 -8 25 -13 25 -20 24 * -16 39 * -12 61 * -9 58 Nevada 26 * -20 9 * -7 36 * -15 26 * -19 25 * -14 36 * -8 67 * 1 75 New Hampshire 20 * -16 6 -5 13 * -5 19 * -14 15 * -9 38 * -16 62 * -6 53 New Jersey 25 * -21 5 * -4 22 * -13 22 * -17 20 * -11 32 * -5 62 * -2 63 New Mexico 20 * -15 6 -3 37 * -14 19 * -13 24 * -13 39 -6 65 * -10 66 New York 15 * -11 3 * -2 18 * -8 17 * -11 20 * -9 33 * -7 63 * -4 59 North Carolina 29 * -25 6 * -4 27 * -11 31 * -22 19 * -7 33 * -11 63 -11 53 North Dakota 20 * -17 14 * -11 28 * -6 14 * -10 25 * -15 43 -15 62 -7 58 Ohio 14 * -11 4 * -3 20 * -8 18 * -11 22 * -13 36 -10 67 -9 59 Oklahoma 35 * -28 8 * -4 28 * -14 27 * -22 26 * -13 41 * -11 63 * -10 69 Oregon 15 * -11 4 * -3 21 * -4 18 * -13 21 * -11 42 * -18 65 * -5 59 Pennsylvania 15 * -12 7 * -5 17 -6 17 * -8 22 -11 33 * -6 60 * -3 57 Rhode Island 10 * -8 1 * 0 16 * -9 19 * -15 17 * -11 26 * -5 56 * -6 66 South Carolina 27 * -22 5 * -3 24 * -9 27 * -21 27 * -17 38 * -15 67 * -7 57 South Dakota 26 * -22 5 * -5 26 * -4 17 * -13 20 -11 38 -15 56 * -8 56 Tennessee 24 * -20 4 * -3 24 * -6 22 * -15 27 -14 35 * -10 67 -4 58 Texas 42 * -35 12 * -8 41 * -22 32 * -23 31 * -19 44 * -19 70 -12 69 Utah 24 * -20 9 * -7 34 -11 21 * -13 22 * -12 36 * -10 72 * -10 47 Vermont 7 * -4 1 * 0 13 * -5 10 * -4 22 * -16 42 * -18 68 -11 50 Virginia 29 * -25 9 -7 30 * -16 31 * -25 21 * -12 33 * -9 65 * -11 63 Washington 16 * -13 4 * -3 27 * -9 18 * -12 26 -15 35 * -8 65 * -10 65 West Virginia 11 * -8 1 * -1 20 * -4 19 * -10 25 * -15 36 * -10 60 * -6 53 Wisconsin 15 * -12 5 * -3 20 -9 18 -12 17 * -11 29 * -7 69 * -6 58 Wyoming 26 * -20 8 * -3 40 * -21 24 * -16 22 -12 40 * -6 72 * -10 54 Notes: Rates are for the states' low-income population, generally those whose household income is under 200% FPL. Disparity is the difference between the states' low-income and higher-income (400%+ FPL) populations. (* Notes: Rates are for the states’ low-income population, generally those whose household income is under 200% FPL. Disparity is the difference between the states’ low-income and higher-income (400%+ FPL) populations. * Denotes meaningful improvement or worsening from the baseline period. Baseline data not shown; refer to state profiles at datacenter. commonwealthfund.org for baseline data. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 54 APPENDIX G2. Disparity: Indicator Rates for Low-Income Population and Difference from Higher-Income Population (continued) her-Income Population Disparity: Indicator Rates for Low-Income Population and Difference from Higher-Income Population Appendix G2. Preventable s without all Adults without all Children ages 19–35 Medicare Adults without all hospitalizations, 30-day readmissions, Avoidable Adults without all and gender- age-appropriate Children without all Children without a months without all Adults who went beneficiaries Hospitalwithout a Adults admissions Medicaregender- age- and duals, age Medicare duals, age Children wit age-appropriate departm priate cancer recommended Adults ages 19–64 medical and dental components of a Children ages 0–18 Adults without a recommended received a high-risk for pediatricin past appropriate cancer without care dental visit asthma 65+ (rate per recommended 65+ (rate per Medicare d componen reenings vaccines medical home uninsured preventive care visit usual source of care uninsured vaccines because of cost drug (rate per 100,000) year screenings 100,000) vaccines 100,000) medical h (rate per 2016 2016 2016 2016 2016 2016 2016 2014 2016 2014 2016 2015 2016 2015 2016 20 te Disparity Rate Disparity Rate Disparity Rate Rate Disparity Rate Disparity Disparity Rate Disparity Rate Disparity Rate Disparity Rate Disparity Rate Disparity Rate Disparity Rate Disparity Rate Disparity Rate Rate Di % -10 United States 67% -8 63% 23% -26 -19 38% 6% -15 -4 27% 33% -12 -10 23% 16% -16 -4 24% 166 -13 -95 35% 99 -10 -56 67% 63 -33 -8 63% 366 37 * -13 Alabama 71 * -9 51 27 * -12 -23 27 4 * -3 0 26 27 * -11 -14 33 22 * * -28 -5 25 * — — -13— 118 ** 37 -13 -66 71 ** 69 -9 -36 51 396 34 * 1 Alaska 77 * -16 65 34 * -27 -24 49 14 * -10 -20 34 42 * -23 -6 28 13 * * -20 -1 14 * — — -5 — 34 * 77 -52 1 77 ** 34 -16 -19 65 453 34 * -6 Arizona 70 * -9 65 22 * -27 -17 34 10 * -13 -7 32 27 * -149 23 13 * * -160 115 * 26 * -14 -62 34 ** 64 -36 -6 70 ** 46 -9 -22 65 413 38 * -10 Arkansas 70 * -13 59 18 * -23 -13 44 5 -17 -3 23 36 * -11 -16 23 21 * * -16 -6 113 * 23 -14— 120 * 38 -10 -75 70 ** 70 -13 -41 59 385 29 * -6 California 70 -8 70 19 * -32 -15 48 4 * -27 -3 35 38 * -19 -10 18 13 * * -11 -2 144 * 25 * -15 -85 29 ** 68 -40 -6 70 * 51 -8 -28 70 301 34 * -7 Colorado 65 -12 66 19 * -28 -15 44 7 * -22 -5 31 23 -13 -3 21 13 * * -14 -1 214 * 24 * -101 -13 34 * 61 -37 -7 65 * 36 -12 -18 66 339 31 * -11 Connecticut * 61 -7 61 14 * -27 -11 32 2 * -14 0 19 30 * -10 -13 15 12 * -9 -3 17 * — — -10— 31 * 94 -11 -51 61 ** 66 -7 -33 61 379 35 * -16 Delaware 65 * -8 60 15 * -25 -12 32 6 -4 -8 21 22 * -10 -3 21 12 * * -17 -2 24 * — — -16— 109 * 35 -16 -67 65 ** 70 -8 -43 60 385 28 * -8 District of 72 * Columbia -17 62 8 * -23 -6 30 5 * -4 -7 20 35 * -11 -3 20 15 * -16 -2 14 * — — -4 — 109 ** 28 -72 -8 72 ** 61 -17 -35 62 430 36 * -8 Florida 73 -10 67 31 * -22 -24 42 8 * -12 -5 36 41 -15 -15 29 18 * -22 -6 192 26 -126 -12 122 ** 36 -75 -8 73 * 91 -10 -56 67 369 36 -12 Georgia 73 * -13 62 35 * -26 -29 30 9 * -6 -8 33 25 * -15 -3 31 19 * * -25 -3 103 * 25 -14 -46 101 * 36 -12 -58 73 ** 63 -13 -35 62 396 36 * -18 Hawaii 66 -7 59 10 * -14 -8 37 3 * -13 -1 17 28 * -10 -7 16 13 * -12 -5 18 — — -8 — 36 ** 52 -18 -29 66 * 29 -7 -14 59 232 39 * -5 Idaho 74 * -12 55 27 * -13 -21 36 6 * -2 -3 33 24 * -11 -3 27 15 * * -18 -3 25 * — — -15— 39 * 61 -36 -5 74 ** 28 -12 -14 55 294 33 * -6 Illinois 68 * -5 62 19 * -27 -16 33 3 * -10 -2 19 32 * -10 -8 17 13 * * -12 -3 197 * 21 -109 -8 119 ** 33 -70 -6 68 ** 74 -5 -38 62 400 42 * -14 Indiana 69 -9 60 21 * -25 -17 35 8 * -15 -6 24 30 * -11 -6 23 18 * * -17 -6 172 * 25 * -127 -15 112 * 42 -14 -65 69 * 69 -9 -40 60 408 33 * -8 Iowa 59 * -7 53 11 * -26 -9 40 3 * -16 -2 18 32 * -10 -4 15 14 * * -11 -6 163 * 22 * -118 -14 33 ** 88 -49 -8 59 ** 43 -7 -20 53 353 38 -11 Kansas 70 -12 65 27 * -30 -23 49 8 * -29 -6 30 33 * -15 -14 25 17 * -20 -6 193 * 23 * -14 -50 38 * 92 -11 -50 70 * 53 -12 -28 65 349 38 -14 Kentucky 66 * -8 52 11 * -23 -9 36 5 * -4 -8 17 23 * 0 4 19 23 * -13 -8 156 * 24 * -112 -13 146 * 38 -14 -88 66 ** 80 -8 -44 52 427 33 * -7 Louisiana 70 * -4 65 26 * -32 -21 33 4 -2 28 32 * -108 31 23 * -23 -3 165 * 29 -14 -98 115 * 33 -63 -7 70 ** 61 -4 -29 65 441 35 * -13 Maine 62 -7 57 20 * -24 -16 25 7 * -3 -5 12 30 * -3 -3 17 16 * * -11 -6 21 * — — -14— 35 ** 93 -13 -55 62 * 42 -7 -20 57 355 33 -8 Maryland63 * -11 55 18 * -20 -15 33 5 * -12 -3 22 33 * -13 -14 21 14 * -16 -3 478 * 26 * -402 -16 33 * 99 -54 -8 63 ** 66 -11 -30 55 358 33 * -11 Massachusetts 61 -6 56 6 * -24 -4 27 2 -1 -8 11 19 * -4 -7 12 12 * -6 -4 17 * — — -9 — 33 ** 97 -11 -44 61 * 63 -6 -24 56 343 35 -12 Michigan 69 * -8 63 14 * -24 -11 43 4 * -27 -3 16 38 * -19 -7 18 16 * -10 -5 195 * 19 * -121 -10 110 * 35 -12 -56 69 ** 77 -8 -36 63 398 33 * -9 Minnesota * 61 -8 57 11 * -22 -9 44 4 * -18 -2 30 34 * -13 -7 16 11 * * -10 -4 162 * 18 -109 -10 33 ** 68 -28 -9 61 ** 43 -8 -16 57 332 34 * -10 Mississippi 68 -8 59 31 * -37 -26 40 6 * -4 -2 26 32 * -10 -11 32 22 * * -21 -4 24 * — — -11— 128 ** 34 -10 -81 68 72 -8 -42 59 466 43 * -19 Missouri 67 * -14 63 26 * -29 -22 52 7 * -29 -4 22 41 * -28 -6 28 19 * * -22 -7 271 * 29 * -162 -16 109 * 43 -19 -62 67 ** 70 -14 -36 63 411 47 * -15 Montana 69 * -15 55 23 * -19 36 7 -10 -4 32 40 * -10 -5 18 14 * * -13 -5 20 * — — -6 — 47 * 76 -15 -44 69 ** 29 -15 -14 55 384 39 * -12 Nebraska 61 * -9 58 29 * -28 -26 44 10 -18 -8 25 26 * -13 -12 25 15 * -20 -7 108 * 24 * -16 -75 39 ** 98 -12 -60 61 ** 46 -9 -23 58 320 36 * -8 Nevada 67 * 1 75 26 * -27 -20 45 9 * -13 -7 36 33 * -15 -13 26 13 * * -190 144 * 25 * -14 -77 36 * 85 -54 -8 67 ** 58 -34 1 75 305 38 * -16 New Hampshire 62 * -6 53 20 * -19 -16 30 6 -15 -5 13 31 * -15 -5 19 16 * * -14 -6 15 * — — -9 — 117 ** 38 -16 -71 62 ** 50 -6 -25 53 390 32 * -5 New Jersey *62 -2 63 25 * -26 -21 34 5 * -14 -4 22 39 * -13 -20 22 14 * -17 -5 278 * 20 * -169 -11 103 ** 32 -54 -5 62 ** 77 -2 -40 63 320 39 -6 New Mexico *65 -10 66 20 * -26 -15 32 6 -15 -3 37 35 * -14 -14 19 14 * -13 -1 141 * 24 -13 -74 39 63 -34 -6 65 ** 40 -10 -19 66 348 33 * -7 New York 63 * -4 59 15 * -24 -11 38 3 * -13 -2 18 32 * -8 -8 17 12 * -11 -3 584 * 20 * -452 -9 33 ** 87 -40 -7 63 ** 59 -4 -21 59 283 33 * -11 North Carolina 63 -11 53 29 * -20 -25 29 6 * -10 -4 27 25 * -11 -13 31 19 * * -22 -6 131 * 19 * -85 -7 108 ** 33 -11 -66 63 * 66 -11 -39 53 445 43 -15 North Dakota62 -7 58 20 * -15 -17 49 14 * -11 -10 28 40 * -15 -6 14 14 * -10 -7 25 * — — -15— 43 * 83 -15 -42 62 32 -7 -13 58 358 36 -10 Ohio 67 -9 59 14 * -23 -11 39 4 * -16 -3 20 43 * -28 -8 18 17 * * -11 -6 22 * — — -13— 121 36 -10 -68 67 * 74 -9 -39 59 436 41 * -11 Oklahoma * 63 -10 69 35 * -33 -28 42 8 * -11 -4 28 33 * -14 -1 27 24 * -22 -7 201 * 26 -121 -13 126 * 41 -11 -79 63 ** 69 -10 -38 69 458 42 * -18 Oregon 65 * -5 59 15 * -21 -11 45 4 * -24 -3 21 41 * -4 -8 18 15 * -13 -5 21 * 51 -11-6 42 ** 62 -18 -33 65 ** 32 -5 -14 59 309 33 * -6 Pennsylvania * 60 -3 57 15 * -27 -12 33 7 * -15 -5 17 28 -6 -2 17 12 * * -8 -3 423 22 -348 -11 101 ** 33 -50 -6 60 ** 64 -3 -28 57 330 26 * -5 Rhode Island * 56 -6 66 10 * -29 -8 34 1 * -13 0 16 32 * -19 -9 19 13 * * -15 -4 270 * 17 * -186 -11 111 ** 26 -62 -5 56 ** 61 -6 -22 66 437 38 * -15 South Carolina 67 * -7 57 27 * -22 24 5 * -3 -2 24 34 * -9 -9 27 19 * * -21 -3 131 * 27 * -17 -97 101 * 38 -15 -61 67 ** 69 -7 -42 57 440 38 -15 South Dakota* 56 -8 56 26 * -19 -22 43 5 * -12 -5 26 36 * -15 -4 17 13 * * -13 -6 20 94 -11 -13 38 89 -15 -52 56 * 39 -8 -19 56 289 35 * -10 Tennessee 67 -4 58 24 * -30 -20 41 4 * -13 -3 24 41 * -28 -6 22 22 * * -15 -7 27 * 93 -14 -59 121 * 35 -10 -75 67 * 73 -4 -42 58 411 44 * -19 Texas 70 -12 69 42 * -29 -35 39 12 * -11 -8 41 31 * -22 -6 32 18 * * -23 -2 126 * 31 * -19 -70 100 ** 44 -19 -57 70 * 59 -12 -30 69 360 36 * -10 Utah 72 * -10 47 24 * -11 -20 43 9 * -15 -7 34 31 -11 -10 21 13 * * -13 -1 22 * — — -12— 36 ** 53 -10 -30 72 ** 38 -10 -21 47 276 42 * -18 Vermont 68 -11 50 7 * -16 -4 27 1 * -14 0 13 29 * -15 -5 10 13 * -4 -5 22 * — — -16— 42 * 75 -18 -42 68 * 30 -11 -11 50 321 33 * -9 Virginia 65 * -11 63 29 * -21 -25 30 9 -11 -7 30 37 * -16 -6 31 16 * * -25 -4 168 * 21 -123 -12 112 * 33 -71 -9 65 ** 76 -11 -46 63 423 35 * -8 Washington *65 -10 65 16 * -24 -13 32 4 * -3 -8 27 28 * -10 -9 18 13 * * -12 -1 26 50 -15 12 35 ** 70 -40 -8 65 ** 40 -10 -19 65 317 36 * -10 West Virginia * 60 -6 53 11 * -20 -8 33 1 * -17 -1 20 43 * -24 -4 19 17 * * -10 -3 25 * 93 -15— 132 * 36 -10 -74 60 ** 68 -6 -30 53 444 29 * -7 Wisconsin69 * -6 58 15 * -21 -12 41 5 * -20 -3 20 21 * -91 18 12 -12 -3 215 * 17 * -153 -11 29 ** 89 -49 -7 69 ** 45 -6 -20 58 369 40 * -6 Wyoming72 * -10 54 26 * -17 -20 33 8 * -3 -2 40 48 * -21 -20 24 15 * * -16 -4 22 — — -12— 101 ** 40 -66 -6 72 ** 48 -10 -29 54 341 ow-income andNotes: Rates are for the FPL) populations. (*) denotes meaningfulthose whose household income is the baseline period. Baseline the difference between the states' low-income and higher-income (400%+ FPL) populations. ( higher-income (400%+ states' low-income population, generally improvement or worsening from under 200% FPL. Disparity is data not shown; refer to state profiles at datacenter.commonwealthfund.org for baseline dat Notes: Rates are for the states’ low-income population, generally those whose household income is under 200% FPL. Disparity is the difference between the states’ low-income and higher-income (400%+ FPL) populations. * Denotes meaningful improvement or worsening from the baseline period. Baseline data not shown; refer to state profiles at datacenter. commonwealthfund.org for baseline data. Trend data not available for children without all components of a medical home, and children without a medical and dental preventive care visit. — Indicates that estimates are not available. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 55 APPENDIX G2. Disparity: Indicator Rates for Low-Income Population and Difference from Higher-Income Population (continued) Appendix G2. Disparity: Indicator Rates for Low-Income Population and Difference from Higher-Income Population ventable talizations, 30-day readmissions, Avoidable emergency Adults without all Adults without all are duals, age Medicare duals, age department visits, Adults who went Adults without a age- and gender- age-appropriate Children wit (rate per 65+ (rate per Adults ages 19–64 Children ages 0–18 Medicare duals, age 65+ Adults without a Adults who are Adults who have lost dental visit inreport appropriate cancer without care Adults who past recommended componen 00,000) 100,000) (rate per 100,000) uninsured Adults who smoke usual source of care uninsured obese because of cost six or more teeth fair/poor health year screenings vaccines medical h 2015 2015 2016 2015 2016 2016 2016 2016 2016 2016 2016 2016 2016 2016 2016 e Disparity Rate Disparity Rate Disparity Rate Disparity Rate Disparity Rate Disparity Rate Disparity Rate Disparity Rate Disparity Rate Disparity Rate Disparity Rate Disparity Rate Disparity Rate Disparity Rate D 9 -56 United 63 States -33 23% 366 -19 -191 6% 23% -4 -12 27% 38% -12-9 23% 17% -16 -12 24% 29% -13 -22 35% -10 67% -8 63% 8 * -66 Alabama69 * -36 27 * 396 * -23 -226 4 * 31 -3 -16 26 * 46 -11-9 33 * * 22 -28 -15 25 * * 34 -13 -25 37 * -13 71 * -9 51 7 -52 Alaska 34 * -19 34 * 453 -24 -282 14 * * 37 -10 -25 34 * 35 -6-4 28 * * 23 -20 -18 14 * * 21 -5 -14 34 * 1 77 * -16 65 4 * -36 Arizona 46 * -22 22 * 413 * -17 -236 10 * * 18 -7-9 32 * * 37 -14 -10 23 * * 12 -16-8 26 * * 30 -14 -23 34 * -6 70 * -9 65 0 -75 Arkansas *70 -41 18 * 385 * -13 -215 5 * 33 -3 -21 23 * * 40 -11 0 23 * 23 -16 -17 23 * * 34 -14 -24 38 * -10 70 * -13 59 8 * -40 California * 51 -28 19 * 301 * -15 -156 4 ** 13 -3-5 35 * * 33 -19 -11 18 9 * * -11-6 25 * * 30 -15 -23 29 * -6 70 -8 70 1 -37 Colorado36 * -18 19 * 339 * -15 -178 7 * 25 -5 -15 31 * 30 -13-8 21 * * 14 -14 -11 24 * * 28 -13 -22 34 * -7 65 -12 66 4 -51 Connecticut * 66 -33 14 * 379 * -11 -209 2 ** 21 -12 0 19 * 36 -10 -12 15 * * 13 -9 -10 17 * * 28 -10 -22 31 * -11 61 * -7 61 9 -67 Delaware *70 -43 15 * 385 * -12 -228 6 * 25 -4 -14 21 * * 34 -10-3 21 * 18 -17 -12 24 * * 26 -16 -21 35 * -16 65 * -8 60 9 * -72 District of Columbia 61 * -35 8 * 430 * -6 -259 5 ** 22 -4 -13 20 * * 45 -3 -26 20 * * 12 -16-9 14 * * 27 -4 -24 28 * -8 72 * -17 62 2 * -75 Florida 91 * -56 31 * 369 * -24 -192 8 ** 22 -5 -12 36 * 35 -15 -10 29 * * 21 -22 -16 26 * 32 -12 -26 36 * -8 73 -10 67 1 * -58 Georgia 63 * -35 35 * 396 * -29 -228 9 ** 24 -6 -12 33 * * 45 -15 -15 31 * 22 -25 -15 25 * 34 -14 -27 36 -12 73 * -13 62 2 * -29 Hawaii 29 * -14 10 * 232 * -8 -101 3 ** 21 -1 -12 17 * 33 -7-7 16 * 12 -12-9 18 * 20 -8 -11 36 * -18 66 -7 59 1 -36 Idaho 28 * -14 27 * 294 * -21 -135 6 ** 24 -2 -17 33 * 33 -11-7 27 * * 14 -18 -12 25 * * 26 -15 -19 39 * -5 74 * -12 55 9 * -70 Illinois 74 * -38 19 * 400 * -16 -216 3 ** 20 -2-7 19 * 39 -8-7 17 * * 12 -12-7 21 * 27 -8 -20 33 * -6 68 * -5 62 2 -65 Indiana 69 * -40 21 * 408 * -17 -223 8 ** 31 -6 -18 24 * * 38 -11-5 23 * * 21 -17 -15 25 * * 29 -15 -21 42 * -14 69 -9 60 8 * -49 Iowa 43 * -20 11 * 353 * -9 -183 3 ** 30 -2 -18 18 * * 39 -4-9 15 * * 16 -11 -12 22 * * 31 -14 -25 33 * -8 59 * -7 53 2 * -50 Kansas 53 * -28 27 * 349 * -23 -175 8 ** 28 -6 -17 30 * * 41 -15 -11 25 * 16 -20 -12 23 * 26 -14 -20 38 -11 70 -12 65 6 * -88 Kentucky80 * -44 11 * 427 * -9 -225 5 ** 39 -4 -23 17 * 44 -11 0 19 * * 33 -13 -25 24 * * 38 -13 -31 38 -14 66 * -8 52 5 -63 Louisiana * 61 -29 26 * 441 -21 -248 4 * 27 -2 -10 28 * * 41 -10-6 31 * * 22 -23 -14 29 * * 30 -14 -22 33 * -7 70 * -4 65 3 * -55 Maine 42 * -20 20 * 355 * -16 -177 7 ** 31 -3 -21 12 * * 36 -3-7 17 * * 25 -11 -19 21 * 26 -14 -19 35 * -13 62 -7 57 9 * -54 Maryland *66 -30 18 * 358 * -15 -184 5 ** 22 -3 -13 22 * * 40 -13 -11 21 * * 14 -16 -10 26 * * 30 -16 -23 33 -8 63 * -11 55 7 * -44 Massachusetts 63 * -24 6 * 343 * -4 -154 2 * 20 -1 -10 11 * 33 -4 -11 12 * 16 -6 -12 17 * * 23 -9 -17 33 * -11 61 -6 56 0 * -56 Michigan *77 -36 14 * 398 * -11 -190 4 ** 33 -3 -20 16 * * 39 -7-9 18 * * 23 -10 -19 19 * * 30 -10 -22 35 -12 69 * -8 63 8 * -28 Minnesota * 43 -16 11 * 332 * -9 -156 4 ** 25 -2 -15 30 * * 38 -7 -12 16 * * 16 -10 -13 18 * * 24 -10 -18 33 * -9 61 * -8 57 8 * -81 Mississippi 72 -42 31 * 466 * -26 -278 6 ** 28 -4 -11 2648 -10 -11 32 * * 26 -21 -17 24 * * 29 -11 -21 34 * -10 68 -8 59 9 -62 Missouri 70 * -36 26 * 411 * -22 -219 7 ** 37 -4 -22 22 * 36 -6-4 28 * * 28 -22 -22 29 * 33 -16 -25 43 * -19 67 * -14 63 6 -44 Montana * 29 -14 23 * 384 * -19 -239 731 -4 -19 32 * 33 -10-9 18 * * 24 -13 -20 20 * * 24 -6 -16 47 * -15 69 * -15 55 8 * -60 Nebraska *46 -23 29 * 320 * -26 -175 1028 -8 -16 2539 -13-7 2512 -20-8 24 * 25 -16 -19 39 * -12 61 * -9 58 5 -54 Nevada 58 * -34 26 * 305 * -20 -158 9 ** 21 -7-9 36 * 31 -15-9 26 * * 16 -19 -11 25 * 29 -14 -19 36 * -8 67 * 1 75 7 * -71 New Hampshire 50 * -25 20 * 390 * -16 -218 6 * 33 -5 -22 13 * * 40 -5 -15 19 * * 23 -14 -19 15 * * 34 -9 -27 38 * -16 62 * -6 53 3 * -54 New Jersey * 77 -40 25 * 320 * -21 -157 5 ** 19 -4-8 22 * * 36 -13-9 22 * * 15 -17-9 20 * * 29 -11 -21 32 * -5 62 * -2 63 3 -34 New Mexico * 40 -19 20 * 348 * -15 -181 622 -3 -12 37 * * 32 -14-5 19 * * 11 -13-7 24 * 27 -13 -20 39 -6 65 * -10 66 7 * -40 New York *59 -21 15 * 283 -11 -121 3 ** 19 -2-9 18 * 33 -8-9 17 * 13 -11-8 20 * * 25 -9 -18 33 * -7 63 * -4 59 8 * -66 North Carolina 66 * -39 29 * 445 * -25 -265 6 ** 27 -4 -15 27 * 47 -11 -15 31 * * 19 -22 -13 19 * * 39 -7 -33 33 * -11 63 -11 53 3 * -42 North Dakota 32 -13 20 * 358 * -17 -200 14 * * 32 -11 -18 28 * * 41 -6 -10 14 * * 18 -10 -14 25 * * 24 -15 -17 43 -15 62 -7 58 1 -68 Ohio 74 * -39 14 * 436 * -11 -227 4 ** 37 -3 -24 20 * * 43 -8 -13 18 * * 26 -11 -21 22 * * 31 -13 -24 36 -10 67 -9 59 6 -79 Oklahoma *69 -38 35 * 458 * -28 -247 8 ** 28 -4 -17 28 * * 45 -14 -14 27 * * 26 -22 -20 26 * * 36 -13 -29 41 * -11 63 * -10 69 2 * -33 Oregon 32 * -14 15 * 309 * -11 -158 4 ** 26 -3 -16 21 * 37 -4 -10 18 * * 19 -13 -16 21 * * 30 -11 -25 42 * -18 65 * -5 59 1 * -50 Pennsylvania 64 * -28 15 * 330 * -12 -150 7 ** 27 -5 -15 17 * 37 -6-7 17 * * 21 -8 -15 22 * 24 -11 -17 33 * -6 60 * -3 57 1 * -62 Rhode Island* 61 -22 10 * 437 * -8 -255 1 ** 21 -12 0 16 * * 39 -9 -16 19 * * 12 -15-9 17 * * 24 -11 -18 26 * -5 56 * -6 66 1 -61 South Carolina 69 * -42 27 * 440 * -22 -274 5 ** 29 -3 -18 24 * * 43 -9 -12 27 * 21 -21 -17 27 * * 29 -17 -23 38 * -15 67 * -7 57 9 -52 South Dakota 39 -19 26 * 289 * -22 -147 5 * 33 -5 -19 26 * 36 -4-1 17 * * 17 -13 -11 20 * 22 -11 -17 38 -15 56 * -8 56 1 -75 Tennessee * 73 -42 24 * 411 * -20 -232 4 ** 32 -3 -17 24 * 47 -6 -11 22 * * 24 -15 -18 27 * 31 -14 -23 35 * -10 67 -4 58 0 * -57 Texas 59 * -30 42 * 360 * -35 -182 12 * * 16 -8-5 41 * 42 -22-8 32 * * 10 -23-6 31 * * 24 -19 -17 44 * -19 70 -12 69 3 * -30 Utah 38 * -21 24 * 276 -20 -131 9 ** 13 -7-7 34 * 31 -11-5 21 9 * * -13-6 22 * * 19 -12 -13 36 * -10 72 * -10 47 5 -42 Vermont30 * -11 7 * 321 * -4 -172 1 * 31 -21 0 13 * * 32 -5-7 10 * * 24 -4 -19 22 * * 28 -16 -23 42 * -18 68 -11 50 2 -71 Virginia 76 * -46 29 * 423 * -25 -245 9 * 24 -7 -13 30 * 38 -16 -10 31 * * 20 -25 -16 21 * 30 -12 -22 33 * -9 65 * -11 63 0 * -40 Washington * 40 -19 16 * 317 * -13 -160 4 ** 22 -3 -13 27 * * 37 -9 -10 18 * * 14 -12 -11 26 * 25 -15 -19 35 * -8 65 * -10 65 2 -74 West Virginia 68 * -30 11 * 444 * -8 -229 1 ** 38 -1 -23 20 * * 42 -4-2 19 * 33 -10 -24 25 * 36 -15 -26 36 * -10 60 * -6 53 9 * -49 Wisconsin * 45 -20 15 * 369 * -12 -190 5 ** 28 -3 -16 20 * 32 -9 0 18 * 19 -12 -15 17 * * 33 -11 -26 29 * -7 69 * -6 58 1 * -66 Wyoming * 48 -29 26 * 341 * -20 -177 8 ** 31 -3 -20 40 * * 36 -21 -10 24 * * 19 -16 -12 22 * 29 -12 -23 40 * -6 72 * -10 54 s at datacenter.commonwealthfund.orgstates' low-income population, generally those whose household income is under 200% FPL. Disparity is the difference between the states' low-income and higher-income (400%+ FPL) populations. ( Notes: Rates are for the for baseline data. Notes: Rates are for the states’ low-income population, generally those whose household income is under 200% FPL. Disparity is the difference between the states’ low-income and higher-income (400%+ FPL) populations. * Denotes meaningful improvement or worsening from the baseline period. Baseline data not shown; refer to state profiles at datacenter. commonwealthfund.org for baseline data. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 56 APPENDIX G3. Disparity: Summary of Indicator Change Over Time Appendix G3. Disparity: Summary of Indicator Change Over Time Number of states where disparity for the low-income population: Disparity Indicator • Improved a • No Change b • Worsened a Income 0 Adults ages 19–64 uninsured 51 0 Children ages 0–18 uninsured 37 9 5 Adults without a usual source of care 36 9 6 Adults who went without care because of cost 42 3 6 Adults without a dental visit in past year 27 8 16 Adults without all age- and gender-appropriate cancer screenings 29 9 13 Adults without all age-appropriate recommended vaccines 19 15 17 Children ages 19–35 months without all recommended vaccines 16 18 17 Medicare beneficiaries received a high-risk drug 32 17 2 Hospital admissions for pediatric asthma, per 100,000 children 12 30 9 Preventable hospitalizations, Medicare duals, age 65+ 5 20 26 30-day readmissions, Medicare duals, age 65+ 45 3 3 Avoidable emergency department visits, Medicare duals, age 65+ 6 4 41 Adults who smoke 28 7 16 Adults who are obese 11 18 22 Adults who have lost six or more teeth 19 9 23 Adults who report fair/poor health 17 9 25 Notes: Selected indicators only. Trend data generally reflect the two-year period ending in 2015 or 2016; refer to Appendix A1 for additional detail. For the purposes of this analysis we count the District of Columbia as a state. (a) Improvement indicates that the rate for the low-income population within the state improved and the disparity between the low-income population and the higher-income population narrowed. (b) Includes the number of states with no change or without sufficient data for this subpopulation to assess change over time. Notes: Selected indicators only. Trend data generally reflect the two-year period ending in 2015 or 2016; refer to Appendix A1 for additional detail. For the purposes of this analysis we count the District of Columbia as a state. (a) Improvement indicates that the rate for the low-income population within the state improved and the disparity between the low-income population and the higher-income population narrowed. (b) Includes the number of states with no change or without sufficient data for this subpopulation to assess change over time. commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 57 APPENDIX H. State Scorecard Indicator Descriptions and Source Notes ABBREVIATIONS ACS PUMS = American Community Survey, Public Use Micro MEPS IC = Medical Expenditure Panel Survey, Insurance Sample Component AHRQ = Agency for Healthcare Research and Quality NCCDPHP = National Center for Chronic Disease Prevention and Health Promotion BRFSS = Behavioral Risk Factor Surveillance System NCHS = National Center for Health Statistics CAHMI = Child and Adolescent Health Measurement Initiative NCIRD = National Center for Immunization and Respiratory Diseases CCW = Chronic Conditions Warehouse NIS PUF = National Immunization Survey, Public Use Data File CDC = Centers for Disease Control and Prevention NSCH = National Survey of Children’s Health CMS = Centers for Medicare and Medicaid Services NSDUH = National Survey of Drug Use and Health CPS ASEC = Current Population Survey, Annual Social and Economic Supplement NVSS-I = National Vital Statistics System–Linked Birth and Infant Death Data HCAHPS = Hospital Consumer Assessment of Healthcare Providers and Systems Survey NVSS-M = National Vital Statistics System–Mortality Data HCUP NIS = Healthcare Cost and Utilization Project, OASIS = Outcome and Assessment Information Set Nationwide Inpatient Sample SAF = Standard Analytic Files HCUP SID = Healthcare Cost and Utilization Project, State SAMHSA = Substance Abuse and Mental Health Services Inpatient Databases Administration MDS = Minimum Data Set WONDER = Wide-ranging Online Data for Epidemiologic MedPAR = Medicare Provider and Analytic Review Research DEFINITIONS FOR INDICATORS 1. Adults ages 19–64 uninsured: Percent of adults ages 19–64 that equaled 10 percent or more of income, or 5 percent or more without health insurance coverage. Authors’ analysis of 2013 and of income if low-income (under 200% of federal poverty level), 2016 1-year ACS PUMS (U.S. Census Bureau). not including health insurance premiums if insured. This measure includes both insured and uninsured individuals. Two years of 2. Children ages 0–18 uninsured: Percent of children ages 0–18 data are combined to ensure adequate sample size for state-level without health insurance coverage. Authors’ analysis of 2013 and estimation. Ougni Chakraborty, Robert F. Wagner School of Public 2016 1-year ACS PUMS (U.S. Census Bureau). Service, New York University, analysis of 2014, 2015, 2016, and 2017 CPS ASEC (U.S. Census Bureau). 3. Adults without a usual source of care: Percent of adults age 18 and older who did not have one (or more) person they think of as 6. Employee health insurance contributions as a share of median their personal health care provider. Authors’ analysis of 2013 and income: We compared employees’ average contributions to their 2016 BRFSS (CDC, NCCDPHP). employer-sponsored health insurance premiums as a percent of state median household incomes for the under-65 population 4. Adults who went without care because of cost in the past year: in each state. Premium contribution data are originally reported Percent of adults age 18 and older who reported a time in the separately for single-person and family plans; we therefore used past 12 months when they needed to see a doctor but could not a weighted average of single and family premium contributions because of cost. Authors’ analysis of 2013 and 2016 BRFSS (CDC, compared with single and family median household incomes. NCCDPHP). Authors’ analysis of 2013 and 2016 MEPS-IC (AHRQ) and 2014 5. Individuals with high out-of-pocket medical spending: Percent and 2017 CPS ASEC (U.S. Census Bureau). of individuals under age 65 with out-of-pocket medical spending commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 58 APPENDIX H. State Scorecard Indicator Descriptions and Source Notes (continued) 7. Adults without a dental visit in past year: Percent of adults age treatment or counseling and who did not receive treatment 18 and older who did not visit a dentist, or dental clinic within from a mental health professional (as defined) during the past the past year. Authors’ analysis of 2012 and 2016 BRFSS (CDC, 12 months, according to parents’ reports. For more information, NCCDPHP). see www.childhealthdata.org. Authors’ analysis of 2016 NSCH (CAHMI). 8. Adults without all age- and gender-appropriate cancer screenings: Percent of adults ages 50–74 who did not receive 15. Children ages 19–35 months who did not receive all sigmoidoscopy or colonoscopy in the last ten years or a fecal recommended vaccines: Percent of children ages 19–35 months occult blood test in the last two years; a mammogram in the last who did not receive at least 4 doses of diphtheria, tetanus, and two years (women ages 50–74 only); and a pap smear in the last accellular pertussis (DTaP/DT/DTP) vaccine; at least 3 doses of three years (women ages 25–64 only). Authors’ analysis of 2012 poliovirus vaccine; at least 1 dose of measles-containing vaccine and 2016 BRFSS (CDC, NCCDPHP). (including mumps-rubella (MMR) vaccine); the full series of Haemophilus influenza type b (Hib) vaccine (3 or 4 doses 9. Adults without all age-appropriate vaccines: Percent of adults depending on product type); at least 3 doses of hepatitis B vaccine age 18 and older who did not receive a flu shot in the past year (HepB); at least 1 dose of varicella vaccine, and at least 4 doses and a pneumonia vaccine ever if age 65 and older. Authors’ of pneumococcal conjugate vaccine (PCV). Data from the 2013, analysis of 2013 and 2016 BRFSS (CDC, NCCDPHP). 2014, 2015, and 2016 NIS-PUF (CDC, NCIRD). 10. Diabetic adults ages 18–64 without a hemoglobin A1c test: 16. Hospital 30-day mortality: Risk-standardized, all-cause 30-day The share of adult diabetic patients ages 18–64 who did not have mortality rates for fee-for-service Medicare patients age 65 and at least one hemoglobin A1c test during the year (expressed as older hospitalized with a principal diagnosis of heart attack, heart a rate per 100 employer-insured enrollees). Michael E. Chernew failure, pneumonia or stroke between July 2010 and June 2013, and Andrew Hicks, Harvard Medical School Department of and July 2013 and June 2016. All-cause mortality is defined as Health Care Policy, analysis of the 2015 Truven Marketscan death from any cause within 30 days after the index admission, Database. regardless of whether the patient dies while still in the hospital or after discharge. Authors’ analysis of Medicare enrollment and 11. Medicare beneficiaries received a high-risk drug: Percent claims data retrieved from 4th Quarter 2017 and 4th Quarter 2014 of fee-for-service Medicare beneficiaries ages 65 and older who Hospital Compare (CMS). received at least one drug from a list of 13 classes of high-risk prescriptions that should be avoided by the elderly. Yuting Zhang, 17. Central line-associated bloodstream infections (CLABSI), University of Pittsburgh, analysis of 2012 and 2014 5% sample of Standardized Infection Ratio (SIR): All CLABSIs reported to the Medicare beneficiaries enrolled in stand-alone Medicare Part D National Healthcare Safety Network from all applicable hospital plans. locations, including intensive care units, neonatal intensive care units, and wards. The standardized infection ratio compares 12. Children without all components of a medical home: Percent the observed number of CLABSIs reported by hospitals within of children ages 0–17 who did not have all of the following, the state to the predicted number of infections based on the according to parents’ reports: a personal doctor or nurse, a usual referent period, adjusting for key risk factors. Data are from the source for sick and well care, family-centered care, any problems CDC’s 2015 National and State Healthcare-Associated Infections getting needed referrals, and effective care coordination when Progress Reports. needed. For more information, see www.childhealthdata.org. Authors’ analysis of 2016 NSCH (CAHMI). 18. Hospital patients discharged without instructions for home recovery: Percent of hospitalized patients who were not given 13. Children without a medical and dental preventive care visit information about what to do during their recovery at home. in the past year: Percent of children ages 0–17 who did not have Authors’ analysis of 2013 and 2016 HCAHPS as administered to a preventive medical visit and, if ages 1–17, a preventive dental adults discharged from acute care hospitals. Retrieved from 4th visit in the past year, according to parents’ reports. For more Quarter 2017 and 4th Quarter 2014 Hospital Compare (CMS). information, see www.childhealthdata.org. Authors’ analysis of 2016 NSCH (CAHMI). 19. Hospital patients who did not receive patient-centered care: Percent of patients who reported hospital staff did not always 14. Children who did not receive needed mental health manage pain well, did not always respond when they needed treatment: Percent of children ages 3–17 who had any kind of help to get to the bathroom or pressed a call button, and did not emotional, developmental, or behavioral problem that required always explain medicines and side effects. Authors’ analysis of commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 59 APPENDIX H. State Scorecard Indicator Descriptions and Source Notes (continued) 2013 and 2016 HCAHPS, as administered to adults discharged Mental Disorders, 4th edition, regardless of the level of from acute care hospitals. Retrieved from retrieved from 4th impairment in carrying out major life activities. AMI was Quarter 2017 and 4th Quarter 2014 Hospital Compare (CMS). estimated based on a statistical model of a clinical diagnosis and responses to questions on distress, impairment, past year 20. Home health patients who did not get better at walking or major depressive episode, past year suicidal thoughts, and age. moving around: Percent of all home health episodes in which a For more information, see: SAMHSA, NSDUH, Methodological person did not improve at walking or moving around compared Summary and Definitions, https://www.samhsa.gov/data/ to a prior assessment. Episodes for which the patient, at start sites/default/files/NSDUH-MethodSummDefsHTML-2015/ or resumption of care, was able to ambulate independently NSDUH-MethodSummDefsHTML-2015/NSDUH- are excluded. Authors’ analysis of 2013 and 2016 OASIS. Data MethodSummDefs-2015.htm. retrieved from 3rd quarter 2017 and 2nd quarter 2014 Home Health Compare (CMS). 24. Hospital admissions for pediatric asthma, per 100,000 children: Excludes patients with cystic fibrosis or anomalies of 21. Nursing home residents with an antipsychotic medication: the respiratory system, and transfers from other institutions. Percent of long-stay nursing home residents who received Authors’ analysis of 2012 and 2014 HCUP SID (AHRQ); not all an antipsychotic medication, excluding residents with states participate in HCUP. Estimates for total U.S. are from the Schizophrenia, Tourette’s syndrome, and Huntington’s disease. HCUP NIS (AHRQ). Authors’ analysis of 2013–2016 MDS. Data retrieved from June 2017 and June 2014 Nursing Home Compare (CMS). 25. Potentially avoidable emergency department (ED) visits: Potentially avoidable ED visits were those that, based on 22. Adults with any mental illness (AMI) reporting unmet need: diagnoses recorded during the visit and the health care service Percent of adults ages 18 or older with AMI (defined below) the patient received, were considered to be either nonemergent who reported a perceived need for mental health treatment or (care was not needed within 12 hours), or emergent (care needed counseling in the past 12 months that was not received. This within 12 hours) but that could have been treated safely and measure could include adults who reported that they received effectively in a primary care setting. This definition excludes any some type of mental health service in the past 12 months; ED visit that resulted in an admission, as well as ED visits where an unmet need for services after adults had received some the level of care provided in the ED was clinically indicated. services would indicate a perceived need for additional services This approach uses the New York University Center for Health that they did not receive. Data are from the 2009–2011 and and Public Service Research emergency department algorithm 2013–2015 NSDUH (SAMHSA), as reported in Mental Health developed by John Billings, Nina Parikh, and Tod Mijanovich (see: America’s 2018 State of Mental Health in America (http://www. Emergency Room Use — The New York Story, The Commonwealth mentalhealthamerica.net). Fund, Nov. 2000, http://www.commonwealthfund.org/ publications/issue-briefs/2000/nov/emergency-room-use--the- 23. Adults with any mental illness (AMI) who did not receive new-york-story). treatment: Percent of adults ages 18 or older with AMI (defined below) who reported they did not receive mental health Ages 18–64, per 1,000 employer-insured enrollees: Michael treatment in the past 12 months. Mental health treatment is E. Chernew and Andrew Hicks, Harvard Medical School defined as receiving treatment or counseling for any problem Department of Health Care Policy, analysis of the 2015 Truven with emotions, nerves, or mental health in the 12 months prior Marketscan Database. to the interview in any inpatient or outpatient setting, or the use of prescription medication for treatment of any mental or Ages 65 and older, per 1,000 Medicare beneficiaries: Jie Zheng, emotional condition that was not caused by the use of alcohol Harvard University, analysis of 2012 and 2015 Medicare or drugs. Data are from the 2009–2011 and 2013–2015 NSDUH Enrollment and SAF Claims Data 20% sample of fee-for-service (SAMHSA), as reported in Mental Health America’s 2018 State of Medicare beneficences ages 65 and older (CMS, CCW). Mental Health in America (http://www.mentalhealthamerica. net). 26. Admissions for ambulatory care–sensitive conditions: Hospital admissions for one of the following eight ambulatory Note: Adults with any mental illness (AMI) is defined as adults care–sensitive (ACS) conditions: long-term diabetes ages 18 or older who currently or at any time in the past year complications, lower extremity amputation among patients have had a diagnosable mental, behavioral, or emotional with diabetes, asthma or chronic obstructive pulmonary disease, disorder (other than a developmental or substance use hypertension, congestive heart failure, dehydration, bacterial disorder) of sufficient duration to meet diagnostic criteria pneumonia, and urinary tract infection. specified within the Diagnostic and Statistical Manual of commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 60 APPENDIX H. State Scorecard Indicator Descriptions and Source Notes (continued) Ages 18–64, per 1,000 employer-insured enrollees: Michael 31. Adults ages 18–50 with low back pain who had an imaging E. Chernew and Andrew Hicks, Harvard Medical School study at diagnosis: The share of employer-insured adults ages Department of Health Care Policy, analysis of the 2015 Truven 18–50 who had a new primary diagnosis of low back pain with an Marketscan Database. imaging study (plain X-ray, MRI, or CT scan) within 28 days of the diagnosis (expressed as a rate per 100 enrollees). Enrollees who Ages 65–74 and age 75 and older, per 1,000 Medicare have a diagnosis for which an imaging study may be clinically beneficiaries: Admissions of fee-for-service Medicare appropriate (cancer, recent trauma, IV drug abuse, or neurologic beneficiaries ages 65–74 or ages 75 and older (measure reported impairment) are excluded. Michael E. Chernew and Andrew separately for each age group). Authors’ analysis of 2012 and Hicks, Harvard Medical School Department of Health Care Policy, 2015 CCW data, retrieved from the April 2017 CMS Geographic analysis of the 2015 Truven Marketscan Database. Variation Public Use File (CMS, Office of Information Products and Analytics). 32. Total employer-sponsored insurance spending per enrollee: Total spending per enrollee in employer-sponsored insurance 27. 30-day hospital readmissions: All hospital admissions among plans estimated from a regression model of reimbursed costs for patients who were readmitted within 30 days of an acute hospital health care services from all sources of payment including the stay for any cause. A correction was made to account for likely health plan, enrollee, and any third party payers incurred in 2013 transfers between hospitals. and in 2015. Outpatient prescription drug charges are excluded. Enrollees with capitated plans and their associated claims are also Ages 18–64, per 1,000 employer-insured enrollees: Michael excluded. Estimates for each state were adjusted for enrollees’ age E. Chernew and Andrew Hicks, Harvard Medical School and sex, the interaction of age and sex, partial year enrollment Department of Health Care Policy, analysis of the 2015 Truven and regional wage differences. Michael E. Chernew and Andrew Marketscan Database. Hicks, Harvard Medical School Department of Health Care Policy, Age 65 and older, per 1,000 Medicare beneficiaries: analysis of the 2015 Truven Marketscan Database. Readmissions among fee-for-service Medicare beneficiaries 33. Total Medicare (Parts A and B) reimbursements per enrollee: ages 65 and older. Authors’ analysis of 2012 and 2015 CCW Total Medicare fee-for-service reimbursements include payments data, retrieved from the April 2017 CMS Geographic Variation for both Part A and Part B but exclude Part D (prescription drug Public Use File (CMS, Office of Information Products and costs) and extra CMS payments for graduate medical education Analytics). and for treating low-income patients. Reimbursements reflect 28. Short-stay nursing home residents with a 30-day readmission only the age 65 and older Medicare fee-for-service population. to the hospital: Percent of newly admitted nursing home Authors’ analysis of 2012 and 2015 CCW data, retrieved from the residents who are rehospitalized within 30 days of being April 2017 CMS Geographic Variation Public Use File (CMS, Office discharged from a hospital to the nursing home. Vincent Mor, of Information Products and Analytics). Brown University, analysis of 2012 and 2014 Medicare enrollment 34. Mortality amenable to health care, deaths per 100,000 data, MDS, and MedPAR File (CMS). population: Number of deaths before age 75 per 100,000 29. Long-stay nursing home residents with a hospital admission: population that resulted from causes considered at least partially Percent of long-stay residents (residing in a nursing home for treatable or preventable with timely and appropriate medical at least 90 consecutive days) who were hospitalized within six care (see list), as described in E. Nolte and M. McKee, “Measuring months of baseline assessment. Vincent Mor, Brown University, the Health of Nations: Analysis of Mortality Amenable to Health analysis of 2012 and 2014 Medicare enrollment data, MDS, and Care,” British Medical Journal, Nov. 15, 2003, 327 (7424): 1129–32. MedPAR File (CMS). Authors’ analysis of mortality data from CDC restricted-use Multiple Cause-of-Death file (NCHS) and U.S. Census Bureau 30. Home health patients with a hospital admission: Percent population data, 2003–2015. of home health episodes among fee-for-service Medicare beneficiaries during which the patient was admitted to an acute- Causes of death Ages care hospital. Authors’ analysis data from CMS Medicare claims Intestinal infections 0–14 data. Data retrieved from 4th quarter 2017 and 3rd quarter 2014 Tuberculosis0–74 Home Health Compare (CMS), representing patient experiences Other infections (diphtheria, tetanus, septicaemia, poliomyelitis) 0–74 in 2016 and 2013. Whooping cough 0–14 Measles1–14 commonwealthfund.org May 2018 2018 Scorecard on State Health System Performance 61 APPENDIX H. State Scorecard Indicator Descriptions and Source Notes (continued) Malignant neoplasm of colon and rectum 0–74 41. Adults who are obese: Percent of adults ages 18–64 who are Malignant neoplasm of skin 0–74 obese (Body Mass Index [BMI] ≥ 30). BMI was calculated based Malignant neoplasm of breast 0–74 on reported height and weight. Authors’ analysis of 2013 and Malignant neoplasm of cervix uteri 0–74 2016 BRFSS (CDC, NCCDPHP). Malignant neoplasm of cervix uteri and body of uterus 0–44 Malignant neoplasm of testis 0–74 42. Children who are overweight or obese: Children ages Hodgkin’s disease 0–74 10–17 who are overweight or obese (BMI >= 85th percentile). Leukemia0–44 Overweight is defined as an age- and gender-specific body mass Diseases of the thyroid 0–74 index (BMI-for-age) between the 85th and 94th percentile of the Diabetes mellitus 0–49 CDC growth charts. Obese is defined as a BMI-for-age at or above Epilepsy0–74 the 95th percentile. BMI was calculated based on parent-reported Chronic rheumatic heart disease 0–74 height and weight. For more information, see www.nschdata.org. Hypertensive disease 0–74 Authors’ analysis of 2016 NSCH (CAHMI). Cerebrovascular disease 0–74 43. Adults who have lost six or more teeth: Percent of adults ages All respiratory diseases (excluding pneumonia and influenza) 1–14 18–64 who have lost six or more teeth because of tooth decay, Influenza0–74 infection, or gum disease. Authors’ analysis of 2012 and 2016 Pneumonia0–74 BRFSS (CDC, NCCDPHP). Peptic ulcer 0–74 Appendicitis0–74 Abdominal hernia 0–74 Cholelithiasis and cholecystitis 0–74 Nephritis and nephrosis 0–74 Benign prostatic hyperplasia 0–74 Maternal death All Congenital cardiovascular anomalies 0–74 Perinatal deaths, all causes, excluding stillbirths All Misadventures to patients during surgical and medical care All Ischaemic heart disease: 50% of mortality rates included 0–74 35. Breast cancer deaths per 100,000 female population: Authors’ analysis of NVSS–M, 2013 and 2016 (NCHS), retrieved using CDC WONDER. 36. Colorectal cancer deaths per 100,000 population: Authors’ analysis of NVSS–M, 2013 and 2016 (NCHS), retrieved using CDC WONDER. 37. Deaths from suicide, alcohol, and drug use per 100,000 population: Authors’ analysis of NVSS-M, 2013 and 2016 (NCHS), retrieved using CDC WONDER. 38. Infant mortality, deaths per 1,000 live births: Authors’ analysis of NVSS-I, 2012 and 2015 (NCHS), retrieved using CDC WONDER. 39. Adults who report fair/poor health: Percent of adults age 18 and older who reported being in fair or poor health. Authors’ analysis of 2013 and 2016 BRFSS (CDC, NCCDPHP). 40. Adults who smoke: Percent of adults age 18 and older who ever smoked 100 or more cigarettes (five packs) and currently smoke every day or some days. Authors’ analysis of 2013 and 2016 BRFSS (CDC, NCCDPHP). commonwealthfund.org May 2018 For more information about this report, please contact: David C. Radley, Ph.D., M.P.H., Senior Scientist, Westat and The Commonwealth Fund Health System Scorecard Project, at drcmwf.org. About The Commonwealth Fund The Commonwealth Fund, among the first private foundations started by a woman philanthropist — Anna M. Harkness — was established in 1918 with the broad charge to enhance the common good. The mission of the Commonwealth Fund is to promote a high performance health care system. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. An international program in health policy is designed to stimulate innovative policies and practices in the United States and other industrialized countries. Support for this research was provided by the Commonwealth Fund. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund or its directors, officers, or staff. To learn more about new publications when they become available, visit the Fund’s website and register to receive email alerts.