2020 David C. Radley Senior Scientist The Commonwealth Fund Scorecard on Sara R. Collins State Health System Vice President The Commonwealth Fund Performance Jesse C. Baumgartner Research Associate The Commonwealth Fund FOR MORE ON HEALTH CARE IN YOUR STATE, VISIT OUR DATA CENTER: SEPTEMBER 2020 datacenter.commonwealthfund.org 2020 Scorecard on State Health System Performance INTRODUCTION The COVID-19 pandemic has disrupted health Second, Black, Latino, and other communities care around the globe. In the United States, of color, already more likely to be uninsured, where it has claimed the lives of more than have been disproportionally burdened 185,000 people, health systems in every state by COVID-19 and the related economic have been stretched — in some cases severely. fallout. Systemic racial and ethnic inequities in health care access and quality have The novel coronavirus has exposed and contributed to higher hospitalization and exacerbated existing weaknesses that have mortality rates from COVID-19 among Black, long been the focus of the Commonwealth Latino, American Indian, and Alaska Native Fund’s Scorecard on State Health System individuals, among others. Performance. First, because most Americans Third, the pandemic has exposed the get their health insurance through an vulnerability of health providers reliant on employer, recent job losses have widened the fee-for-service payment system. Many are coverage gaps that existed prior to the crisis. facing steep revenue losses and the threat of The Urban Institute projects that 10 million closure as social-distancing restrictions, fear, people will lose their employer coverage by and a nose-diving economy have driven down year’s end, leaving 3.5 million uninsured.1 both the supply and demand for routine and The loss of job-based coverage has also elective care. 3 brought into sharp relief the impact of states’ Finally, the country faces many unanswered decisions not to expand Medicaid eligibility questions on the extent to which COVID-19 for low-income residents; 12 states have yet to and the ongoing economic fallout will expand their programs as allowed under the contribute to suicides, deaths from alcohol Affordable Care Act (ACA).2 and substance use, and further erosion of Americans’ life expectancy. 2020 Scorecard on State Health System Performance 3 SCORECARD HIGHLIGHTS ABOUT THE 2020 STATE SCORECARD Hawaii, Massachusetts, The Commonwealth Fund’s 2020 Scorecard on State Health Minnesota, Iowa, and System Performance assesses all 50 states and the District of Connecticut are the top- Columbia on 49 measures of access to health care, quality ranked states in the 2020 of care, service use and costs of care, health outcomes, and Scorecard on State Health income-based health care disparities. System Performance. See here COVID-19. The 2020 Scorecard documents state-level for complete state rankings. variation in U.S. health care performance prior to In the following sections, COVID-19’s emergence. The report draws on the most we examine three areas currently available, comprehensive, state-level data, which of concern that may be unfortunately lags in this rapidly evolving environment. exacerbated by the pandemic: Still, the report provides important state-specific context for discussing the pandemic’s implications. Insurance coverage gains associated with What’s New? The 2020 Scorecard introduces new the Affordable Care performance measures: Act (ACA) have stalled, • State-based public health spending. and affordability and out-of-pocket costs are • Primary care spending among Medicare beneficiaries worsening. and those with employer coverage. Also included are data on racial and ethnic inequity, Increased prices for health care services are focusing on the disparity between white people and a major driver of overall communities of color for a subset of indicators spanning spending growth, and health care access, quality, and health outcomes. (These this has led to higher data are referenced throughout the report but are not costs for consumers in used to calculate state rankings.) commercial plans. For the first time, the 2020 Scorecard also reports price information for health services at a state level (not used in Premature deaths from treatable conditions and state rankings). deaths from suicide, See “Scorecard Methods” for additional information on alcohol, and drug indicators and ranking approach. overdose continue to impact life expectancy. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 4 Exhibit 1 Previous Insurance Coverage Gains Exhibit 1. Gains in uninsured rates Have Stalled; Affordability a Major Gains in uninsured flattened, ratesdirection, and even changed flattened, and Concern after after2016 2016 Health insurance in the United States is built around Average annual percent change, 2014 to 2016 employment, and most Americans under age 65 (around 159 million people) get their insurance through their own job or the job of a family member.4 The ACA’s subsidized coverage expansions were designed to fill the gap for people without access to employer health plans, including those who lose their benefits because of job loss. The economic collapse triggered by the coronavirus pandemic is the first recession in which these provisions have been in place to stem job-related coverage losses. Below we describe the state of coverage before the pandemic, what is known about the number of people Improving (50 states) who lost employer coverage in the downturn, and the Uninsured rate fell by 2% or more per year degree Exhibitto 1 which people found insurance through the No change (0 states) Uninsured rate changed less than 2% per year Gains in uninsured rates flattened, and evenWorsening ACA’s expansions. changed (0 states) direction, afterin2016 Uninsured rate rose by 2% or more per year Trends coverage and access. Federal data indicate more than 30 million people were uninsured in 2018, aboutAverage annual 30 million percent fewer change, than the 2014 to 2016 Congressional Average Notes: Nonelderly adults annual ages 19–64. percent District of Columbiachange, not included2016 tocounts. in legend 2018 Data: U.S. Census Bureau, 2014–2018 One-Year American Community Survey, Public Use Microdata Sample (ACS Budget Office (CBO) had predicted prior to the ACA’s major coverage reforms.5 The biggest post-ACA coverage Source: David C. Radley, Sara R. Collins, and Jesse C. Baumgartner, 2020 Score gains in all states occurred between 2014 and 2016. After 2016, gains stalled in 23 states and even began to erode in 22 states (Exhibit 1). The five states whose uninsured rates fell after 2016 had all expanded Medicaid eligibility; they include Alaska and Louisiana, which expanded Medicaid in 2015 and 2016, respectively. The primary purpose of health insurance is to enable timely access to health care through the reduction of cost barriers. In most states, Improving (50access states) improvements Improving (5 states) Uninsured rate fell by 2% or more per year Uninsured rate fell by 2% or more per year post-ACA enactment followed a pattern similar to No change (0 states) No change (23 states) what was seen for insurance coverage. The share of Uninsured rate changed less than 2% per year Uninsured rate changed less than 2% per year adults who reported going without Worsening (0 states)care because of cost Worsening (22 states) declined in a majorityUninsured of statesratebetween rose by 2% or2014 and more per year2016. Uninsured rate rose by 2% or more per year But after 2016, adults in 21 states experienced little or no improvement on this access measure, and 15 states saw Notes: Nonelderly adults ages 19–64. District of Columbia not included in legend counts. Notes: Nonelderly adults ages 19–64. District of Columbia not included in legend counts. a rise in Census Data: U.S. the share of adults Bureau, 2014–2018 going One-Year without American care Community because Survey, Public Use Microdata Sample (ACS PUMS). Data: U.S. Census Bureau, 2014–2018 One-Year American Community Survey, of cost (Exhibit 2). Public Use Microdata Sample (ACS PUMS). Source: David C. Radley, Sara R. Collins, and Jesse C. Baumgartner, 2020 Scorecard on State Health System Performance (Commonwealth Fund, Sept. 2020). commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 5 Racial and ethnic inequities in coverage persist Exhibit Exhibit 2 2. Adults in 15 states were more and are at risk of worsening. Before the ACA, the Adults inavoid likely to 15 states wereofmore care because cost likely to avoid care because of cost uninsured were disproportionately people with low and concerns after concerns after 2016 2016 moderate incomes and people of color. Research has found that the coverage expansions significantly narrowed both Average annual percent change, 2014 to 2016 Average income andannual percent racial and change, ethnic 2016intocoverage inequities 2018 and access.6 However, these improvements largely stalled in most states after 2016. In 2018, the uninsured rate for both Black and Latino adults was at least five percentage points higher than it was for white adults in 17 states (Exhibit 3). Four principal factors have driven the stalled gains and coverage erosion after 2016: • Twelve states have yet to expand eligibility for Medicaid; uninsured rates in those states were among the highest in 2018 (Exhibit 4). Improving (35 states) • In theImproving individual market, premiums become less (14 states) Adults with cost barriers fell by 2% or more per year Adults with cost barriers fell by 2% or more per year affordable as income rises, particularly over the subsidy No change (9 states) No change (21 states) Adults with cost barriers changed less than 2% per year threshold of 400 percent of the federal poverty level Adults with cost barriers changed less than 2% per year likely to avoid care because of cost Worsening (6 states) Adults with cost barriers rose by 2% or more per year ($49,960 for an(15 Worsening four in 2020) Adults individual states) where with cost and $103,000 for a family of people barriers rose by pay 2% orthe morefull premium. per year • Actions by Congress and the Trump administration 16 Notes: Adults age 18 and older. District of Columbia not included in legend counts. Average annual percent change, 2016 to 2018 related to the individual market and Medicaid Data: 2014–2018 Behavioral Risk Factor Surveillance System (BRFSS). programs, along with immigration policies, have reduced Source: David C. Radley, Sara R. Collins, and Jesse C. Baumgartner, 2020 Scorecard enrollment. on State Health System Performance (Commonwealth Fund, Sept. 2020). • Undocumented immigrants are ineligible for subsidized coverage under the ACA. Implications of the pandemic for health insurance coverage. More than 50 million people have lost jobs or been furloughed since March.7 By August, the national unemployment rate was 8.4 percent; and as of July, Massachusetts, New York, and Nevada had the highest unemployment rates.8 A Commonwealth Fund survey Improving (14 states) conducted in May 2020 found that about 40 percent of Adults with cost barriers fell by 2% or more per year respondents, or their spouses or partners, who experienced No change (21 states) ar Adults with cost barriers changed less than 2% per year job dislocation had coverage through an affected job, and Worsening (15 states) one in five of those affected reported being uninsured.9 Adults with cost barriers rose by 2% or more per year Because many of the affected jobs were in industries that often do not provide insurance, many respondents (three Notes: Adults age 18 and older. District of Columbia not included in legend counts. in 10) were uninsured prior to the pandemic. Black and Data: 2014–2018 Behavioral Risk Factor Surveillance System (BRFSS). Latino adults have been more likely to lose jobs during the Baumgartner, 2020 Scorecard on State Health System Performance (Commonwealth Fund, Sept. 2020). commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 6 Exhibit 3 In 17 states, there was at least a five-point disparity in the adult Exhibit 3. In 17 states, there was at least a five-point disparity in the adult uninsured rate uninsured rate between white and both Black and Hispanic adults between white and both Black and Hispanic adults Percent Hispanic 50 Black 45 White 40 35 30 25 20 15 10 5 0 New… Connecticut Oklahoma Michigan Colorado Missouri Rhode Island Illinois Arizona South Dakota Ohio Alabama Kentucky Mississippi New York South Carolina Massachusetts Washington Louisiana Maryland Wyoming Utah Indiana Texas Oregon Kansas Pennsylvania New Jersey North Carolina West Virginia Iowa Idaho Wisconsin Delaware Hawaii California New Mexico Nebraska Georgia Virginia Nev ada Minnesota Arkansas Tennessee Florida Notes: States arranged in order of the uninsured rate for white adults. Nonelderly adults ages 19–64. Alaska, Montana, Maine, North Dakota, Vermont, and the Notes: States District arranged indo of Columbia order notofhave the uninsured sufficientrate for white sample adults. size for atNonelderly least twoadults ages races or 19–64. Alaska,Rhode ethnicities. Montana, Maine,Hawaii, Island, North Dakota, Vermont, andNew New Hampshire, the District Mexico, of Columbia do notDakota, Utah, South have sufficient sample size for at least two races or ethnicities. Rhode Island, Hawaii, New Hampshire, New Mexico, Utah, South Dakota, West Virginia, Wyoming and Idaho do not have sufficient West Virginia, Wyoming and Idaho do not have sufficient sample size for one race or ethnicity. sample size for one race or ethnicity. Exhibit Data: U.S. Data: U.S. 4Census Census Bureau, Bureau, 20182018 One-Year One-Year AmericanAmerican Community Community Survey, Survey, Public Public Use Use Microdata Microdata Sample Sample (ACS PUMS). (ACS PUMS). Four of the 12 states that have yet to expand Medicaid had Exhibit 4. Four ofSource: theDavid 12C.states that have yet to expand Medicaid had among the highest Radley, Sara R. Collins, and Jesse C. Baumgartner, 2020 Scorecard on State Health System Performance (Commonwealth Fund, Sept. 2020). among the highest adult uninsured rates in 2018 adult uninsured rates in 2018 Percent Medicaid expansion states as of January 1, 2018 24% 25 Medicaid nonexpansion states as of January 1, 2018 20 15 10 4% 5 0 Connecticut Oklahoma Michigan Colorado Missouri Rhode Island Illinois Arizona South Dakota Vermont Ohio Alabama Mississippi New York Kentucky Massachusetts Maine South Carolina Iowa Washington Louisiana Maryland Wyoming Indiana Utah Texas North Dakota New Hampshire Oregon Kansas United States District of Columbia Pennsylvania New Jersey North Carolina West Virginia Idaho Wisconsin Virginia Delaware Hawaii Alaska California Nebraska New Mexico Georgia Nev ada Minnesota Montana Arkansas Tennessee Florida Notes: Maine, Virginia, Utah, and Idaho implemented Medicaid expansion after January 1, 2018. Missouri, Nebraska, and Oklahoma have passed but have not yet implemented. Nonelderly adults ages 19–64. Notes: Maine, Virginia, Utah, and Idaho implemented Medicaid expansion after January 1, 2018. Missouri, Nebraska, and Oklahoma have passed but have not yet implemented. Nonelderly adults Data: U.S. Census Bureau, 2018 One-Year American Community Survey, Public Use Microdata Sample (ACS PUMS). ages 19–64. Data: U.S. Census Bureau, 2018 One-Year American Community Survey, Public Use Microdata Sample (ACS PUMS). commonwealthfund.org Source: David C. Radley, Sara R. Collins, and Jesse C. Baumgartner, 2020 Scorecard on State Health System Performance (Commonwealth Fund, Sept. 2020). September 2020 2020 Scorecard on State Health System Performance 7 pandemic, but almost half of Black adults and one-third of reasons. In Rhode Island, for example, where prices are 158 of Latino adults live in states that have not yet expanded percent of Medicare, the state drove down prices through Medicaid, leaving them at high risk of staying or becoming insurer rate regulation.15 The presence of market-dominant, uninsured. As of September 2020, more than 35 million not-for-profit insurers with strong price negotiation leverage people in the United States are estimated to be uninsured.10 also can work to mitigate higher prices. The question is how many people who have lost job-based High prices have consequences. When health providers coverage will enroll in marketplace plans during the open charge private insurers higher prices, insurers pass along enrollment period that begins on November 1. those higher costs to employers by increasing premiums. Ultimately, employees bear the burden through higher Health Care Prices Drive Spending premium contributions, deductibles, out-of-pocket medical costs, and reduced wages. States where providers charge Growth and Rising Costs for the highest prices also tended to have the highest average Consumers premium costs in terms of both employer and employee Health care spending growth is a perpetual policy contributions (Exhibit 6). concern in the United States. High spending threatens the U.S. investment in primary care is low and sustainability of public insurance programs and affects could be further weakened by the pandemic. premium costs and out-of-pocket cost-sharing for the more The COVID-19 pandemic fueled a 70 percent drop in than 170 million Americans enrolled in commercial plans.11 in-person outpatient visits in March 2020, including a Fee-for-service payment models have left many providers 50 percent drop for primary care providers. This was financially vulnerable in the wake of social-distancing the result of social distancing restrictions, public fear of restrictions and lower demand for care. the virus, and safety precautions taken by providers.16 Short-term revenue losses among providers will certainly Visit volumes have rebounded somewhat, and that will rebound, but the long-term impact of the pandemic on continue. Still, primary care’s vulnerability to steep providers’ bottom line is uncertain. To the extent that 12 demand and revenue declines is concerning. volumes remain lower than once expected or the supply Pre-COVID data on primary care spending can inform of providers decreases within markets, providers may our eventual understanding of the outbreak’s impact. raise prices. Among Medicare beneficiaries in 2017, for example, Prices paid by commercial insurers are higher primary care accounted for just under 6 percent of than Medicare rates for similar services. all medical spending, translating to about $712 per Researchers and policymakers have been able to track beneficiary per year nationally. State rates ranged from spending for health care services, but only recently have less than 5 percent in Rhode Island and New Hampshire they been able to break down total spending estimates into to more than 7 percent in Tennessee (Exhibit 7). American utilization and price-per-service components. Estimates investment in primary care was already low relative to suggest that about three-quarters of the growth in health international benchmarks. Among Medicare beneficiaries, care spending between 2014 and 2018 can be attributed to for example, primary care spending amounts to only price increases.13 about half the OECD country average of 12 percent.17 There A recent state analysis compared prices paid by commercial is significant uncertainty about whether the combined employer-sponsored plans for inpatient hospital services effects of the pandemic and economic collapse will further to Medicare payment rates for similar services. It found drive down primary care use. If that scenario materializes, significant variation, with commercial insurers paying forgone care and subsequent gaps in chronic disease between 140 percent of Medicare prices in Hawaii and 274 management will contribute to avoidable illness and higher percent in Oregon (Exhibit 5). Prices can vary for a number 14 non-COVID mortality.18 commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 8 Exhibit 5 Prices for hospital inpatient care paid by commercial insurers are higher Exhibit than for 5. Prices Medicare pricescare hospital inpatient in every paid bystate commercial insurers are higher than Medicare prices in every state Commercial prices for inpatient care as a percentage of Medicare prices 274% 275% 250% 225% 200% OF MEDICARE RATE 200% 175% 140% 150% 125% 100% Connecticut Vermont Oklahoma Michigan Colorado Massachusetts Missouri Rhode Island Illinois Arizona South Dakota Indiana Ohio Alabama Mississippi Kentucky New York Maine Washington Iowa Louisiana Idaho Wisconsin Wyoming Utah North Dakota Texas Kansas New Hampshire Oregon Pennsylvania New Jersey North Carolina West Virginia Virginia Arkansas Delaware Alaska Hawaii Georgia California New Mexico Nebraska Nev ada Montana Minnesota Tennessee Florida Note: Data not available for District of Columbia, Maryland, or South Carolina. Data: 2017 IBM Watson Health MarketScan Database and Medicare’s Healthcare Cost Report Information System (HCRIS); Michael E. Chernew, Andrew L. Hicks, and Shivani Exhibit A.Note: Shah, 6“Wide Data State-Level not available Variation for District in Commercial of Columbia, Maryland,Health Care or South Prices Suggests Uneven Impact of Price Regulation,” Health Affairs, published online May 4, 2020. Carolina. Higher premiums for employer coverage are associated with Data: 2017 IBM Watson Health MarketScan Database and Medicare’s Healthcare Cost Report Information System (HCRIS); Michael E. Chernew, Andrew L. Hicks, and Shivani A. Shah, “Wide State- Level Variation in Commercial Health Care Prices Suggests Uneven Impact of Price Regulation,” Health Affairs, published online May 4, 2020. higher Exhibit 6.commercial prices Higher premiums for health for employer care coverage services,with are associated 2017higher commercial Source: David C. Radley, Sara R. Collins, and Jesse C. Baumgartner, 2020 Scorecard on State Health System Performance (Commonwealth Fund, Sept. 2020). prices for health care services, 2017 $20,000 State values $19,000 State median AK Average premiums for employer coverage $18,000 WY NY MA NJ $17,000 WV CT IL DE MD CO $16,000 MO MI HI MN CA $15,000 TN OR MS MT AL ID $14,000 NV FL AR IA KY r = 0.59 UT $13,000 $12,000 $4,000 $6,000 $8,000 $10,000 $12,000 $14,000 $16,000 Average commercial prices paid for health care services (employer coverage) Notes: The x-axis and y-axis do not start at $0. State abbreviations left off some data points clustered near the U.S. average for legibility. Notes: The x-axis and y-axis do not start at $0. State abbreviations left off some data points clustered near the U.S. average for legibility. Data: Prices: 2017 IBM Watson Health MarketScan Database, analysis by Michael Chernew, Harvard Medical School. Premiums: Medical Expenditure Panel Survey– Data: Prices: 2017 IBM Watson Health MarketScan Database, analysis by Michael Chernew, Harvard Medical School. Premiums: Medical Expenditure Panel Survey–Insurance Component Insurance Component (MEPS-IC, 2017). (MEPS-IC, 2017). Source: David C. Radley, Sara R. Collins, and Jesse C. Baumgartner, 2020 Scorecard on State Health System Performance (Commonwealth Fund, Sept. 2020). commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 9 Exhibit 7 The percentage of total Medicare spending on primary care is low throughout Exhibit the U.S., but 7. The percentage it varies of total byspending Medicare more than 50 percent on primary across care is low states throughout the U.S., but it varies by more than 50 percent across states Percent of each state’s total Medicare spending on primary care 7.2% 8 6 4.8% 4 2 0 Connecticut Oklahoma Vermont Michigan Missouri Rhode Island Colorado Illinois Arizona South Dakota Indiana Ohio Alabama Mississippi New York Kentucky Massachusetts Maine South Carolina Louisiana Idaho Iowa Washington Wyoming Maryland Utah Texas New Hampshire North Dakota United States New Jersey Oregon Kansas District of Columbia Pennsylvania North Carolina West Virginia Wisconsin Virginia Delaware California Hawaii Alaska New Mexico Nebraska Georgia Nev ada Minnesota Montana Arkansas Florida Tennessee Data: Centers for Medicare and Medicaid Services, 2017 Limited Data Set (LDS) 5% sample. Analysis by Westat. Health Outcomes (Exhibit 10). In 2018, the U.S. reported its first significant Data: Centers for Medicare and Medicaid Services, 2017 Limited Data Set (LDS) 5% sample. Analysis by Westat. decline in drug overdose deaths in decades; however, Source: David C. Radley, Sara R. Collins, and Jesse C. Baumgartner, 2020 Scorecard on State Health System Performance (Commonwealth Fund, Sept. 2020). The COVID-19 pandemic has triggered a public health and the rate of synthetic opioid overdose deaths increased economic crisis at a time when American health outcomes another 10 percent. Ten states and the District of Columbia were already moving in the wrong direction. Decades-long attributed more than 20 deaths per 100,000 people to this gains in life expectancy reversed after 2014, and adults of all cause. Unfortunately, preliminary estimates from the races and ethnicities have been dying at increased rates.19 Centers for Disease Control and Prevention also show that These trends are likely to continue in the wake of more than drug overdose deaths jumped again in 2019, despite recent 185,000 COVID-19 deaths, and they may be exacerbated by federal support and state efforts (preliminary 2019 data not the deep decline in the use of health care services unrelated shown in Exhibit 8).21 to the disease and the greatest increase in unemployment Research indicates that higher local unemployment or since the Great Depression. economic shocks may be associated with increased overdose Deaths from suicide, alcohol, and drug deaths from opioids or other drugs, as well as poor mental overdose. Deaths from suicide, alcohol, and drug health.22 Experts have warned about potential consequences overdose have all climbed over the past few decades and from COVID-19 on so-called deaths of despair, and recent have been an important contributor to recent mortality reports indicate increases in overdose deaths in 2020.23 trends (Exhibit 8).20 These types of death differ significantly The 38 states that, along with the District of Columbia, have expanded their Medicaid programs are much better in terms of regional impact (Exhibit 9). prepared to address a pandemic-related rise in substance Opioids have been a critical driver, particularly since use. Studies have found that the ACA’s Medicaid expansion 2012, when the impact of synthetic opioids like fentanyl is associated with improvement in access to mental health expanded. Since then, synthetic opioid overdoses have care,24 greater access to medication-assisted treatment,25 and grown from 6 percent of all overdose deaths to nearly half fewer opioid-related overdose deaths and hospitalizations.26 commonwealthfund.org September 2020 2020 ExhibitScorecard 8 on State Health System Performance 10 Suicide and alcohol deaths rose modestly in 2018. Though drug overdoses Exhibit dropped 8. Suicide fordeaths and alcohol the first rosetime in decades, modestly preliminary in 2018. Though 2019dropped drug overdoses data shows for that the first they time have jumped in decades, back preliminary 2019 up data shows that they have jumped back up Age-adjusted deaths per 100,000 Cumulative percent increase 25 2005–2018 20.7 20 105% Drug overdose 15 14.2 30% 10.9 Suicide 10 10.1 41% 9.9 Alcohol 5 7.0 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Note: Preliminary 2019 drug overdose data from the CDC is not included in this exhibit (see text). Exhibit 9 Data: 2005–2018 National Vital Statistics System (NVSS), via CDC WONDER. Deaths from suicide, alcohol, and drug overdoses display Note: Preliminary 2019 drug overdose data from the CDC is not included in this exhibit (see text). significant regional variation Data: 2005–2018 National Vital Statistics System (NVSS), via CDC WONDER. Exhibit 9. Deaths Source: from suicide, David alcohol, C. Radley, Sara R. and Collins, and Jesse drug2020 C. Baumgartner, overdoses Scorecard on Statedisplay Health System significant regional Performance (Commonwealth Fund, Sept. 2020). variation Suicide Alcohol Drug overdose Age-adjusted deaths per 100,000 Age-adjusted deaths per 100,000 Age-adjusted deaths per 100,000 7.5–13.7 (14 states) 5.7–7.8 (14 states) 6.9–14.3 (14 states) 13.8–19.3 (24 states) 8.6–13.0 (23 states) 14.6–27.5 (24 states) 19.4–25.2 (12 states) 13.6–32.7 (13 states) 27.9–51.5 (12 states) Note: District of Columbia not included in legend counts. Note: District Data: 2018 of National Columbia Vital not included in legend Statistics Systemcounts. (NVSS), via CDC WONDER. Data: 2018 National Vital Statistics System (NVSS), via CDC WONDER. Source: David C. Radley, Sara R. Collins, and Jesse C. Baumgartner, 2020 Scorecard on State Health System Performance (Commonwealth Fund, Sept. 2020). commonwealthfund.org September 2020 2020 Scorecard Exhibit 10 on State Health System Performance 11 Opioids contributed heavily to the overall rise in overdose deaths between 2009contributed Exhibit 10. Opioids and 2018, largely heavily due to the to rise overall synthetic opioids in overdose deaths between 2009 and 2018, largely due to synthetic opioids Share of drug overdose deaths due to opioids 25 55% 71% 20 Age-adjusted deaths per 100,000 15 10 All drug overdose deaths All opioid overdose deaths 5 Synthetic opioid overdose deaths 0 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Note: Data categories are overlaid, not stacked/aggregated; synthetic opioid deaths are from synthetic opioids other than methadone. Data:Data Note: 2009–2018 categoriesNational Vitalnot are overlaid, Statistics System (NVSS), stacked/aggregated; via CDC synthetic WONDER. opioid deaths are from synthetic opioids other than methadone. Data: 2009–2018 National Vital Statistics System (NVSS), via CDC WONDER. Premature deaths from treatable Source: David C. Radley, Saraconditions. of these R. Collins, and Jesse C. Baumgartner, conditions, 2020 Scorecard several on State Health of which System are(Commonwealth Performance key risk factors Fund, Sept. 2020). Americans can expect to live a shorter life today than they for COVID-19.30 Significant racial disparities in mortality did in 2014.27 A number of factors contribute to this decline, amenable to health care exist in nearly every state (Exhibit including deaths from suicide, alcohol, and drug overdose, 12). The pandemic threatens to exacerbate these trends but another is premature deaths from health care–treatable even further through the disruption of primary care and conditions — also known as mortality amenable to health other critical health services. Early data suggest elevated care. The Scorecard tracks deaths before age 75 from acute mortality from non-COVID-19 causes.31 and chronic causes that are considered treatable when they Public health investment. States are navigating are identified early and well managed; examples include unprecedented public health threats from COVID-19, as appendicitis, certain cancers, heart disease, and diabetes, well as economic disruptions that have shrunk the tax among others. Higher mortality rates in these categories revenues used to fund critical health and social services. But point to deficiencies in the health system. historically, most states have made only modest investments Between 2012–2013 and 2016–2017, these mortality in their public health systems. Between 2014–2015 and rates either increased slightly or were unchanged in 37 2017–2018, per capita public health spending was flat in states.28 Oklahoma, Arkansas, New Mexico, Kentucky, and most states, and increases were modest in the states where Mississippi saw the biggest rise in premature deaths. States funding did rise (Exhibit 13). with the highest premature death rates also have lower life Not only is public health funding low relative to other health expectancies (Exhibit 11), and recent research linked life care spending, but public health dollars are stretched thin. expectancy disparities to specific state policy choices.29 Competing for funding are various initiatives for emergency Black Americans, who have suffered disproportionately preparedness, disease prevention, promoting healthy from the pandemic, are much more likely to die from some behaviors, and, increasingly, fighting the opioid epidemic.32 commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 12 Exhibit 11 Premature deaths from treatable conditions are closely linked to the wide Exhibit variation 11. Premature in state deaths life expectancy from treatable conditions are closely linked to the wide variation in state life expectancy Life expectancy Mortality amenable to health care (years) (deaths per 100,000) 84 160 82 140 120 80 100 78 80 76 60 74 40 72 20 70 0 Kansas Montana North Carolina Arkansas New Mexico Delaware Colorado Maine Wisconsin Florida Missouri Idaho Nebraska California Hawaii Mississippi Michigan Virginia Illinois Alabama Pennsylvania West Virginia Texas New Hampshire Vermont Georgia South Dakota Nevada North Dakota Ohio Washington New Jersey Louisiana Maryland Wyoming Arizona Minnesota Oklahoma Indiana South Carolina Tennessee Rhode Island Kentucky Massachusetts Connecticut New York Alaska Iowa Utah Oregon Data: Life Expectancy: United States Mortality Database, University of California, Berkeley; available at usa.mortality.org (data shown on 2020-05-11 12:22:03). Mortality Amenable to Health Care: Centers for Disease Control and Prevention, 2016 and 2017 National Vital Statistics System (NVSS), All-County Micro Data, Data: Life Expectancy: Restricted United States Mortality Database, University of California, Berkeley; available at usa.mortality.org (data shown on 2020-05-11 12:22:03). Use Files. ExhibitAmenable Mortality 12 to Health Care: Centers for Disease Control and Prevention, 2016 and 2017 National Vital Statistics System (NVSS), All-County Micro Data, Restricted Use Files. In every state, Black people are more likely to die early from Source: David C. Radley, Sara R. Collins, and Jesse C. Baumgartner, 2020 Scorecard on State Health System Performance (Commonwealth Fund, Sept. 2020). Exhibit 12. In every state, Black people are more likely to die early from treatable conditions, treatable conditions, 2016–17 2016–17 Mortality amenable to health care: deaths per 100,000 population 200 Black White 150 100 50 0 Connecticut Alabama Oklahoma South Carolina Michigan Maine Massachusetts Colorado Missouri Rhode Island Illinois Louisiana Arizona South Dakota Indiana Ohio Kentucky Mississippi New Hampshire Oregon New York Pennsylvania Washington Iowa Wisconsin Maryland Utah Texas North Dakota Kansas New Jersey District of Columbia North Carolina West Virginia Hawaii Alaska New Mexico Georgia Virginia Arkansas Tennessee Delaware Florida California Nebraska Nev ada Minnesota Notes: Data for Black individuals not available for Idaho, Montana, Vermont, or Wyoming. States arranged in rank order based on Black mortality rates. Data: Notes:CDC Data 2016 and for Black 2017 National individuals Vitalfor not available Statistics System Idaho, Montana, (NVSS),orAll-County Vermont, Micro Wyoming. States Data, Restricted arranged in rank order Use basedFiles. on Black mortality rates. Data: CDC 2016 and 2017 National Vital Statistics System (NVSS), All-County Micro Data, Restricted Use Files. commonwealthfund.org September 2020 Source: David C. Radley, Sara R. Collins, and Jesse C. Baumgartner, 2020 Scorecard on State Health System Performance (Commonwealth Fund, Sept. 2020). 2020 Scorecard on State Health System Performance 13 Exhibit 13 Most states Exhibit 13. Mosthave seenseen states have modest modestchanges changes in in perper capita capita public public health health spending in spending recent years in recent years Per capita state-based public health spending 160 2017–2018 140 2014–2015 120 100 80 60 40 20 0 District of… Connecticut Oklahoma Vermont Michigan Colorado Massachusetts Missouri Rhode Island Illinois Arizona Indiana South Dakota Alabama Ohio Mississippi New Hampshire Kentucky South Carolina Maine New York Louisiana Washington Iowa Idaho Wisconsin Maryland Wyoming Utah Texas North Dakota Kansas Oregon Pennsylvania New Jersey North Carolina West Virginia Virginia Arkansas Delaware Alaska Hawaii Georgia California Nebraska New Mexico Nev ada Minnesota Montana Florida Tennessee Notes: Estimates here include only state-based funding; federal public health funds are not included. Notes: Estimates here include only state-based funding; federal public health funds are not included. Data: 2017–2018 estimates: Trust for America’s Health, The Impact of Chronic Underfunding on America’s Public Health System: Trends, Risks, and Data: 2017–2018 estimates: Trust for America’s Health, The Impact of Chronic Underfunding on America’s Public Health System: Trends, Risks, and Recommendations, 2019 (TFAH, Apr. 2019); Recommendations, 2019 (TFAH, Apr. 2019); 2014–2015 estimates: Trust for America’s Health, Investing in America’s Health: A State-by-State Look at Public Health 2014–2015 estimates: Trust for America’s Health, Investing in America’s Health: A State-by-State Look at Public Health Funding and Key Health Facts (TFAH, Apr. 2016). Funding and Key Health Facts (TFAH, Apr. 2016). Source: David C. Radley, Sara R. Collins, and Jesse C. Baumgartner, 2020 Scorecard on State Health System Performance (Commonwealth Fund, Sept. 2020). commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 14 Conclusion National gains if all The 2020 Scorecard offers the latest available federal data on the state of the states achieved top U.S. health system before it headed into the most severe public health crisis and rates* of performance: economic collapse in modern times. It also highlights health system weaknesses that have left the U.S. far less prepared than other high-income countries to cope with public health threats like COVID-19. These weaknesses include: 18 million more adults and • a health care delivery system that is highly unequal in its care of people of children insured, color and those with low and moderate incomes. beyond those who • an insurance system that still leaves millions without coverage. already gained coverage • exorbitant commercial insurance prices that fuel growth in health spending through the ACA and expose people to high premiums and deductibles, even as many make 14 million wage concessions to keep their employer benefits. • an inadequate primary care system. fewer adults skipping • declining life expectancy. care because of its cost Some regions lag even further. The Scorecard also highlights the fact that the U.S. health system is characterized by considerable geographic variation in each of these areas. Some regions of the U.S. not only lag other regions on health 24 million performance indicators, but they also lag other economically advanced countries more adults with a usual even further than national averages suggest. source of care For example, uninsured rates ranged from 4 percent of the adult population in the District of Columbia and Massachusetts to a high of 24 percent in Texas. These differences reflect demographic differences and U.S. immigration policy, but also 11 million political choices in the implementation of federal law. If states continue to be left more adults receiving to address the coronavirus pandemic with little federal leadership, performance recommended cancer gaps will only widen as the health and economic crises persist. screenings A looming court decision could further disrupt the health system. Moreover, looming on the U.S. Supreme Court’s 2020–2021 docket is California v. Texas (originally Texas v. Azar), in which a group of Republican-led states, with 632,000 more young support from the Trump administration, is seeking to declare the entirety of the Affordable Care Act unconstitutional. Given the increased reliance of Americans children receiving all on Medicaid and the marketplaces in the wake of job-based coverage losses over recommended vaccines the past six months, a decision by the Supreme Court to overturn the law could result in more than 50 million uninsured people. * Performance benchmarks set at the level achieved by the top- Because the ACA touches nearly every corner of the health system — not just performing state with available coverage — such a decision also would trigger severe disruptions throughout a data for this indicator. health system already severely compromised by the pandemic. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 15 Daunting tasks for the federal government in 2021. The presidential election is just two months away. The federal government will face the National gains if all daunting task of both controlling the pandemic and rebuilding a health system states achieved top that had already been underperforming and unequal. The collection and analysis of new data on the effects of the pandemic will be critical to the ability rates* of performance: of federal and state governments to craft evidence-based policy to move the health system forward and bring lagging states closer to the front of the pack. 9 million We have amassed the most recent federal data as a baseline, but they are more children would egregiously lagged. Timely data are needed in the critical areas of insurance receive recommended coverage, racial and ethnic inequity in access and care, causes of mortality and annual medical and life expectancy, provider performance during the pandemic, and more. And this information is needed quickly. dental visits 1 million** fewer hospital readmissions 10 million** fewer emergency department visits for nonemergency care or conditions treatable with primary care 91,000 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. ** E stimate based on working-age population, ages 18–64, with employer-sponsored insurance, and Medicare beneficiaries age 65 and older. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 16 SCORECARD METHODS The Commonwealth Fund’s 2020 Scorecard on State Health System Performance evaluates states on 49 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 receipt of dental visits. • Prevention and Treatment (15 indicators): includes measures of receipt of 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 (14 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 (13 indicators): includes measures of premature death, health status, health risk behaviors (including smoking and obesity), tooth loss, and state public health funding. INCOME DISPARITY DIMENSION. This year, the We’ve included racial and ethnic differences in Scorecard reports on performance differences 10 of the 49 indicators where data are available within states associated with individuals’ to support a population analysis by race and/ income level for 11 of the 49 indicators where or ethnicity; these indicators span three of the data are available to support a population four dimensions. Rates for all available races analysis by income; these indicators span three and ethnicities can be found in Appendix H1. of the four dimensions. For each indicator, GUIDING PRINCIPLES. The following principles we measure the difference between rates for guided the development of the Scorecard: a state’s low-income population (generally under 200% of the federal poverty level) and Performance Metrics. The 49 metrics higher-income population (generally more selected for this report span health care than 400% of the federal poverty level). States system performance, representing important are ranked on the relative magnitude of the dimensions and measurable aspects of resulting disparities in performance. care. Where possible, indicators align with those used in previous state Scorecards. The income disparity indicators are different Several indicators used in previous versions than those used in the 2019 Scorecard; hence, of the Scorecard have been dropped either these disparity rankings are not strictly because all states improved to the point comparable to those published previously. where no meaningful variations existed (for RACE EQUITY DATA. This year, the Scorecard example, measures that assessed hospitals includes racial and ethnic equity data based on processes of care) or the data to construct on within-state differences between racial and the measures were no longer available (for ethnic communities. These data are included example, hospitalizations for children with for informational purposes but are not ranked. asthma). New indicators have been added to commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 17 the Scorecard series over time in response to score. Ranks are assigned based on the overall evolving priorities. Refer to “About the 2020 score. This approach gives each dimension State Scorecard” for more detail on changes in equal weight and, within each dimension, it indicators. weights all indicators equally. This method was introduced in the 2018 Scorecard, and Measuring Change over Time. We were able to it better accommodates the different scales track performance over time for 43 of the 49 used across Scorecard indicators (for example, indicators. Not all indicators could be trended percentages, dollars, and population- because of changes in the underlying data or based rates). This method also aligns with measure definitions. methods used in the Commonwealth Fund’s There were generally five years between international health system rankings. indicators’ baseline and current-year data As in previous Scorecards, if historical data observation, though the starting and ending were not available for a particular indicator in points depended on data availability (see the baseline period, the current-year data point Appendix A1). was used as a substitute, thus ensuring that We considered a change in an indicator’s value ranks in each time period were based on the between the baseline and current-year data same number of indicators. points to be meaningful if it was at least one- REGIONAL COMPARISONS. The Scorecard half (0.5) of a standard deviation larger than groups states into the eight regions used by the indicator’s combined distribution over the the Bureau of Economic Analysis to measure two time points — a common approach used and compare economic activity. The regions in social science research. We did not formally are: Great Lakes (Illinois, Indiana, Michigan, evaluate change over time for indicators in the Ohio, Wisconsin); Mid-Atlantic (Delaware, income dimension. District of Columbia, Maryland, New Jersey, Data Sources. Indicators draw from publicly New York, Pennsylvania); New England available data sources, including government- (Connecticut, Maine, Massachusetts, New sponsored surveys, registries, publicly reported Hampshire, Rhode Island, Vermont); Plains quality indicators, vital statistics, mortality (Iowa, Kansas, Minnesota, Missouri, Nebraska, data, and administrative databases. The most North Dakota, South Dakota); Rocky Mountain current data available were used in this report (Colorado, Idaho, Montana, Utah, Wyoming); whenever possible. Appendix A1 provides Southeast (Alabama, Arkansas, Florida, detail on the data sources and time frames. Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Scoring and Ranking Methodology. For each Virginia, West Virginia); Southwest (Arizona, indicator, a state’s standardized z-score is New Mexico, Oklahoma, Texas); and West calculated by subtracting the 51-state average (Alaska, California, Hawaii, Nevada, Oregon, (including the District of Columbia as if it were Washington). a state) from the state’s observed rate, and then dividing by the standard deviation of all observed state rates. States’ standardized z-scores are averaged across all indicators within the performance dimension, and dimension scores are averaged into an overall commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 18 2020 State Rankings on Health System Performance Which states lead the overall rankings? What are the leading states by region? (See Scorecard Methods for states in each region) Hawaii, Massachusetts, Minnesota, Iowa, and Connecticut Great Lakes Wisconsin Mid-Atlantic New York Which states are ranked at the bottom? New England Massachusetts West Virginia, Missouri, Nevada, Oklahoma, Plains Minnesota and Mississippi Rocky Mountain Colorado Southeast Virginia Southwest New Mexico West Hawaii Exhibit 14 Overall health Overall health system system performance performance (Prior to COVID-19) (prior to COVID-19) Better performance 1.1 0.9 HI 0.7 MA MN IA CT 0.5 CO VT WA UT NY 0.3 NH WI ND MD RI DC NJ MT CA NE ID PA OR 0.1 DE IL VA MI OH SD U.S. AVERAGE NM ME AK AZ KS -0.1 WY NC -0.3 SC IN KY AL FL -0.5 AR TX LA TN GA WV MO NV -0.7 OK -0.9 MS Worse performance -1.1 Note: States are arranged in rank order from left (best) to right (worst), based on their overall 2020 Scorecard rank. The 2020 Scorecard rank reflects data generally from 2018, prior to the COVID- 19Note: States are arranged in rank order from left (best) to right (worst), based on their overall 2020 Scorecard rank. The 2020 Scorecard rank reflects data pandemic. generally from 2018, prior to the COVID-19 pandemic. Source: David C. Radley, Sara R. Collins, and Jesse C. Baumgartner, 2020 Scorecard on State Health System Performance (Commonwealth Fund, Sept. 2020). commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 19 Exhibit 15 Moreimprovement More improvementthanthandecline: decline: Florida, Florida, Kentucky, Kentucky, Louisiana, Louisiana,and andVirginia Virginia improved improved most, with with gains on on 17 17 indicators indicatorsbetween between2014 2014and and2018, 2018,prior priorto toCOVID-19 COVID-19 MOST IMPROVED Improved over five-year period 17 Worsened over five-year period INDICATORS IMPROVED FL LA VA KY AZ AR MS MO WV NM MD IN WA PA DC TN NJ MT MI NY HI RI NV NH UT CA CO KS NE OH CT ND IL OR IA AL SC ID DE GA 8 NC VT MN AK SD MA ME TX WY OK WI INDICATORS WORSENED 12 16 Notes: Based Notes: Based on five-year on five-year trends trends for 43 offor 43 of 49 total 49 total(disparity indicators indicators (disparity dimension dimension not included), notreflecting generally included), 2014generally reflecting to 2018, prior 2014 to COVID-19 to 2018, pandemic; prior trend datatoareCOVID-19 not available for all pandemic; indicators. Bartrend length data equalsare thenot totalavailable number of for all indicators. indicators Bar lengthorequals with any improvement thewith worsening total numbervalue an absolute of indicators greater thanwith any improvement 0.5 standard or worsening deviations (StDev) with an of the state distribution. absolute value greater than 0.5 standard deviations (StDev) of the state distribution. Source: David C. Radley, Sara R. Collins, and Jesse C. Baumgartner, 2020 Scorecard on State Health System Performance (Commonwealth Fund, Sept. 2020). Which states moved up the most in the Which states improved on the most indicators? rankings between 2014 and 2018, and which Florida, Kentucky, Louisiana, and Virginia states dropped? each improved on 17 of 43 indicators we track The District of Columbia had the largest jump over time, although Louisiana had a larger net in rankings, up 13 spots. New York gained gain, having gotten worse on fewer indicators 10 spots in the rankings and New Jersey rose (seven indicators) than Florida and Virginia nine spots. (12 indicators). Five states (Arizona, Arkansas, Mississippi, Missouri, and West Virginia) each South Dakota fell 19 spots in the rankings, improved on 16 indicators. while Wyoming and Maine fell 12 and 17 spots, respectively. Fourteen states got worse on more indicators than they improved on. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 20 NOTES 1. Jessica Banthin et al., Changes in Health Insurance 9. Sara R. Collins et al., An Early Look at the Potential Im- Coverage Due to the COVID-19 Recession: Preliminary plications of the COVID-19 Pandemic for Health Insur- Estimates Using Microsimulation (Urban Institute, July ance Coverage (Commonwealth Fund, June 2020). 2020). 10. Robin A. Cohen et al., Health Insurance Coverage: 2. Voters in Oklahoma and Missouri passed Medicaid Early Release of Estimates from the National Health expansion by ballot in June and August of 2020; the Interview Survey, 2019 (National Center for Health states are expected to implement expansion by the Statistics, Sept. 2020). summer of 2021. 11.CBO, Federal Subsidies, 2019. 3. Ateev Mehrotra et al., The Impact of the COVID-19 12. Michael E. Chernew, “How to Read National Health Pandemic on Outpatient Visits: Changing Patterns Expenditure Projections in Light of COVID-19: of Care in the Newest COVID-19 Hot Spots Uncertain Long-Run Effects, but Challenges for All,” (Commonwealth Fund, Aug. 2020). Health Affairs Blog, Apr. 20, 2020. 4. Congressional Budget Office, Federal Subsidies for 13. Health Care Cost Institute, 2018 Health Care Cost and Health Insurance Coverage for People Under Age 65: Utilization Report (HCCI, Feb. 2020). 2019 to 2029 (CBO, May 2019). 14. Michael E. Chernew, Andrew L. Hicks, and Shivani 5. Sherry A. Glied, Sara R. Collins, and Saunders Lin, “Did A. Shah, “Wide State-Level Variation in Commercial the Affordable Care Act Lower Americans’ Financial Health Care Prices Suggests Uneven Impact of Price Barriers to Health Care?,” Health Affairs 39, no. 3 (Mar. Regulation,” Health Affairs 39, no. 5 (May 4, 2020): 2020): 379–86. 791–99. 6. Jesse C. Baumgartner et al., How the Affordable Care 15. Christopher F. Koller, “Health Care Costs — Mapping Act Has Narrowed Racial and Ethnic Disparities in the Forest and Finding a Path,” President’s Blog, Access to Health Care (Commonwealth Fund, Jan. Milbank Memorial Fund, Feb. 21, 2019. 2020); Ajay Chaudry, Adlan Jackson, and Sherry A. Glied, Did the Affordable Care Act Reduce Racial and 16. Mehrotra et al., Impact of COVID-19, 2020. Ethnic Disparities in Health Insurance Coverage? (Commonwealth Fund, Aug. 2019); and Sara R. Collins, 17. OECD is the Organisation for Economic Co-operation Munira Z. Gunja, and Gabriella N. Aboulafia, U.S. and Development. See Christopher F. Koller and Dhruv Health Insurance Coverage in 2020: A Looming Crisis Khullar, “Primary Care Spending Rate — A Lever in Affordability — Findings from the Commonwealth for Encouraging Investment in Primary Care,” New Fund Biennial Health Insurance Survey, 2020 England Journal of Medicine 377, no. 18 (Nov. 2, 2017): (Commonwealth Fund, Aug. 2020). 1709–11. 7. U.S. Bureau of Labor Statistics, “Unemployment 18. Primary Care Collaborative, “Primary Care & Insurance Weekly Clams,” news release, Sept. 3, 2020. COVID-19: Week 8 Survey,” PCC, May 6, 2020. 8. U.S. Bureau of Labor Statistics, “Employment Situation 19. Steven H. Woolf and Heidi Schoomaker, “Life Summary,” news release, Sept. 4, 2020; and U.S. Expectancy and Mortality Rates in the United States, Bureau of Labor Statistics, “State Employment and 1959–2017,” JAMA 322, no. 20 (Nov. 26, 2019): 1996– Unemployment — July 2020,” news release, Aug. 21, 2016. 2020. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 21 20. Anne Case and Angus Deaton, Deaths of Despair and 25. Hefei Wen et al., “Impact of Medicaid Expansion on the Future of Capitalism (Princeton University Press, Medicaid-Covered Utilization of Buprenorphine for 2020). Opioid Use Disorder Treatment,” Medical Care 55, no. 4 (Apr. 2017): 336–41. 21. Farida B. Ahmad, Lauren M. Rossen, and Paul Sutton, Provisional Drug Overdose Death Counts (National 26. Nicole Kravitz-Wirtz et al., “Association of Medicaid Center for Health Statistics, 2020). Expansion with Opioid Overdose Mortality in the United States,” JAMA Network Open 3, no. 1 (Jan. 22. Christopher J. Ruhm, “Recessions, Healthy No More?,” 2020): e1919066; and Hefei Wen et al., “Association Journal of Health Economics 42 (July 2015): 17–28; Erin C. Between Medicaid Expansion and Rates of Opioid- Strumpf et al., “Did the Great Recession Affect Mortality Related Hospital Use,” JAMA Internal Medicine 180, no. Rates in the Metropolitan United States? Effects on 5 (Mar. 23, 2020): 753–59. Mortality by Age, Gender and Cause of Death,” Social Science and Medicine 189 (Sept. 2017): 11–16; Atheendar 27. Kenneth D. Kochanek, Robert N. Anderson, and S. Venkataramani et al., “Association Between Elizabeth Arias, “Changes in Life Expectancy at Birth, Automotive Assembly Plant Closures and Opioid 2010–2018,” NCHS E-Stat, National Center for Health Overdose Mortality in the United States: A Difference- Statistics, updated Jan. 30, 2020. in-Differences Analysis,” JAMA Internal Medicine 180, 28. Only Oklahoma had a change that exceeded + or – no. 2 (Dec. 2019): 254–62; Kathleen A. Cagney et al., 0.5 standard deviations to meet our definition of “The Onset of Depression During the Great Recession: “meaningful change” during this period. Foreclosure and Older Adult Mental Health,” American Journal of Public Health 104, no. 3 (Mar. 2014): 498–505; 29. Jennifer Karas Montez et al., “U.S. State Policies, Politics, Alex Hollingsworth, Christopher J. Ruhm, and Kosali and Life Expectancy,” Milbank Quarterly, published Simon, “Macroeconomic Conditions and Opioid online Aug. 4, 2020. Abuse,” Working Paper 23192 (National Bureau of Economic Research, March 2017). 30. David C. Radley, “Diving into the Data: How Many Americans Die Prematurely from Treatable Causes?,” 23. Douglas Belkin, “Nation’s Top Mental-Health Official To the Point (blog), Commonwealth Fund, Aug. 6, 2019. Warns Against a Second Coronavirus Lockdown,” Wall Street Journal, May 21, 2020; Stephen Petterson, John 31. Reis Thebault et al., “Heart Conditions Drove Spike M. Westfall, and Benjamin F. Miller, Projected Deaths in Deaths Beyond Those Attributed to COVID-19, of Despair During the Coronavirus Recession (Well Analysis Shows,” Washington Post, July 2, 2020. Being Trust, May 2020); Brianna Ehley, “Pandemic 32. Trust for America’s Health, The Impact of Chronic Unleashes a Spike in Overdose Deaths,” Politico, Underfunding on America’s Public Health System: updated July 2, 2020; and Jesse C. Baumgartner, Trends, Risks, and Recommendations (TFAH, Apr. 2020). Gabriella N. Aboulafia, and Sara R. Collins, “The Implications of COVID-19 for Opioid-Related Mortality,” To the Point (blog), Commonwealth Fund, Aug. 28, 2020. 24. Jesse C. Baumgartner, Gabriella N. Aboulafia, and Audrey McIntosh, “The ACA at 10: How Has It Impacted Mental Health Care?,” To the Point (blog), Commonwealth Fund, Apr. 3, 2020. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 22 ABOUT THE AUTHORS ACKNOWLEDGMENTS David C. Radley, Ph.D., M.P.H., is senior scientist for We owe our sincere appreciation to all of the researchers the Commonwealth Fund’s Tracking Health System who developed indicators and conducted data analyses Performance initiative, working on the Scorecard for this scorecard. These include: Michael E. Chernew, project. Dr. Radley and his team develop national, state, Ph.D., and Andrew Hicks, Department of Health Care and substate regional analyses on health care system Policy, Harvard Medical School; Sherry Glied, Ph.D., performance and related insurance and care system and Ougni Chakraborty, New York University Robert F. market structure analyses. He is also a senior study Wagner Graduate School of Public Service; Ashish Jha, director at Westat, a research firm that supports the M.D., M.P.H., and Jie Zheng, Ph.D., Harvard School of Public Scorecard project. Previously, he was associate in domestic Health; Vincent Mor, Ph.D., Emily Gadbois, Ph.D., Brown health policy for Abt Associates, with responsibility for a University; and Angelina Lee and Kevin Neipp, Westat. We number of projects related to measuring long-term care acknowledge Mental Health America for data reported quality and evaluating health information technology in The State of Mental Health in America and Trust for initiatives. Dr. Radley received his Ph.D. in health America’s Health for data reported in The Impact of policy from the Dartmouth Institute for Health Policy Chronic Underfunding on America’s Public Health System. and Clinical Practice, and holds a B.A. from Syracuse We also would like to thank the following Commonwealth University and an M.P.H. from Yale University. Fund staff: David Blumenthal, M.D., Eric Schneider, M.D., Sara R. Collins, Ph.D., is vice president for Health Care Elizabeth Fowler, Melinda Abrams, and Rachel Nuzum Coverage and Access at the Commonwealth Fund. An for providing constructive guidance throughout; and the economist, Dr. Collins directs the Fund’s program on Fund’s communications and support teams, including insurance coverage and access. She also directs the Barry Scholl, Chris Hollander, Deborah Lorber, Bethanne Fund’s research initiative on Tracking Health System Fox, Josh Tallman, Jen Wilson, Paul Frame, Naomi Performance. Since joining the Fund in 2002, Dr. Collins Leibowitz, Samantha Chase, Gabriella Aboulafia, and has led several national surveys on health insurance and Munira Gunja for their guidance, editorial and production authored numerous reports, issue briefs, and journal support, and public dissemination efforts. articles on health insurance coverage and policy. She has Finally, the authors wish to acknowledge Caroline Broder provided invited testimony before several Congressional and Maya Brod of Burness Communications for their committees and subcommittees. Prior to joining the Fund, assistance with media outreach, and Westat for its support Dr. Collins was associate director/senior research associate of the research unit, which enabled the analysis and at the New York Academy of Medicine. Earlier in her development of the scorecard report. career, she was an associate editor at U.S. News & World Report, a senior economist at Health Economics Research, and a senior health policy analyst in the New York City Editorial support was provided by Maggie Van Dyke. Office of the Public Advocate. Dr. Collins holds a Ph.D. in economics from George Washington University. Jesse C. Baumgartner is a research associate in the For more information about this report, please contact: Health Care Coverage, Access, and Tracking program at David C. Radley, Ph.D., M.P.H. the Commonwewalth Fund. Before joining the Fund, he Senior Scientist, Westat and the Commonwealth Fund worked as a technology development/licensing manager Health System Scorecard Project at Memorial Sloan Kettering Cancer Center, a life sciences drcmwf.org consultant at Stern Investor Relations, and earlier in his career as a reporter for the Lewiston Tribune in Idaho. Mr. Baumgartner earned his B.A. in journalism and history from the University of North Carolina at Chapel Hill, where he was elected Phi Beta Kappa, and is currently pursuing his M.P.H. at the CUNY Graduate School of Public Health and Health Policy. He is also a CFA® charterholder. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 23 APPENDIX A1. State Appendix A1. State Scorecard Scorecard Data Years Data Years and Databases and Databases Indicator Past year Current year Database Access and Affordability 1 Uninsured adults 2014 2018 American Community Survey, Public Use Microdata Sample (ACS PUMS) 2 Uninsured children 2014 2018 American Community Survey, Public Use Microdata Sample (ACS PUMS) 3 Adults without a usual source of care 2014 2018 Behavioral Risk Factor Surveillance System (BRFSS) 4 Adults who went without care because of cost 2014 2018 Behavioral Risk Factor Surveillance System (BRFSS) 5 High out-of-pocket medical spending — 2017–18 Current Population Survey Annual Social and Economic Supplement (CPS ASEC) 6 Employee insurance costs as a share of median income 2014 2018 Medical Expenditure Panel Survey Insurance Component (MEPS-IC) 7 Adults without a dental visit 2014 2018 Behavioral Risk Factor Surveillance System (BRFSS) Prevention and Treatment 8 Adults without all recommended cancer screenings 2014 2018 Behavioral Risk Factor Surveillance System (BRFSS) 9 Adults without all recommended vaccines 2014 2018 Behavioral Risk Factor Surveillance System (BRFSS) 10 Diabetic adults without an annual hemoglobin A1c test 2015 2017 IBM Watson Health MarketScan Database 11 Elderly patients who received a high-risk prescription drug — 2016 Medicare Part D Claims 12 Children without a medical home 2016 2018 National Survey of Children’s Health (NSCH) 13 Children without a medical and dental preventive care visit — 2018 National Survey of Children’s Health (NSCH) 14 Children who did not receive needed mental health care 2016 2018 National Survey of Children’s Health (NSCH) 15 Children without all recommended vaccines 2014 2018 National Immunization Survey (NIS) 16 Hospital 30-day mortality 07/2011 – 06/2014 07/2015 – 06/2018 CMS Hospital Compare 17 Central line-associated blood stream infection (CLABSI) 2015 2018 CDC Healthcare-Associated Infections (HAI) Progress Report 18 Hospitals with lower-than-average patient experience ratings — 2018 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), via CMS Hospital Compare 19 Home health patients without improved mobility 2014 2018 Outcome and Assessment Information Set (OASIS), via CMS home Health Compare 20 Nursing home residents with an antipsychotic medication 2013 2017 Minimum Dataset (MDS), via CMS Nursing Home Compare 21 Adults with any mental illness reporting unmet need 2012–14 2016–17 National Survey on Drug Use and Health (NSDUH), via State of Mental Health in America 22 Adults with any mental illness who did not receive treatment 2012–14 2016–17 National Survey on Drug Use and Health (NSDUH), via State of Mental Health in America Avoidable Hospital Use and Cost Potentially avoidable emergency department visits 23 Ages 18–64, per 1,000 employer-insured enrollees 2015 2017 IBM Watson Health MarketScan Database 24 Age 65 and older, per 1,000 Medicare beneficiaries 2013 2016 Chronic Conditions Data Warehouse (CCW), via CMS Geographic Variation Public Use File Admissions for ambulatory care–sensitive conditions 25 Ages 18–64, per 1,000 employer-insured enrollees 2015 2017 IBM Watson Health MarketScan Database 26 Age 65 and older, per 1,000 Medicare beneficiaries 2014 2018 Chronic Conditions Data Warehouse (CCW), via CMS Geographic Variation Public Use File 30-day hospital readmissions 27 Ages 18–64, per 1,000 employer-insured enrollees 2015 2017 IBM Watson Health MarketScan Database 28 Age 65 and older, per 1,000 Medicare beneficiaries 2014 2018 Chronic Conditions Data Warehouse (CCW), via CMS Geographic Variation Public Use File 29 Skilled nursing facility patients with a hospital readmission 2012 2016 Residential History File 30 Nursing home residents with a hospital admission 2012 2016 Residential History File 31 Home health patients with a hospital admission 2014 2018 Medicare Claims, via CMS Home Health Compare 32 Adults with inappropriate lower back imaging 2015 2017 IBM Watson Health MarketScan Database 33 Employer-sponsored insurance spending per enrollee 2013 2017 IBM Watson Health MarketScan Database 34 Medicare spending per beneficiary 2014 2018 Chronic Conditions Data Warehouse (CCW), via CMS Geographic Variation Public Use File Primary care as a share of total medical spending 35 Ages 18–64, employer-insured enrollees — 2018 IBM Watson Health MarketScan Database 36 Age 65 and older, Medicare beneficiaries — 2017 CMS Limited Data Set (LDS) Healthy Lives 37 Mortality amenable to health care 2012–13 2016–17 CDC National Vital Statistics System (NVSS): Restricted Use Mortality Microdata 38 Breast cancer deaths 2014 2018 CDC National Vital Statistics System (NVSS): WONDER 39 Colorectal cancer deaths 2014 2018 CDC National Vital Statistics System (NVSS): WONDER 40 Suicide deaths 2014 2018 CDC National Vital Statistics System (NVSS): WONDER 41 Alcohol deaths 2014 2018 CDC National Vital Statistics System (NVSS): WONDER 42 Drug poisoning deaths 2014 2018 CDC National Vital Statistics System (NVSS): WONDER 43 Infant mortality 2013 2017 CDC National Vital Statistics System (NVSS): WONDER 44 Adults who report fair or poor health 2014 2018 Behavioral Risk Factor Surveillance System (BRFSS) 45 Adults who smoke 2014 2018 Behavioral Risk Factor Surveillance System (BRFSS) 46 Adults who are obese 2014 2018 Behavioral Risk Factor Surveillance System (BRFSS) 47 Children who are overweight or obese 2016 2018 National Survey of Children’s Health (NSCH) 48 Adults who have lost six or more teeth 2014 2018 Behavioral Risk Factor Surveillance System (BRFSS) 49 Public health funding 2014/15 2017/18 Trust for America’s Health (TFAH) 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. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 24 APPENDIX Appendix A2.A2. ListList of Indicators of Indicators in the in the State State Scorecard Scorecard on State on Health System Health System Performance Performance Data years represented U.S. average rate Range of state performance Indicator Baseline 2020 Scorecard Baseline 2020 Scorecard Baseline 2020 Scorecard Access and Affordability 1 Uninsured adults 2014 2018 16% 12% 5–26 4–24 2 Uninsured children 2014 2018 6% 5% 2–12 1–11 3 Adults without a usual source of care 2014 2018 23% 23% 11–35 13–37 4 Adults who went without care because of cost 2014 2018 14% 13% 7–19 7–18 5 High out-of-pocket medical spending — 2017–18 — 8.3% — 4.8–14.2 6 Employee insurance costs as a share of median income 2014 2018 6.6% 6.8% 4.3–8.9 4.1–10 7 Adults without a dental visit 2014 2018 36% 34% 25–46 24–46 Prevention and Treatment 8 Adults without all recommended cancer screenings 2014 2018 32% 32% 23–40 24–41 9 Adults without all recommended vaccines 2014 2018 63% 69% 53–71 57–75 10 Diabetic adults without an annual hemoglobin A1c test 2015 2017 16.9% 10.7% 11–23.7 6.5–22.2 11 Elderly patients who received a high-risk prescription drug — 2016 — 9.6% — 4.6–15.5 12 Children without a medical home 2016 2018 51% 52% 40–66 41–59 13 Children without a medical and dental preventive care visit — 2018 — 42% — 29–51 14 Children who did not receive needed mental health care 2016 2018 18% 18% 5–34 5–39 15 Children without all recommended vaccines 2014 2018 28% 27% 15–37 16–38 16 Hospital 30-day mortality 2010-13 2014-17 12.8% 13.7% 11.9–13.6 12.5–14.8 17 Central line-associated blood stream infection (CLABSI) 2015 2018 0.994 0.739 0.324–1.434 0.087–0.923 18 Hospitals with lower-than-average patient experience ratings — 2018 — 46% — 15–83 19 Home health patients without improved mobility 2014 2018 37% 22% 31–49 17–35 20 Nursing home residents with an antipsychotic medication 2013 2017 21% 15% 11–27 7–20 21 Adults with any mental illness reporting unmet need 2012–14 2016–17 20% 22% 14–26 14–31 22 Adults with any mental illness who did not receive treatment 2012–14 2016–17 57% 57% 43–68 41–65 Avoidable Hospital Use and Cost Potentially avoidable emergency department visits 23 Ages 18–64, per 1,000 employer-insured enrollees 2015 2017 159.0 149.5 130–203.4 84.2–258.1 24 Age 65 and older, per 1,000 Medicare beneficiaries 2013 2016 181.4 189.4 127.5–250.8 140.9–244.9 Admissions for ambulatory care–sensitive conditions 25 Ages 18–64, per 1,000 employer-insured enrollees 2015 2017 4.6 6.8 3.3–6.1 6–7.9 26 Age 65 and older, per 1,000 Medicare beneficiaries 2014 2018 44.7 41.6 22.8–66.3 20.4–56 30-day hospital readmissions 27 Ages 18–64, per 1,000 employer-insured enrollees 2015 2017 2.9 3.2 1.2–5.5 2.3–3.6 28 Age 65 and older, per 1,000 Medicare beneficiaries 2014 2018 42.0 40.0 19.9–54.7 18.5–51.1 29 Skilled nursing facility patients with a hospital readmission 2012 2016 20% 19% 13–26 11–24 30 Nursing home residents with a hospital admission 2012 2016 17% 15% 7–30 5–28 31 Home health patients with a hospital admission 2014 2018 16% 16% 12–18 14–17 32 Adults with inappropriate lower back imaging 2015 2017 71.1% 70.1% 59.2–83.7 57.5–76.4 33 Employer-sponsored insurance spending per enrollee 2013 2017 $4,697 $5,137 $3,117–$7,186 $3,606–$8,104 34 Medicare spending per beneficiary 2014 2018 $9,025 $9,847 $5,640–$10,851 $6,473–$11,604 Primary care as a share of total medical spending 35 Ages 18–64, employer-insured enrollees — 2018 — 6.0% — 3.59–11.29 36 Age 65 and older, Medicare beneficiaries — 2017 — 5.7% — 4.75–7.16 Healthy Lives 37 Mortality amenable to health care 2012–13 2016–17 83.7 84.5 55.6–136.7 54.5–143.4 38 Breast cancer deaths 2014 2018 20.6 19.7 14.2–28.9 15.1–26.7 39 Colorectal cancer deaths 2014 2018 14.3 12.6 10.9–19.3 9.1–17.2 40 Suicide deaths 2014 2018 13.0 14.2 7.8–23.9 7.5–25.2 41 Alcohol deaths 2014 2018 8.5 9.9 4.4–23.8 5.7–32.7 42 Drug poisoning deaths 2014 2018 14.7 20.7 6.3–35.5 6.9–51.5 43 Infant mortality 2013 2017 6.0 5.8 4.2–9.6 3.7–8.7 44 Adults who report fair or poor health 2014 2018 16% 17% 10–23 11–23 45 Adults who smoke 2014 2018 17% 16% 10–27 9–25 46 Adults who are obese 2014 2018 29% 32% 21–38 23–41 47 Children who are overweight or obese 2016 2018 31% 31% 19–38 19–39 48 Adults who have lost six or more teeth 2014 2018 10% 9% 6–22 5–20 49 Public health funding 2014/15 2017/18 $36 $37 $4–$163 $7–$137 Notes: (—) Previous data are not shown because of changes in the indicators' definitions or data were not available. Notes: (—) Previous data are not shown because of changes in the indicators’ definitions or data were not available. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 25 APPENDIX Appendix A3. A3. National National and Regional and Regional Performance Performance Benchmarks Benchmarks National Great Lakes Mid-Atlantic New England Plains Rocky Mountain Best Best Best Best Best Best Indicator Rate state(s) Rate state(s) Rate state(s) Rate state(s) Rate state(s) Rate state(s) Access and Affordability 1 Uninsured adults 4% DC, MA 8 MI, WI 4 DC 4 MA 6 MN 10 CO 2 Uninsured children 1% MA 3 IL, MI 2 NY 1 MA 3 IA 5 CO, MT 3 Adults without a usual source of care 13% MA 15 MI 15 PA 13 MA 18 IA 26 CO 4 Adults who went without care because of cost 7% HI 10 OH, WI 8 DC 8 VT 8 IA 10 MT 5 High out-of-pocket medical spending 4.8% DC 7.5 IN 4.8 DC 6.1 MA 6.0 MN 9.5 CO 6 Employee insurance costs as a share of median income 4.1% WA 5.2 MI 5.4 DC 5.1 NH 5.7 ND 5.1 UT 7 Adults without a dental visit 24% CT 29 MI, WI 26 DC 24 CT 26 MN 28 UT Prevention and Treatment 8 Adults without all recommended cancer screenings 24% MA 28 MI 26 DC 24 MA 28 MN 34 CO, UT 9 Adults without all recommended vaccines 57% DC 66 OH 57 DC 65 MA, RI, VT 61 IA 65 CO 10 Diabetic adults without an annual hemoglobin A1c test 6.5% IA 9.0 MI 11.2 MD 9.4 MA 6.5 IA 11.3 CO, MT 11 Elderly patients who received a high-risk prescription drug 4.6% HI 7.2 IL 6.4 NY 6.4 MA 6.2 MN 8.9 MT 12 Children without a medical home 41% IA, NH 46 WI 49 NJ 41 NH 41 IA 45 ID 13 Children without a medical and dental preventive care visit 29% MA 39 OH 33 DE 29 MA 33 IA 34 MT 14 Children who did not receive needed mental health care 5% ND 11 OH 7 NJ 10 VT 5 ND 11 CO, ID 15 Children without all recommended vaccines 16% CT 21 WI 20 PA 16 CT 18 ND 25 CO 16 Hospital 30-day mortality 12.5% MA 13.1 OH 13.0 DC, NJ 12.5 MA 13.4 MN 13.5 CO 17 Central line-associated blood stream infection (CLABSI) 0.087 WY 0.603 WI 0.649 DE 0.585 NH 0.616 NE 0.087 WY 18 Hospitals with lower-than-average patient experience ratings 15% CO 23 WI 51 PA 33 VT 23 MN 15 CO 19 Home health patients without improved mobility 17% AL, MS 23 MI, OH, WI 20 MD 21 MA 21 KS, ND 19 UT 20 Nursing home residents with an antipsychotic medication 7% HI 13 MI, WI 11 DC, NJ 15 NH 14 MN 13 WY 21 Adults with any mental illness reporting unmet need 14% AL 20 OH 20 NY 20 ME 18 IA 19 WY 22 Adults with any mental illness who did not receive treatment 41% VT 51 MI 48 DE 41 VT 47 IA 49 CO Avoidable Hospital Use and Cost Potentially avoidable emergency department visits 23 Ages 18–64, per 1,000 employer-insured enrollees 84.2 OR 150.5 IL 93.0 NY 95.4 MA 96.0 MN 86.9 UT 24 Age 65 and older, per 1,000 Medicare beneficiaries 140.9 HI 191.5 WI 167.5 NJ 174.9 VT 153.2 SD 155.1 UT Admissions for ambulatory care–sensitive conditions 25 Ages 18–64, per 1,000 employer-insured enrollees 6.0 OR 6.4 WI 6.3 NY 6.3 CT, NH 6.3 MN 6.1 CO 26 Ages 65 and older, per 1,000 Medicare beneficiaries 20.4 HI 35.1 WI 38.4 MD 33.4 VT 33.1 MN 22.6 UT 30-day hospital readmissions 27 Ages 18–64, per 1,000 employer-insured enrollees 2.3 AL 3.1 IL 2.9 NY 2.7 ME 3.0 NE 2.8 CO, WY 28 Age 65 and older, per 1,000 Medicare beneficiaries 18.5 HI 33.0 WI 35.4 DE 30.4 VT 29.7 IA 21.9 UT DC, DE, MD, 29 Skilled nursing facility patients with a hospital readmission 11% AK 17 WI 19 16 ME, VT 15 ND, NE, SD 13 ID, UT PA 30 Nursing home residents with a hospital admission 5% HI 11 WI 12 PA 8 RI 7 MN 9 CO AZ, CA, DC, HI, 31 Home health patients with a hospital admission 14% 15 WI 14 DC 16 CT, ME, VT 15 ND 14 ID, UT ID, NM, OR, UT 32 Adults with inappropriate lower back imaging 57.5% AL 65.6 IN 67.8 NJ 65.1 RI 65.0 MO 69.2 CO 33 Employer-sponsored insurance spending per enrollee $3,606 MS $4,134 MI $4,037 MD $4,413 RI $4,569 IA $4,926 UT 34 Medicare spending per beneficiary $6,473 HI $8,517 WI $9,480 DE $7,634 VT $8,491 SD $7,879 MT Primary care as a share of total medical spending 35 Ages 18–64, employer-insured enrollees 11.29% AK 8.65 WI 6.32 MD 7.28 MA 8.29 IA 7.21 ID 36 Ages 65 and older, Medicare beneficiaries 7.16% TN 5.62 IL 5.68 PA 6.40 VT 6.55 KS 6.08 CO Healthy Lives 37 Mortality amenable to health care 54.5 MN 69.1 WI 72.2 NJ 57.4 MA 54.5 MN 61.9 CO 38 Breast cancer deaths 15.1 HI 19.6 WI 19.3 NY 15.7 MA 16.9 ND 16.5 MT 39 Colorectal cancer deaths 9.1 UT 11.7 WI 11.2 NY 9.8 CT 11.3 MN 9.1 UT 40 Suicide deaths 7.5 DC 11.3 IL 7.5 DC 9.5 RI 13.1 MN 21.9 CO 41 Alcohol deaths 5.7 HI 7.7 IL 5.8 MD 7.6 CT 8.6 MO 10.9 UT 42 Drug poisoning deaths 6.9 SD 19.2 WI 18.4 NY 26.6 VT 6.9 SD 11.1 WY 43 Infant mortality 3.7 MA 6.1 IL 4.5 NJ 3.7 MA 4.4 ND 4.5 CO 44 Adults who report fair or poor health 11% ND 14 WI 12 DC 12 CT, VT 11 ND 13 CO, MT, UT 45 Adults who smoke 9% UT 15 IL 13 MD, NJ, NY 12 CT 15 MN 9 UT 46 Adults who are obese 23% CO 32 IL 25 DC 26 MA 29 SD 23 CO 47 Children who are overweight or obese 19% HI 25 IL 25 DE 26 MA, ME 23 NE 21 MT, UT 48 Adults who have lost six or more teeth 5% UT 8 IL 6 DC 7 CT 6 MN 5 UT 49 Public health funding $137 DC, NM $26 IL $135 DC $77 MA $55 ND $88 ID commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 26 APPENDIX Appendix A3. A3. National National and Regional and Regional Performance Performance Benchmarks Benchmarks (continued) reat Lakes Mid-Atlantic New England Plains Rocky National Mountain Southeast Great Lakes Southwest Mid-Atlantic New West England Plains Rocky Mountain Best Best Best Best Best Best Best Best Best Best Best Best Best Best state(s) Indicator Rate state(s) Rate state(s) Rate state(s) Rate Rate state(s) state(s) Rate Rate state(s) state(s) Rate Rate state(s) state(s) Rate Rate state(s) state(s) Rate state(s) Rate state(s) Access and Affordability 8 MI, WI 1 Uninsured 4 adults DC 4 MA 6 MN 10 4% DC, CO MA 88 MI, KY WI 144 NM DC 64 HIMA 6 MN 10 CO 3 IL, MI 2 Uninsured 2 children NY 1 MA 3 IA 1% 5 CO,MA MT 33 KY, LA, IL, MI WV 62 NM NY 31 CA, HI, MAWA 3 IA 5 CO, MT 15 MI 3 Adults 15 without PAa usual source13 of care MA 18 IA 13% 26 CO MA 19 15 AR, KY, MIWV 24 15 OK PA 15 13 HIMA 18 IA 26 CO 10 OH, WI 4 Adults 8 who went DC without care because 8 VT of cost 8 IA 10 7% MTHI 13 10 KY, OH,VAWI 138 AZ, DC NM 78 HIVT 8 IA 10 MT 7.5 IN 5 High 4.8out-of-pocket DC medical spending 6.1 MA 6.0 MN 4.8% 9.5 CO DC 8.3 7.5 VAIN 8.0 4.8 NM DC 6.5 6.1 WA MA 6.0 MN 9.5 CO 5.2 MI 6 Employee 5.4 insurance DC costs as5.1 a share ofNH median income5.7 ND 4.1% 5.1 UT WA 7.1 5.2 VA MI 7.5 5.4 OK DC 4.1 5.1 WA NH 5.7 ND 5.1 UT 29 MI, WI 7 Adults 26 without DCa dental visit 24 CT 26 MN 24% 28 UTCT 28 29 MI, VA WI 35 26 NM DC 25 24 HICT 26 MN 28 UT Prevention and Treatment 28 MI 8 Adults 26 without DCall recommended 24 cancer MAscreenings 28 MN 24% 34 CO,MA UT 29 28 LA, MI VA 34 26 AZ DC 25 24 HIMA 28 MN 34 CO, UT 66 OH 9 Adults 57 without DCall recommended 65 vaccines MA, RI, VT 61 IA 57% 65 CO DC 59 66 WV OH 64 57 OK DC 63 65 MA, WARI, VT 61 IA 65 CO 9.0 MI 10 Diabetic 11.2 adults MDwithout an annual 9.4 hemoglobin MA A1c test 6.5 IA 11.3 6.5% CO, MT IA 7.8 9.0 NC MI 9.8 11.2 TX MD 7.9 9.4 WA MA 6.5 IA 11.3 CO, MT 7.2 IL 11 Elderly 6.4 patients NY who received6.4 a high-risk MAprescription drug 6.2 MN 4.6% 8.9 MTHI 9.8 7.2 VAIL 9.6 6.4 AZ NY 4.6 6.4 HIMA 6.2 MN 8.9 MT 46 WI 12 Children 49 without NJ a medical home 41 NH 41 IA 41% 45 IA, ID NH 45 46 VA WI 51 49 TXNJ 50 41 OR,NH WA 41 IA 45 ID 39 OH 13 Children 33 without DE a medical and29dental preventive MA care visit 33 IA 29% 34 MT MA 32 39 VA OH 41 33 NM DE 37 29 OR MA 33 IA 34 MT 11 OH 14 Children 7 whoNJ did not receive needed 10 mental VT health care 5 ND 11 5% CO,ND ID 10 11 FL OH 117 TXNJ 9 10 HIVT 5 ND 11 CO, ID 21 WI 15 Children 20 without PA all recommended 16 vaccines CT 18 ND 16% 25 CO CT 19 21 KY WI 23 20 NM PA 28 16 CA CT 18 ND 25 CO 3.1 OH 16 Hospital 13.0 30-day DC, NJmortality 12.5 MA 13.4 MN 12.5% 13.5 CO MA 13.5 13.1 FL,OH VA 13.4 13.0 DC, AZ NJ 13.2 12.5 CA MA 13.4 MN 13.5 CO 03 WI 17 Central 0.649 line-associated DE blood 0.585 stream infection NH (CLABSI) 0.616 NE 0.087 0.087 WY WY 0.620 0.603 VA WI 0.398 0.649 NM DE 0.337 0.585 HINH 0.616 NE 0.087 WY 23 WI 18 Hospitals 51 withPAlower-than-average 33 patient VT experience ratings 23 MN 15% 15 CO CO 31 23 LAWI 34 51 TXPA 29 33 OR VT 23 MN 15 CO 23 MI, OH, WI 19 Home 20 healthMD patients without21 improved MAmobility 21 KS, ND 17% 19 AL, UT MS 17 23 MI, AL, OH, MS WI 21 20 OK MD 24 21 CA,MA WA 21 KS, ND 19 UT 13 MI, WI 20 Nursing 11 home DC, NJ residents with 15 an antipsychotic NH medication 14 MN 13 7% WY HI 13 13 NC MI, WI 14 11 DC, AZ NJ 7 15 HINH 14 MN 13 WY 20 OH 21 Adults 20 with any NYmental illness 20 reportingME unmet need 18 IA 14% 19 WY AL 14 20 AL OH 19 20 TX NY 15 20 HIME 18 IA 19 WY 51 MI 22 Adults 48 with any DE mental illness 41 who did not VT receive treatment 47 IA 41% 49 CO VT 51 51 TN, MI WV 54 48 NM DE 53 41 WA VT 47 IA 49 CO Avoidable Hospital Use and Cost Potentially avoidable emergency department visits 0.5 IL 23 Ages 18–64, 93.0 NY per 1,000 employer-insured 95.4 MA enrollees96.0 MN 86.9 84.2 UT OR 121.9 150.5 KYIL 133.3 93.0 NM NY 84.2 95.4 OR MA 96.0 MN 86.9 UT 1.5 WI 24 167.5 Age 65 andNJolder, per 1,000 174.9 MedicareVTbeneficiaries153.2 SD 155.1 140.9 UTHI 175.4 191.5 SC WI 183.7 167.5 AZNJ 140.9 174.9 HIVT 153.2 SD 155.1 UT Admissions for ambulatory care–sensitive conditions 6.4 WI 25 Ages 6.3 18–64, NY per 1,000 employer-insured 6.3 CT, NH enrollees 6.3 MN 6.1 6.0 CO OR 6.6 6.4 VA WI 6.5 6.3 NM NY 6.0 6.3 CT, OR NH 6.3 MN 6.1 CO 5.1 WI 26 38.4 Ages 65 and MDolder, per 1,000 33.4Medicare VT beneficiaries33.1 MN 22.6 20.4 UTHI 37.8 35.1 SC WI 27.0 38.4 AZ MD 20.4 33.4 HIVT 33.1 MN 22.6 UT 30-day hospital readmissions 3.1 IL 27 2.9 18–64, Ages NY per 1,000 employer-insured 2.7 ME enrollees 3.0 NE 2.8 2.3 CO, AL WY 2.3 3.1 ALIL 2.9 2.9 NM NY 2.7 2.7 OR ME 3.0 NE 2.8 CO, WY 3.0 WI 28 35.4 Age 65 and DEolder, per 1,000 30.4 MedicareVTbeneficiaries 29.7 IA 21.9 18.5 UTHI 32.7 33.0 SC WI 27.0 35.4 NM DE 18.5 30.4 HIVT 29.7 IA 21.9 UT DC, DE, MD, DC, DE, MD, 17 WI 29 Skilled 19 nursing facility patients16 with a hospital ME, VT readmission 15 ND, NE, SD 11% 13 ID, UT AK 19 17 NC, TN, WIVA 18 19 NM 11 16 ME, AK VT 15 ND, NE, SD 13 ID, UT PA PA 11 WI 30 Nursing 12 home PAresidents with a8hospitalRI admission 7 MN 5% 9 COHI 15 11 VA WI 7 12 AZPA 58 HIRI 7 MN 9 CO AZ, CA, DC, HI, 15 WI 31 Home 14 healthDC patients with a hospital 16 CT, admission ME, VT 15 ND 14% 14 ID, UT 15 15 FLWI 14 14 AZ, DC NM 14 16 CA, CT,HI, ME,ORVT 15 ND 14 ID, UT ID, NM, OR, UT 5.6 IN 32 Adults 67.8 with inappropriate NJ lower 65.1back imaging RI 65.0 MO 57.5% 69.2 CO AL 57.5 65.6 ALIN 64.0 67.8 OKNJ 64.7 65.1 NVRI 65.0 MO 69.2 CO 34 MI 33 $4,037 Employer-sponsored MD insurance $4,413 spending RI per enrollee $4,569 IA $4,926 $3,606 UT MS $3,606 $4,134 MS MI $4,962 $4,037 AZ MD $3,948 $4,413 HIRI $4,569 IA $4,926 UT 17 WI 34 $9,480 Medicare spending DE per beneficiary $7,634 VT $8,491 SD $7,879 $6,473 MTHI $9,084 $8,517 VA WI $7,881 $9,480 NM DE $6,473 $7,634 HIVT $8,491 SD $7,879 MT Primary care as a share of total medical spending 65 WI 35 Ages 18–64, 6.32 MD employer-insured 7.28 enrollees MA 8.29 IA 11.29% 7.21 IDAK 7.68 8.65 NC WI 6.40 6.32 AZ,MD NM 11.29 7.28 AK MA 8.29 IA 7.21 ID 62 IL 36 5.68 Ages 65 and PAolder, Medicare 6.40beneficiaries VT 6.55 KS 7.16% 6.08 CO TN 7.16 5.62 TNIL 6.39 5.68 AZ PA 6.30 6.40 WA VT 6.55 KS 6.08 CO Healthy Lives 9.1 WI 37 Mortality 72.2 amenable NJ to health57.4 care MA 54.5 MN 61.9 54.5 CO MN 80.3 69.1 VA WI 76.3 72.2 AZNJ 63.2 57.4 WA MA 54.5 MN 61.9 CO 9.6 WI 38 Breast 19.3 cancer NYdeaths 15.7 MA 16.9 ND 16.5 15.1 MTHI 17.8 19.6 AR WI 17.1 19.3 AZ NY 15.1 15.7 HIMA 16.9 ND 16.5 MT 1.7 WI 39 Colorectal 11.2 cancer NY deaths 9.8 CT 11.3 MN 9.1 9.1 UT UT 12.0 11.7 NC WI 11.9 11.2 AZ NY 10.3 9.8 HICT 11.3 MN 9.1 UT 1.3 IL 40 Suicide 7.5 deaths DC 9.5 RI 13.1 MN 21.9 7.5 CO DC 13.7 11.3 NCIL 13.7 7.5 TX DC 10.9 9.5 CARI 13.1 MN 21.9 CO 7.7 IL 41 Alcohol 5.8 deaths MD 7.6 CT 8.6 MO 10.9 5.7 UTHI 5.9 7.7 MSIL 7.8 5.8 TX MD 5.7 7.6 HICT 8.6 MO 10.9 UT 9.2 WI 42 Drug 18.4poisoning NY deaths 26.6 VT 6.9 SD 11.1 6.9 WY SD 10.8 19.2 MS WI 10.4 18.4 TX NY 12.6 26.6 OR VT 6.9 SD 11.1 WY 6.1 IL 43 Infant 4.5 mortality NJ 3.7 MA 4.4 ND 4.5 3.7 CO MA 5.9 6.1 VAIL 5.7 4.5 AZNJ 3.9 3.7 WA MA 4.4 ND 4.5 CO 14 WI 44 Adults 12 who report DC fair or poor12 health CT, VT 11 ND 11% 13 CO, MT, NDUT 15 14 VA WI 17 12 TX DC 15 12 AK,CT, HI, WA VT 11 ND 13 CO, MT, UT 15 IL 45 Adults 13 who MD, smoke NJ, NY 12 CT 15 MN 9% 9 UT UT 14 15 FLIL 14 13 MD, AZ, TX NJ, NY 11 12 CA CT 15 MN 9 UT 32 IL 46 Adults 25 who are DCobese 26 MA 29 SD 23% 23 CO CO 31 32 VAIL 31 25 AZ DC 26 26 CA MA 29 SD 23 CO 25 IL 47 Children 25 whoDE are overweight or 26obese MA, ME 23 NE 19% 21 MT, HI UT 29 25 NCIL 30 25 AZ, DE NM 19 26 MA, HI ME 23 NE 21 MT, UT 8 IL 48 Adults 6 who have DC lost six or more 7 teeth CT 6 MN 5% 5 UT UT 88 VAIL 76 TX DC 67 CA,CT HI 6 MN 5 UT 26 IL 49 Public $135 healthDC funding $77 MA $55 ND $88 $137 DC, ID NM $61 $26 WVIL $137 $135 NM DC $124 $77 HIMA $55 ND $88 ID commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 27 Appendix APPENDIX A4. A4. Change Change in State in State Health Health System System Performance Performance by Indicator by Indicator Number of states that: Indicator • Improved a • No Change b • Worsened a Access and Affordability 0 Uninsured adults 35 16 Uninsured children 15 36 Adults without a usual source of care 5 42 4 Adults who went without care because of cost 19 31 1 Employee insurance costs as a share of median income 4 25 22 Adults without a dental visit 18 30 3 Prevention and Treatment Adults without all recommended cancer screenings 7 36 8 Adults without all recommended vaccines 1 10 40 Diabetic adults without an annual hemoglobin A1c test 47 4 Children without a medical home 7 22 22 Children who did not receive needed mental health care 20 10 21 Children without all recommended vaccines 20 20 11 Hospital 30-day mortality 1 50 Central line-associated blood stream infection (CLABSI) 42 8 1 Home health patients without improved mobility 51 Nursing home residents with an antipsychotic medication 50 1 Adults with any mental illness reporting unmet need 6 19 26 Adults with any mental illness who did not receive treatment 14 20 17 Avoidable Hospital Use and Cost Potentially avoidable emergency department visits ages 18–64 29 17 5 Potentially avoidable emergency department visits age 65 and older 1 35 15 Preventable hospitalizations ages 18–64 2 49 Preventable hospitalizations age 65 and older 12 39 Hospital 30-day readmission rate ages 18–64 2 27 22 Hospital 30-day readmission rate age 65 and older 5 46 Skilled nursing facility patients with a hospital readmission 19 32 Nursing home residents with a hospital admission 17 34 Home health patients with a hospital admission 21 25 5 Adults with inappropriate lower back imaging 16 35 Employer-sponsored insurance spending per enrollee 1 16 34 Medicare spending per beneficiary 6 45 Healthy Lives Mortality amenable to health care 50 1 Breast cancer deaths 21 23 7 Colorectal cancer deaths 43 7 1 Suicide deaths 41 10 Alcohol deaths 37 14 Drug poisoning deaths 1 24 26 Infant mortality 10 34 7 Adults who report fair or poor health 2 32 17 Adults who smoke 27 24 Adults who are obese 27 24 Children who are overweight or obese 14 23 14 Adults who have lost six or more teeth 14 35 2 Public health funding 32 19 Notes: Only Scorecard indicators with trends are shown. Trend data generally reflect the four- to five-year period ending in 2017 or 2018—refer to Appendix Exhibit A1 for additional detail (trend data were not available for all indicators). For purposes of this analysis we count District of Columbia as a state. (a) Improvement or Notes: Only Scorecard worsening refers toindicators a changewith trends are between theshown. baselineTrend anddata generally current timereflect the of periods four- atto five-year least period ending 0.5 standard in 2017 (b) deviations. or 2018—refer to number Includes the Appendixof A1states for additional with nodetail change(trendordata were not available for all indicators). For purposes of this analysis we count District of Columbia as a state. (a) Improvement or worsening refers to a change between the baseline and current without time sufficient periods data of at least for this subpopulation 0.5 standard to assess deviations. (b) Includes thechange over number of time. states with no change or without sufficient data for this subpopulation to assess change over time. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 28 APPENDIX A5. Change in State Health System Performance by Indicator Appendix A5. Change in State Health System Performance by Indicator Number of states that: Indicator • Improved a • No Change b • Worsened a 2014–2016 2016–2018 Access and Affordability 0 Uninsured adults 38 13 1 50 Uninsured children 19 31 1 2 47 2 Adults without a usual source of care 11 36 4 2 42 7 Adults who went without care because of cost 20 30 1 2 46 3 Employee insurance costs as a share of median income 8 23 20 6 37 8 Adults without a dental visit 11 40 5 42 4 Prevention and Treatment Adults without all recommended cancer screenings 4 37 10 12 35 4 Adults without all recommended vaccines 10 30 11 1 7 43 Diabetic adults without an annual hemoglobin A1c test 8 36 7 45 6 Children without all recommended vaccines 18 16 17 21 20 10 Hospital 30-day mortality 51 43 8 Central line-associated blood stream infection (CLABSI) 27 20 4 38 11 2 Home health patients without improved mobility 51 51 Nursing home residents with an antipsychotic medication 49 2 7 44 Adults with any mental illness reporting unmet need 9 33 9 6 16 29 Adults with any mental illness who did not receive treatment 12 27 12 9 28 14 Avoidable Hospital Use and Cost Potentially avoidable emergency department visits ages 18–64 44 7 18 20 13 Preventable hospitalizations ages 18–64 2 49 14 27 10 Preventable hospitalizations age 65 and older 2 49 1 50 Hospital 30-day readmission rate ages 18–64 2 25 24 20 17 14 Hospital 30-day readmission rate age 65 and older 4 47 51 Home health patients with a hospital admission 5 22 24 37 12 2 Adults with inappropriate lower back imaging 21 30 2 46 3 Employer-sponsored insurance spending per enrollee 1 38 12 2 43 6 Medicare spending per beneficiary 49 2 33 18 Healthy Lives Mortality amenable to health care 51 51 Breast cancer deaths 13 30 8 16 28 7 Colorectal cancer deaths 34 15 2 17 32 2 Suicide deaths 1 47 3 47 4 Alcohol deaths 44 7 1 47 3 Drug poisoning deaths 25 26 1 48 2 Infant mortality 8 37 6 6 41 4 Adults who report fair or poor health 4 38 9 3 35 13 Adults who smoke 14 36 1 14 37 Adults who are obese 3 35 13 36 15 Adults who have lost six or more teeth 7 41 3 6 44 1 Public health funding 27 24 28 23 Notes: Only Scorecard indicators with trends are shown. Trend calculated over two periods, generally 2014 to 2016, and 2016 to 2018—refer to Appendix Exhibit A1 for additional detail (trend data were not available for all indicators). For purposes of this analysis we count District of Columbia as a state. (a) Improvement or worsening refers to a change within the time period 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 calculated over two periods, generally 2014 to 2016, and 2016 to 2018—refer to Appendix A1 for additional detail (trend data were not available for all indicators). For purposes of this analysis we count District of Columbia as a state. (a) Improvement or worsening refers to a change within the time period 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 September 2020 2020 Scorecard on State Health System Performance 29 APPENDIX A6. Appendix A6. National NationalCumulative CumulativeImpact if All Impact if States Achieved All States Top State Achieved Rate Rate Top State 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 15,479,728 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 3,108,255 would be more likely to receive health care when needed. Went without care because of cost 14,950,671 fewer adults (age 18 and older) would go without needed health care because of cost. High out-of-pocket medical spending 9,492,104 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 24,917,786 coordinated and accessible when needed. more adults would receive age- and gender-appropriate recommended cancer screenings, including Adult cancer screening 11,701,222 tests for colon, breast, and cervical cancers. Adult vaccines 29,901,343 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 8,046,095 accessible when needed. Children vaccines 632,208 more children (ages 19–35 months) would receive all recommended vaccines. Children with preventive medical and 9,509,021 more children (ages 0–17) would receive annual preventive medical and dental care visits each year. dental visits Medicare received a high-risk drug 172,403 fewer Medicare beneficiaries would receive an inappropriately prescribed medication. fewer employer-insured adults and elderly Medicare beneficiaries would experience a hospital Hospital readmissions 1,164,798 readmission within 30 days of discharge. Potentially avoidable emergency fewer employer-insured adults and elderly Medicare beneficiaries would seek care in emergency 10,449,205 department visits departments for nonemergent or primary-care-treatable conditions. fewer premature deaths (before age 75) might occur from causes that are potentially treatable or Mortality amenable to health care 91,127 preventable with timely and appropriate health care. Breast cancer deaths 7,580 fewer women would die from breast cancer. Colon cancer deaths 11,281 fewer individuals would die from colon cancer. Suicides 21,596 fewer individuals would take their own lives. Adults who smoke 17,442,450 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 17,825,100 complications. fewer children (ages 10–17) would be overweight or obese, thus reducing the potential for poor Children who are overweight or obese 4,047,634 health as they transition into adulthood. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 30 Appendix B1. State Scorecard Summary of Health System Performance Across Dimensions APPENDIX B1. State Scorecard Summary of Health System Performance Across Dimensions nd ity ea en nd ar es Us ty p tm n a rd d is iv ili t st le fo an eD ea io yL ab Co dab Current Ranking Tr ent Af ss th om ce oi ev al c Av He Ac Pr In 1 Hawaii 1 1 1 1 1 Overall performance 2 Massachusetts 1 1 3 1 1 Top quartile 3 Minnesota 1 1 2 1 1 Second quartile 4 Iowa 1 1 1 2 1 Third quartile 5 Connecticut 1 1 3 1 1 Bottom quartile 6 Colorado 2 1 1 1 2 Data not available 6 Vermont 1 1 2 2 2 8 Washington 1 3 1 1 2 9 Utah 3 3 1 1 1 10 New York 1 3 3 1 1 11 New Hampshire 1 1 3 2 3 11 Wisconsin 2 1 2 2 2 13 North Dakota 2 2 1 2 1 14 Maryland 2 2 2 2 2 15 Rhode Island 1 1 3 1 3 16 District of Columbia 1 2 4 2 3 16 New Jersey 2 2 3 1 3 18 Montana 3 3 1 1 1 19 California 2 4 2 1 2 20 Nebraska 3 2 2 1 3 21 Idaho 4 3 1 2 1 21 Pennsylvania 2 2 3 3 2 23 Oregon 3 4 1 2 4 24 Delaware 2 2 3 3 2 25 Illinois 2 3 3 2 2 25 Virginia 3 1 2 2 4 27 Michigan 1 2 4 3 3 28 Ohio 2 2 4 4 1 29 South Dakota 3 2 2 3 3 30 New Mexico 3 3 1 4 1 31 Maine 2 1 2 3 4 32 Alaska 3 4 1 3 2 33 Arizona 4 3 1 3 2 34 Kansas 2 3 3 3 3 35 Wyoming 4 4 2 3 2 36 North Carolina 4 2 2 3 4 37 South Carolina 3 4 2 3 4 38 Indiana 2 4 4 4 3 39 Kentucky 3 2 4 4 3 40 Alabama 4 3 3 4 4 41 Florida 4 3 4 3 4 42 Arkansas 3 4 3 4 3 42 Texas 4 4 4 2 2 44 Louisiana 4 4 4 4 3 44 Tennessee 4 3 2 4 4 46 Georgia 4 4 3 3 4 47 West Virginia 3 2 4 4 3 48 Missouri 3 3 4 4 4 49 Nevada 4 4 4 4 3 50 Oklahoma 4 4 4 4 4 51 Mississippi 4 4 4 4 4 commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 31 AppendixB2. APPENDIX B2.Summary Summary of State of State Rankings Rankings in Current in Current and Previous and Previous Scorecards Scorecards 2020 Scorecard Rankings Overall ranking Overall Access and Prevention and Avoidable Use Healthy Income in the baseline a State ranking Affordability Treatment and Cost Lives Disparity time period Alabama 40 41 29 27 42 49 37 Alaska 32 35 48 8 28 17 35 Arizona 33 43 36 9 32 16 36 Arkansas 42 37 46 36 45 37 42 California 19 20 44 21 6 19 23 Colorado 6 24 6 4 6 13 10 Connecticut 5 6 10 31 3 7 5 Delaware 24 19 14 34 31 18 16 District of Columbia 16 2 16 42 25 30 29 Florida 41 48 33 47 27 44 43 Georgia 46 49 39 32 35 47 43 Hawaii Hawaii 1 3 2 1 1 10 1 Idaho Idaho 21 45 30 5 16 8 22 Illinois Illinois 25 16 31 38 19 22 26 Indiana Indiana 38 24 40 41 43 31 40 Iowa Iowa 4 7 1 12 20 9 6 Kansas Kansas 34 22 27 29 34 34 30 Kentucky Kentucky 39 28 24 45 48 35 39 Louisiana Louisiana 44 40 44 48 46 28 50 Maine Maine 31 21 12 21 26 47 14 Maryland Maryland 14 13 14 23 22 24 9 Massachusetts Massachusetts 2 1 7 37 2 3 3 Michigan Michigan 27 11 13 39 37 33 31 Minnesota Minnesota 3 9 3 13 4 6 2 Mississippi Mississippi 51 50 50 50 50 41 51 Missouri Missouri 48 34 38 46 44 50 41 Montana Montana 18 30 34 7 12 12 21 Nebraska Nebraska 20 29 23 14 11 32 19 Nevada Nevada 49 44 51 40 40 36 47 New Hampshire New Hampshire 11 8 5 26 14 38 16 New Jersey New Jersey 16 17 16 35 10 26 25 New Mexico New Mexico 30 36 34 10 39 5 33 New York New York 10 9 37 28 8 2 20 North Carolina North Carolina 36 39 22 18 36 46 32 North Dakota North Dakota 13 23 20 11 15 11 12 Ohio Ohio 28 18 16 44 41 3 34 Oklahoma Oklahoma 50 46 49 49 49 40 43 Oregon Oregon 23 27 40 2 20 41 16 PennsylvaniaPennsylvania 21 14 21 32 33 23 26 Rhode IslandRhode Island 15 5 9 29 12 38 13 South Carolina South Carolina 37 37 43 16 38 43 38 South Dakota South Dakota 29 31 19 20 28 29 10 Tennessee Tennessee 44 42 32 24 46 51 46 Texas Texas 42 51 40 42 23 24 48 Utah Utah 9 32 28 3 5 1 6 Vermont Vermont 6 4 4 15 17 14 4 Virginia Virginia 25 26 8 19 18 45 28 Washington Washington 8 12 26 6 9 20 14 West VirginiaWest Virginia 47 33 25 51 51 27 49 Wisconsin Wisconsin 11 15 11 24 24 15 8 Wyoming Wyoming 35 47 47 17 30 20 23 Notes: (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 Notes: as reported (a) The in our baseline period 2019 State generally reflectsScorecard two to threeand yearsshould nottime prior to the be compared tofor of observation thethe2019 latest ranking because year of data available.ofThis changes is not theinsame the underlying set ofinperformance ranking as reported our 2019 State indicators Scorecard evaluated and should notin bethe two reports. compared to the 2019 ranking because of changes in the underlying set of performance indicators evaluated in the two reports. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 32 Appendix C1. Access & Affordability: Dimension Ranking and Indicator Rates APPENDIX C1. Access & Affordability: Dimension Ranking and Indicator Rates Adults age 18 Individuals under and older age 65 with high Employee Adults age Adults age 18 who went out-of-pocket insurance 18 and Access and and older without care medical costs costs as a older Affordability Adults ages Children without a because of relative to their share of without a Dimension 19–64 ages 0–18 usual source cost in past annual household median dental visit Summary uninsured uninsured of care year income income in past year 2020 2018 rank 2018 rank 2018 rank 2018 rank 2017–18 rank 2018 rank 2018 rank United States — 12% — 5% — 23% — 13% — 8.3% — 6.8% — 34% — Alabama 41 16 42 4 16 22 22 16 45 11.0 48 7.7 40 39 44 Alaska 35 16 42 8 42 37 51 13 28 7.4 10 5.3 5 31 15 Arizona 43 15 38 8 42 27 41 13 28 9.3 31 7.9 41 38 40 Arkansas 37 12 28 4 16 19 15 15 38 9.8 39 9.1 49 44 49 California 20 10 20 3 5 25 35 12 20 6.6 7 6.9 32 33 27 Colorado 24 10 20 5 24 26 38 12 20 9.5 34 5.3 5 32 19 Connecticut 6 8 8 3 5 16 9 9 5 8.3 21 6.0 15 24 1 Delaware 19 8 8 4 16 18 12 11 13 9.5 34 6.3 23 34 30 District of Columbia 2 4 1 — — 22 22 8 2 4.8 1 5.4 7 26 3 Florida 48 19 47 8 42 26 38 16 45 9.0 27 8.6 48 35 32 Georgia 49 19 47 8 42 28 44 18 50 9.9 40 8.1 44 38 40 Hawaii 3 6 4 3 5 15 5 7 1 7.3 9 5.5 8 25 2 Idaho 45 16 42 7 38 29 46 15 38 11.0 48 7.1 34 35 32 Illinois 16 10 20 3 5 18 12 12 20 7.9 15 6.0 15 32 19 Indiana 24 11 26 7 38 20 18 12 20 7.5 12 5.7 10 36 38 Iowa 7 7 7 3 5 18 12 8 2 7.7 13 5.8 13 29 11 Kansas 22 12 28 5 24 22 22 12 20 8.1 19 6.2 19 32 19 Kentucky 28 8 8 3 5 19 15 13 28 9.4 33 7.9 41 38 40 Louisiana 40 12 28 3 5 23 28 15 38 9.1 29 10.0 51 42 47 Maine 21 11 26 5 24 15 5 12 20 8.9 26 6.5 27 35 32 Maryland 13 8 8 3 5 17 10 11 13 6.6 7 5.7 10 33 27 Massachusetts 1 4 1 1 1 13 1 9 5 6.1 4 5.5 8 26 3 Michigan 11 8 8 3 5 15 5 12 20 7.9 15 5.2 4 29 11 Minnesota 9 6 4 4 16 24 29 10 9 6.0 3 6.1 18 26 3 Mississippi 50 19 47 5 24 26 38 18 50 10.5 46 9.7 50 46 51 Missouri 34 13 35 5 24 24 29 13 28 10.3 44 6.5 27 37 39 Montana 30 12 28 5 24 27 41 10 9 10.4 45 6.4 24 34 30 Nebraska 29 12 28 6 35 22 22 12 20 10.1 42 6.4 24 32 19 Nevada 44 15 38 8 42 31 47 15 38 7.9 15 8.4 47 35 32 New Hampshire 8 8 8 2 2 14 2 11 13 8.3 21 5.1 2 31 15 New Jersey 17 10 20 4 16 20 18 13 28 7.4 10 6.2 19 28 6 New Mexico 36 14 37 6 35 31 47 13 28 8.0 18 8.0 43 35 32 New York 9 8 8 2 2 20 18 11 13 5.8 2 6.4 24 30 14 North Carolina 39 16 42 5 24 22 22 15 38 10.8 47 8.2 45 35 32 North Dakota 23 10 20 7 38 27 41 9 5 8.7 25 5.7 10 32 19 Ohio 18 9 17 5 24 20 18 10 9 7.8 14 6.2 19 33 27 Oklahoma 46 20 50 8 42 24 29 15 38 9.2 30 7.5 38 40 45 Oregon 27 10 20 4 16 25 35 13 28 9.3 31 6.8 30 32 19 Pennsylvania 14 8 8 4 16 15 5 9 5 8.1 19 6.2 19 31 15 Rhode Island 5 6 4 2 2 14 2 11 13 6.3 5 6.9 32 28 6 South Carolina 37 16 42 5 24 24 29 16 45 9.6 37 7.3 37 38 40 South Dakota 31 13 35 6 35 25 35 11 13 10.2 43 6.8 30 32 19 Tennessee 42 15 38 5 24 24 29 16 45 9.7 38 7.6 39 42 47 Texas 51 24 51 11 49 32 49 17 49 9.5 34 8.2 45 40 45 Utah 32 12 28 7 38 28 44 13 28 11.7 50 5.1 2 28 6 Vermont 4 5 3 — — 14 2 8 2 9.0 27 6.0 15 28 6 Virginia 26 12 28 5 24 22 22 13 28 8.3 21 7.1 34 28 6 Washington 12 9 17 3 5 24 29 11 13 6.5 6 4.1 1 31 15 West Virginia 33 9 17 3 5 19 15 15 38 9.9 40 7.2 36 45 50 Wisconsin 15 8 8 4 16 17 10 10 9 8.5 24 5.8 13 29 11 Wyoming 47 15 38 8 42 32 49 13 28 14.2 51 6.5 27 32 19 Notes: — Indicates that estimates are not available. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 33 Appendix APPENDIX C2.C2. Access Access & Affordability: & Affordability: KeyTrends Key Indicator Indicator Trends Adults age 18 and older who went without care because of Employee insurance costs as a Adults ages 19–64 uninsured cost in past year share of median income Average Average Average annual annual annual change change change 2014– 2016– 2014– 2016– 2014– 2016– 2014 2016 2018 2016 2018 2014 2016 2018 2016 2018 2014 2016 2018 2016 2018 United States 16% 12% 12% -13.4% 0.0% 14% 13% 13% -3.6% 0.0% 6.6% 6.7% 6.8% 0.8% 0.7% Alabama 18 14 16 -11.8 6.9 17 16 16 -3.0 0.0 7.6 7.5 7.7 -0.7 1.3 Alaska 22 18 16 -9.5 -5.7 12 13 13 4.1 0.0 5.1 5.6 5.3 4.8 -2.7 Arizona 18 14 15 -11.8 3.5 16 14 13 -6.5 -3.6 7.8 8.3 7.9 3.2 -2.4 Arkansas 18 12 12 -18.4 0.0 18 15 15 -8.7 0.0 7.1 7.8 9.1 4.8 8.0 California 17 10 10 -23.3 0.0 14 11 12 -11.4 4.4 7.5 6.8 6.9 -4.8 0.7 Colorado 14 10 10 -15.5 0.0 13 12 12 -3.9 0.0 5.8 5.5 5.3 -2.6 -1.8 Connecticut 9 7 8 -11.8 6.9 11 10 9 -4.7 -5.1 4.6 5.8 6.0 12.3 1.7 Delaware 10 8 8 -10.6 0.0 11 11 11 0.0 0.0 5.9 7.7 6.3 14.2 -9.5 District of Columbia 7 5 4 -15.5 -10.6 11 9 8 -9.5 -5.7 5.6 5.9 5.4 2.6 -4.3 Florida 24 18 19 -13.4 2.7 18 17 16 -2.8 -3.0 8.4 9.9 8.6 8.6 -6.8 Georgia 22 18 19 -9.5 2.7 19 17 18 -5.4 2.9 7.2 8.2 8.1 6.7 -0.6 Hawaii 7 5 6 -15.5 9.5 9 7 7 -11.8 0.0 4.3 5.5 5.5 13.1 0.0 Idaho 19 15 16 -11.1 3.3 16 14 15 -6.5 3.5 6.7 7.3 7.1 4.4 -1.4 Illinois 14 9 10 -19.8 5.4 12 11 12 -4.3 4.4 6.2 6.2 6.0 0.0 -1.6 Indiana 17 11 11 -19.6 0.0 15 13 12 -6.9 -3.9 6.9 5.6 5.7 -9.9 0.9 Iowa 8 6 7 -13.4 8.0 9 8 8 -5.7 0.0 5.1 5.4 5.8 2.9 3.6 Kansas 15 12 12 -10.6 0.0 13 12 12 -3.9 0.0 5.9 6.5 6.2 5.0 -2.3 Kentucky 12 7 8 -23.6 6.9 16 12 13 -13.4 4.1 8.2 7.2 7.9 -6.3 4.7 Louisiana 22 15 12 -17.4 -10.6 17 18 15 2.9 -8.7 8.5 9.4 10.0 5.2 3.1 Maine 14 11 11 -11.4 0.0 11 11 12 0.0 4.4 5.5 6.7 6.5 10.4 -1.5 Maryland 11 8 8 -14.7 0.0 10 11 11 4.9 0.0 5.6 6.0 5.7 3.5 -2.5 Massachusetts 5 4 4 -10.6 0.0 8 9 9 6.1 0.0 5.4 5.1 5.5 -2.8 3.8 Michigan 12 8 8 -18.4 0.0 15 13 12 -6.9 -3.9 5.6 4.8 5.2 -7.4 4.1 Minnesota 8 6 6 -13.4 0.0 9 9 10 0.0 5.4 4.6 5.1 6.1 5.3 9.4 Mississippi 22 18 19 -9.5 2.7 19 19 18 0.0 -2.7 8.9 10.1 9.7 6.5 -2.0 Missouri 16 13 13 -9.9 0.0 14 13 13 -3.6 0.0 5.7 8.0 6.5 18.5 -9.9 Montana 19 12 12 -20.5 0.0 12 11 10 -4.3 -4.7 6.4 7.6 6.4 9.0 -8.2 Nebraska 13 12 12 -3.9 0.0 12 12 12 0.0 0.0 5.7 5.9 6.4 1.7 4.2 Nevada 21 15 15 -15.5 0.0 17 16 15 -3.0 -3.2 6.8 7.7 8.4 6.4 4.4 New Hampshire 13 9 8 -16.8 -5.7 11 10 11 -4.7 4.9 5.3 5.1 5.1 -1.9 0.0 New Jersey 16 11 10 -17.1 -4.7 14 13 13 -3.6 0.0 5.2 6.1 6.2 8.3 0.8 New Mexico 21 13 14 -21.3 3.8 17 13 13 -12.6 0.0 8.6 9.6 8.0 5.7 -8.7 New York 12 9 8 -13.4 -5.7 14 11 11 -11.4 0.0 6.0 6.2 6.4 1.7 1.6 North Carolina 19 15 16 -11.1 3.3 16 16 15 0.0 -3.2 7.0 7.0 8.2 0.0 8.2 North Dakota 10 9 10 -5.1 5.4 7 8 9 6.9 6.1 4.6 5.4 5.7 8.3 2.7 Ohio 12 8 9 -18.4 6.1 13 11 10 -8.0 -4.7 5.5 5.6 6.2 0.9 5.2 Oklahoma 21 20 20 -2.4 0.0 15 15 15 0.0 0.0 7.7 7.5 7.5 -1.3 0.0 Oregon 14 9 10 -19.8 5.4 14 11 13 -11.4 8.7 7.1 5.6 6.8 -11.2 10.2 Pennsylvania 12 8 8 -18.4 0.0 12 11 9 -4.3 -9.5 4.8 5.9 6.2 10.9 2.5 Rhode Island 10 6 6 -22.5 0.0 12 10 11 -8.7 4.9 6.2 6.3 6.9 0.8 4.7 South Carolina 20 15 16 -13.4 3.3 18 16 16 -5.7 0.0 6.8 7.4 7.3 4.3 -0.7 South Dakota 13 12 13 -3.9 4.1 10 9 11 -5.1 10.6 6.3 6.7 6.8 3.1 0.7 Tennessee 17 14 15 -9.3 3.5 16 12 16 -13.4 15.5 8.9 7.2 7.6 -10.1 2.7 Texas 26 23 24 -5.9 2.2 18 18 17 0.0 -2.8 8.7 8.0 8.2 -4.1 1.2 Utah 16 12 12 -13.4 0.0 14 12 13 -7.4 4.1 6.3 5.0 5.1 -10.9 1.0 Vermont 7 5 5 -15.5 0.0 9 8 8 -5.7 0.0 5.3 5.7 6.0 3.7 2.6 Virginia 15 12 12 -10.6 0.0 13 13 13 0.0 0.0 6.2 7.0 7.1 6.3 0.7 Washington 13 9 9 -16.8 0.0 12 10 11 -8.7 4.9 5.7 6.5 4.1 6.8 -20.6 West Virginia 13 8 9 -21.6 6.1 17 15 15 -6.1 0.0 7.2 7.1 7.2 -0.7 0.7 Wisconsin 10 7 8 -16.3 6.9 11 10 10 -4.7 0.0 5.1 5.4 5.8 2.9 3.6 Wyoming 17 15 15 -6.1 0.0 12 14 13 8.0 -3.6 5.0 5.9 6.5 8.6 5.0 commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 34 AppendixD1. APPENDIX D1. Prevention Prevention & Treatment: & Treatment: Dimension Dimension Ranking Ranking and Indicatorand Indicator Rates Rates C Elderly patients w Prevention who received a m and Treatment Adults without all Adults without all Diabetic adults without high-risk Children Dimension recommended recommended an annual hemoglobin prescription without a prev Summary cancer screenings vaccines A1c test drug medical home 2020 2018 rank 2018 rank 2017 rank 2016 rank 2018 rank 2 United States — 32% — 69% — 10.7% — 9.6% — 52% — 4 Alabama 29 31 19 68 27 9.7 10 12.8 45 56 47 Alaska 48 39 49 68 27 13.1 37 9.5 25 52 29 Arizona 36 34 32 71 42 10.6 16 9.6 26 54 38 Arkansas 46 36 43 71 42 12.5 33 11.8 42 53 30 California 44 29 12 70 35 15.3 43 9.2 23 55 42 Colorado 6 34 32 65 14 11.3 22 10.9 36 49 18 Connecticut 10 25 2 67 25 12.7 34 7.4 11 45 5 Delaware 14 28 6 64 12 13.5 39 8.4 18 54 38 District of Columbia 16 26 4 57 1 — — 9.3 24 57 49 Florida 33 31 19 72 44 13.3 38 10.4 35 59 51 Georgia 39 32 23 72 44 8.7 6 12.2 44 55 42 Hawaii 2 25 2 69 30 10.3 13 4.6 1 53 30 Idaho 30 39 49 70 35 14.2 41 11.4 40 45 5 Illinois 31 34 32 70 35 11.8 30 7.2 9 53 30 Indiana 40 34 32 73 47 12.3 32 9.9 30 54 38 Iowa 1 30 17 61 4 6.5 1 6.7 6 41 1 Kansas 27 35 39 66 19 11.4 24 9.6 26 46 8 Kentucky 24 34 32 66 19 9.3 8 13.7 48 49 18 Louisiana 44 29 12 75 50 16.7 46 15.4 50 50 21 Maine 12 28 6 69 30 10.6 16 8.2 16 43 3 Maryland 14 28 6 62 5 11.2 21 8.9 20 55 42 Massachusetts 7 24 1 65 14 9.4 9 6.4 3 48 14 Michigan 13 28 6 69 30 9.0 7 8.2 16 53 30 Minnesota 3 28 6 62 5 6.8 2 6.2 2 46 8 Mississippi 50 35 39 70 35 11.9 31 15.5 51 55 42 Missouri 38 33 29 66 19 11.5 26 10.0 31 51 25 Montana 34 37 46 66 19 11.3 22 8.9 20 50 21 Nebraska 23 32 23 62 5 10.4 15 7.7 13 48 14 Nevada 51 36 43 70 35 17.3 47 11.3 39 55 42 New Hampshire 5 28 6 69 30 11.7 29 8.4 18 41 1 New Jersey 16 31 19 65 14 12.9 36 7.9 15 49 18 New Mexico 34 36 43 68 27 15.4 44 10.2 33 57 49 New York 37 29 12 74 49 12.8 35 6.4 3 56 47 North Carolina 22 30 17 60 3 7.8 4 11.2 37 54 38 North Dakota 20 35 39 62 5 10.7 18 7.3 10 48 14 Ohio 16 33 29 66 19 15.4 44 9.1 22 47 12 Oklahoma 49 38 48 64 12 10.9 19 13.7 48 53 30 Oregon 40 31 19 70 35 11.0 20 10.2 33 50 21 Pennsylvania 21 32 23 62 5 13.7 40 6.7 6 53 30 Rhode Island 9 27 5 65 14 18.4 48 6.5 5 48 14 South Carolina 43 32 23 67 25 — — 13.3 46 51 25 South Dakota 19 35 39 66 19 7.4 3 7.1 8 47 12 Tennessee 32 33 29 73 47 10.3 13 13.4 47 51 25 Texas 40 37 46 75 50 9.8 11 11.8 42 51 25 Utah 28 34 32 69 30 11.4 24 11.2 37 46 8 Vermont 4 32 23 65 14 11.6 28 7.7 13 43 3 Virginia 8 29 12 63 10 9.8 11 9.8 29 45 5 Washington 26 32 23 63 10 7.9 5 9.7 28 50 21 West Virginia 25 34 32 59 2 15.1 42 11.6 41 53 30 Wisconsin 11 29 12 72 44 11.5 26 7.4 11 46 8 Wyoming 47 41 51 70 35 22.2 49 10.0 31 53 30 Notes: — Indicates that estimates are not available. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 35 cator Rates AppendixD1. APPENDIX D1. Prevention Prevention & Treatment: & Treatment: Dimension Dimension Ranking Ranking and Indicatorand Indicator Rates Rates (continued) Children C Elderly patients without a Children who Elderly patients Hospitalsw who received a Prevention medical and did not receive who received Central a line- lower-th m s without high-risk and Children Treatment Adults dentalwithout allneeded Adults without Children all without Diabetic adults without high-risk Children associated blood average pa moglobin prescription without a Dimension preventive recommended health all recommended care mental recommended an annual hemoglobin Hospital 30-dayprescription stream infection without aexperien prev st drug medical Summary home cancer visit screenings care vaccines vaccines A1c testmortality drug (CLABSI)medical homerating 07/2015 – rank 2016 rank 2018 rank 2020 20182018rank rank 2018 2018 rank 2018 rank rank 2017 06/2018 rank rank 2016 2018 rank 2018 rank rank 2018 2 —United 9.6% States — 52% — — 42% 32% — —18% 69% — 27% — 10.7% — 13.7% — 9.6% — 0.739 — 52%— —46% 4 10Alabama 12.8 45 56 47 29 46 31 42 1913 68 13 27 21 7 9.7 14.1 10 32 12.8 0.780 45 5640 4743 37Alaska 9.5 25 52 29 48 45 39 40 4912 68 12 27 32 4313.1 14.1 37 329.5 0.694 25 5224 2937 16Arizona 9.6 26 54 38 36 46 34 42 3216 71 24 42 30 3710.6 13.4 16 139.6 0.650 26 5416 3862 33Arkansas11.8 42 53 30 46 51 36 51 4314 71 15 42 29 3112.5 14.8 33 51 11.8 0.634 42 5313 3049 43California9.2 23 55 42 44 48 29 48 1230 70 48 35 28 2715.3 13.2 43 69.2 0.793 23 5541 4257 22Colorado10.9 36 49 18 6 35 34 11 3211 65 8 14 25 1711.3 13.5 22 16 10.9 0.596 36 49 8 1815 34Connecticut 7.4 11 45 5 10 31 25 2 218 67 28 25 16 112.7 13.3 34 87.4 0.846 11 4547 563 39Delaware8.4 18 54 38 14 33 28 6 618 64 28 12 26 2213.5 13.2 39 68.4 0.649 18 5416 3867 —District of9.3 Columbia 24 57 49 16 37 26 15 424 57 46 27 1 26 — 13.0 — 39.3 0.719 24 5727 4971 38Florida 10.4 35 59 51 33 39 31 19 1910 72 5 44 30 3713.3 13.5 38 16 10.4 0.749 35 5934 5161 6Georgia12.2 44 55 42 39 40 32 21 2321 72 40 44 23 13 8.7 13.9 6 27 12.2 0.772 44 5539 4243 13Hawaii 4.6 1 53 30 2 44 25 37 29 69 4 30 29 3110.3 13.3 13 84.6 0.3371 53 2 3042 41Idaho 11.4 40 45 5 30 43 39 34 4911 70 8 35 29 3114.2 14.3 41 42 11.4 0.483 40 45 4 527 30Illinois 7.2 9 53 30 31 42 34 31 3222 70 43 35 24 1511.8 13.3 30 87.2 0.6439 5314 3044 32Indiana 9.9 30 54 38 40 40 34 21 3217 73 27 47 36 4912.3 14.0 32 299.9 0.679 30 5420 3825 1Iowa 6.7 6 41 1 1 33 30 6 1713 61 13 26 4 22 6.5 14.7 1 506.7 0.8386 4146 134 24Kansas 9.6 26 46 8 27 40 35 21 3910 66 5 19 25 1711.4 14.3 24 429.6 0.738 26 4633 825 8Kentucky13.7 48 49 18 24 36 34 12 3215 66 20 19 4 9.3 14.0 8 29 13.7 0.646 48 4915 1839 46Louisiana 15.4 50 50 21 44 47 29 47 1221 75 40 50 28 2716.7 13.6 46 22 15.4 0.732 50 5031 2131 16Maine 8.2 16 43 3 12 32 28 4 619 69 36 30 24 1510.6 13.9 16 278.2 0.729 16 4330 353 21Maryland8.9 20 55 42 14 38 28 17 618 62 28 26 5 2211.2 13.5 21 168.9 0.796 20 5542 42— 9Massachusetts 6.4 3 48 14 7 29 24 1 139 65 51 14 18 2 9.4 12.5 9 16.4 0.8663 4849 1463 7Michigan8.2 16 53 30 13 43 28 34 616 69 24 30 29 31 9.0 13.3 7 88.2 0.678 16 5320 3040 2Minnesota 6.2 2 46 8 3 41 28 27 615 62 20 33 5 45 6.8 13.4 2 136.2 0.7662 4636 823 31Mississippi 15.5 51 55 42 50 50 35 50 3918 70 28 35 29 3111.9 14.5 31 47 15.5 0.864 51 5548 4243 26Missouri10.0 31 51 25 38 46 33 42 2918 66 28 19 33 4511.5 13.8 26 24 10.0 0.825 31 5145 2539 22Montana8.9 20 50 21 34 34 37 8 4614 66 15 19 38 5111.3 14.3 22 428.9 0.680 20 5022 2136 15Nebraska 7.7 13 48 14 23 44 32 37 2316 62 24 22 5 1010.4 14.5 15 477.7 0.616 13 4810 1437 47Nevada11.3 39 55 42 51 49 36 49 4335 70 50 35 36 4917.3 13.8 47 24 11.3 0.923 39 5551 4265 29New Hampshire 8.4 18 41 1 5 31 28 2 619 69 36 30 19 411.7 13.5 29 168.4 0.585 18 41 7 146 36New Jersey7.9 15 49 18 16 34 31 8 19 7 65 2 14 30 3712.9 13.0 36 37.9 0.724 15 4928 1875 44New Mexico 10.2 33 57 49 34 41 36 27 4314 68 15 27 23 1315.4 13.7 44 23 10.2 0.398 33 57 3 4968 35New York 6.4 3 56 47 37 45 29 40 1218 74 28 49 31 4012.8 13.4 35 136.4 0.8063 5643 4781 4North Carolina 11.2 37 54 38 22 41 30 27 1718 60 28 22 3 10 7.8 14.1 4 32 11.2 0.899 37 5450 3847 18North Dakota 7.3 10 48 14 20 43 35 34 39 5 62 1 18 5 210.7 14.2 18 407.3 0.650 10 4816 1483 44Ohio 9.1 22 47 12 16 39 33 19 2911 66 8 19 25 1715.4 13.1 44 59.1 0.712 22 4725 1240 19Oklahoma13.7 48 53 30 49 46 38 42 4824 64 46 12 31 4010.9 14.1 19 32 13.7 0.711 48 5325 3035 20Oregon10.2 33 50 21 40 37 31 15 1923 70 45 35 34 4711.0 14.3 20 42 10.2 0.523 33 50 5 2129 40Pennsylvania 6.7 6 53 30 21 38 32 17 2319 62 36 20 5 613.7 13.3 40 86.7 0.7356 5332 3051 48Rhode Island 6.5 5 48 14 9 36 27 12 514 65 15 14 25 1718.4 12.9 48 26.5 0.7675 4837 1450 —South Carolina 13.3 46 51 25 43 41 32 27 2330 67 48 25 17 — 14.1 — 32 13.3 0.807 46 5144 2541 3South Dakota 7.1 8 47 12 19 40 35 21 39 7 66 2 19 31 40 7.4 14.3 3 427.1 0.6878 4723 1227 13Tennessee 13.4 47 51 25 32 42 33 31 2921 73 40 47 29 3110.3 14.1 13 32 13.4 0.677 47 5119 2541 11Texas 11.8 42 51 25 40 46 37 42 4611 75 8 50 28 27 9.8 13.5 11 16 11.8 0.771 42 5138 2534 24Utah 11.2 37 46 8 28 44 34 37 3215 69 20 30 26 2211.4 14.1 24 32 11.2 0.620 37 4611 826 28Vermont7.7 13 43 3 4 34 32 8 2310 65 5 14 21 711.6 14.0 28 297.7 0.753 13 4335 333 11Virginia 9.8 29 45 5 8 32 29 4 1218 63 28 10 22 10 9.8 13.5 11 169.8 0.620 29 4511 543 5Washington9.7 28 50 21 26 40 32 21 2315 63 20 10 35 48 7.9 14.2 5 409.7 0.535 28 50 6 2152 42West Virginia 11.6 41 53 30 25 36 34 12 3222 59 43 28 2 2715.1 13.8 42 24 11.6 0.724 41 5328 3056 26Wisconsin 7.4 11 46 8 11 42 29 31 1220 72 39 44 21 711.5 14.1 26 327.4 0.603 11 46 9 823 49Wyoming 10.0 31 53 30 47 40 41 21 5114 70 15 35 32 4322.2 14.5 49 47 10.0 0.087 31 53 1 3056 Notes: — Indicates that estimates are not available. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 36 AppendixD1. APPENDIX D1. Prevention Prevention & Treatment: & Treatment: Dimension Dimension Ranking Ranking and Indicatorand Indicator Rates Rates (continued) C Hospitals with Adults Elderly withpatients any w Central line- Prevention lower-than- Home health Nursing home Adults with any mental who illness received a m associated blood and Treatment average patient Adults patients without who did all not Adults withoutwith residents all an Diabetic adults mental without who high-risk illness did not Children l 30-day stream infection Dimension experience recommended get better at walkingrecommended antipsychotican annual reporting hemoglobin receive prescription without a prev ality (CLABSI) Summary ratings cancer or moving screenings around vaccines medication unmet A1c test need treatment drug medical home – 8 rank 2018 rank 2018 2020 rank 2018 2018 rankrank 20182017 rank rank 2016–17 2017 rankrank 2016–17 2016 rank rank 2018 rank 2 % —United0.739 States — 46% —— 32% 22% — — 69% 15% — — 10.7% 22% — — 57% 9.6% —— 52% — 4 1 32 Alabama0.780 40 43 2925 31 17 19 1 68 19 27 44 9.714 1 10 64 12.8 47 45 56 47 1 32 Alaska 0.694 24 37 4816 39 35 49 51 68 12 27 5 13.122 15 37 629.5 44 25 52 29 4 13 Arizona 0.650 16 62 3641 34 24 32 33 71 14 42 12 10.621 12 16 619.6 42 26 54 38 8 51 Arkansas0.634 13 49 4632 36 19 43 4 71 15 42 16 12.525 39 33 53 11.8 15 42 53 30 2 California 6 0.793 41 57 4439 29 24 12 33 70 11 35 2 15.322 15 43 659.2 50 23 55 42 5 16 Colorado0.596 8 15 61 34 22 32 20 65 15 14 16 11.322 15 22 49 10.9 6 36 49 18 3 Connecticut 8 0.846 47 63 1042 25 25 2 40 67 16 25 27 12.723 30 34 567.4 28 11 45 5 2 Delaware 6 0.649 16 67 1445 28 25 6 40 64 14 12 12 13.522 15 39 488.4 5 18 54 38 0 District 3 of0.719 Columbia 27 71 1647 26 21 4 13 57 11 1 2 —25 39 — 559.3 23 24 57 49 5 16 Florida 0.749 34 61 3340 31 20 19 7 72 15 44 16 13.322 15 38 59 10.4 37 35 59 51 9 27 Georgia 0.772 39 43 3925 32 20 23 7 72 19 44 44 8.723 30 6 61 12.2 42 44 55 42 3 Hawaii 8 0.337 2 42 224 25 28 2 48 69 7 30 1 10.315 2 13 654.6 50 1 53 30 3 42 Idaho 0.483 4 27 30 7 39 20 49 7 70 18 35 40 14.222 15 41 57 11.4 33 40 45 5 3 Illinois 8 0.643 14 44 3129 34 24 32 33 70 19 35 44 11.822 15 30 567.2 28 9 53 30 0 29 Indiana 0.679 20 25 40 4 34 24 32 33 73 15 47 16 12.325 39 32 549.9 19 30 54 38 7 50 Iowa 0.838 46 34 112 30 23 17 24 61 15 4 16 6.518 3 1 476.7 4 6 41 1 3 42 Kansas 0.738 33 25 27 4 35 21 39 13 66 19 19 44 11.426 46 24 579.6 33 26 46 8 0 29 Kentucky0.646 15 39 2418 34 20 32 7 66 19 19 44 9.323 30 8 55 13.7 23 48 49 18 6 22 Louisiana0.732 31 31 4410 29 20 12 7 75 17 50 35 16.720 7 46 62 15.4 44 50 50 21 9 27 Maine 0.729 30 53 1236 28 24 6 33 69 18 30 40 10.620 7 16 508.2 7 16 43 3 5 16 Maryland0.796 42 — 14— 28 20 6 7 62 13 5 7 11.223 30 21 568.9 28 20 55 42 5 Massachusetts 1 0.866 49 63 742 24 21 1 13 65 18 14 40 9.422 15 9 526.4 14 3 48 14 3 Michigan 8 0.678 20 40 1320 28 23 6 24 69 13 30 7 9.022 15 7 518.2 9 16 53 30 4 13 Minnesota 0.766 36 23 32 28 27 6 47 62 14 5 12 6.819 4 2 506.2 7 2 46 8 5 47 Mississippi0.864 48 43 5025 35 17 39 1 70 19 35 44 11.922 15 31 55 15.5 23 51 55 42 8 24 Missouri 0.825 45 39 3818 33 22 29 20 66 19 19 44 11.525 39 26 51 10.0 9 31 51 25 3 42 Montana0.680 22 36 3415 37 28 46 48 66 15 19 16 11.323 30 22 588.9 36 20 50 21 5 47 Nebraska0.616 10 37 2316 32 24 23 33 62 18 5 40 10.423 30 15 537.7 15 13 48 14 8 24 Nevada 0.923 51 65 5144 36 25 43 40 70 16 35 27 17.329 48 47 64 11.3 47 39 55 42 5 16 New Hampshire 0.585 7 46 530 28 23 6 24 69 15 30 16 11.729 48 29 458.4 2 18 41 1 0 New 3 Jersey 0.724 28 75 1648 31 23 19 24 65 11 14 2 12.923 30 36 607.9 38 15 49 18 7 23 New Mexico 0.398 3 68 3446 36 25 43 40 68 16 27 27 15.424 37 44 54 10.2 19 33 57 49 4 13 New York 0.806 43 81 3749 29 23 12 24 74 12 49 5 12.820 7 35 606.4 38 3 56 47 1 32 North Carolina 0.899 50 47 2231 30 21 17 13 60 13 3 7 7.822 15 4 55 11.2 23 37 54 38 2 40 North Dakota 0.650 16 83 2050 35 21 39 13 62 17 5 35 10.721 12 18 567.3 28 10 48 14 1 Ohio 5 0.712 25 40 1620 33 23 29 24 66 16 19 27 15.420 7 44 549.1 19 22 47 12 1 32 Oklahoma 0.711 25 35 4914 38 21 48 13 64 20 12 51 10.922 15 19 60 13.7 38 48 53 30 3 42 Oregon 0.523 5 29 40 9 31 26 19 44 70 15 35 16 11.029 48 20 60 10.2 38 33 50 21 3 Pennsylvania 8 0.735 32 51 2134 32 22 23 20 62 16 5 27 13.725 39 40 546.7 19 6 53 30 9 Rhode 2 Island 0.767 37 50 933 27 22 5 20 65 16 14 27 18.424 37 48 466.5 3 5 48 14 1 32 South Carolina 0.807 44 41 4322 32 21 23 13 67 14 25 12 —25 39 — 57 13.3 33 46 51 25 3 42 South Dakota 0.687 23 27 19 7 35 23 39 24 66 17 19 35 7.422 15 3 567.1 28 8 47 12 1 32 Tennessee 0.677 19 41 3222 33 19 29 4 73 17 47 35 10.322 15 13 51 13.4 9 47 51 25 5 16 Texas 0.771 38 34 4012 37 26 46 44 75 16 50 27 9.819 4 11 62 11.8 44 42 51 25 1 32 Utah 0.620 11 26 28 6 34 19 32 4 69 16 30 27 11.431 51 24 51 11.2 9 37 46 8 0 29 Vermont0.753 35 33 411 32 26 23 44 65 17 14 35 11.621 12 28 417.7 1 13 43 3 5 16 Virginia 0.620 11 43 825 29 23 12 24 63 15 10 16 9.828 47 11 559.8 23 29 45 5 2 40 Washington 0.535 6 52 2635 32 24 23 33 63 15 10 16 7.925 39 5 539.7 15 28 50 21 8 24 West Virginia 0.724 28 56 2537 34 18 32 3 59 15 2 16 15.120 7 42 51 11.6 9 41 53 30 1 32 Wisconsin 0.603 9 23 11 2 29 23 12 24 72 13 44 7 11.522 15 26 537.4 15 11 46 8 5 47 Wyoming0.087 1 56 4737 41 28 51 48 70 13 35 7 22.219 4 49 64 10.0 47 31 53 30 Notes: — Indicates that estimates are not available. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 37 Appendix D2. Prevention & Treatment: Key Indicator Trends APPENDIX D2. Prevention & Treatment: Key Indicator Trends Adult diabetic patients ages 18–64 with employer- Children ages 19–35 Adults age 18 and older Adults without all age- sponsored insurance months who did not with any mental illness and gender-appropriate without a hemoglobin A1c receive all recommended who did not receive cancer screenings test during the year vaccines treatment 2012– 2016– 2014 2018 2015 2017 2014 2018 14 17 United States 32% 32% No Change 16.9% 10.7% Improved 28% 27% No Change 57% 57% No Change Alabama 33 31 Improved 15.2 9.7 Improved 23 21 No Change 54 64 Worsened Alaska 38 39 No Change 16.4 13.1 Improved 33 32 No Change 61 62 No Change Arizona 34 34 No Change 15.9 10.6 Improved 34 30 Improved 59 61 No Change Arkansas 37 36 No Change 17.7 12.5 Improved 34 29 Improved 51 53 No Change California 30 29 No Change 19.2 15.3 Improved 22 28 Worsened 62 65 Worsened Colorado 32 34 Worsened 16.6 11.3 Improved 27 25 No Change 62 49 Improved Connecticut 25 25 No Change 20.9 12.7 Improved 27 16 Improved 50 56 Worsened Delaware 28 28 No Change 20.8 13.5 Improved 25 26 No Change 52 48 Improved District of Columbia 27 26 No Change — — — 29 27 No Change 55 55 No Change Florida 33 31 Improved 18.9 13.3 Improved 27 30 Worsened 62 59 Improved Georgia 30 32 Worsened 14.8 8.7 Improved 26 23 Improved 62 61 No Change Hawaii 30 25 Improved 15.2 10.3 Improved 26 29 Worsened 66 65 No Change Idaho 40 39 No Change 16.4 14.2 Improved 34 29 Improved 53 57 Worsened Illinois 34 34 No Change 17.8 11.8 Improved 32 24 Improved 55 56 No Change Indiana 38 34 Improved 18.4 12.3 Improved 34 36 No Change 57 54 Improved Iowa 30 30 No Change 15.1 6.5 Improved 29 26 Improved 45 47 No Change Kansas 34 35 No Change 16.2 11.4 Improved 24 25 No Change 53 57 Worsened Kentucky 33 34 No Change 14.4 9.3 Improved 28 19 Improved 52 55 Worsened Louisiana 33 29 Improved 17.0 16.7 No Change 27 28 No Change 59 62 Worsened Maine 27 28 No Change 16.8 10.6 Improved 15 24 Worsened 45 50 Worsened Maryland 27 28 No Change 16.4 11.2 Improved 26 26 No Change 57 56 No Change Massachusetts 23 24 No Change 16.3 9.4 Improved 25 18 Improved 46 52 Worsened Michigan 29 28 No Change 15.5 9.0 Improved 35 29 Improved 53 51 No Change Minnesota 28 28 No Change 11.0 6.8 Improved 30 33 Worsened 46 50 Worsened Mississippi 36 35 No Change 14.8 11.9 Improved 29 29 No Change 61 55 Improved Missouri 36 33 Improved 17.9 11.5 Improved 30 33 Worsened 51 51 No Change Montana 37 37 No Change 16.0 11.3 Improved 33 38 Worsened 54 58 Worsened Nebraska 33 32 No Change 18.5 10.4 Improved 20 22 No Change 56 53 Improved Nevada 37 36 No Change 19.6 17.3 Improved 32 36 Worsened 68 64 Improved New Hampshire 28 28 No Change 20.9 11.7 Improved 20 19 No Change 49 45 Improved New Jersey 31 31 No Change 18.6 12.9 Improved 33 30 Improved 56 60 Worsened New Mexico 37 36 No Change 19.6 15.4 Improved 24 23 No Change 57 54 Improved New York 30 29 No Change 21.2 12.8 Improved 29 31 No Change 60 60 No Change North Carolina 28 30 Worsened 13.4 7.8 Improved 19 22 Worsened 49 55 Worsened North Dakota 34 35 No Change 14.6 10.7 Improved 29 18 Improved 58 56 No Change Ohio 34 33 No Change 18.4 15.4 Improved 32 25 Improved 54 54 No Change Oklahoma 40 38 Improved 15.8 10.9 Improved 27 31 Worsened 58 60 No Change Oregon 32 31 No Change 16.0 11.0 Improved 35 34 No Change 53 60 Worsened Pennsylvania 32 32 No Change 18.9 13.7 Improved 21 20 No Change 52 54 No Change Rhode Island 25 27 Worsened 23.7 18.4 Improved 24 25 No Change 55 46 Improved South Carolina 33 32 No Change — — — 27 25 No Change 55 57 No Change South Dakota 31 35 Worsened 13.2 7.4 Improved 24 31 Worsened 53 56 Worsened Tennessee 32 33 No Change 13.5 10.3 Improved 28 29 No Change 57 51 Improved Texas 36 37 No Change 15.0 9.8 Improved 36 28 Improved 60 62 No Change Utah 32 34 Worsened 15.2 11.4 Improved 29 26 Improved 56 51 Improved Vermont 30 32 Worsened 19.3 11.6 Improved 28 21 Improved 43 41 No Change Virginia 29 29 No Change 14.2 9.8 Improved 26 22 Improved 51 55 Worsened Washington 31 32 No Change 12.7 7.9 Improved 33 35 No Change 59 53 Improved West Virginia 35 34 No Change 19.6 15.1 Improved 37 28 Improved 54 51 Improved Wisconsin 27 29 Worsened 13.7 11.5 Improved 29 21 Improved 53 53 No Change Wyoming 40 41 No Change 22.4 22.2 No Change 36 32 Improved 53 64 Worsened Notes: — Indicates that estimates are not available. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 38 AppendixE1.E1. APPENDIX Avoidable Avoidable Hospital Hospital UseDimension Use & Cost: & Cost: Ranking Dimension Ranking and Indicator and Indicator Rates Rates Potentially Potentially Avoidable Hospital avoidable avoidable Use and Cost emergency emergency Preventable Preventable Hospi Dimension department visits department visits hospitalizations hospitalizations age readmi Summary ages 18–64 age 65 and older ages 18–64 65 and older ages 2020 2017 rank 2016 rank 2017 rank 2018 rank 2017 United States — 149.5 — 189.4 — 6.8 — 41.6 — 3.2 Alabama 27 163.0 37 188.3 28 7.9 49 52.8 47 2. Alaska 8 152.4 30 207.2 42 6.4 11 23.7 4 2. Arizona 9 146.8 28 183.7 26 6.6 18 27.0 7 3. Arkansas 36 170.3 43 193.4 34 6.8 27 46.6 39 3. California 21 97.9 7 172.3 14 6.2 3 33.5 14 2. Colorado 4 110.9 11 174.0 15 6.1 2 23.4 3 2. Connecticut 31 140.0 26 193.4 34 6.3 4 43.1 30 2. Delaware 34 98.0 7 168.7 8 7.5 47 42.5 29 3. District of Columbia 42 — — 243.3 50 — — 47.5 41 — Florida 47 206.2 47 190.4 30 7.4 46 44.3 34 3. Georgia 32 169.1 42 193.0 33 6.9 32 44.1 33 3. Hawaii 1 156.8 32 140.9 1 6.6 18 20.4 1 3. Idaho 5 117.6 14 176.3 18 6.3 4 23.9 5 3. Illinois 38 150.5 29 192.4 32 6.8 27 48.5 45 3. Indiana 41 162.4 35 199.8 39 7.0 38 46.3 37 3. Iowa 12 116.7 13 182.9 25 6.5 15 34.6 16 3. Kansas 29 139.4 25 177.2 19 6.9 32 39.5 25 3. Kentucky 45 121.9 18 223.5 46 7.2 42 56.0 51 3. Louisiana 48 162.8 36 223.9 47 6.7 24 54.8 48 3. Maine 21 135.6 23 212.0 43 6.6 18 35.6 19 2. Maryland 23 122.6 19 181.0 21 7.0 38 38.4 23 3. Massachusetts 37 95.4 5 196.6 38 6.4 11 50.1 46 3. Michigan 39 166.8 39 218.4 45 7.3 43 47.8 43 3. Minnesota 13 96.0 6 182.6 23 6.3 4 33.1 12 3. Mississippi 50 173.7 45 229.3 49 7.3 43 55.0 49 3. Missouri 46 258.1 49 202.2 41 7.3 43 45.7 36 3. Montana 7 127.6 20 170.3 10 6.3 4 28.7 10 3. Nebraska 14 118.8 15 155.2 3 6.8 27 34.7 17 3. Nevada 40 224.3 48 172.1 12 7.1 40 38.0 22 3. New Hampshire 26 105.5 9 179.4 20 6.3 4 39.2 24 3. New Jersey 35 107.5 10 167.5 6 6.5 15 44.7 35 3. New Mexico 10 133.3 22 187.0 27 6.5 15 28.5 9 2. New York 28 93.0 4 172.0 12 6.3 4 43.2 31 2. North Carolina 18 163.9 38 201.5 40 6.7 24 41.9 27 3. North Dakota 11 158.1 33 166.6 5 6.6 18 35.9 20 3. Ohio 44 168.7 41 217.2 44 6.9 32 47.8 43 3. Oklahoma 49 171.8 44 226.2 48 6.9 32 47.5 41 3. Oregon 2 84.2 1 170.5 11 6.0 1 26.6 6 2. Pennsylvania 32 111.7 12 181.0 21 6.8 27 46.3 37 3. Rhode Island 29 120.4 17 182.6 23 6.9 32 42.4 28 3. South Carolina 16 — — 175.4 17 — — 37.8 21 — South Dakota 20 118.9 16 153.2 2 6.7 24 34.3 15 3. Tennessee 24 167.4 40 195.2 37 7.1 40 47.4 40 3. Texas 42 196.6 46 194.4 36 6.9 32 44.0 32 3. Utah 3 86.9 2 155.1 3 6.4 11 22.6 2 2. Vermont 15 136.3 24 174.9 16 6.6 18 33.4 13 3. Virginia 19 145.4 27 189.1 29 6.6 18 39.7 26 3. Washington 6 89.5 3 169.9 9 6.3 4 27.5 8 3. West Virginia 51 160.3 34 244.9 51 7.7 48 55.7 50 3. Wisconsin 24 155.5 31 191.5 31 6.4 11 35.1 18 3. Wyoming 17 127.9 20 167.8 7 6.8 27 32.5 11 2. Notes: — Indicates that estimates are not available. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 39 ndicator Appendix Rates E1.E1. APPENDIX Avoidable Avoidable Hospital Hospital UseDimension Use & Cost: & Cost: Ranking Dimension Ranking and Indicator and(continued) Rates Indicator Rates Potentially Potentially Avoidable Hospital avoidable avoidable Skilled nursing Nursing home Home health Adults ble Preventable Hospital Use and30-day Cost Hospital emergency 30-day facility patients Preventable emergency residents with a patients with a Preventable inappro Hospi ions hospitalizations age readmission Dimensionrate readmission department visits rate agedepartment with a hospital visits hospitalizations hospital hospitalizations hospital age readmi lower b 64 65 and older ages Summary 18–64 ages 65 and 18–64 older age 65 readmission and older ages admission 18–64 65 admission and older imag ages rank 2018 rank 2017 rank 2020 2017 2018 rankrank 2016 2016 rankrank 2017 2016 rank rank 2018 2018 rank rank 2017 2017 — United 41.6 States — 3.2 —— 149.5 40.0 — — 189.419% —— 6.8 15% —— 16% 41.6 — — 70.1%3.2 49 Alabama 52.8 47 2.3 127 163.0 43.2 37 35 188.3 20 28 32 7.919 4939 52.8 17 43 47 57.52. 11 Alaska 23.7 4 2.9 78 152.4 24.2 30 4 207.2 11 42 1 6.413 1114 23.7 15 9 4 73.52. 18 Arizona27.0 7 3.3 349 146.8 28.4 28 11 183.7 19 26 22 6.6 7 18 2 27.0 14 1 7 66.93. 27 Arkansas 46.6 39 3.3 3436 170.3 41.0 43 31 193.4 22 34 47 6.823 2748 46.6 16 19 39 65.43. 3 California 33.5 14 2.8 421 97.9 36.8 7 22 172.3 20 14 32 6.219 339 33.5 14 1 14 73.42. 2 Colorado 23.4 3 2.8 44 110.9 24.4 11 5 174.0 15 15 6 6.1 9 25 23.4 15 9 3 69.22. 4 Connecticut 43.1 30 2.9 731 140.0 46.8 26 46 193.4 19 34 22 6.313 414 43.1 16 19 30 68.12. 47 Delaware 42.5 29 3.4 4234 98.0 35.4 7 21 168.7 19 8 22 7.516 4728 42.5 15 9 29 69.93. — District47.5 of Columbia 41 — —42 43.7 — — 37 243.3 19 50 22 —19 —39 47.5 14 1 41 —— 46 Florida 44.3 34 3.5 4447 206.2 46.3 47 44 190.4 21 30 43 7.421 4646 44.3 15 9 34 65.13. 32 Georgia44.1 33 3.2 2632 169.1 40.3 42 27 193.0 20 33 32 6.916 3228 44.1 17 43 33 62.63. 18 Hawaii20.4 1 3.1 191 156.8 18.5 32 1 140.9 13 1 2 6.6 5 18 1 20.4 14 1 1 73.53. 4 Idaho 23.9 5 3.2 265 117.6 22.9 14 3 176.3 13 18 2 6.311 48 23.9 14 1 5 69.43. 27 Illinois 48.5 45 3.1 1938 150.5 47.4 29 47 192.4 20 32 32 6.817 2734 48.5 16 19 45 68.93. 38 Indiana46.3 37 3.3 3441 162.4 40.7 35 29 199.8 18 39 20 7.017 3834 46.3 16 19 37 65.63. 15 Iowa 34.6 16 3.2 2612 116.7 29.7 13 12 182.9 16 25 12 6.514 1521 34.6 16 19 16 75.73. 32 Kansas39.5 25 3.3 3429 139.4 38.0 25 26 177.2 17 19 16 6.919 3239 39.5 17 43 25 71.13. 42 Kentucky 56.0 51 3.5 4445 121.9 49.5 18 50 223.5 21 46 43 7.221 4246 56.0 16 19 51 65.63. 24 Louisiana54.8 48 3.1 1948 162.8 45.1 36 41 223.9 24 47 50 6.726 2450 54.8 16 19 48 62.33. 18 Maine 35.6 19 2.7 221 135.6 32.2 23 15 212.0 16 43 12 6.612 1810 35.6 16 19 19 74.42. 38 Maryland 38.4 23 3.0 1223 122.6 41.4 19 33 181.0 19 21 22 7.016 3828 38.4 15 9 23 67.93. 11 Massachusetts 50.1 46 3.2 2637 95.4 48.1 5 48 196.6 20 38 32 6.413 1114 50.1 17 43 46 71.63. 43 Michigan 47.8 43 3.5 4439 166.8 49.0 39 49 218.4 20 45 32 7.315 4323 47.8 16 19 43 68.63. 4 Minnesota33.1 12 3.3 3413 96.0 37.4 6 25 182.6 16 23 12 6.3 7 42 33.1 16 19 12 72.63. 43 Mississippi 55.0 49 3.1 1950 173.7 45.3 45 42 229.3 22 49 47 7.328 4351 55.0 17 43 49 64.73. 43 Missouri45.7 36 3.3 3446 258.1 44.4 49 39 202.2 20 41 32 7.317 4334 45.7 16 19 36 65.03. 4 Montana 28.7 10 3.0 127 127.6 25.0 20 7 170.3 14 10 5 6.313 414 28.7 15 9 10 69.33. 27 Nebraska 34.7 17 3.0 1214 118.8 33.0 15 18 155.2 15 3 6 6.816 2728 34.7 16 19 17 74.83. 40 Nevada38.0 22 3.5 4440 224.3 40.7 48 29 172.1 24 12 50 7.120 4044 38.0 16 19 22 64.73. 4 New Hampshire 39.2 24 3.2 2626 105.5 35.2 9 20 179.4 17 20 16 6.313 414 39.2 17 43 24 65.53. 15 New Jersey 44.7 35 3.1 1935 107.5 44.3 10 38 167.5 21 6 43 6.518 1537 44.7 16 19 35 67.83. 15 New Mexico 28.5 9 2.9 710 133.3 27.0 22 8 187.0 18 27 20 6.513 1514 28.5 14 1 9 74.22. 4 New York 43.2 31 2.9 728 93.0 46.7 4 45 172.0 20 12 32 6.313 414 43.2 16 19 31 69.02. 24 North Carolina 41.9 27 3.0 1218 163.9 37.2 38 23 201.5 19 40 22 6.716 2428 41.9 16 19 27 64.93. 18 North Dakota 35.9 20 3.1 1911 158.1 32.5 33 16 166.6 15 5 6 6.614 1821 35.9 15 9 20 68.13. 32 Ohio 47.8 43 3.3 3444 168.7 44.9 41 40 217.2 20 44 32 6.912 3210 47.8 16 19 43 67.73. 32 Oklahoma 47.5 41 3.6 4949 171.8 41.5 44 34 226.2 22 48 47 6.923 3248 47.5 16 19 41 64.03. 1 Oregon26.6 6 2.7 22 84.2 24.9 1 6 170.5 17 11 16 6.0 9 15 26.6 14 1 6 75.52. 27 Pennsylvania 46.3 37 3.3 3432 111.7 43.6 12 36 181.0 19 21 22 6.812 2710 46.3 17 43 37 69.23. 32 Rhode Island 42.4 28 3.2 2629 120.4 45.3 17 42 182.6 19 23 22 6.9 8 32 4 42.4 17 43 28 65.13. — South Carolina 37.8 21 — —16 32.7 — — 17 175.4 20 17 32 —18 —37 37.8 16 19 21 —— 24 South Dakota 34.3 15 3.2 2620 118.9 30.8 16 14 153.2 15 2 6 6.715 2423 34.3 16 19 15 76.43. 40 Tennessee47.4 40 3.0 1224 167.4 41.0 40 31 195.2 19 37 22 7.119 4039 47.4 16 19 40 63.03. 32 Texas 44.0 32 3.5 4442 196.6 40.3 46 27 194.4 21 36 43 6.920 3244 44.0 15 9 32 64.23. 11 Utah 22.6 2 2.9 73 86.9 21.9 2 2 155.1 13 3 2 6.410 11 7 22.6 14 1 2 71.52. 18 Vermont 33.4 13 3.0 1215 136.3 30.4 24 13 174.9 16 16 12 6.615 1823 33.4 16 19 13 72.63. 18 Virginia39.7 26 3.0 1219 145.4 37.2 27 23 189.1 19 29 22 6.615 1823 39.7 16 19 26 65.23. 4 Washington 27.5 8 3.1 196 89.5 27.7 3 10 169.9 15 9 6 6.312 410 27.5 15 9 8 75.73. 48 West Virginia 55.7 50 3.2 2651 160.3 51.1 34 51 244.9 20 51 32 7.716 4828 55.7 17 43 50 64.23. 11 Wisconsin35.1 18 3.4 4224 155.5 33.0 31 18 191.5 17 31 16 6.411 11 8 35.1 15 9 18 72.53. 27 Wyoming 32.5 11 2.8 417 127.9 27.5 20 9 167.8 15 7 6 6.815 2723 32.5 16 19 11 71.12. Notes: — Indicates that estimates are not available. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 40 AppendixE1.E1. APPENDIX Avoidable Avoidable Hospital Hospital UseDimension Use & Cost: & Cost: Ranking Dimension Ranking and Indicator and(continued) Rates Indicator Rates Employer- Potentially Potentially g home Home health Avoidable Adults with Hospital sponsored avoidable Total avoidable Medicare Primary care Primary care ts with a patients with a inappropriate Use and Cost insurance emergency (Parts A & B) emergency spending as share spending Preventable as share Preventable Hospi spital hospital lower Dimension back department spending pervisits reimbursements department visits hospitalizations of total, ages of hospitalizations total, age 65 age readmi ission admission imaging Summary enrollee ages 18–64 age per65 enrollee and older ages 18–64 18–64 and 65older and older ages rank 2018 rank 2017 rank 2020 2017 2017 rank rank 2018 2016 rank 2018 2017 rank rank 2017 2018 rank rank 2017 % —United 16% States — 70.1% —— $5,137 149.5 —— $9,847 189.4 — 6.0% 6.8 —— 5.7%41.6 — — 3.2 9 39 Alabama 17 43 57.5 127 4,068 163.0 537 10,758 188.3 28 46 7.3 7.9 1249 6.3 52.8 7 47 2. 3 14 Alaska 15 9 73.5 41 8 8,104 152.4 4930 7,109 207.2 422 11.3 6.4 111 5.8 23.7 20 4 2. 7 2 Arizona 14 1 66.9 19 9 4,962 146.8 2128 9,003 183.7 26 19 6.4 6.6 1818 6.4 27.0 6 7 3. 3 48 Arkansas 16 19 65.4 1536 3,874 170.3 243 10,068 193.4 34 38 7.0 6.8 1527 6.0 46.6 17 39 3. 9 39 California 14 1 73.4 4021 5,376 97.9 38 7 9,529 172.3 14 27 5.0 6.2 41 3 5.1 33.5 48 14 2. 9 5 Colorado 15 9 69.2 28 4 5,057 110.9 2711 8,504 174.0 15 11 5.6 6.1 32 2 6.1 23.4 15 3 2. 3 14 Connecticut16 19 68.1 2331 5,447 140.0 4126 10,525 193.4 34 44 6.4 6.3 18 4 5.3 43.1 35 30 2. 6 28 Delaware 15 9 69.9 3234 5,173 98.0 33 7 9,480 168.7 25 8 4.5 7.5 4647 5.3 42.5 35 29 3. 9 39 District of Columbia 14 1 — —42 —— —— 9,624 243.3 50 28 —— —— 5.2 47.5 41 41 — 1 46 Florida 15 9 65.1 1247 5,176 206.2 3347 11,316 190.4 30 50 4.7 7.4 4546 6.1 44.3 13 34 3. 6 28 Georgia 17 43 62.6 332 5,063 169.1 2842 9,840 193.0 33 30 6.2 6.9 2332 6.1 44.1 12 33 3. 5 1 Hawaii 14 1 73.5 41 1 3,948 156.8 332 6,473 140.9 1 6.2 6.6 2218 5.7 20.4 22 1 3. 1 8 Idaho 14 1 69.4 31 5 5,225 117.6 3514 8,328 176.3 189 7.2 6.3 14 4 5.3 23.9 37 5 3. 7 34 Illinois 16 19 68.9 2638 5,110 150.5 3029 10,226 192.4 32 41 5.8 6.8 3027 5.6 48.5 24 45 3. 7 34 Indiana 16 19 65.6 1741 5,799 162.4 4635 9,925 199.8 39 33 3.9 7.0 4838 5.2 46.3 42 37 3. 4 21 Iowa 16 19 75.7 4712 4,569 116.7 1013 8,613 182.9 25 13 8.3 6.5 315 6.3 34.6 9 16 3. 9 39 Kansas 17 43 71.1 3329 4,657 139.4 1625 9,987 177.2 19 37 6.0 6.9 2732 6.6 39.5 4 25 3. 1 46 Kentucky 16 19 65.6 1745 4,488 121.9 918 10,254 223.5 46 42 4.5 7.2 4742 6.2 56.0 10 51 3. 6 50 Louisiana 16 19 62.3 248 4,633 162.8 1536 11,604 223.9 47 51 6.1 6.7 2524 5.1 54.8 44 48 3. 2 10 Maine 16 19 74.4 4421 5,152 135.6 3223 8,808 212.0 43 17 5.9 6.6 2918 5.6 35.6 24 19 2. 6 28 Maryland 15 9 67.9 2223 4,037 122.6 419 9,691 181.0 21 29 6.3 7.0 2138 5.5 38.4 30 23 3. 3 14 Massachusetts17 43 71.6 3637 5,042 95.4 26 5 9,949 196.6 38 34 7.3 6.4 1311 5.3 50.1 38 46 3. 5 23 Michigan 16 19 68.6 2539 4,134 166.8 639 10,125 218.4 45 39 7.7 7.3 843 5.5 47.8 31 43 3. 7 2 Minnesota 16 19 72.6 3813 5,105 96.0 29 6 8,697 182.6 23 16 8.1 6.3 44 5.2 33.1 43 12 3. 8 51 Mississippi 17 43 64.7 850 3,606 173.7 145 11,193 229.3 49 5.3 7.3 3643 5.6 55.0 26 49 3. 7 34 Missouri 16 19 65.0 1146 4,618 258.1 1449 9,874 202.2 41 31 5.0 7.3 4043 5.3 45.7 39 36 3. 3 14 Montana 15 9 69.3 30 7 5,232 127.6 3620 7,879 170.3 105 5.3 6.3 36 4 5.7 28.7 21 10 3. 6 28 Nebraska 16 19 74.8 4514 5,016 118.8 2415 9,452 155.2 24 3 7.8 6.8 727 6.1 34.7 13 17 3. 0 44 Nevada 16 19 64.7 840 4,597 224.3 1248 9,473 172.1 12 25 5.0 7.1 4340 5.5 38.0 32 22 3. 3 14 New Hampshire17 43 65.5 1626 5,818 105.5 47 9 8,674 179.4 20 14 6.1 6.3 24 4 4.9 39.2 50 24 3. 8 37 New Jersey 16 19 67.8 2135 5,240 107.5 3710 10,595 167.5 45 6 5.6 6.5 3415 5.1 44.7 45 35 3. 3 14 New Mexico14 1 74.2 4310 5,006 133.3 2322 7,881 187.0 275 6.4 6.5 1815 6.1 28.5 15 9 2. 3 14 New York 16 19 69.0 2728 5,631 93.0 42 4 10,356 172.0 12 43 5.5 6.3 35 4 5.3 43.2 39 31 2. 6 28 North Carolina 16 19 64.9 1018 4,916 163.9 1938 9,245 201.5 40 21 7.7 6.7 924 6.9 41.9 3 27 3. 4 21 North Dakota 15 9 68.1 2311 4,888 158.1 1833 8,684 166.6 14 5 8.0 6.6 518 5.6 35.9 27 20 3. 2 10 Ohio 16 19 67.7 2044 5,137 168.7 3141 10,142 217.2 44 40 4.7 6.9 4432 5.1 47.8 46 43 3. 3 48 Oklahoma 16 19 64.0 549 5,022 171.8 2544 10,947 226.2 48 47 6.1 6.9 2632 5.1 47.5 49 41 3. 9 5 Oregon 14 1 75.5 46 2 4,598 84.2 12 1 7,586 170.5 113 8.0 6.0 61 6.2 26.6 11 6 2. 2 10 Pennsylvania 17 43 69.2 2832 4,587 111.7 1112 9,953 181.0 21 34 5.1 6.8 3827 5.7 46.3 23 37 3. 8 4 Rhode Island 17 43 65.1 1229 4,413 120.4 817 9,314 182.6 23 5.7 6.9 3132 4.8 42.4 51 28 3. 8 37 South Carolina 16 19 — —16 —— —— 9,289 175.4 17 22 —— —— 6.9 37.8 2 21 — 5 23 South Dakota 16 19 76.4 4920 5,379 118.9 3916 8,491 153.2 10 2 6.8 6.7 1624 5.1 34.3 46 15 3. 9 39 Tennessee 16 19 63.0 424 4,355 167.4 740 9,966 195.2 37 36 7.6 7.1 1040 7.2 47.4 1 40 3. 0 44 Texas 15 9 64.2 642 5,707 196.6 4346 11,137 194.4 36 48 5.9 6.9 2832 5.5 44.0 29 32 3. 0 7 Utah 14 1 71.5 35 3 4,926 86.9 20 2 8,955 155.1 18 3 5.6 6.4 3311 5.6 22.6 28 2 2. 5 23 Vermont 16 19 72.6 3815 5,420 136.3 4024 7,634 174.9 164 5.1 6.6 3918 6.4 33.4 5 13 3. 5 23 Virginia 16 19 65.2 1419 4,725 145.4 1727 9,084 189.1 29 20 6.5 6.6 1718 6.0 39.7 18 26 3. 2 10 Washington15 9 75.7 47 6 4,957 89.5 21 3 8,044 169.9 98 7.5 6.3 11 4 6.3 27.5 7 8 3. 6 28 West Virginia17 43 64.2 651 5,729 160.3 4434 9,908 244.9 51 32 3.6 7.7 4948 5.9 55.7 19 50 3. 1 8 Wisconsin 15 9 72.5 3724 6,350 155.5 4831 8,517 191.5 31 12 8.7 6.4 211 5.3 35.1 34 18 3. 5 23 Wyoming 16 19 71.1 3317 5,727 127.9 4420 8,017 167.8 7 5.0 6.8 4227 5.4 32.5 33 11 2. Notes: — Indicates that estimates are not available. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 41 Appendix APPENDIX E2.E2. Avoidable Avoidable Hospital Hospital Use Use & Cost: &Indicator Key Cost: Key Indicator Trends Trends Hospital admissions for ambulatory Potentially avoidable emergency department visits care–sensitive conditions Total em insuranc Ages 18–64 Age 65 and older Ages 18–64 Age 65 and older per en 2015 2017 2013 2016 2015 2017 2014 2018 2013 United States 159.0 149.5 No Change 181.4 189.4 No Change 4.6 6.8 No Change 44.7 41.6 No Change $4,697 Alabama 171.5 163.0 No Change 183.9 188.3 No Change 6.0 7.9 Worsened 52.4 52.8 No Change 3,706 Alaska 166.0 152.4 No Change 203.1 207.2 No Change 4.4 6.4 Worsened — 23.7 — 7,186 Arizona 175.7 146.8 Improved 170.5 183.7 Worsened 4.6 6.6 Worsened 30.4 27.0 No Change 4,453 Arkansas 157.1 170.3 No Change 176.6 193.4 Worsened 5.3 6.8 Worsened 52.3 46.6 Improved 3,117 California 130.0 97.9 Improved 163.0 172.3 No Change 3.6 6.2 Worsened 33.1 33.5 No Change 4,915 Colorado 147.4 110.9 Improved 163.6 174.0 No Change 3.5 6.1 Worsened 27.7 23.4 No Change 4,625 Connecticut 162.9 140.0 Improved 188.8 193.4 No Change 3.9 6.3 Worsened 45.0 43.1 No Change 5,067 Delaware 150.6 98.0 Improved 158.9 168.7 No Change 5.2 7.5 Worsened 45.8 42.5 No Change 4,509 District of Columbia — — — 250.8 243.3 No Change — — — 49.7 47.5 No Change 3,548 Florida 177.6 206.2 Worsened 175.8 190.4 Worsened 5.7 7.4 Worsened 49.3 44.3 Improved 4,748 Georgia 164.0 169.1 No Change 187.8 193.0 No Change 5.1 6.9 Worsened 45.9 44.1 No Change 4,951 Hawaii 137.6 156.8 Worsened 127.5 140.9 Worsened 4.3 6.6 Worsened 22.8 20.4 No Change 3,460 Idaho 133.5 117.6 Improved 159.5 176.3 Worsened 3.6 6.3 Worsened 26.3 23.9 No Change 4,906 Illinois 154.4 150.5 No Change 185.7 192.4 No Change 4.8 6.8 Worsened 48.8 48.5 No Change 4,575 Indiana 171.5 162.4 No Change 191.6 199.8 No Change 5.6 7.0 Worsened 50.3 46.3 No Change 4,955 Iowa 151.1 116.7 Improved 178.8 182.9 No Change 4.4 6.5 Worsened 40.0 34.6 Improved 3,784 Kansas 160.8 139.4 Improved 168.7 177.2 No Change 5.3 6.9 Worsened 44.8 39.5 Improved 4,079 Kentucky 151.2 121.9 Improved 218.5 223.5 No Change 5.4 7.2 Worsened 66.3 56.0 Improved 4,393 Louisiana 173.9 162.8 No Change 219.4 223.9 No Change 5.6 6.7 Worsened 62.2 54.8 Improved 4,404 Maine 172.4 135.6 Improved 216.9 212.0 No Change 3.8 6.6 Worsened 40.9 35.6 Improved 4,661 Maryland 148.5 122.6 Improved 185.6 181.0 No Change 4.7 7.0 Worsened 44.6 38.4 Improved 3,683 Massachusetts 142.1 95.4 Improved 197.3 196.6 No Change 4.0 6.4 Worsened 50.3 50.1 No Change 4,659 Michigan 159.4 166.8 No Change 209.9 218.4 No Change 4.9 7.3 Worsened 51.7 47.8 No Change 3,903 Minnesota 139.2 96.0 Improved 175.3 182.6 No Change 3.8 6.3 Worsened 34.5 33.1 No Change 4,483 Mississippi 182.6 173.7 No Change 222.0 229.3 No Change 6.1 7.3 Worsened 61.8 55.0 Improved 3,982 Missouri 203.4 258.1 Worsened 190.0 202.2 Worsened 5.1 7.3 Worsened 47.8 45.7 No Change 4,266 Montana 144.6 127.6 Improved 159.1 170.3 No Change 4.1 6.3 Worsened 32.4 28.7 No Change 4,553 Nebraska 140.3 118.8 Improved 148.7 155.2 No Change 4.7 6.8 Worsened 39.5 34.7 No Change 4,507 Nevada 186.7 224.3 Worsened 157.9 172.1 Worsened 4.9 7.1 Worsened 35.0 38.0 No Change 4,022 New Hampshire 155.5 105.5 Improved 174.6 179.4 No Change 3.9 6.3 Worsened 39.8 39.2 No Change 5,245 New Jersey 145.3 107.5 Improved 160.3 167.5 No Change 4.6 6.5 Worsened 46.2 44.7 No Change 4,771 New Mexico 149.2 133.3 Improved 170.1 187.0 Worsened 3.9 6.5 Worsened 35.7 28.5 Improved 4,407 New York 155.0 93.0 Improved 165.0 172.0 No Change 4.7 6.3 Worsened 44.1 43.2 No Change 5,279 North Carolina 159.2 163.9 No Change 192.3 201.5 No Change 4.4 6.7 Worsened 43.6 41.9 No Change 4,497 North Dakota 161.7 158.1 No Change 177.6 166.6 No Change 3.9 6.6 Worsened 41.5 35.9 Improved 4,306 Ohio 177.0 168.7 No Change 213.8 217.2 No Change 5.3 6.9 Worsened 54.1 47.8 Improved 4,464 Oklahoma 172.3 171.8 No Change 205.6 226.2 Worsened 5.2 6.9 Worsened 51.2 47.5 No Change 4,312 Oregon 137.1 84.2 Improved 155.4 170.5 Worsened 3.5 6.0 Worsened 29.6 26.6 No Change 4,300 Pennsylvania 158.6 111.7 Improved 181.3 181.0 No Change 4.6 6.8 Worsened 47.9 46.3 No Change 4,185 Rhode Island 157.9 120.4 Improved 195.6 182.6 Improved 4.2 6.9 Worsened — 42.4 — 4,018 South Carolina — — — 168.7 175.4 No Change — — — 40.1 37.8 No Change — South Dakota 143.3 118.9 Improved 149.1 153.2 No Change 4.2 6.7 Worsened — 34.3 — 5,042 Tennessee 168.3 167.4 No Change 189.2 195.2 No Change 5.7 7.1 Worsened 52.3 47.4 No Change 4,081 Texas 175.6 196.6 Worsened 180.2 194.4 Worsened 5.3 6.9 Worsened 47.7 44.0 No Change 5,110 Utah 131.9 86.9 Improved 141.7 155.1 Worsened 4.0 6.4 Worsened 25.6 22.6 No Change 4,322 Vermont 163.5 136.3 Improved 178.0 174.9 No Change 4.1 6.6 Worsened — 33.4 — 5,384 Virginia 168.4 145.4 Improved 186.6 189.1 No Change 4.6 6.6 Worsened 40.5 39.7 No Change 4,203 Washington 137.5 89.5 Improved 156.4 169.9 Worsened 3.3 6.3 Worsened 29.2 27.5 No Change 4,545 West Virginia 181.7 160.3 Improved 222.5 244.9 Worsened 5.5 7.7 Worsened 59.6 55.7 No Change 5,345 Wisconsin 163.8 155.5 No Change 175.8 191.5 Worsened 4.3 6.4 Worsened 37.6 35.1 No Change 5,871 Wyoming 165.8 127.9 Improved 159.6 167.8 No Change 5.0 6.8 Worsened — 32.5 — 5,779 Notes: — Indicates that estimates are not available. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 42 Appendix APPENDIX E2.E2. Avoidable Avoidable Hospital Hospital Use Use & Cost: &Indicator Key Cost: Key Indicator Trends Trends (continued) ons for ambulatory Hospital admissions for ambulatory Potentially avoidable emergency department visits tive conditions Total employer-sponsored Total Medicare (Parts A & care–sensitive conditions Total em insurance reimbursements B) reimbursements per insuranc Age 65 and older per enrollee, Ages 18–64 ages 18–64 Age 65 and enrollee older Ages 18–64 Age 65 and older per en 2014 2018 2015 2013 2017 2017 2013 2014 20162018 2015 2017 2014 2018 2013 e 44.7 United 41.6 States No Change $4,697 159.0 149.5 $5,137 No Worsened Change 181.4 $9,025 189.4 $9,847 No Change Worsened4.6 6.8 No Change 44.7 41.6 No Change $4,697 d 52.4 Alabama 52.8 No Change 171.5 3,706 163.0 4,068 NoNo Change Change 183.9 9,426188.310,758No Change Worsened6.0 7.9 Worsened 52.4 52.8 No Change 3,706 d — Alaska 23.7 — 166.0 7,186 152.4 8,104 No Change Worsened 203.16,237207.2 7,109No Change Worsened4.4 6.4 Worsened — 23.7 — 7,186 d 30.4 Arizona 27.0 No Change 175.7 4,453 146.8 4,962 Improved Worsened 170.58,137183.7 9,003 Worsened Worsened4.6 6.6 Worsened 30.4 27.0 No Change 4,453 d 52.3 Arkansas 46.6 Improved 157.1 3,117 170.3 3,874 No Change Worsened 176.68,877193.410,068 Worsened Worsened5.3 6.8 Worsened 52.3 46.6 Improved 3,117 d 33.1 California 33.5 No Change 130.0 4,915 97.9 5,376 Improved Worsened 163.08,409172.3 9,529No Change Worsened3.6 6.2 Worsened 33.1 33.5 No Change 4,915 d 27.7 Colorado 23.4 No Change 147.4 4,625 110.9 5,057 Improved Worsened 163.67,632174.0 8,504No Change Worsened3.5 6.1 Worsened 27.7 23.4 No Change 4,625 d 45.0 Connecticut 43.1 No Change 162.9 5,067 140.0 5,447 Improved Worsened 188.89,174193.410,525No Change Worsened3.9 6.3 Worsened 45.0 43.1 No Change 5,067 d 45.8 Delaware 42.5 No Change 150.6 4,509 98.0 5,173 Improved Worsened 158.98,899168.7 9,480No Change No Change5.2 7.5 Worsened 45.8 42.5 No Change 4,509 — 49.7 District 47.5 of Columbia No Change 3,548 — —— —— 250.8 8,843243.3 9,624No Change Worsened — — — 49.7 47.5 No Change 3,548 d 49.3 Florida 44.3 Improved 177.6 4,748 206.2 5,176 Worsened Worsened 175.8 10,683190.411,316 Worsened Worsened5.7 7.4 Worsened 49.3 44.3 Improved 4,748 d 45.9 Georgia 44.1 No Change 164.0 4,951 169.1 5,063 NoNo Change Change 187.8 8,890193.0 9,840No Change Worsened5.1 6.9 Worsened 45.9 44.1 No Change 4,951 d 22.8 Hawaii 20.4 No Change 137.6 3,460 156.8 3,948 Worsened Worsened 127.55,640140.9 6,473 Worsened Worsened4.3 6.6 Worsened 22.8 20.4 No Change 3,460 d 26.3 Idaho23.9 No Change 133.5 4,906 117.6 5,225 Improved No Change 159.57,564176.3 8,328 Worsened Worsened3.6 6.3 Worsened 26.3 23.9 No Change 4,906 d 48.8 Illinois 48.5 No Change 154.4 4,575 150.5 5,110 No Change Worsened 185.79,362192.410,226No Change Worsened4.8 6.8 Worsened 48.8 48.5 No Change 4,575 d 50.3 Indiana 46.3 No Change 171.5 4,955 162.4 5,799 No Change Worsened 191.69,199199.8 9,925No Change Worsened5.6 7.0 Worsened 50.3 46.3 No Change 4,955 d 40.0 Iowa 34.6 Improved 151.1 3,784 116.7 4,569 Improved Worsened 178.87,766182.9 8,613No Change Worsened4.4 6.5 Worsened 40.0 34.6 Improved 3,784 d 44.8 Kansas 39.5 Improved 160.8 4,079 139.4 4,657 Improved Worsened 168.78,887177.2 9,987No Change Worsened5.3 6.9 Worsened 44.8 39.5 Improved 4,079 d 66.3 Kentucky 56.0 Improved 151.2 4,393 121.9 4,488 Improved No Change 218.59,288223.510,254No Change Worsened5.4 7.2 Worsened 66.3 56.0 Improved 4,393 d 62.2 Louisiana 54.8 Improved 173.9 4,404 162.8 4,633 NoNo Change Change 219.4 10,851223.911,604No Change Worsened5.6 6.7 Worsened 62.2 54.8 Improved 4,404 d 40.9 Maine35.6 Improved 172.4 4,661 135.6 5,152 Improved Worsened 216.97,957212.0 8,808No Change Worsened3.8 6.6 Worsened 40.9 35.6 Improved 4,661 d 44.6 Maryland 38.4 Improved 148.5 3,683 122.6 4,037 Improved No Change 185.68,986181.0 9,691No Change Worsened4.7 7.0 Worsened 44.6 38.4 Improved 3,683 d 50.3 Massachusetts 50.1 No Change 142.1 4,659 95.4 5,042 Improved Worsened 197.39,058196.6 9,949No Change Worsened4.0 6.4 Worsened 50.3 50.1 No Change 4,659 d 51.7 Michigan 47.8 No Change 159.4 3,903 166.8 4,134 NoNo Change Change 209.9 9,739218.410,125No Change No Change4.9 7.3 Worsened 51.7 47.8 No Change 3,903 d 34.5 Minnesota 33.1 No Change 139.2 4,483 96.0 5,105 Improved Worsened 175.37,697182.6 8,697No Change Worsened3.8 6.3 Worsened 34.5 33.1 No Change 4,483 d 61.8 Mississippi 55.0 Improved 182.6 3,982 173.7 3,606 No Change Improved 222.0 10,087229.311,193No Change Worsened6.1 7.3 Worsened 61.8 55.0 Improved 3,982 d 47.8 Missouri 45.7 No Change 203.4 4,266 258.1 4,618 Worsened No Change 190.08,967202.2 9,874 Worsened Worsened5.1 7.3 Worsened 47.8 45.7 No Change 4,266 d 32.4 Montana 28.7 No Change 144.6 4,553 127.6 5,232 Improved Worsened 159.16,836170.3 7,879No Change Worsened4.1 6.3 Worsened 32.4 28.7 No Change 4,553 d 39.5 Nebraska 34.7 No Change 140.3 4,507 118.8 5,016 Improved Worsened 148.78,339155.2 9,452No Change Worsened4.7 6.8 Worsened 39.5 34.7 No Change 4,507 d 35.0 Nevada 38.0 No Change 186.7 4,022 224.3 4,597 Worsened Worsened 157.98,656172.1 9,473 Worsened Worsened4.9 7.1 Worsened 35.0 38.0 No Change 4,022 d 39.8 New 39.2 HampshireNo Change 155.5 5,245 105.5 5,818 Improved Worsened 174.67,853179.4 8,674No Change Worsened3.9 6.3 Worsened 39.8 39.2 No Change 5,245 d 46.2 New 44.7 Jersey No Change 145.3 4,771 107.5 5,240 Improved Worsened 160.39,740167.510,595No Change Worsened4.6 6.5 Worsened 46.2 44.7 No Change 4,771 d 35.7 New 28.5 Mexico Improved 149.2 4,407 133.3 5,006 Improved Worsened 170.17,148187.0 7,881 Worsened Worsened3.9 6.5 Worsened 35.7 28.5 Improved 4,407 d 44.1 New 43.2 York No Change 155.0 5,279 93.0 5,631 Improved No Change 165.09,171172.010,356No Change Worsened4.7 6.3 Worsened 44.1 43.2 No Change 5,279 d 43.6 North41.9Carolina No Change 159.2 4,497 163.9 4,916 No Change Worsened 192.38,448201.5 9,245No Change Worsened4.4 6.7 Worsened 43.6 41.9 No Change 4,497 d 41.5 North35.9Dakota Improved 161.7 4,306 158.1 4,888 No Change Worsened 177.67,888166.6 8,684No Change Worsened3.9 6.6 Worsened 41.5 35.9 Improved 4,306 d 54.1 Ohio 47.8 Improved 177.0 4,464 168.7 5,137 No Change Worsened 213.89,598217.210,142No Change No Change5.3 6.9 Worsened 54.1 47.8 Improved 4,464 d 51.2 Oklahoma 47.5 No Change 172.3 4,312 171.8 5,022 No Change Worsened 205.69,462226.210,947 Worsened Worsened5.2 6.9 Worsened 51.2 47.5 No Change 4,312 d 29.6 Oregon 26.6 No Change 137.1 4,300 84.2 4,598 Improved No Change 155.46,743170.5 7,586 Worsened Worsened3.5 6.0 Worsened 29.6 26.6 No Change 4,300 d 47.9 Pennsylvania 46.3 No Change 158.6 4,185 111.7 4,587 Improved Worsened 181.39,468181.0 9,953No Change No Change4.6 6.8 Worsened 47.9 46.3 No Change 4,185 d — Rhode42.4Island — 157.9 4,018 120.4 4,413 Improved Worsened 195.68,925182.6 9,314 Improved No Change4.2 6.9 Worsened — 42.4 — 4,018 — 40.1 South37.8Carolina No Change —— —— —— 168.7 8,629175.4 9,289No Change Worsened — — — 40.1 37.8 No Change — d — South34.3Dakota — 143.3 5,042 118.9 5,379 Improved No Change 149.17,567153.2 8,491No Change Worsened4.2 6.7 Worsened — 34.3 — 5,042 d 52.3 Tennessee 47.4 No Change 168.3 4,081 167.4 4,355 NoNo Change Change 189.2 9,252195.2 9,966No Change Worsened5.7 7.1 Worsened 52.3 47.4 No Change 4,081 d 47.7 Texas44.0 No Change 175.6 5,110 196.6 5,707 Worsened Worsened 180.2 10,387194.411,137 Worsened Worsened5.3 6.9 Worsened 47.7 44.0 No Change 5,110 d 25.6 Utah 22.6 No Change 131.9 4,322 86.9 4,926 Improved Worsened 141.78,206155.1 8,955 Worsened Worsened4.0 6.4 Worsened 25.6 22.6 No Change 4,322 d — Vermont 33.4 — 163.5 5,384 136.3 5,420 Improved No Change 178.07,046174.9 7,634No Change No Change4.1 6.6 Worsened — 33.4 — 5,384 d 40.5 Virginia 39.7 No Change 168.4 4,203 145.4 4,725 Improved Worsened 186.68,156189.1 9,084No Change Worsened4.6 6.6 Worsened 40.5 39.7 No Change 4,203 d 29.2 Washington 27.5 No Change 137.5 4,545 89.5 4,957 Improved Worsened 156.47,315169.9 8,044 Worsened Worsened3.3 6.3 Worsened 29.2 27.5 No Change 4,545 d 59.6 West 55.7 VirginiaNo Change 181.7 5,345 160.3 5,729 Improved Worsened 222.58,681244.9 9,908 Worsened Worsened5.5 7.7 Worsened 59.6 55.7 No Change 5,345 d 37.6 Wisconsin 35.1 No Change 163.8 5,871 155.5 6,350 No Change Worsened 175.87,826191.5 8,517 Worsened Worsened4.3 6.4 Worsened 37.6 35.1 No Change 5,871 d — Wyoming 32.5 — 165.8 5,779 127.9 5,727 Improved No Change 159.67,012167.8 8,017No Change Worsened5.0 6.8 Worsened — 32.5 — 5,779 Notes: — Indicates that estimates are not available. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 43 AppendixF1.F1. APPENDIX Healthy Healthy Lives: Lives: Dimension Dimension Ranking Ranking and and Indicator Indicator Rates Rates Healthy Lives Mortality Breast Colorectal Drug Dimension amenable to cancer cancer Suicide Alcohol poisoning Infa Summary health care deaths deaths deaths deaths deaths morta 2020 2016–17 rank 2018 rank 2018 rank 2018 rank 2018 rank 2018 rank 2017 United States — 84.5 — 19.7 — 12.6 — 14.2 — 9.9 — 20.7 — 5.8 Alabama 42 112.0 44 21.9 45 14.7 46 16.5 29 7.2 8 16.6 19 7.4 Alaska 28 74.7 21 16.0 3 13.4 34 24.6 48 26.6 50 14.6 15 5.7 Arizona 32 76.3 22 17.1 9 11.9 13 19.2 36 15.1 43 23.8 31 5.7 Arkansas 45 127.5 49 17.8 11 13.5 35 18.3 32 9.8 22 15.7 18 8.1 California 6 71.2 17 19.0 18 11.6 11 10.9 8 11.8 34 12.8 12 4.2 Colorado 6 61.9 4 18.2 13 10.5 4 21.9 45 16.7 45 16.8 20 4.5 Connecticut 3 61.0 3 16.4 5 9.8 2 10.6 7 7.6 10 30.7 41 4.5 Delaware 31 88.5 32 21.8 44 13.0 31 11.4 10 7.7 11 43.8 50 6.3 District of Columbia 25 123.4 48 26.7 51 12.7 26 7.5 1 11.1 29 35.4 45 8.2 Florida 27 82.3 29 18.1 12 12.2 16 15.2 23 10.7 24 22.8 30 6.1 Georgia 35 103.3 42 20.6 33 13.5 35 14.6 18 7.7 11 13.2 13 7.2 Hawaii 1 77.8 24 15.1 1 10.3 3 11.9 11 5.7 1 14.3 14 5.4 Idaho 16 66.2 10 22.2 46 12.3 19 23.9 47 13.9 40 14.6 15 4.6 Illinois 19 83.8 30 20.7 34 13.5 35 11.3 9 7.7 11 21.3 27 6.1 Indiana 43 94.4 36 20.8 37 13.7 39 16.0 28 10.7 24 25.6 33 7.2 Iowa 20 73.7 20 18.3 14 14.1 43 15.5 26 10.9 26 9.6 3 5.3 Kansas 34 80.1 26 20.3 28 13.8 40 19.3 38 11.0 28 12.4 10 6.0 Kentucky 48 113.1 45 19.8 24 15.6 49 17.5 31 9.4 21 30.9 42 6.6 Louisiana 46 122.2 47 22.6 48 14.8 47 15.1 22 6.7 6 25.4 32 7.1 Maine 26 66.3 10 16.3 4 12.2 16 18.5 33 12.0 35 27.9 39 5.9 Maryland 22 89.2 33 21.2 39 12.8 29 10.2 6 5.8 2 37.2 49 6.4 Massachusetts 2 57.4 2 15.7 2 10.7 5 9.9 5 8.9 16 32.8 43 3.7 Michigan 37 92.3 34 21.7 42 12.6 24 15.0 21 9.3 19 26.6 34 6.8 Minnesota 4 54.5 1 18.3 14 11.3 8 13.1 12 11.7 32 11.5 8 4.8 Mississippi 50 143.4 51 21.5 41 16.1 50 13.8 16 5.9 3 10.8 6 8.7 Missouri 44 95.7 38 19.2 19 14.0 41 19.5 41 8.6 15 27.5 37 6.3 Montana 12 70.3 16 16.5 6 11.3 8 24.9 49 14.7 42 12.2 9 5.5 Nebraska 11 67.2 13 18.3 14 14.6 45 13.4 13 13.0 38 7.4 2 5.5 Nevada 40 97.3 40 21.2 39 12.7 26 20.8 43 15.8 44 21.2 25 5.9 New Hampshire 14 62.1 5 16.7 7 11.9 13 19.4 40 11.7 32 35.8 46 4.2 New Jersey 10 72.2 19 20.7 34 12.5 22 8.3 2 6.5 5 33.1 44 4.5 New Mexico 39 86.4 31 19.4 21 12.2 16 25.0 50 32.7 51 26.7 36 5.9 New York 8 76.6 23 19.3 20 11.2 7 8.3 2 7.3 9 18.4 22 4.6 North Carolina 36 92.5 35 20.3 28 12.0 15 13.7 14 9.2 18 22.4 28 7.0 North Dakota 15 71.6 18 16.9 8 12.5 22 19.2 36 17.2 46 10.2 4 4.4 Ohio 41 95.9 39 21.0 38 14.1 43 15.3 24 8.9 16 35.9 47 7.2 Oklahoma 49 129.5 50 24.3 50 15.1 48 20.0 42 14.3 41 18.4 22 7.8 Oregon 20 63.6 8 18.4 17 11.5 10 19.0 35 18.2 47 12.6 11 5.3 Pennsylvania 33 81.7 28 20.4 32 13.3 33 14.9 20 5.9 3 36.1 48 6.1 Rhode Island 12 69.3 14 17.1 9 12.3 19 9.5 4 12.4 37 30.1 40 6.2 South Carolina 38 99.9 41 21.7 42 12.4 21 15.4 25 9.3 19 22.6 29 6.5 South Dakota 28 78.7 25 20.0 25 13.5 35 19.3 38 22.0 48 6.9 1 7.8 Tennessee 46 114.4 46 23.2 49 14.0 41 16.6 30 11.4 31 27.5 37 7.3 Texas 23 95.0 37 20.0 25 12.9 30 13.7 14 7.8 14 10.4 5 5.9 Utah 5 64.3 9 20.1 27 9.1 1 22.2 46 10.9 26 21.2 25 5.9 Vermont 17 63.1 6 20.3 28 12.7 26 18.8 34 12.3 36 26.6 34 4.8 Virginia 18 80.3 27 20.7 34 12.6 24 14.0 17 6.9 7 17.1 21 5.9 Washington 9 63.2 7 19.4 21 10.9 6 15.9 27 13.6 39 14.8 17 3.9 West Virginia 51 108.9 43 22.3 47 17.2 51 21.2 44 10.6 23 51.5 51 7.0 Wisconsin 24 69.1 14 19.6 23 11.7 12 14.8 19 11.3 30 19.2 24 6.4 Wyoming 30 66.3 10 20.3 28 13.1 32 25.2 51 23.3 49 11.1 7 4.6 commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 44 AppendixF1.F1. APPENDIX Healthy Healthy Lives:Lives: Dimension Dimension Ranking Ranking and and Indicator Indicator Rates Rates (continued) Healthy Children who State-based Drug Lives Adults Mortality who Breast Colorectal are Adults who Drug public health Alcohol poisoning Dimension Infant amenable report fair or to Adults who cancer Adults who cancer Suicide overweight have lost six Alcohol or spending poisoning per Infa deaths deaths mortality Summary poorhealth healthcare smokedeathsare obesedeathsor obesedeathsmore teeth deaths resident deaths mort 2018 rank 2018 rank 2017 rank 2020 2018 2016–17rank rank 2018 2018 rank rank 2018 2018 rank 2018 rank 2018 rank rank 2018 2018 rank rank 2017/18 2018 rank rank 2017 9.9 United — 20.7 States — 5.8 —— 17%84.5 — 16% — 19.7 — 32%— 12.6 — 31% — 14.2 — —9% 9.9— — $3720.7 —— 5.8 7.2 Alabama 8 16.6 19 7.4 46 42 20112.0 44 4419 21.9 36 45 38 14.7 46 46 33 16.5 35 2914 7.246 8 5816.6 10 19 7.4 26.6 Alaska 50 14.6 15 5.7 19 28 15 74.7 18 2119 16.0 36 30 3 13.4 16 34 26 24.6 11 4810 26.627 50 10014.6 4 15 5.7 15.1 Arizona 43 23.8 31 5.7 19 32 18 76.3 36 2214 17.19 31 9 11.9 21 13 30 19.2 24 36 8 15.113 43 1023.8 49 31 5.7 9.8 Arkansas 22 15.7 18 8.1 49 45 22127.5 50 4923 17.8 49 11 39 13.5 48 35 33 18.3 35 3217 9.849 22 5115.7 14 18 8.1 11.8 California 34 12.8 12 4.2 3 6 17 71.2 29 1711 19.02 18 26 11.63 11 33 10.9 35 86 11.8 2 34 6612.8 8 12 4.2 16.7 Colorado 45 16.8 20 4.5 6 6 13 61.9 8 414 18.29 13 23 10.51 24 4 21.95 45 7 16.7 6 45 5016.8 15 20 4.5 7.6 Connecticut 10 30.7 41 4.5 6 3 12 61.0 2 312 16.43 28 5 9.87 30 2 10.6 24 77 7.6 6 10 3130.7 29 41 4.5 7.7 Delaware 11 43.8 50 6.3 32 31 15 88.5 18 3216 21.8 22 44 34 13.0 32 31 25 11.46 1010 7.727 11 4143.8 22 50 6.3 11.1 District 29 of35.4Columbia 45 8.2 50 25 12123.4 2 4814 26.79 51 25 12.72 26 28 7.5 19 16 11.1 2 29 13535.4 1 45 8.2 10.7 Florida 24 22.8 30 6.1 28 27 19 82.3 41 2914 18.19 12 32 12.2 25 16 30 15.2 24 2311 10.733 24 1922.8 38 30 6.1 7.7 Georgia 11 13.2 13 7.2 42 35 17103.3 29 4216 20.6 22 33 33 13.5 29 35 30 14.6 24 1811 7.733 11 2313.2 36 13 7.2 5.7 Hawaii 1 14.3 14 5.4 16 1 15 77.8 18 2413 15.15 27 1 10.36 19 3 11.91 11 6 5.7 2 1 12414.3 3 14 5.4 13.9 Idaho 40 14.6 15 4.6 9 16 14 66.2 14 1015 22.2 16 46 28 12.37 19 27 23.9 17 47 8 13.913 40 8814.6 5 15 4.6 7.7 Illinois 11 21.3 27 6.1 28 19 15 83.8 18 3015 20.7 16 34 32 13.5 25 35 25 11.36 98 7.713 11 2621.3 32 27 6.1 10.7 Indiana 24 25.6 33 7.2 42 43 18 94.4 36 3621 20.8 44 37 35 13.7 34 39 38 16.0 48 2812 10.740 24 1425.6 47 33 7.2 10.9 Iowa 26 9.6 3 5.3 14 20 12 73.7 2 2017 18.3 29 14 36 14.1 42 43 36 15.5 42 26 8 10.913 26 41 9.6 223 5.3 11.0 Kansas 28 12.4 10 6.0 27 34 16 80.1 26 2617 20.3 29 28 35 13.8 34 40 25 19.36 3811 11.033 28 1412.4 46 10 6.0 9.4 Kentucky 21 30.9 42 6.6 37 48 20113.1 44 4523 19.8 49 24 39 15.6 48 49 36 17.5 42 3115 9.448 21 3530.9 27 42 6.6 6.7 Louisiana 6 25.4 32 7.1 41 46 20122.2 44 4721 22.6 44 48 38 14.8 46 47 36 15.1 42 2213 6.743 6 2525.4 34 32 7.1 12.0 Maine 35 27.9 39 5.9 21 26 17 66.3 29 1018 16.3 33 31 4 12.2 21 16 26 18.5 11 3313 12.043 35 1827.9 39 39 5.9 5.8 Maryland 2 37.2 49 6.4 34 22 14 89.2 14 3313 21.25 39 32 12.8 25 29 32 10.2 32 67 5.8 6 2 4337.2 21 49 6.4 8.9 Massachusetts 16 32.8 43 3.7 1 2 13 57.4 8 214 15.79 26 2 10.73 26 5 9.9 11 58 8.913 16 7732.8 7 43 3.7 9.3 Michigan 19 26.6 34 6.8 38 37 18 92.3 36 3419 21.7 36 42 33 12.6 29 24 26 15.0 11 2110 9.327 19 1526.6 43 34 6.8 11.7 Minnesota 32 11.5 8 4.8 12 4 12 54.5 2 115 18.3 16 14 30 11.3 16 25 8 13.16 12 6 11.7 2 32 4411.5 208 4.8 5.9 Mississippi 3 10.8 6 8.7 51 50 20143.4 44 5121 21.5 44 41 41 16.1 50 50 39 13.8 51 1617 5.949 3 1510.8 446 8.7 8.6 Missouri 15 27.5 37 6.3 32 44 19 95.7 41 3820 19.2 42 19 36 14.0 42 41 37 19.5 47 4111 8.633 15 727.5 51 37 6.3 14.7 Montana 42 12.2 9 5.5 17 12 13 70.3 8 1618 16.5 33 28 6 11.37 21 8 24.92 4910 14.727 42 2312.2 369 5.5 13.0 Nebraska 38 7.4 2 5.5 17 11 13 67.2 8 1316 18.3 22 14 35 14.6 34 45 23 13.44 13 8 13.013 38 47 7.4 182 5.5 15.8 Nevada 44 21.2 25 5.9 21 40 18 97.3 36 4016 21.2 22 39 30 12.7 16 26 34 20.8 40 43 8 15.813 44 821.2 50 25 5.9 11.7 New32 Hampshire 35.8 46 4.2 3 14 13 62.1 8 516 16.7 22 30 7 11.9 16 13 27 19.4 17 40 9 11.722 32 2335.8 35 46 4.2 6.5 New 5 Jersey 33.1 44 4.5 6 10 15 72.2 18 1913 20.75 34 26 12.53 22 31 8.3 29 27 6.5 6 5 2933.1 30 44 4.5 32.7 New51 Mexico 26.7 36 5.9 21 39 19 86.4 41 3115 19.4 16 21 35 12.2 34 16 30 25.0 24 50 9 32.722 51 13726.7 1 36 5.9 7.3 New 9 York18.4 22 4.6 9 8 15 76.6 18 2313 19.35 20 28 11.27 29 7 8.3 22 29 7.322 9 8518.4 6 22 4.6 9.2 North 18 Carolina 22.4 28 7.0 39 36 17 92.5 29 3517 20.3 29 28 35 12.0 34 15 29 13.7 22 1411 9.233 18 1522.4 42 28 7.0 17.2 North 46 Dakota 10.2 4 4.4 5 15 11 71.6 1 1819 16.9 36 35 8 12.5 34 22 32 19.2 32 36 7 17.2 6 46 5510.2 114 4.4 8.9 Ohio 16 35.9 47 7.2 42 41 16 95.9 26 3921 21.0 44 38 34 14.1 32 43 31 15.3 29 2412 8.940 16 1335.9 48 47 7.2 14.3 Oklahoma 41 18.4 22 7.8 47 49 20129.5 44 5020 24.3 42 50 36 15.1 42 48 36 20.0 42 4213 14.343 41 4018.4 24 22 7.8 18.2 Oregon 47 12.6 11 5.3 14 20 18 63.6 36 816 18.4 22 17 31 11.5 21 10 25 19.06 3511 18.233 47 2812.6 31 11 5.3 5.9 Pennsylvania 3 36.1 48 6.1 28 33 17 81.7 29 2817 20.4 29 32 32 13.3 25 33 26 14.9 11 2010 5.927 3 1536.1 44 48 6.1 12.4 Rhode 37 Island 30.1 40 6.2 31 12 16 69.3 26 1415 17.1 16 28 9 12.37 19 31 9.5 29 48 12.413 37 5430.1 13 40 6.2 9.3 South 19 Carolina 22.6 29 6.5 36 38 17 99.9 29 4118 21.7 33 42 35 12.4 34 21 38 15.4 48 2512 9.340 19 2622.6 32 29 6.5 22.0 South 48 Dakota6.9 1 7.8 47 28 12 78.7 2 2519 20.0 36 25 29 13.5 14 35 26 19.3 11 38 9 22.022 48 35 6.9 261 7.8 11.4 Tennessee 31 27.5 37 7.3 45 46 20114.4 44 4621 23.2 44 49 36 14.0 42 41 36 16.6 42 3014 11.446 31 5027.5 15 37 7.3 7.8 Texas 14 10.4 5 5.9 21 23 17 95.0 29 3714 20.09 25 35 12.9 34 30 33 13.7 35 14 7 7.8 6 14 1710.4 415 5.9 10.9 Utah 26 21.2 25 5.9 21 5 13 64.3 8 99 20.11 27 28 9.17 21 1 22.22 46 5 10.9 1 26 3321.2 28 25 5.9 12.3 Vermont 36 26.6 34 4.8 12 17 12 63.1 2 614 20.39 28 28 12.77 26 33 18.8 35 3410 12.327 36 4826.6 17 34 4.8 6.9 Virginia 7 17.1 21 5.9 21 18 15 80.3 18 2715 20.7 16 34 31 12.6 21 24 32 14.0 32 17 8 6.913 7 3917.1 25 21 5.9 13.6 Washington 39 14.8 17 3.9 2 9 15 63.2 18 712 19.43 21 29 10.9 14 28 6 15.9 19 27 7 13.6 6 39 4614.8 19 17 3.9 10.6 West 23 Virginia 51.5 51 7.0 39 51 23108.9 51 4325 22.3 51 47 41 17.2 50 51 38 21.2 48 4420 10.651 23 6151.5 9 51 7.0 11.3 Wisconsin 30 19.2 24 6.4 34 24 14 69.1 14 1416 19.6 22 23 33 11.7 29 12 35 14.8 41 19 9 11.322 30 1819.2 40 24 6.4 23.3 Wyoming 49 11.1 7 4.6 9 30 14 66.3 14 1019 20.3 36 28 30 13.1 16 32 28 25.2 19 5111 23.333 49 5411.1 117 4.6 commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 45 Appendix APPENDIX F2.F2. Healthy Healthy Lives: Lives: Key KeyTrends Indicator Indicator Trends Mortality amenable to Infant mortality, Adults ages 18–64 who State-based public health care, deaths per deaths per 1,000 live report fair or poor health spending per 100,000 population births health resident 2012– 2016– 2014/ 2017/ 13 17 2013 2017 2014 2018 15 18 United States 83.7 84.5 No Change 6.0 5.8 No Change 16% 17% No Change $36 $37 Improved Alabama 111.3 112.0 No Change 8.6 7.4 Improved 20 20 No Change $60 $58 Worsened Alaska 71.6 74.7 No Change 5.8 5.7 No Change 12 15 Worsened $131 $100 Worsened Arizona 72.4 76.3 No Change 5.3 5.7 No Change 18 18 No Change $9 $10 Improved Arkansas 118.9 127.5 No Change 7.9 8.1 No Change 21 22 No Change $50 $51 Improved California 72.0 71.2 No Change 4.8 4.2 No Change 17 17 No Change $56 $66 Improved Colorado 59.2 61.9 No Change 5.1 4.5 No Change 12 13 No Change $49 $50 Improved Connecticut 61.3 61.0 No Change 4.8 4.5 No Change 13 12 No Change $31 $31 Worsened Delaware 85.0 88.5 No Change 6.4 6.3 No Change 13 15 Worsened $45 $41 Worsened District of Columbia 123.9 123.4 No Change 6.7 8.2 Worsened 11 12 No Change $139 $135 Worsened Florida 80.0 82.3 No Change 6.1 6.1 No Change 17 19 Worsened $20 $19 Worsened Georgia 100.4 103.3 No Change 7.0 7.2 No Change 17 17 No Change $19 $23 Improved Hawaii 75.3 77.8 No Change 6.4 5.4 Improved 13 15 Worsened $163 $124 Worsened Idaho 66.7 66.2 No Change 5.6 4.6 Improved 11 14 Worsened $95 $88 Worsened Illinois 87.1 83.8 No Change 6.0 6.1 No Change 15 15 No Change $26 $26 Improved Indiana 91.0 94.4 No Change 7.2 7.2 No Change 17 18 No Change $13 $14 Improved Iowa 71.8 73.7 No Change 4.3 5.3 Worsened 12 12 No Change $39 $41 Improved Kansas 78.1 80.1 No Change 6.5 6.0 No Change 13 16 Worsened $13 $14 Improved Kentucky 105.8 113.1 No Change 6.4 6.6 No Change 22 20 Improved $34 $35 Improved Louisiana 123.5 122.2 No Change 8.7 7.1 Improved 19 20 No Change $20 $25 Improved Maine 62.3 66.3 No Change 7.1 5.9 Improved 14 17 Worsened $22 $18 Worsened Maryland 88.7 89.2 No Change 6.6 6.4 No Change 13 14 No Change $40 $43 Improved Massachusetts 60.4 57.4 No Change 4.2 3.7 No Change 13 13 No Change $50 $77 Improved Michigan 91.3 92.3 No Change 7.1 6.8 No Change 15 18 Worsened $24 $15 Worsened Minnesota 55.6 54.5 No Change 5.1 4.8 No Change 10 12 Worsened $15 $44 Improved Mississippi 136.7 143.4 No Change 9.6 8.7 Improved 20 20 No Change $12 $15 Improved Missouri 95.1 95.7 No Change 6.5 6.3 No Change 14 19 Worsened $6 $7 Improved Montana 70.3 70.3 No Change 5.6 5.5 No Change 13 13 No Change $22 $23 Improved Nebraska 64.9 67.2 No Change 5.2 5.5 No Change 12 13 No Change $44 $47 Improved Nevada 91.7 97.3 No Change 5.3 5.9 Worsened 17 18 No Change $4 $8 Improved New Hampshire 58.4 62.1 No Change 5.6 4.2 Improved 12 13 No Change $16 $23 Improved New Jersey 75.1 72.2 No Change 4.5 4.5 No Change 15 15 No Change $27 $29 Improved New Mexico 78.6 86.4 No Change 5.3 5.9 Worsened 19 19 No Change $48 $137 Improved New York 79.0 76.6 No Change 4.9 4.6 No Change 15 15 No Change $96 $85 Worsened North Carolina 92.5 92.5 No Change 7.0 7.0 No Change 17 17 No Change $14 $15 Improved North Dakota 70.5 71.6 No Change 6.0 4.4 Improved 12 11 No Change $98 $55 Worsened Ohio 94.5 95.9 No Change 7.3 7.2 No Change 16 16 No Change $14 $13 Worsened Oklahoma 117.5 129.5 Worsened 6.7 7.8 Worsened 18 20 Worsened $40 $40 Worsened Oregon 61.9 63.6 No Change 4.9 5.3 No Change 14 18 Worsened $26 $28 Improved Pennsylvania 82.0 81.7 No Change 6.7 6.1 Improved 15 17 Worsened $15 $15 Improved Rhode Island 68.5 69.3 No Change 6.5 6.2 No Change 13 16 Worsened $54 $54 Worsened South Carolina 99.2 99.9 No Change 6.9 6.5 No Change 18 17 No Change $21 $26 Improved South Dakota 74.5 78.7 No Change 6.5 7.8 Worsened 12 12 No Change $36 $35 Worsened Tennessee 110.0 114.4 No Change 6.8 7.3 No Change 22 20 Improved $46 $50 Improved Texas 93.4 95.0 No Change 5.8 5.9 No Change 18 17 No Change $28 $17 Worsened Utah 61.4 64.3 No Change 5.2 5.9 Worsened 11 13 Worsened $31 $33 Improved Vermont 57.2 63.1 No Change 4.4 4.8 No Change 10 12 Worsened $45 $48 Improved Virginia 81.3 80.3 No Change 6.2 5.9 No Change 15 15 No Change $37 $39 Improved Washington 62.2 63.2 No Change 4.5 3.9 Improved 15 15 No Change $38 $46 Improved West Virginia 103.5 108.9 No Change 7.6 7.0 No Change 23 23 No Change $74 $61 Worsened Wisconsin 69.4 69.1 No Change 6.3 6.4 No Change 14 14 No Change $15 $18 Improved Wyoming 68.0 66.3 No Change 4.8 4.6 No Change 12 14 Worsened $57 $54 Worsened commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 46 Appendix APPENDIX F3.F3. Deaths Death from Suicide, from Suicide, Alcohol, Alcohol, and and Drugs, 2005–2018 Drugs, 2005–2018 Suicide deaths Alcohol deaths Drug poisoning deaths (rate per 100,000) (rate per 100,000) (rate per 100,000) % Change % Change % Change 2005 2012 2018 2005–2018 2005 2012 2018 2005–2018 2005 2012 2018 2005–2018 United States 10.9 12.6 14.2 30% 7.0 8.0 9.9 41% 10.1 13.1 20.7 105% Alabama 11.5 14.7 16.5 43 5.2 5.1 7.2 38 6.3 12.1 16.6 163 Alaska 19.9 23.0 24.6 24 19.5 15.9 26.6 36 11.4 17.4 14.6 28 Arizona 16.4 17.3 19.2 17 11.3 14.9 15.1 34 14.1 17.7 23.8 69 Arkansas 14.3 16.3 18.3 28 4.9 5.3 9.8 100 10.1 13.1 15.7 55 California 9.1 10.0 10.9 20 11.2 11.0 11.8 5 9.0 10.3 12.8 42 Colorado 17.2 19.7 21.9 27 10.5 13.2 16.7 59 12.7 15.0 16.8 32 Connecticut 8.1 9.9 10.6 31 4.8 4.5 7.6 58 8.5 12.1 30.7 261 Delaware 9.7 13.2 11.4 18 6.2 5.7 7.7 24 7.5 15.2 43.8 484 District of Columbia 5.4 5.7 7.5 39 14.5 11.7 11.1 -23 13.7 12.6 35.4 158 Florida 12.5 14.3 15.2 22 8.0 8.4 10.7 34 13.5 13.3 22.8 69 Georgia 10.6 11.7 14.6 38 5.7 5.9 7.7 35 8.2 10.6 13.2 61 Hawaii 8.2 13.1 11.9 45 3.5 5.3 5.7 63 9.4 11.0 14.3 52 Idaho 16.5 19.0 23.9 45 9.5 13.0 13.9 46 8.1 11.9 14.6 80 Illinois 8.6 9.8 11.3 31 4.4 5.5 7.7 75 8.4 12.5 21.3 154 Indiana 11.8 14.3 16.0 36 4.9 7.0 10.7 118 9.8 16.0 25.6 161 Iowa 11.2 12.7 15.5 38 6.1 8.0 10.9 79 4.8 8.7 9.6 100 Kansas 13.3 17.4 19.3 45 6.3 7.2 11.0 75 9.1 11.5 12.4 36 Kentucky 13.4 16.2 17.5 31 5.6 7.2 9.4 68 15.3 25.0 30.9 102 Louisiana 11.0 12.4 15.1 37 4.6 4.4 6.7 46 14.7 12.3 25.4 73 Maine 12.4 14.5 18.5 49 8.2 7.8 12.0 46 12.4 11.5 27.9 125 Maryland 8.4 9.5 10.2 21 4.7 4.1 5.8 23 11.4 13.7 37.2 226 Massachusetts 7.2 8.7 9.9 38 5.5 6.9 8.9 62 12.0 12.7 32.8 173 Michigan 11.0 12.5 15.0 36 6.8 7.7 9.3 37 9.8 13.5 26.6 171 Minnesota 10.5 12.0 13.1 25 6.5 8.4 11.7 80 5.4 8.9 11.5 113 Mississippi 12.7 14.0 13.8 9 5.5 5.3 5.9 7 8.8 10.7 10.8 23 Missouri 12.5 14.9 19.5 56 5.5 6.8 8.6 56 10.7 16.2 27.5 157 Montana 21.7 22.6 24.9 15 12.1 14.6 14.7 21 10.1 11.9 12.2 21 Nebraska 10.9 12.5 13.4 23 6.4 8.5 13.0 103 5.0 7.9 7.4 48 Nevada 19.8 18.2 20.8 5 8.9 12.3 15.8 78 18.7 21.0 21.2 13 New Hampshire 12.0 14.1 19.4 62 7.5 8.8 11.7 56 10.7 13.4 35.8 235 New Jersey 6.1 7.4 8.3 36 5.2 5.0 6.5 25 9.4 13.7 33.1 252 New Mexico 17.8 21.3 25.0 40 16.2 22.5 32.7 102 20.1 24.7 26.7 33 New York 6.0 8.3 8.3 38 5.2 6.3 7.3 40 4.8 10.4 18.4 283 North Carolina 11.5 12.7 13.7 19 6.7 6.7 9.2 37 11.4 13.3 22.4 96 North Dakota 13.7 15.2 19.2 40 10.9 15.4 17.2 58 — 3.1 10.2 — Ohio 11.5 13.0 15.3 33 6.1 6.4 8.9 46 10.9 18.9 35.9 229 Oklahoma 14.8 17.6 20.0 35 9.3 11.3 14.3 54 13.8 20.6 18.4 33 Oregon 14.9 17.8 19.0 28 13.4 14.9 18.2 36 10.4 12.5 12.6 21 Pennsylvania 11.1 12.4 14.9 34 3.5 5.1 5.9 69 13.2 19.0 36.1 173 Rhode Island 6.3 9.5 9.5 51 4.9 11.0 12.4 153 14.3 18.2 30.1 110 South Carolina 11.8 13.7 15.4 31 8.3 7.9 9.3 12 9.9 12.5 22.6 128 South Dakota 15.4 16.8 19.3 25 11.0 16.6 22.0 100 5.5 5.5 6.9 25 Tennessee 14.0 14.6 16.6 19 6.9 8.3 11.4 65 14.5 17.6 27.5 90 Texas 10.9 11.9 13.7 26 5.8 6.3 7.8 34 8.5 9.4 10.4 22 Utah 15.4 21.0 22.2 44 6.7 8.1 10.9 63 19.3 23.1 21.2 10 Vermont 12.5 13.0 18.8 50 7.5 8.0 12.3 64 8.5 10.9 26.6 213 Virginia 11.2 12.6 14.0 25 4.4 5.7 6.9 57 7.5 8.9 17.1 128 Washington 12.8 14.5 15.9 24 9.4 12.3 13.6 45 13.0 13.7 14.8 14 West Virginia 13.2 17.1 21.2 61 5.3 7.9 10.6 100 10.5 32.0 51.5 390 Wisconsin 11.6 12.4 14.8 28 7.9 8.6 11.3 43 9.3 12.2 19.2 106 Wyoming 17.3 29.6 25.2 46 11.6 17.0 23.3 101 4.9 16.8 11.1 127 Notes: — Indicates that estimates are not available. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 47 APPENDIX AppendixG1. G1.Income Disparity: Income Dimension Disparity: RankingRanking Dimension and Indicator and Rates Indicator Rates Income Disparity Adults who went Adult Dimension without care because High out-of-pocket medical Adults without a recomm Summary Uninsured adults of cost spending dental visit sc 2018 2018 2017–18 2018 0%–199% 0%–199% 0%–199% 0%–199% 0%–199% 400% and 400% and 400% and 400% and 400% and Disparity Disparity Disparity Disparity above above above above rank rank rank rank 2020 United States — 23% 5% -18 — 22% 6% -16 — 19.3% 1.6% -17.7 — 49% 20% -29 — 37% 2 Alabama 49 30 5 -25 45 30 5 -25 49 24.3 1.0 -23.3 43 56 21 -35 44 37 Alaska 17 27 8 -19 34 21 6 -15 19 18.4 2.4 -16.0 6 45 18 -27 14 42 Arizona 16 24 6 -18 32 21 6 -15 19 19.8 2.4 -17.4 17 52 23 -29 23 38 Arkansas 37 19 5 -14 22 23 5 -18 33 19.1 1.6 -17.5 19 62 22 -40 50 38 California 19 18 4 -14 22 19 5 -14 15 15.5 1.1 -14.4 3 47 18 -29 23 36 Colorado 13 19 5 -14 22 22 6 -16 26 25.3 2.4 -22.9 41 49 21 -28 18 39 Connecticut 7 16 3 -13 17 17 5 -12 9 19.6 2.8 -16.8 13 38 14 -24 4 28 Delaware 18 11 4 -7 3 19 4 -15 19 23.5 3.9 -19.6 34 55 18 -37 47 30 District of Columbia 30 8 2 -6 1 12 5 -7 2 15.1 0.6 -14.5 4 37 18 -19 1 37 Florida 44 32 8 -24 43 27 7 -20 40 18.8 2.3 -16.5 10 51 20 -31 31 39 Georgia 47 36 7 -29 50 32 7 -25 49 21.0 1.7 -19.3 31 53 20 -33 39 38 Hawaii 10 10 3 -7 3 14 3 -11 6 19.0 0.7 -18.3 24 40 14 -26 11 35 Idaho 8 26 6 -20 35 28 4 -24 47 22.9 2.0 -20.9 36 52 20 -32 33 49 Illinois 22 20 4 -16 28 21 4 -17 29 20.1 1.8 -18.3 24 45 20 -25 6 38 Indiana 31 20 5 -15 26 22 5 -17 29 16.3 1.1 -15.2 5 51 22 -29 23 38 Iowa 9 13 2 -11 12 15 3 -12 9 18.6 2.0 -16.6 11 43 18 -25 6 32 Kansas 34 26 4 -22 38 25 4 -21 41 21.0 2.2 -18.8 28 51 17 -34 41 43 Kentucky 35 12 3 -9 7 21 7 -14 15 20.0 2.4 -17.6 21 53 24 -29 23 42 Louisiana 28 18 6 -12 15 23 7 -16 26 17.4 1.1 -16.3 8 54 29 -25 6 33 Maine 47 21 5 -16 28 20 5 -15 19 23.2 — — — 57 17 -40 50 35 Maryland 24 18 3 -15 26 24 5 -19 36 21.3 1.6 -19.7 35 53 21 -32 33 31 Massachusetts 3 8 2 -6 1 18 5 -13 12 20.0 0.7 -19.3 31 39 18 -21 2 28 Michigan 33 13 3 -10 10 20 5 -15 19 17.7 1.4 -16.3 8 45 16 -29 23 30 Minnesota 6 12 2 -10 10 17 5 -12 9 18.6 1.6 -17.0 16 42 17 -25 6 35 Mississippi 41 32 7 -25 45 30 4 -26 51 19.0 1.6 -17.4 17 58 27 -31 31 38 Missouri 50 27 5 -22 38 27 4 -23 45 23.9 — — — 54 22 -32 33 40 Montana 12 20 6 -14 22 15 5 -10 4 21.3 2.8 -18.5 26 46 22 -24 4 44 Nebraska 32 26 4 -22 38 23 5 -18 33 25.0 2.3 -22.7 40 48 19 -29 23 39 Nevada 36 25 8 -17 30 23 7 -16 26 17.9 1.1 -16.8 13 53 17 -36 46 44 New Hampshire 38 15 4 -11 12 24 5 -19 36 28.0 0.7 -27.3 45 57 18 -39 49 32 New Jersey 26 24 4 -20 35 23 6 -17 29 20.4 1.8 -18.6 27 45 18 -27 14 40 New Mexico 5 19 6 -13 17 19 6 -13 12 14.5 2.2 -12.3 1 45 20 -25 6 39 New York 2 13 4 -9 7 17 6 -11 6 14.4 1.2 -13.2 2 42 20 -22 3 35 North Carolina 46 30 5 -25 45 27 6 -21 41 21.3 3.5 -17.8 22 51 17 -34 41 36 North Dakota 11 21 4 -17 30 19 4 -15 19 20.8 1.8 -19.0 30 52 20 -32 33 41 Ohio 3 16 3 -13 17 15 6 -9 3 17.9 1.3 -16.6 11 46 20 -26 11 34 Oklahoma 40 33 8 -25 45 27 4 -23 45 19.5 1.5 -18.0 23 57 23 -34 41 42 Oregon 41 17 4 -13 17 21 6 -15 19 23.8 — — — 49 17 -32 33 36 Pennsylvania 23 14 3 -11 12 15 5 -10 4 21.7 0.7 -21.0 37 48 20 -28 18 36 Rhode Island 38 10 3 -7 3 18 4 -14 15 15.3 — — — 42 14 -28 18 35 South Carolina 43 28 6 -22 38 28 6 -22 44 21.7 2.3 -19.4 33 55 20 -35 44 36 South Dakota 29 29 4 -25 45 23 4 -19 36 23.5 2.1 -21.4 38 46 18 -28 18 42 Tennessee 51 26 5 -21 37 25 7 -18 33 21.6 — — — 60 23 -37 47 40 Texas 24 43 9 -34 51 25 8 -17 29 20.8 2.0 -18.8 28 54 26 -28 18 39 Utah 1 23 5 -18 32 26 7 -19 36 29.5 1.9 -27.6 46 45 19 -26 11 41 Vermont 14 9 2 -7 3 10 5 -5 1 24.3 1.2 -23.1 42 43 16 -27 14 41 Virginia 45 28 4 -24 43 29 5 -24 47 22.6 1.2 -21.4 38 49 16 -33 39 37 Washington 20 17 4 -13 17 20 6 -14 15 17.4 1.3 -16.1 7 49 19 -30 29 41 West Virginia 27 13 4 -9 7 21 8 -13 12 18.5 1.0 -17.5 19 58 26 -32 33 38 Wisconsin 15 15 3 -12 15 17 6 -11 6 18.9 2.1 -16.8 13 44 17 -27 14 35 Wyoming 20 29 6 -23 42 26 5 -21 41 30.8 4.0 -26.8 44 50 20 -30 29 41 Notes: — Indicates that estimates are not available. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 48 APPENDIX AppendixG1. G1.Income Disparity: Income Dimension Disparity: RankingRanking Dimension and Indicator and Rates (continued) Indicator Rates Income Disparity Adults without all Adults who Children went without a Children without all Adult medical Adults without a Dimension recommended cancer Children without without a care because medical andHigh out-of-pocket dental medical Adults recommended Adults without whoareport recomm fair dental visit Summary screeningsUninsured adults medical home of cost preventive care visit spending vaccines dental orvisit poor health scA 2018 2018 2018 2018 2018 2018 2017–18 2018 2018 2018 0%–199% 0%–199% 0%–199% 0%–199% 0%–199% 0%–199% 0%–199% 0%–199% 0%–199% 0%–199% 0%–199% 400% and 400% and rank and 400% and rank and 400% and 400% and 300% and 400% and 400% and 400% and Disparity Disparity Disparity Disparity Disparity Disparity Disparity Disparity Disparity Disparity Disparity above above above above above above above above above above 400% 400% rank rank rank rank rank rank rank rank rank 2020 7 — United 49% 20%States-29 — 37% 26%— -11 23% —5% 64% -18 39%— -25 22% —6% 52% -16 29%— -23 19.3%— 1.6% 33% -17.7 19% -14 — 49% — 20% 29% -29 7% — -22 37%— 2 3 43 Alabama 56 21 -35 44 37 2549 -1230 31 5 67-25 3545 -3230 43 5 58-25 3749 -21 24.3 19 1.026 -23.3 12 -14 43 24 56 21 33 -358 44 -25 3739 0 6 Alaska 45 18 -27 14 42 3417 -827 9 8 65-19 4734 -1821 13 6 63-15 3919 -24 18.4 32 2.429 -16.0 34 56 45 2 18 31 -278 14 -23 4231 4 17 Arizona 52 23 -29 23 38 3016 -824 9 6 64-18 3832 -2621 32 6 51-15 3319 -18 19.8 8 2.434 -17.4 28 -6 17 10 52 23 26 -29 10 23 -16 38 3 5 19 Arkansas 62 22 -40 50 38 2837 -1019 19 5 61-14 4222 -1923 14 5 61-18 3733 -24 19.1 32 1.631 -17.5 16 -15 19 28 62 22 32 -409 50 -23 3831 4 3 California 47 18 -29 23 36 2219 -1418 39 4 63-14 4722 -1619 9 5 60-14 3615 -24 15.5 32 1.139 -14.4 15 -243 47 18 27 -297 23 -20 3619 9 41 Colorado 49 21 -28 18 39 2913 -1019 19 5 57-14 4122 -1622 9 6 46-16 2426 -22 25.3 26 2.432 -22.9 21 -11 41 18 49 21 24 -286 18 -18 39 7 8 13 Connecticut 38 14 -24 4 28 22 7 -616 4 3 65-13 3517 -3017 40 5 44-12 23 9 -21 19.6 19 2.816 -16.8 15 -1 13 38 7 14 25 -245 4 -20 2819 6 34 Delaware 55 18 -37 47 30 2218 -811 9 4 65 -7 41 3 -2419 23 4 43-15 2119 -22 23.5 26 3.934 -19.6 16 -18 34 38 55 18 26 -378 47 -18 30 7 5 4 District 37 of 18Columbia -19 1 37 2030 -17 8 50 2 71 -6 40 1 -3112 42 5 49 -7 24 2 -25 15.1 37 0.633 -14.5 23 -104 15 37 18 26 -194 1 -22 3728 5 10 Florida 51 20 -31 31 39 2544 -1432 39 8 73-24 3143 -4227 51 7 44-20 2640 -18 18.8 8 2.335 -16.5 16 -19 10 42 51 20 31 -318 31 -23 3931 3 31 Georgia 53 20 -33 39 38 2447 -1436 39 7 67-29 3550 -3232 43 7 52-25 2349 -29 21.0 44 1.729 -19.3 12 -17 31 35 53 20 29 -338 39 -21 3826 3 24 Hawaii 40 14 -26 11 35 1910 -1610 48 3 58 -7 42 3 -1614 9 3 54-11 36 6 -18 19.0 8 0.735 -18.3 17 -18 24 38 40 14 24 -26 10 11 -14 35 1 9 36 Idaho52 20 -32 33 49 34 8 -1526 45 6 44-20 4535 128 2 4 46-24 3547 -11 22.9 4 2.025 -20.9 38 13 36 52 1 20 23 -325 33 -18 49 7 3 24 Illinois 45 20 -25 6 38 3022 -820 9 4 72-16 3528 -3721 49 4 53-17 3329 -20 20.1 15 1.831 -18.3 14 -17 24 35 45 20 28 -256 6 -22 3828 2 5 Indiana 51 22 -29 23 38 3031 -820 9 5 70-15 3426 -3622 48 5 58-17 2429 -34 16.3 51 1.144 -15.2 28 -165 32 51 22 32 -298 23 -24 3836 6 11 Iowa 43 18 -25 6 32 27 9 -513 2 2 48-11 4112 -715 3 3 47-12 21 9 -26 18.6 39 2.039 -16.6 10 -29 11 51 43 18 24 -256 6 -18 32 7 8 28 Kansas 51 17 -34 41 43 2934 -1426 39 4 54-22 3538 -1925 14 4 47-21 2641 -21 21.0 19 2.230 -18.8 20 -10 28 15 51 17 27 -348 41 -19 4313 6 21 Kentucky 53 24 -29 23 42 2735 -1512 45 3 52 -9 36 7 -1621 9 7 47-14 2315 -24 20.0 32 2.423 -17.68 -15 21 28 53 24 36 -298 23 -28 4248 3 8 Louisiana 54 29 -25 6 33 2328 -1018 19 6 62-12 2915 -3323 46 7 60-16 2926 -31 17.4 49 1.125 -16.3 26 18 54 5 29 32 -258 6 -24 3336 — — Maine57 17 -40 50 35 2447 -1121 26 5 56-16 3228 -2420 23 5 47-15 1919 -28 23.2 43 —32 —14 -18 — 38 57 17 32 -406 50 -26 3544 7 35 Maryland 53 21 -32 33 31 2424 -718 7 3 69-15 4026 -2924 37 5 49-19 2736 -22 21.3 26 1.637 -19.7 18 -19 35 42 53 21 26 -328 33 -18 31 7 3 31 Massachusetts 39 18 -21 2 28 21 3 -7 8 7 2 72 -6 33 1 -3918 50 5 40-13 2112 -19 20.0 13 0.720 -19.3 15 -5 31 39 9 18 23 -216 2 -17 28 4 3 8 Michigan 45 16 -29 23 30 2533 -513 2 3 66-10 3710 -2920 37 5 60-15 2919 -31 17.7 49 1.435 -16.3 19 -168 32 45 16 34 -297 23 -27 3046 0 16 Minnesota 42 17 -25 6 35 24 6 -1112 26 2 66-10 3910 -2717 34 5 52-12 30 9 -22 18.6 26 1.635 -17.0 25 -10 16 15 42 17 24 -255 6 -19 3513 4 17 Mississippi 58 27 -31 31 38 2841 -1032 19 7 66-25 4145 -2530 29 4 57-26 3951 -18 19.0 8 1.635 -17.4 20 -15 17 28 58 27 32 -317 31 -25 3839 — — Missouri 54 22 -32 33 40 2650 -1427 39 5 65-22 4138 -2427 23 4 58-23 2845 -30 23.9 47 —41 —18 -23 — 46 54 22 34 -326 33 -28 4048 5 26 Montana 46 22 -24 4 44 3212 -1220 31 6 61-14 3622 -2515 29 5 42-10 22 4 -20 21.3 15 2.842 -18.5 35 -7 26 12 46 22 25 -245 4 -20 4419 7 40 Nebraska 48 19 -29 23 39 2732 -1226 31 4 61-22 3238 -2923 37 5 54-18 3333 -21 25.0 19 2.327 -22.7 21 -6 40 10 48 19 26 -296 23 -20 3919 8 13 Nevada 53 17 -36 46 44 2836 -1625 48 8 60-17 4530 -1523 8 7 58-16 3126 -27 17.9 41 1.139 -16.8 31 -8 13 13 53 17 36 -367 46 -29 4450 3 45 New 57Hampshire 18 -39 49 32 2338 -915 16 4 44-11 3512 -924 4 5 37-19 2736 -10 28.0 2 0.732 -27.3 10 -22 45 45 57 18 29 -396 49 -23 3231 6 27 New 45Jersey18 -27 14 40 2926 -1124 26 4 62-20 3835 -2423 23 6 44-17 2329 -21 20.4 19 1.838 -18.6 27 -11 27 18 45 18 27 -277 14 -20 4019 3 1 New 45Mexico20 -25 6 39 33 5 -619 4 6 64-13 4317 -2119 18 6 46-13 2612 -20 14.5 15 2.226 -12.3 14 -121 22 45 20 29 -258 6 -21 3926 2 2 New 42York20 -22 3 35 22 2 -1313 34 4 66 -9 44 7 -2217 20 6 53-11 31 6 -22 14.4 26 1.230 -13.2 30 02 42 6 20 26 -226 3 -20 3519 8 22 North51 Carolina 17 -34 41 36 2346 -1330 34 5 71-25 4145 -3027 40 6 52-21 2241 -30 21.3 47 3.528 -17.8 13 -15 22 28 51 17 31 -346 41 -25 3639 0 30 North52 Dakota 20 -32 33 41 3011 -1121 26 4 56-17 4230 -1419 6 4 53-15 3219 -21 20.8 19 1.828 -19.0 14 -14 30 24 52 20 21 -326 33 -15 41 2 6 11 Ohio 46 20 -26 11 34 30 3 -416 1 3 61-13 3717 -2415 23 6 48 -9 31 3 -17 17.9 7 1.333 -16.6 15 -18 11 38 46 20 27 -269 11 -18 34 7 0 23 Oklahoma 57 23 -34 41 42 3240 -1033 19 8 61-25 3345 -2827 36 4 51-23 3045 -21 19.5 19 1.537 -18.0 24 -13 23 23 57 23 33 -348 41 -25 4239 — — Oregon 49 17 -32 33 36 2541 -1117 26 4 67-13 3517 -3221 43 6 49-15 2219 -27 23.8 41 —38 —29 -9 — 14 49 17 31 -326 33 -25 3639 0 37 Pennsylvania 48 20 -28 18 36 2823 -814 9 3 67-11 4012 -2715 34 5 50-10 24 4 -26 21.7 39 0.727 -21.0 16 -11 37 18 48 20 32 -288 18 -24 3636 — — Rhode42 Island 14 -28 18 35 2038 -1510 45 3 62 -7 38 3 -2418 23 4 50-14 2615 -24 15.3 32 —30 —13 -17 — 35 42 14 32 -285 18 -27 3546 4 33 South55 Carolina 20 -35 44 36 2743 -928 16 6 62-22 4038 -2228 20 6 52-22 2344 -29 21.7 44 2.331 -19.4 15 -16 33 32 55 20 26 -357 44 -19 3613 4 38 South46 Dakota 18 -28 18 42 2929 -1329 34 4 57-25 3445 -2323 22 4 48-19 3436 -14 23.5 5 2.141 -21.4 15 -26 38 49 46 18 24 -287 18 -17 42 4 — — Tennessee 60 23 -37 47 40 2351 -1726 50 5 63-21 3037 -3325 46 7 48-18 2333 -25 21.6 37 —32 —28 -4 — 60 8 23 38 -378 47 -30 4051 8 28 Texas54 26 -28 18 39 3124 -843 9 9 57-34 3851 -1925 14 8 54-17 3229 -22 20.8 26 2.031 -18.8 20 -11 28 18 54 26 27 -288 18 -19 3913 6 46 Utah 45 19 -26 11 41 32 1 -923 16 5 44-18 4732 326 1 7 48-19 4136 -7 29.5 1 1.923 -27.6 27 46 4 45 4 19 24 -267 11 -17 41 4 1 42 Vermont 43 16 -27 14 41 2714 -14 9 39 2 51 -7 32 3 -1910 14 5 48 -5 19 1 -29 24.3 44 1.221 -23.1 26 42 5 43 2 16 24 -275 14 -19 4113 4 38 Virginia 49 16 -33 39 37 2445 -1328 34 4 55-24 4243 -1329 5 5 42-24 2447 -18 22.6 8 1.238 -21.4 10 -28 38 50 49 16 30 -338 39 -22 3728 1 7 Washington 49 19 -30 29 41 2820 -1317 34 4 66-13 4017 -2620 32 6 48-14 2915 -19 17.4 13 1.347 -16.1 23 -247 47 49 19 27 -308 29 -19 4113 5 19 West 58 Virginia 26 -32 33 38 2827 -1013 19 4 65 -9 40 7 -2521 29 8 41-13 2712 -14 18.5 5 1.033 -17.5 14 -19 19 42 58 26 36 -32 10 33 -26 3844 8 13 Wisconsin 44 17 -27 14 35 2515 -1015 19 3 57-12 4315 -1417 6 6 56-11 36 6 -20 18.9 15 2.127 -16.8 13 -14 13 24 44 17 29 -276 14 -23 3531 8 44 Wyoming 50 20 -30 29 41 3520 -629 4 6 61-23 4042 -2126 18 5 44-21 3441 -10 30.8 2 4.036 -26.8 22 -14 44 24 50 20 27 -307 29 -20 4119 commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 49 APPENDIX AppendixG1. G1.Income Disparity: Income Dimension Disparity: RankingRanking Dimension and Indicator and Rates (continued) Indicator Rates Income ut a Children without all Disparity Adults who went Adult ental recommended Dimension Adults who report fair without care Adults because who have Highlost out-of-pocket medical Adults without a recomm visit vaccines Summary or poor health Uninsured Adults adults who are obeseof cost six or more teeth spending dental visit sc 2018 2018 2018 2018 2018 2018 2017–18 2018 0%–199% 0%–199% 0%–199% 0%–199% 0%–199% 0%–199% 0%–199% 0%–199% 0%–199% 300% and 400% and 400% and 400% and 400% and 400% and 400% and 400% and 400% and Disparity Disparity Disparity Disparity Disparity Disparity Disparity Disparity above above above above above above above above rank rank rank rank rank rank rank rank rank 2020 — 33% United 19% States -14 — 29% 7%— -22 23% — 5% 36% -18 29%— 22% -7 — 6% 16% -16 5%— -11 19.3%— 1.6% -17.7 — 49% 20% -29 — 37% 2 19 Alabama 26 12 -14 24 33 849 -2530 39 5 41 -25 3445 -730 23 5 22 -25 549 -17 24.3 42 1.0 -23.3 43 56 21 -35 44 37 32 Alaska 29 34 5 2 31 817 -2327 31 8 31 -19 2734 -421 86 26 -15 419 -22 18.4 51 2.4 -16.0 6 45 18 -27 14 42 8 Arizona 34 28 -6 10 26 1016 -1624 36 37 -18 2432 -1321 50 6 12 -15 419 -8 19.8 5 2.4 -17.4 17 52 23 -29 23 38 32 Arkansas 31 16 -15 28 32 937 -2319 31 5 44 -14 3822 -623 20 5 25 -18 833 -17 19.1 42 1.6 -17.5 19 62 22 -40 50 38 32 California 39 15 -24 47 27 719 -2018 19 4 32 -14 2222 -1019 41 5 -14 9 315 -6 15.5 2 1.1 -14.4 3 47 18 -29 23 36 26 Colorado 32 21 -11 18 24 613 -1819 75 26 -14 2322 -322 56 12 -16 426 -8 25.3 5 2.4 -22.9 41 49 21 -28 18 39 19 Connecticut 16 15 -1 7 25 57 -2016 19 3 33 -13 2517 -817 36 5 14 -12 49 -10 19.6 17 2.8 -16.8 13 38 14 -24 4 28 26 Delaware 34 16 -18 38 26 818 -1811 74 36-7 32 3 -419 84 16 -15 619 -10 23.5 17 3.9 -19.6 34 55 18 -37 47 30 37 District 33 of23Columbia -10 15 26 430 -22 8 28 2 40-6 17 1 -2312 51 5 15-7 12 -14 15.1 30 0.6 -14.5 4 37 18 -19 1 37 8 Florida 35 16 -19 42 31 844 -2332 31 8 36 -24 2943 -727 23 7 18 -20 640 -12 18.8 23 2.3 -16.5 10 51 20 -31 31 39 44 Georgia 29 12 -17 35 29 847 -2136 26 7 37 -29 3050 -732 23 7 19 -25 649 -13 21.0 26 1.7 -19.3 31 53 20 -33 39 38 8 Hawaii 35 17 -18 38 24 1010 -1410 13 32-7 22 3 -1014 41 3 10 -11 46 -6 19.0 2 0.7 -18.3 24 40 14 -26 11 35 4 Idaho 25 38 13 1 23 58 -1826 76 30 -20 2835 -228 24 13 -24 347 -10 22.9 17 2.0 -20.9 36 52 20 -32 33 49 15 Illinois 31 14 -17 35 28 622 -2220 28 4 36 -16 2928 -721 23 4 12 -17 429 -8 20.1 5 1.8 -18.3 24 45 20 -25 6 38 51 Indiana 44 28 -16 32 32 831 -2420 36 5 36 -15 3526 -122 15 20 -17 629 -14 16.3 30 1.1 -15.2 5 51 22 -29 23 38 39 Iowa 39 10 -29 51 24 69 -1813 72 42 -11 3312 -915 37 3 13 -12 49 -9 18.6 13 2.0 -16.6 11 43 18 -25 6 32 19 Kansas 30 20 -10 15 27 834 -1926 13 4 39 -22 3438 -525 16 4 19 -21 541 -14 21.0 30 2.2 -18.8 28 51 17 -34 41 43 32 Kentucky 23 8 -15 28 36 835 -2812 48 3 44-9 37 7 -721 23 7 26 -14 615 -20 20.0 49 2.4 -17.6 21 53 24 -29 23 42 49 Louisiana 25 26 1 5 32 828 -2418 36 6 43 -12 3615 -723 23 7 21 -16 626 -15 17.4 36 1.1 -16.3 8 54 29 -25 6 33 43 Maine 32 14 -18 38 32 647 -2621 44 5 39 -16 2828 -1120 47 5 25 -15 619 -19 23.2 47 — — — 57 17 -40 50 35 26 Maryland 37 18 -19 42 26 824 -1818 73 38 -15 3126 -724 23 5 13 -19 536 -8 21.3 5 1.6 -19.7 35 53 21 -32 33 31 13 Massachusetts 20 15 -5 9 23 63 -17 8 42 30-6 25 1 -518 16 5 13 -13 412 -9 20.0 13 0.7 -19.3 31 39 18 -21 2 28 49 Michigan 35 19 -16 32 34 733 -2713 46 3 40 -10 3110 -920 37 5 20 -15 419 -16 17.7 40 1.4 -16.3 8 45 16 -29 23 30 26 Minnesota 35 25 -10 15 24 56 -1912 13 2 33 -10 2910 -417 85 10 -12 49 -6 18.6 2 1.6 -17.0 16 42 17 -25 6 35 8 Mississippi 35 20 -15 28 32 741 -2532 39 7 46 -25 4145 -530 16 4 24 -26 851 -16 19.0 40 1.6 -17.4 17 58 27 -31 31 38 47 Missouri 41 18 -23 46 34 650 -2827 48 5 42 -22 3538 -727 23 4 22 -23 545 -17 23.9 42 — — — 54 22 -32 33 40 15 Montana 42 35 -7 12 25 512 -2020 19 6 31 -14 2722 -415 85 19 -10 44 -15 21.3 36 2.8 -18.5 26 46 22 -24 4 44 19 Nebraska 27 21 -6 10 26 632 -2026 19 4 39 -22 3338 -623 20 5 15 -18 433 -11 25.0 21 2.3 -22.7 40 48 19 -29 23 39 41 Nevada 39 31 -8 13 36 736 -2925 50 8 36 -17 2930 -723 23 7 12 -16 426 -8 17.9 5 1.1 -16.8 13 53 17 -36 46 44 2 New 32 Hampshire 10 -22 45 29 638 -2315 31 4 39 -11 2812 -1124 47 5 20 -19 536 -15 28.0 36 0.7 -27.3 45 57 18 -39 49 32 19 New 38 Jersey 27 -11 18 27 726 -2024 19 4 34 -20 2435 -1023 41 6 13 -17 429 -9 20.4 13 1.8 -18.6 27 45 18 -27 14 40 15 New 26 Mexico 14 -12 22 29 85 -2119 26 6 38 -13 3117 -719 23 6 14 -13 512 -9 14.5 13 2.2 -12.3 1 45 20 -25 6 39 26 New 30 York30 0 6 26 62 -2013 19 4 32-9 25 7 -717 23 6 13 -11 56 -8 14.4 5 1.2 -13.2 2 42 20 -22 3 35 47 North 28 Carolina 13 -15 28 31 646 -2530 39 5 39 -25 3245 -727 23 6 19 -21 441 -15 21.3 36 3.5 -17.8 22 51 17 -34 41 36 19 North 28 Dakota 14 -14 24 21 611 -1521 24 38 -17 3630 -219 24 13 -15 319 -10 20.8 17 1.8 -19.0 30 52 20 -32 33 41 7 Ohio 33 15 -18 38 27 93 -1816 73 38 -13 3417 -415 86 19-9 63 -13 17.9 26 1.3 -16.6 11 46 20 -26 11 34 19 Oklahoma 37 24 -13 23 33 840 -2533 39 8 40 -25 3745 -327 54 20 -23 645 -14 19.5 30 1.5 -18.0 23 57 23 -34 41 42 41 Oregon 38 29 -9 14 31 641 -2517 39 4 34 -13 2817 -621 20 6 23 -15 319 -20 23.8 49 — — — 49 17 -32 33 36 39 Pennsylvania 27 16 -11 18 32 823 -2414 36 3 35 -11 3112 -415 85 21 -10 44 -17 21.7 42 0.7 -21.0 37 48 20 -28 18 36 32 Rhode 30 Island 13 -17 35 32 538 -2710 46 3 36-7 25 3 -1118 47 4 17 -14 315 -14 15.3 30 — — — 42 14 -28 18 35 44 South 31 Carolina 15 -16 32 26 743 -1928 13 6 39 -22 3038 -928 37 6 18 -22 544 -13 21.7 26 2.3 -19.4 33 55 20 -35 44 36 5 South 41 Dakota 15 -26 49 24 729 -1729 44 34 -25 3045 -423 84 13 -19 536 -8 23.5 5 2.1 -21.4 38 46 18 -28 18 42 37 Tennessee 32 28 -4 8 38 851 -3026 51 5 40 -21 3037 -1025 41 7 24 -18 633 -18 21.6 46 — — — 60 23 -37 47 40 26 Texas 31 20 -11 18 27 824 -1943 13 9 39 -34 2951 -1025 41 8 10 -17 529 -5 20.8 1 2.0 -18.8 28 54 26 -28 18 39 1 Utah 23 27 4 4 24 71 -1723 45 30 -18 2732 -326 57 11 -19 336 -8 29.5 5 1.9 -27.6 46 45 19 -26 11 41 44 Vermont 21 26 5 2 24 514 -19 9 13 2 32-7 25 3 -710 23 5 19-5 51 -14 24.3 30 1.2 -23.1 42 43 16 -27 14 41 8 Virginia 38 10 -28 50 30 845 -2228 28 4 38 -24 2843 -1029 41 5 17 -24 447 -13 22.6 26 1.2 -21.4 38 49 16 -33 39 37 13 Washington 47 23 -24 47 27 820 -1917 13 4 33 -13 2817 -520 16 6 15 -14 315 -12 17.4 23 1.3 -16.1 7 49 19 -30 29 41 5 West 33 Virginia 14 -19 42 36 1027 -2613 44 4 44-9 40 7 -421 88 29 -13 1012 -19 18.5 47 1.0 -17.5 19 58 26 -32 33 38 15 Wisconsin 27 13 -14 24 29 615 -2315 31 3 38 -12 2915 -917 37 6 17 -11 56 -12 18.9 23 2.1 -16.8 13 44 17 -27 14 35 2 Wyoming 36 22 -14 24 27 720 -2029 19 6 32 -23 3042 -226 25 18 -21 741 -11 30.8 21 4.0 -26.8 44 50 20 -30 29 41 commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 50 APPENDIX AppendixH1. H1.Race RaceDisparity: Indicator Disparity: RatesRates Indicator Adults who went Adults without all Adults Adults without a without care because Adults without a recommended cancer recom Uninsured adults usual source of care of cost dental visit screenings vac 2018 2018 2018 2018 2018 2 Hispanic Hispanic Hispanic Hispanic Hispanic Other Other Other Other Other White White White White White White Black Black Black Black Black United States 9% 14% 25% 10% 18% 23% 39% 25% 11% 16% 20% 13% 30% 40% 42% 33% 31% 28% 33% 35% 66% 74 Alabama 13 18 46 16 20 24 46 29 14 21 24 24 37 45 35 49 31 29 — 36 65 7 Alaska 13 — — 22 35 — 39 40 13 — 15 13 28 — 28 36 40 — 38 35 67 — Arizona 9 13 23 17 21 24 36 35 10 18 21 12 33 46 45 42 34 34 33 39 68 7 Arkansas 10 13 33 14 16 21 39 32 14 13 27 19 42 48 58 50 37 30 39 38 70 7 California 6 8 17 6 19 20 37 19 9 11 17 9 25 39 43 28 27 24 32 33 64 7 Colorado 7 10 22 7 21 28 43 34 10 17 19 15 29 40 43 38 33 26 36 38 63 6 Connecticut 4 9 20 7 11 23 33 21 7 13 18 9 21 31 31 29 25 24 25 26 64 7 Delaware 6 6 25 — 15 20 39 23 9 13 17 11 30 42 42 37 27 27 29 42 62 7 District of Columbia — 6 — — 23 19 23 31 5 9 13 11 17 35 24 36 20 30 30 37 45 6 Florida 15 21 26 17 22 26 35 31 13 21 21 17 32 39 37 38 30 31 31 38 67 8 Georgia 15 19 45 15 24 29 56 31 15 21 28 17 34 41 51 34 33 28 33 31 69 7 Hawaii 4 — 8 6 19 22 20 13 7 1 10 7 22 27 38 24 22 — 22 26 71 5 Idaho 14 — 34 20 26 — 47 38 14 — 17 30 34 — 39 45 39 — 30 44 69 — Illinois 6 12 23 8 15 18 31 23 8 18 20 12 28 39 44 27 35 27 34 37 67 7 Indiana 9 15 27 11 18 26 39 30 11 15 19 19 35 45 39 41 33 29 38 47 73 8 Iowa 5 24 20 9 15 31 45 24 6 23 15 13 28 37 32 42 30 20 22 39 61 6 Kansas 10 15 31 10 19 30 38 33 11 18 17 17 31 38 31 39 35 36 37 41 65 7 Kentucky 7 8 34 10 17 23 49 24 12 14 17 20 38 39 43 42 35 24 29 24 65 7 Louisiana 10 11 40 14 21 25 35 34 13 16 20 22 39 48 40 42 30 25 38 24 73 7 Maine 11 — — 14 14 — 24 19 11 — 12 23 34 — 40 42 28 — 28 38 69 — Maryland 4 9 30 6 12 15 44 19 7 12 32 10 27 41 42 35 30 24 29 32 58 6 Massachusetts 3 6 7 4 11 18 20 22 8 14 15 7 24 31 33 28 24 17 25 31 64 7 Michigan 7 9 16 7 14 17 22 19 11 16 15 17 27 35 40 34 28 28 23 32 67 7 Minnesota 4 8 24 9 22 28 53 30 8 19 23 14 24 34 42 31 27 32 32 37 61 7 Mississippi 16 21 40 23 23 29 — 50 15 20 — 32 44 49 — 50 38 29 — 49 67 7 Missouri 12 18 29 14 21 31 35 36 11 17 35 25 36 41 47 42 34 23 38 43 64 7 Montana 11 — — 23 26 — 30 36 10 — 16 11 32 — 38 45 37 — 39 39 66 — Nebraska 9 14 29 18 18 30 55 35 10 19 22 19 30 46 42 43 32 35 33 44 61 7 Nevada 9 15 27 12 23 28 48 26 11 16 20 12 32 37 42 31 34 32 40 45 66 7 New Hampshire 7 — 18 10 13 — 34 23 10 — 29 16 30 — 43 45 28 — — 26 68 — New Jersey 5 11 25 8 12 19 43 22 8 11 28 14 20 37 43 31 29 29 30 39 61 7 New Mexico 7 — 16 22 24 21 36 42 10 16 15 15 30 27 39 40 37 — 34 43 63 7 New York 5 8 15 8 15 19 32 22 8 11 18 15 26 37 35 37 28 27 30 38 73 8 North Carolina 12 16 44 14 18 22 59 26 12 19 27 15 31 40 47 42 30 33 31 32 57 6 North Dakota 7 — — 23 26 50 43 30 8 24 22 18 30 58 35 42 34 — — 38 61 5 Ohio 8 12 20 10 18 25 36 38 9 11 23 12 32 36 35 34 33 28 39 38 65 7 Oklahoma 15 22 36 28 21 24 44 29 14 16 25 12 39 44 46 38 39 29 37 36 61 7 Oregon 8 11 25 9 22 29 42 30 11 21 23 14 31 31 40 34 32 — 31 24 69 6 Pennsylvania 6 10 17 7 13 16 28 24 8 11 18 10 29 39 31 31 32 26 31 44 61 6 Rhode Island 4 — 13 — 10 21 29 25 8 15 23 11 25 35 38 33 25 23 38 27 64 7 South Carolina 13 17 39 21 21 24 56 37 13 20 28 17 36 43 45 42 34 26 32 38 64 7 South Dakota 9 — 28 41 22 — 45 49 9 — 24 19 30 — 41 43 34 — 32 34 66 — Tennessee 12 17 43 16 21 24 59 31 14 18 23 22 40 43 58 50 32 33 32 38 72 7 Texas 14 21 37 15 23 29 45 33 13 16 23 12 34 40 46 40 37 27 40 39 72 7 Utah 8 — 29 16 24 19 47 36 11 22 22 20 25 33 45 38 34 — 36 39 68 7 Vermont 5 — — — 14 — 21 21 8 — 15 7 27 — 24 37 32 — — 38 65 — Virginia 9 15 32 9 20 20 44 24 11 14 28 12 26 34 38 25 31 25 31 24 59 7 Washington 6 14 29 7 22 21 42 24 9 9 20 12 29 35 40 33 32 42 32 32 62 6 West Virginia 9 15 — — 18 24 — 33 14 19 — 25 44 55 — 60 34 40 — 36 59 6 Wisconsin 6 13 24 13 16 12 36 19 9 13 20 16 26 33 46 46 29 22 34 32 71 7 Wyoming 13 — 24 23 30 — 46 45 12 — 16 18 31 — 42 45 41 — 42 36 70 — Notes: — Indicates that estimates are not available. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 51 APPENDIX AppendixH1. H1.Race RaceDisparity: Indicator Disparity: RatesRates Indicator (continued) Adults without all Adults without all Adults who went Adults without all Adults ut a recommended cancer recommended Mortality Adults without amenable a to without care because Adults without a recommended cancer recom t screenings Uninsured vaccines adults usualhealth sourcecare of care Infant mortality of cost Adults who dental smoke visit Adults who screenings are obese vac 2018 2018 2016–17 2018 2017 2018 2018 2018 2018 2018 2 Hispanic Hispanic Hispanic Hispanic Hispanic Hispanic Hispanic Hispanic Hispanic Hispanic Other Other Other Other Other Other Other Other Other Other White White White White White White White White White White Black Black Black Black Black Black Black Black Black Black % 33% 31% United 28% States 33% 35% 66% 9% 74% 14% 76% 25% 67% 10% 78.5 18% 154.9 23% 39% 66.7 25% 56.1 11% 4.7 16% 10.9 20% 5.1 13% 16% 30% 17% 40% 12% 42% 14% 33% 31% 31% 41% 28% 34% 33% 20% 35% 66% 74 5 49 Alabama 31 29 — 36 65 13 73 18 71 46 73 16 97.8 20 163.0 24 40.7 46 56.5 29 14 5.6 11.1 21 24 5.7 24 19 37 19 45 11 35 31 49 36 31 44 29 31 —25 36 65 7 8 36 Alaska 40 — 38 35 67 13 — — 78 64 22 65.5 35 103.5 — 55.2 39 106.4 40 13 4.2 — — 15 — 13 15 28 — —16 28 32 36 29 40 — —28 38 32 35 67 — 5 42 Arizona 34 34 33 39 689 75 13 75 23 73 17 73.7 21 127.1 24 70.3 36 85.4 35 10 4.9 12.2 18 21 5.1 12 14 33 13 46 13 45 14 42 29 34 33 34 34 33 29 39 68 7 8 50 Arkansas 37 30 39 38 70 10 74 13 67 33 78 14 120.5 16 196.2 21 57.6 39 83.0 32 14 6.9 12.6 13 27 6.2 19 23 42 21 48 16 58 34 50 38 37 44 30 37 39 37 38 70 7 3 28 California 27 24 32 33 646 768 78 17 646 70.3 19 148.2 20 66.0 37 52.3 19 3.1 9 11 8.4 17 4.5 12 9 25 13 39 11 439 28 23 27 39 24 33 32 14 33 64 7 3 38 Colorado 33 26 36 38 637 69 10 66 22 737 58.5 21 115.0 28 70.7 43 49.8 34 10 4.1 17 6.2 19 5.0 15 13 29 21 40 16 43 20 38 21 33 31 26 30 36 20 38 63 6 1 29 Connecticut 25 24 25 26 644 769 76 20 707 55.8 11 105.5 23 63.0 33 36.0 21 3.0 7 10.3 13 18 5.0 11 9 21 18 31 17 318 29 26 25 36 24 32 25 18 26 64 7 2 37 Delaware 27 27 29 42 626 706 69 25 — 65 80.2 15 134.2 20 57.7 39 36.2 23 — 9 12.8 13 17 — 11 17 30 17 42 16 42 10 37 33 27 41 27 34 29 21 42 62 7 4 36 District 20 of30Columbia 30 37 — 45 686 — 58 — 68 37.8 23 193.3 19 51.0 23 31 — — 5 11.8 9 13 — 117 17 22 358 24 17 36 12 20 38 30 31 30 19 37 45 6 7 38 Florida 30 31 31 38 67 15 81 21 79 26 74 17 80.9 22 137.9 26 56.8 35 48.3 31 13 4.8 10.6 21 21 4.5 17 16 32 12 39 13 37 16 38 29 30 38 31 35 31 23 38 67 8 1 34 Georgia 33 28 33 31 69 15 76 19 80 45 74 15 88.4 24 152.7 29 46.6 56 51.1 31 15 4.8 10.9 21 28 6.0 17 19 34 14 41 11 51 12 34 31 33 41 28 29 33 18 31 69 7 8 24 Hawaii 22 — 22 26 714 — 59 778 686 61.2 19 102.4 22 88.8 20 83.7 13 4.9 7 — 1 10 — 12 7 22 13 27 21 38 13 24 18 22 38 —35 22 29 26 71 5 9 45 Idaho 39 — 30 44 69 14 — 70 34 73 20 66.8 26 — — 62.4 47 63.5 38 14 3.8 — — 17 6.1 30 15 34 — —8 39 27 45 27 39 — —32 30 37 44 69 — 4 27 Illinois 35 27 34 37 676 78 12 76 23 648 74.2 15 171.3 18 55.9 31 41.8 23 4.5 8 12.5 18 20 5.0 12 16 28 21 39 10 44 11 27 30 35 44 27 37 34 13 37 67 7 9 41 Indiana 33 29 38 47 739 80 15 76 27 66 11 89.8 18 165.3 26 60.0 39 47.8 30 11 6.4 12.7 15 19 6.0 19 22 35 21 45 13 39 21 41 34 33 41 29 38 38 26 47 73 8 2 42 Iowa 30 20 22 39 615 67 24 66 20 599 72.2 15 151.8 31 54.6 45 58.4 24 4.7 6 23 9.9 15 6.8 13 16 28 23 37 14 32 25 42 36 30 43 20 37 22 33 39 61 6 1 39 Kansas 35 36 37 41 65 10 70 15 70 31 67 10 76.9 19 151.6 30 63.6 38 79.0 33 11 5.6 11.5 18 17 5.9 17 17 31 21 38 17 31 22 39 35 35 41 36 38 37 31 41 65 7 3 42 Kentucky 35 24 29 24 657 758 67 34 66 10 112.1 17 159.0 23 45.1 49 45.2 24 12 6.4 14 9.5 17 6.6 20 23 38 25 39 20 43 28 42 39 35 42 24 35 29 23 24 65 7 0 42 Louisiana 30 25 38 24 73 10 78 11 78 40 81 14 97.3 21 190.2 25 51.3 35 51.8 34 13 4.8 10.5 16 20 6.3 22 23 39 16 48 21 40 18 42 35 30 47 25 32 38 29 24 73 7 0 42 Maine 28 — 28 38 69 11 — — 63 73 14 65.9 14 82.5 — 24 — 85.0 19 11 6.0 — — 12 — 23 18 34 — —27 40 24 42 31 28 — —21 28 32 38 69 — 2 35 Maryland 30 24 29 32 584 689 70 30 606 75.8 12 135.6 15 44.2 44 41.5 19 4.5 7 11.0 12 32 3.9 10 13 27 14 417 42 11 35 29 30 40 24 32 29 20 32 58 6 3 28 Massachusetts 24 17 25 31 643 716 697 614 56.6 11 87.3 18 54.2 20 31.9 22 2.7 8 14 7.4 15 4.6 14 7 24 11 31 14 339 28 26 24 26 17 30 25 13 31 64 7 0 34 Michigan 28 28 23 32 677 779 71 16 707 78.9 14 190.8 17 78.3 22 51.9 19 11 5.1 13.8 16 15 5.0 17 18 27 23 35 26 40 22 34 32 28 42 28 35 23 21 32 67 7 2 31 Minnesota 27 32 32 37 614 718 70 24 659 51.0 22 98.0 28 44.9 53 78.5 30 3.6 8 19 8.1 23 4.8 14 15 24 21 34 14 42 18 31 30 27 31 32 32 32 27 37 61 7 — 50 Mississippi 38 29 — 49 67 16 73 21 — 40 78 23 115.7 23 202.3 29 43.5 — 98.4 50 15 6.3 11.7 20 —— 32 21 44 19 49 — —28 50 38 38 47 29 — —37 49 67 7 7 42 Missouri 34 23 38 43 64 12 71 18 73 29 72 14 88.4 21 175.9 31 53.2 35 47.5 36 11 5.1 11.6 17 35 5.5 25 19 36 22 41 18 47 25 42 34 34 46 23 53 38 32 43 64 7 8 45 Montana 37 — 39 39 66 11 — — 70 62 23 64.5 26 — — 72.2 30 158.5 36 10 4.3 — — 16 — 11 16 32 — —21 38 36 45 27 37 — —22 39 39 39 66 — 2 43 Nebraska 32 35 33 44 619 70 14 67 29 71 18 64.9 18 153.4 30 49.5 55 61.2 35 10 5.1 19 — 22 5.3 19 15 30 29 46 12 42 22 43 34 32 46 35 35 33 28 44 61 7 2 31 Nevada 34 32 40 45 669 76 15 77 27 66 12 101.9 23 167.1 28 60.3 48 78.2 26 11 4.7 16 9.8 20 5.2 12 17 32 22 37 11 42 17 31 28 34 45 32 33 40 20 45 66 7 3 45 New 28 Hampshire — — 26 687 — 87 18 72 10 62.7 13 84.6 — 50.2 34 27.5 23 10 3.6 — — 29 — 16 16 30 — —14 43 24 45 31 28 — —23 —31 26 68 — 3 31 New 29 Jersey 29 30 39 615 71 11 72 25 668 67.2 12 141.5 19 54.6 43 37.2 22 2.7 8 11 9.6 28 4.9 14 14 20 13 37 14 437 31 26 29 36 29 28 30 16 39 61 7 9 40 New 37 Mexico — 34 43 637 — 77 71 16 66 22 78.2 24 122.7 21 90.5 36 101.5 42 10 6.3 16 — 15 5.1 15 15 30 16 27 16 39 17 40 29 37 — —38 34 37 43 63 7 5 37 New 28 York27 30 38 735 818 76 15 708 69.7 15 136.0 19 68.0 32 42.8 22 3.4 8 11 8.7 18 4.7 15 13 26 14 37 12 359 37 28 28 34 27 31 30 16 38 73 8 7 42 North 30 Carolina 33 31 32 57 12 65 16 68 44 66 14 80.2 18 149.2 22 42.0 59 70.5 26 12 5.1 12.0 19 27 6.0 15 18 31 17 40 11 47 18 42 31 30 47 33 31 31 34 32 57 6 5 42 North 34 Dakota — — 38 617 — 53 — 72 61 23 65.6 26 73.7 50 43 — 163.7 30 4.1 8 24 — 22 — 18 18 30 20 58 25 35 38 42 35 34 29 —42 —37 38 61 5 5 34 Ohio 33 28 39 38 658 71 12 67 20 74 10 88.4 18 165.7 25 61.4 36 39.9 38 5.4 9 14.5 11 23 7.6 12 20 32 23 36 19 35 24 34 34 33 37 28 42 39 19 38 65 7 6 38 Oklahoma 39 29 37 36 61 15 74 22 70 36 66 28 124.7 21 194.9 24 79.0 44 145.5 29 14 6.5 13.7 16 25 7.4 12 20 39 21 44 12 46 24 38 37 39 43 29 32 37 34 36 61 7 0 34 Oregon 32 — 31 24 698 62 11 80 25 769 64.4 22 112.0 29 45.5 42 58.9 30 11 4.8 21 — 23 6.3 14 16 31 11 31 12 40 18 34 30 32 38 —36 31 29 24 69 6 1 31 Pennsylvania 32 26 31 44 616 63 10 68 17 647 74.2 13 162.1 16 70.8 28 41.1 24 4.6 8 11.1 11 18 5.9 10 16 29 24 39 19 31 15 31 30 32 44 26 37 31 16 44 61 6 8 33 Rhode 25 Island 23 38 27 644 — 74 69 13 — 61 69.6 10 102.3 21 43.6 29 55.9 25 4.2 8 15 — 23 — 11 16 25 10 35 10 38 18 33 26 25 39 23 32 38 26 27 64 7 5 42 South 34 Carolina 26 32 38 64 13 71 17 74 39 74 21 83.2 21 159.0 24 39.6 56 50.1 37 13 5.1 20 9.0 28 6.7 17 19 36 17 43 13 45 21 42 33 34 43 26 27 32 31 38 64 7 1 43 South 34 Dakota — 32 34 669 — 75 28 70 41 68.9 22 144.6 — 45 — 187.6 49 7.2 9 — — 24 — 19 17 30 — —31 41 31 43 28 34 — —25 32 40 34 66 — 8 50 Tennessee 32 33 32 38 72 12 79 17 76 43 77 16 106.6 21 177.6 24 49.6 59 41.2 31 14 6.1 11.7 18 23 6.4 22 21 40 21 439 58 24 50 34 32 44 33 34 32 27 38 72 7 6 40 Texas 37 27 40 39 72 14 76 21 81 37 67 15 90.4 23 165.5 29 85.5 45 46.9 33 13 4.8 10.1 16 23 5.6 12 15 34 21 40 12 46 13 40 34 37 38 27 38 40 17 39 72 7 5 38 Utah 34 — 36 39 688 — 73 72 29 73 16 64.0 24 106.1 19 59.8 47 71.3 36 11 5.6 22 — 22 5.5 208 25 16 33 12 45 13 38 27 34 43 —30 36 33 39 68 7 4 37 Vermont 32 — — 38 655 — — 65 — 64 63.4 14 — — 21 — 21 — 4.4 8 — — 15 — 13 7 27 — —22 24 30 37 29 32 — —24 —20 38 65 — 8 25 Virginia 31 25 31 24 599 70 15 74 32 619 73.1 20 133.8 20 39.6 44 39.8 24 11 4.8 14 9.6 28 4.9 12 16 26 18 348 38 11 25 30 31 40 25 26 31 20 24 59 7 0 33 Washington 32 42 32 32 626 62 14 74 29 637 62.6 22 106.2 21 53.0 42 58.5 24 3.5 9 8.8 9 20 3.6 12 12 29 11 35 10 40 13 33 30 32 36 42 37 32 19 32 62 6 — 60 West 34 Virginia 40 — 36 599 61 15 — — 64 108.4 18 153.5 24 55.8 — 33 — 14 6.9 19 — —— 25 25 44 27 55 — —28 60 42 34 40 40 — —28 36 59 6 6 46 Wisconsin 29 22 34 32 716 75 13 75 24 73 13 63.0 16 169.0 12 58.9 36 88.9 19 4.4 9 15.9 13 20 7.2 16 16 26 17 33 17 46 16 46 32 29 37 22 41 34 31 32 71 7 2 45 Wyoming 41 — 42 36 70 13 — 73 24 73 23 65.6 30 — — 60.2 46 110.9 45 12 4.9 — — 16 — 18 17 31 — —27 42 31 45 29 41 — —34 42 32 36 70 — Notes: — Indicates that estimates are not available. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 52 APPENDIX I. State Scorecard Indicator Descriptions and Source Notes DEFINITIONS FOR INDICATORS ABBREVIATIONS 1. Adults ages 19–64 uninsured: Percent of adults ages 19–64 without health insurance coverage. Authors’ analysis of 2014 and ACS PUMS = American Community Survey, Public Use 2018 1-year ACS PUMS (U.S. Census Bureau). Micro Sample 2. Children ages 0–18 uninsured: Percent of children ages 0–18 AHRQ = Agency for Healthcare Research and Quality without health insurance coverage. Authors’ analysis of 2014 and BRFSS = Behavioral Risk Factor Surveillance System 2018 1-year ACS PUMS (U.S. Census Bureau). CCW = Chronic Conditions Warehouse 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 CDC = Centers for Disease Control and Prevention their personal health care provider. Authors’ analysis of 2014 and 2018 BRFSS (CDC, NCCDPHP). CMS = Centers for Medicare and Medicaid Services 4. Adults who went without care because of cost in the past CPS ASEC = Current Population Survey, Annual Social year: Percent of adults age 18 and older who reported a time in and Economic Supplement the past 12 months when they needed to see a doctor but could HCAHPS = Hospital Consumer Assessment of not because of cost. Authors’ analysis of 2014 and 2018 BRFSS Healthcare Providers and Systems Survey (CDC, NCCDPHP). LDS = Limited Data Set 5. Individuals with high out-of-pocket medical spending: Percent of individuals residing in households where all residents MDS = Minimum Data Set are under age 65 with out-of-pocket medical spending that equaled MedPAR = Medicare Provider and Analytic Review 10 percent or more of income, or five percent or more of income if low-income (under 200% of federal poverty level), not including MEPS-IC = Medical Expenditure Panel Survey, over-the-counter drug costs or health insurance premiums if Insurance Component insured. This measure includes both insured and uninsured NCCDPHP = National Center for Chronic Disease individuals. Two years of data are combined to ensure adequate Prevention and Health Promotion sample size for state-level estimation. Ougni Chakraborty, Robert F. Wagner School of Public Service, New York University, analysis of NCHS = National Center for Health Statistics 2018 and 2019 CPS ASEC (U.S. Census Bureau). NCIRD = National Center for Immunization and 6. Employee health insurance contributions as a share of Respiratory Diseases median income: We compared employees’ average contributions NIS-PUF = National Immunization Survey, Public Use to their employer-sponsored health insurance premiums as a Data File percent of state median household incomes for the under-65 population in each state. Premium contribution data are NSCH = National Survey of Children’s Health originally reported separately for single-person and family NSDUH = National Survey of Drug Use and Health plans; we therefore used a weighted average of single and family premium contributions compared with single and family median NVSS-I = National Vital Statistics System—Linked household incomes. Authors’ analysis of 2014 and 2018 MEPS-IC Birth and Infant Death Data (AHRQ) and 2015 and 2019 CPS ASEC (U.S. Census Bureau). NVSS-M = National Vital Statistics System—Mortality 7. Adults without a dental visit in past year: Percent of adults Data age 18 and older who did not visit a dentist, or dental clinic OASIS = Outcome and Assessment Information Set within the past year. Authors’ analysis of 2014 and 2018 BRFSS (CDC, NCCDPHP). SAF = Standard Analytic Files 8. Adults without all age- and gender-appropriate cancer SAMHSA = Substance Abuse and Mental Health screenings: Percent of adults ages 50–74 who did not receive Services Administration sigmoidoscopy or colonoscopy in the past 10 years or a fecal occult blood test in the last two years; a mammogram in the last WONDER = Wide-Ranging Online Data for two years (women ages 50–74 only); and a Pap smear in the past Epidemiologic Research three years (women ages 25–64 only). Authors’ analysis of 2014 and 2018 BRFSS (CDC, NCCDPHP). commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 53 APPENDIX I. State Scorecard Indicator Descriptions and Source Notes (continued) 9. Adults without all age-appropriate vaccines: Percent of 16. Hospital 30-day mortality: Risk-standardized, all-cause 30- adults age 18 and older who did not receive a flu shot in the past day mortality rates for fee-for-service Medicare patients age 65 year and a pneumonia vaccine ever if age 65 and older. Authors’ and older hospitalized with a principal diagnosis of heart attack, analysis of 2014 and 2018 BRFSS (CDC, NCCDPHP). heart failure, pneumonia or stroke between July 2011 and June 2014, and July 2015 and June 2018. All-cause mortality is defined 10. Diabetic adults ages 18–64 without a hemoglobin A1c test: as death from any cause within 30 days after the index admission, The share of adult diabetic patients ages 18–64 who did not have regardless of whether the patient dies while still in the hospital at least one hemoglobin A1c test during the year (expressed as or after discharge. Authors’ analysis of Medicare enrollment and a rate per 100 employer-insured enrollees). Michael E. Chernew claims data retrieved from 4th Quarter 2019 and 4th Quarter 2015 and Andrew Hicks, Harvard Medical School Department of Hospital Compare (CMS). Health Care Policy, analysis of the 2015 and 2017 IBM Watson Health MarketScan Database. 17. Central line-associated bloodstream infections (CLABSI), Standardized Infection Ratio (SIR): All CLABSIs reported to the 11. Medicare beneficiaries received a high-risk drug: Percent National Healthcare Safety Network from all applicable hospital of fee-for-service Medicare beneficiaries age 65 and older who locations, including intensive care units, neonatal intensive care received at least one drug from a list of 13 classes of high-risk units, and wards. The standardized infection ratio compares prescriptions that should be avoided by the elderly. Jie Zheng, the observed number of CLABSIs reported by hospitals within Harvard University, analysis of 2016 Medicare Part D claims. the state to the predicted number of infections based on the 12. Children without all components of a medical home: referent period, adjusting for key risk factors. Data are from the Percent of children ages 0–17 who did not have all of the CDC’s 2015 and 2018 National and State Healthcare-Associated following, according to parents’ reports: a personal doctor or Infections (HAI) Progress Reports. nurse, a usual source for sick and well care, family-centered care, any problems getting needed referrals, and effective care 18. Hospitals with lower-than-average patient experience coordination when needed. For more information, see www. ratings: Percent of hospitals in the state with HCAHPS patient childhealthdata.org. Authors’ analysis of 2016 and 2018 NSCH experience summary scores lower than the national median. (U.S. Census Bureau & Data Resource Center for Child and Authors’ analysis of 2018 HCAHPS as administered to adults Adolescent Heath). discharged from acute care hospitals. Retrieved from 4th Quarter 2019 Hospital Compare (CMS). 13. Children without a medical and dental preventive care visit in the past year: Percent of children ages 0–17 who did not 19. Home health patients who did not get better at walking or have a preventive medical visit and, if ages 1–17, a preventive moving around: Percent of all home health episodes in which a dental visit in the past year, according to parents’ reports. For person did not improve at walking or moving around compared more information, see www.childhealthdata.org. Authors’ to a prior assessment. Episodes for which the patient, at start analysis of 2018 NSCH (U.S. Census Bureau & Data Resource or resumption of care, was able to ambulate independently Center for Child and Adolescent Heath). are excluded. Authors’ analysis of 2014 and 2018 OASIS. Data retrieved from 3rd quarter 2019 and 2nd quarter 2015 Home 14. Children who did not receive needed mental health Health Compare (CMS). treatment: Percent of children ages 3–17 who had any kind of emotional, developmental, or behavioral problem that required 20. Nursing home residents with an antipsychotic medication: treatment or counseling and who did not receive treatment from Percent of long-stay nursing home residents who received a mental health professional (as defined) during the past 12 an antipsychotic medication, excluding residents with months, according to parents’ reports. For more information, see Schizophrenia, Tourette’s syndrome, and Huntington’s disease. www.childhealthdata.org. Authors’ analysis of 2016 and 2018 Authors’ analysis of 2013–2017 MDS. Data retrieved from June NSCH (U.S. Census Bureau & Data Resource Center for Child and 2018 and June 2014 Nursing Home Compare (CMS). Adolescent Heath). 21. Adults with any mental illness (AMI) reporting unmet 15. Children ages 19–35 months who did not receive all need: Percent of adults age 18 and older with AMI (defined recommended vaccines: Percent of children ages 19–35 months below) who reported a perceived need for mental health who did not receive at least 4 doses of diphtheria, tetanus, and treatment or counseling in the past 12 months that was not accellular pertussis (DTaP/DT/DTP) vaccine; at least 3 doses of received. This measure could include adults who reported that poliovirus vaccine; at least 1 dose of measles-containing vaccine they received some type of mental health service in the past 12 (including mumps-rubella (MMR) vaccine); the full series months; an unmet need for services after adults had received of Haemophilus influenza type b (Hib) vaccine (3 or 4 doses some services would indicate a perceived need for additional depending on product type); at least 3 doses of hepatitis B vaccine services that they did not receive. Data are from the 2012–2014 (HepB); at least 1 dose of varicella vaccine, and at least 4 doses of and 2016–2017 NSDUH (SAMHSA), as reported in Mental Health pneumococcal conjugate vaccine (PCV). Data from the 2014 and America’s 2019 and 2020 State of Mental Health in America reports 2018 NIS-PUF (CDC, NCIRD). (www.mhanational.org). commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 54 APPENDIX I. State Scorecard Indicator Descriptions and Source Notes (continued) 22. Adults with any mental illness (AMI) who did not receive 25 & 26. Admissions for ambulatory care–sensitive treatment: Percent of adults age 18 and older with AMI (defined conditions: Hospital admissions for one of the following eight below) who reported they did not receive mental health ambulatory care–sensitive (ACS) conditions: long-term diabetes treatment in the past 12 months. Mental health treatment is complications, lower extremity amputation among patients defined as receiving treatment or counseling for any problem with diabetes, asthma or chronic obstructive pulmonary disease, with emotions, nerves, or mental health in the 12 months prior to hypertension, congestive heart failure, dehydration, bacterial the interview in any inpatient or outpatient setting, or the use of pneumonia, and urinary tract infection. prescription medication for treatment of any mental or emotional Ages 18–64, per 1,000 employer-insured enrollees: Michael condition that was not caused by the use of alcohol or drugs. E. Chernew and Andrew Hicks, Harvard Medical School Data are from the 2012–2014 and 2016–2017 NSDUH (SAMSHA), Department of Health Care Policy, analysis of the 2015 and as reported in Mental Health America’s 2019 and 2020 State of 2017 IBM Watson Health MarketScan Database. Mental Health in America reports (www.mhanational.org). Ages 65–74 and older, per 1,000 Medicare beneficiaries: Note: Adults with any mental illness (AMI) is defined as adults age Admissions of fee-for-service Medicare beneficiaries ages 65–74 18 and older who currently or at any time in the past year have had or age 75 and older (measure reported separately for each age a diagnosable mental, behavioral, or emotional disorder (other group but combined into a population-weighted average). than a developmental or substance use disorder) of sufficient Authors’ analysis of 2014 and 2018 CCW data, retrieved from duration to meet diagnostic criteria specified within the Diagnostic the March 2020 CMS Geographic Variation Public Use File and Statistical Manual of Mental Disorders, 4th edition, regardless (CMS, Office of Information Products and Analytics). of the level of impairment in carrying out major life activities. AMI was estimated based on a statistical model of a clinical diagnosis 27 & 28. 30-day hospital readmissions: All hospital admissions and responses to questions on distress, impairment, past year among patients who were readmitted within 30 days of an acute major depressive episode, past year suicidal thoughts, and age. hospital stay for any cause. A correction was made to account for For more information, see: SAMHSA, NSDUH, Methodological likely transfers between hospitals. Summary and Definitions, www.samhsa.gov/data/sites/ default/files/cbhsq-reports/NSDUHMethodSummDefs2017/ Ages 18–64, per 1,000 employer-insured enrollees: Michael NSDUHMethodSummDefs2017.htm. E. Chernew and Andrew Hicks, Harvard Medical School Department of Health Care Policy, analysis of the 2015 and 2017 23 & 24. Potentially avoidable emergency department (ED) IBM Watson Health MarketScan Database. visits: Potentially avoidable ED visits were those that, based on diagnoses recorded during the visit and the health care service the Age 65 and older, per 1,000 Medicare beneficiaries: patient received, were considered to be either non-emergent (care Readmissions among fee-for-service Medicare beneficiaries age was not needed within 12 hours), or emergent (care needed within 65 and older. Authors’ analysis of 2014 and 2018 CCW data, 12 hours) but that could have been treated safely and effectively retrieved from the March 2020 CMS Geographic Variation Public in a primary care setting. This definition excludes any ED visit Use File (CMS, Office of Information Products and Analytics). that resulted in an admission, as well as ED visits where the level 29. Short-stay nursing home residents with a 30-day of care provided in the ED was clinically indicated. This approach readmission to the hospital: Percent of newly admitted nursing uses the New York University Center for Health and Public Service home residents who are rehospitalized within 30 days of being Research emergency department algorithm developed by John discharged from a hospital to the nursing home. Vincent Mor, Billings, Nina Parikh, and Tod Mijanovich (see: Emergency Room Brown University, analysis of 2012 and 2016 Medicare enrollment Use—The New York Story, Commonwealth Fund, Nov. 2000, www. data, MDS, and MedPAR File (CMS). commonwealthfund.org/publications/issue-briefs/2000/nov/ emergency-room-use--the-new-york-story). 30. Long-stay nursing home residents with a hospital admission: Percent of long-stay residents (residing in a nursing Ages 18–64, per 1,000 employer-insured enrollees: Michael home for at least 90 consecutive days) who were hospitalized E. Chernew and Andrew Hicks, Harvard Medical School within six months of baseline assessment. Vincent Mor, Brown Department of Health Care Policy, analysis of the 2015 and University, analysis of 2012 and 2016 Medicare enrollment data, 2017 IBM Watson Health MarketScan Database. MDS, and MedPAR File (CMS). Age 65 and older, per 1,000 Medicare beneficiaries: Jie 31. Home health patients with a hospital admission: Percent of Zheng, Harvard University, analysis of 2013 and 2016 Medicare home health episodes among fee-for-service Medicare beneficiaries Enrollment and SAF Claims Data 20% sample of fee-for-service during which the patient was admitted to an acute-care hospital. Medicare beneficences age 65 and older (CMS, CCW). Authors’ analysis data from CMS Medicare claims data. Data retrieved from 4th quarter 2019 and 3rd quarter 2015 Home Health Compare (CMS), representing patient experiences in 2018 and 2014. commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 55 APPENDIX I. State Scorecard Indicator Descriptions and Source Notes (continued) 32. Adults ages 18–50 with low back pain who had an imaging 37. Mortality amenable to health care, deaths per 100,000 study at diagnosis: The share of employer-insured adults ages population: Number of deaths before age 75 per 100,000 18–50 who had a new primary diagnosis of low back pain with population that resulted from causes considered at least an imaging study (plain x-ray, MRI, or CT scan) within 28 days partially treatable or preventable with timely and appropriate of the diagnosis (expressed as a rate per 100 enrollees). Enrollees medical care (see list), as described in Ellen Nolte and Martin who have a diagnosis for which an imaging study may be clinically McKee, “Measuring the Health of Nations: Analysis of Mortality appropriate (cancer, recent trauma, IV drug abuse, or neurologic Amenable to Health Care,” British Medical Journal, Nov. 15, 2003, impairment) are excluded. Michael E. Chernew and Andrew Hicks, 327 (7424): 1129–32. Authors’ analysis of mortality data from Harvard Medical School Department of Health Care Policy, analysis CDC restricted-use Multiple Cause-of-Death file (NCHS) and U.S. of the 2015 and 2017 IBM Watson Health MarketScan Database. Census Bureau population data, 2012–2013 and 2016–2017. 33. Total employer-sponsored insurance spending per enrollee: Causes of death (Ages) Total spending per enrollee in employer-sponsored insurance Intestinal infections (0–14) plans estimated from a regression model of reimbursed costs for Tuberculosis (0–74) health care services from all sources of payment including the Other infections (diphtheria, tetanus, septicaemia, health plan, enrollee, and any third party payers incurred in 2013 poliomyelitis) (0–74) and in 2017. Outpatient prescription drug charges are excluded. Enrollees with capitated plans and their associated claims are also Whooping cough (0–14) excluded. Estimates for each state were adjusted for enrollees’ age Measles (1–14) and sex, the interaction of age and sex, partial year enrollment and Malignant neoplasm of colon and rectum (0–74) regional wage differences. Michael E. Chernew and Andrew Hicks, Malignant neoplasm of skin (0–74) Harvard Medical School Department of Health Care Policy, analysis Malignant neoplasm of breast (0–74) of the 2013 and 2017 IBM Watson Health MarketScan Database. Malignant neoplasm of cervix uteri (0–74) 34. Total Medicare (Parts A and B) reimbursements per enrollee: Malignant neoplasm of cervix uteri and body of uterus (0–44) Total Medicare fee-for-service reimbursements include payments Malignant neoplasm of testis (0–74) for both Part A and Part B but exclude Part D (prescription drug costs) and extra CMS payments for graduate medical education Hodgkin’s disease (0–74) and for treating low-income patients. Reimbursements reflect only Leukemia (0–44) the age 65 and older Medicare fee-for-service population. Authors’ Diseases of the thyroid (0–74) analysis of 2014 and 2018 CCW data, retrieved from the March Diabetes mellitus (0–49) 2020 CMS Geographic Variation Public Use File (CMS, Office of Epilepsy (0–74) Information Products and Analytics). Chronic rheumatic heart disease (0–74) 35 & 36. Primary care as a share of total medical spending: Share Hypertensive disease (0–74) of health care spending attributed to primary care. We based our Cerebrovascular disease (0–74) approach on the method used by Reid, Damberg, and Friedberg (JAMA 2019) that characterizes a “broad” definition for primary All respiratory diseases (excluding pneumonia and influenza) care provider types and a “broad” definition of included services. (1–14) Under this “broad/broad” definition, we include all professional Influenza (0–74) services billed by physicians, physician assistants, and nurse Pneumonia (0–74) practitioners in family medicine, internal medicine, general Peptic ulcer (0–74) practice, geriatric medicine, and obstetrics and gynecology (this can include child birth for women in the age 18–64 age cohort); Appendicitis (0–74) hospitalists are excluded. Abdominal hernia (0–74) Cholelithiasis and cholecystitis (0–74) Ages 18–64, employer-insured enrollees: Percent of each state’s total employer-based insurance medical spending on primary Nephritis and nephrosis (0–74) care. Michael E. Chernew and Andrew Hicks, Harvard Medical Benign prostatic hyperplasia (0–74) School Department of Health Care Policy, analysis of the 2018 Maternal death (all ages) IBM Watson Health MarketScan Database. Congenital cardiovascular anomalies (0–74) Age 65 and older, Medicare beneficiaries: Percent of each Perinatal deaths, all causes, excluding stillbirths (all ages) state’s total Medicare medical spending on primary care. Misadventures to patients during surgical and medical care Angelina Lee and Kevin Neipp, Westat, analysis of the 2017 LDS (all ages) 5% sample of Medicare claims (CMS). Ischemic heart disease: 50% of mortality rates included (0–74) commonwealthfund.org September 2020 2020 Scorecard on State Health System Performance 56 APPENDIX I. State Scorecard Indicator Descriptions and Source Notes (continued) 38. Breast cancer deaths per 100,000 female population: 48. Adults who have lost six or more teeth: Percent of adults Authors’ analysis of NVSS–M, 2014 and 2018 (NCHS), retrieved ages 18–64 who have lost 6 or more teeth due to tooth decay, using CDC WONDER. infection, or gum disease. Authors’ analysis of 2014 and 2018 BRFSS (CDC, NCCDPHP). 39. Colorectal cancer deaths per 100,000 population: Authors’ analysis of NVSS–M, 2014 and 2018 (NCHS), retrieved using CDC 49. Public health funding: State-based public health spending WONDER. per capita (federal public health funds not included). State public health spending data for 2014/15 and 2017/18 come from Trust for 40. Suicide deaths per 100,000 population: Authors’ analysis of America’s Health (TFAH) reports (2017/18 estimates: “The Impact NVSS-M, 2014 and 2018 (NCHS), retrieved using CDC WONDER. of Chronic Underfunding on America’s Public Health System: 41. Alcohol-related deaths per 100,000 population: Authors’ Trends, Risks, and Recommendations, 2019”; 2014/15 estimates: analysis of NVSS-M, 2014 and 2018 (NCHS), retrieved using CDC “Investing in America’s Health Public Health Report, 2016”). WONDER. 42. Drug poisoning deaths per 100,000 population: Authors’ analysis of NVSS-M, 2014 and 2018 (NCHS), retrieved using CDC WONDER. 43. Infant mortality, deaths per 1,000 live births: Authors’ analysis of NVSS-I, 2013 and 2017 (NCHS), retrieved using CDC WONDER. 44. Adults who report fair/poor health: Percent of adults age 18 and older who reported being in fair or poor health. Authors’ analysis of 2014 and 2018 BRFSS (CDC, NCCDPHP). 45. 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 2014 and 2018 BRFSS (CDC, NCCDPHP). 46. Adults who are obese: Percent of adults ages 18–64 who are obese (Body Mass Index [BMI] ≥ 30). BMI was calculated based on reported height and weight. Authors’ analysis of 2014 and 2018 BRFSS (CDC, NCCDPHP). 47. Children who are overweight or obese: Children ages 10–17 who are overweight or obese (BMI >= 85th percentile). Overweight is defined as an age- and gender-specific body mass index (BMI-for-age) between the 85th and 94th percentile of the CDC growth charts. Obese is defined as a BMI-for-age at or above the 95th percentile. BMI was calculated based on parent-reported height and weight. For more information, see www.nschdata.org. Authors’ analysis of 2016 and 2018 NSCH (U.S. Census Bureau & Data Resource Center for Child and Adolescent Heath). commonwealthfund.org September 2020 About the Commonwealth Fund The mission of the Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, and people of color. 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.