Scorecard on State Health System Performance

A state-by-state report measuring access to care, quality of care, health outcomes, and health disparities across the United States

by David C. Radley, Sara R. Collins, and Susan L. Hayes

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The Top & Bottom

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We use recently available data to assess every state and Washington, DC on more than 40 measures of health care access, quality, efficiency, health outcomes and disparities.

Hawaii, Massachusetts, Minnesota, Washington, Connecticut, and Vermont are the top-ranked states in 2019 according to the Scorecard, which assesses all 50 states and the District of Columbia on 47 measures of access to health care, quality of care, service use and costs of care, health outcomes, and income-based health care disparities.

The Commonwealth Fund’s 2019 Scorecard on State Health System Performance reveals that most states are losing ground on key measures related to life expectancy as premature deaths from suicide, alcohol, and drug overdose continue to increase. Several states that most recently expanded eligibility for their Medicaid programs saw meaningful gains in access to health care; in other states prior gains eroded between 2016 and 2017. Finally, the Scorecard found that health care costs are placing an increasing financial burden on families across the nation.


States face important challenges in promoting affordable health care and the best possible outcomes for their residents.

The widespread gains in people’s coverage and access to health care following the ACA passage in 2010 have largely stalled since 2015, with even some ominous erosion from 2016 to 2017 in 16 states. Stalled gains are attributable to lack of Medicaid expansion in 17 states, people with incomes just over the eligibility threshold for marketplace subsidies (about $48,560 for an individual) and many in employer plans have high premium costs; recent Congressional and executive actions on the individual market and Medicaid have reduced potential enrollment in both; and undocumented immigrants are ineligible for subsidized coverage.

These stalled gains in coverage come at a time when health care spending continues to grow at a faster clip than median income, translating into higher premium and out-of-pocket costs relative to income, for many families. Finally, in some states, people face shorter life expectancies than just a few years ago, thanks in part to unrelenting increases in deaths linked to suicide, alcohol, and drug overdose.