2019 Scorecard on State Health System Performance David C. Radley Senior Scientist The Commonwealth Fund Sara R. Collins Vice President The Commonwealth Fund Susan L. Hayes Senior Researcher The Commonwealth Fund FOR MORE ON HEALTH CARE IN YOUR STATE, VISIT OUR NEW DATA CENTER: JUNE 2019 datacenter.commonwealthfund.org 2019 Scorecard on State Health System Performance OVERVIEW 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. 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 incomebased health care disparities. Overall, three highlights emerge from our analysis of the Scorecard results: The rise in deaths from suicide, alcohol, and drug overdose is a national crisis, but different states are affected in different ways Uninsured rates are down following coverage expansions, but gains have stalled, and in some states have begun to erode Per capita spending growth in employer plans is outpacing that in Medicare 2019 Scorecard on State Health System Performance 3 HIGHLIGHTS Deaths from suicide, alcohol, and drug overdose manifest differently across states The rise in deaths from suicide, alcohol, and drug overdose is a national crisis, but states are affected in different ways What’s often lost in national discussions about the increase By now, we are all too aware of the devastating effects Pennsylvania, the District of Columbia, Kentucky, Delaware, of the opioid crisis. Opioid use disorder, as well as and New Hampshire stand out as having the highest death the emergence of highly lethal synthetic opioids (e.g., rates from drug overdoses. In Pennsylvania, Maryland, and different states have been affected in different ways. States in New England, the Mid-Atlantic, and several Southeastern states have been particularly hard hit by the opioid epidemic (Exhibit 1).3 West Virginia, Ohio, Ohio, mortality rates from drug overdoses were at least five fentanyl and carfentanil) in the illicit drug supply, have times higher than rates for alcohol-related deaths and about fueled a rise in drug overdose deaths that have affected three times higher than suicide rates (Appendix F3). families across the country. Drug overdose deaths are In other states, deaths from suicide and alcohol dominate. part of the term “deaths of despair,” which also refer to In 2017, Montana, Nebraska, the Dakotas, Oregon, and deaths from suicide and alcohol.1 Together, rising death rates from suicide, alcohol, and drug overdose contribute to the recent decline in average life expectancy at birth in the United States. of deaths from suicide, alcohol, and drug overdose is that Wyoming saw higher rates of death from suicide and alcohol than from drugs. In 13 additional states, either suicide or deaths from alcohol (but not both) surpassed drug overdose deaths.4 2 Exhibit 1 Deaths from suicide, alcohol, and drug overdose impact states differently Exhibit 1. Deaths from suicide, alcohol, and drug overdose impact states differently Alcohol Drug overdose Deaths per 100,000 in 2017 6.6–13.6 (12 states) Deaths per 100,000 in 2017 5.5–7.9 (14 states) Deaths per 100,000 in 2017 8.1–13.8 (13 states) 13.8–19.1 (26 states) 8.2–11.8 (24 states) 14.4–29.4 (26 states) 20.1–28.9 (12 states) 13.4–30.6 (12 states) 30.0–57.8 (11 states) Suicide Note: counted in state tallies. Note: D.C.D.C. notnot counted in state tallies. Data: 2005–2017 National Vital Statistics System (NVSS), via CDC WONDER. Data: 2005–2017 National Vital Statistics System (NVSS), via CDC WONDER. commonwealthfund.org Source: David C. Radley, Sara R. Collins, and Susan L. Hayes, 2019 Scorecard on State Health System Performance (Commonwealth Fund, June 2019). June 2019 2019 Scorecard on State Health System Performance 4 Exhibit 2 High-rate states It had the highest rate of drug overdose deaths in 2017 (57.8 100,000 residents (Exhibit 2). West Virginia has also seen the sharpest growth in drug overdose deaths in recent history, with overdose mortality rates climbing from 10.5 deaths per 100,000 in 2005 to 57.8 in 2017 — a fivefold increase. While West Virginia stands out, it’s hardly alone. Additionally, drug-related mortality rates in Ohio, Pennsylvania, and the District of Columbia were at least double the U.S. average in 2017, and along with seven other states, have seen at Exhibit least a2 threefold increase in overdose mortality since 2005 P 60 50 50 40 30 20 Pennsylvania the next highest state, Ohio, which had 46.3 deaths per Deaths per 100,000 in 2017 40 30 20 U.S. times the national average and 25 percent higher than Low-rate states deaths per 100,000 residents) — more than two-and-a-half West Virginia West Virginia has been hardest hit by the opioid epidemic. Exhibit Drug overdose deathsunequal unequal acro Drug 2.overdose deaths across states, disproportionately impact impact Ohio and West Virginia Ohio and West Virginia Ohio West Virginia and Ohio have been hard hit by the opioid epidemic; drug-related mortality in those states far outpaces rates in other parts of the country Drug overdose deaths unequal across states, disproportionately impact Ohio and Westalcohol, Virginia 0 Growth trends: Deaths from suicide, and (Appendix F3). drug overdose hit all-time highs in 2017 High-rate Nationally speaking, the death states rates from suicide, alcohol, 10 Note: “Low-rate” and “lower-growth” refer to the median value among the group of states wi Data: 2005–2017 National Vital Statistics System (NVSS), via CDC WONDER. High-growth states and drug Deaths peroverdose 100,000 ineach 2017rose markedly in the past decade. Percent change 2005–2017 The recent, sharp growth in drug overdose deaths is 60 500 Source: David C. Radley, Sara R. Collins, and Susan L. H (Commonwealth Fund, June 2019). 400 increases the nation has seen. 30 Steady increases in suicides and deaths linked to alcohol 200 U.S. are also concerning and represent yet another marker of 20 complex socioeconomic and behavioral health problems across the nation. Nationally, suicide rates are up nearly 30 10 100 percent since 2005; they rose more sharply between 2016 and 0 2017 than during any other one-year period in recent Ohio 300 U.S. Low-rate states between 2016 and 2017 is still among the highest annual Lower-growth states Pennsylvania has somewhat moderated recently, the 10 percent jump 40 West Virginia Ohio 2017 (Exhibit 3, Appendix F3).5 While the overdose rate Delaware West Virginia most alarming. The rate of death from drug overdose more than doubled across the country between 2005 and 50 0 history. Similarly, the rate of death linked to alcohol has 6 Note: “Low-rate” and “lower-growth” refer to the median value among the group of states with rates below the U.S. average. increased more rapidly in recent years, with average growth Data: 2005–2017 National Vital Statistics System (NVSS), via CDC WONDER. Note: “Low-rate” and “lower growth” refer to the median value among the group of of 4 percent per year between 2013 and 2017, compared states with rates below the U.S. average. Source:2005 David C. Radley, Sara R. Collins, and Susan Data: L. Hayes, 2019 Scorecard State Health System Performance with 2 percent per year between and 2012. 2005–2017 National on Vital Statistics System (NVSS), via CDC WONDER. (Commonwealth Fund, June 2019). commonwealthfund.org 10 June 2019 2019 Scorecard on State Health System Performance 5 Exhibit 3 Deaths from suicide, alcohol, and drug overdose on the rise Exhibit 3. Deaths from suicide, alcohol, and drug overdose on the rise Cumulative increase 2005–2017 Deaths per 100,000 25 Drug overdose 20 115% 15 Suicide 10 Alcohol 28% 37% 5 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Data: 2005–2017 National Vital Statistics System (NVSS), via CDC WONDER. Growth trends: Uneven growth death rates across Data: 2005–2017 National Vital Statistics Systemin (NVSS), via CDC WONDER. access to care following the Affordable Care Act’s major states suggests varying approaches needed to stem coverage expansions in 2014 have stalled or even begun to suicide and alcohol- and drug-related mortality Source: David C. Radley, Sara R. Collins, and Susanerode L. Hayes, Scorecard in2019 some states.on State Health System Performance (Commonwealth Fund, June 2019). Focusing on national growth trends can mask important drug overdose across states. Deaths of each type rose in States’ historic progress in expanding health insurance coverage and access to care has stalled every state between 2005 and 2017, but the increases were In nearly all states, there were widespread reductions in differences in trends in deaths from suicide, alcohol, and far from uniform. Drug overdose mortality has risen the most, more than doubling in 26 states (Exhibit 4). States in New England, the Mid-Atlantic, the Great Lakes states, and several Southeastern and Plains states saw the most intense growth. Suicide and alcohol-related deaths also rose, but more modestly. uninsured rates between 2013 and 2017, in the wake of the ACA’s insurance market reforms and coverage expansions (Exhibit 5, Appendix C2). As more people gained coverage, fewer cited cost as a barrier to receiving needed care. But in most states, progress stalled after 2015. From 2016 to 2017, more than half of states simply held on to earlier gains; 16 states, including those that did and did not expand Uninsured rates are down following coverage expansions, but gains have stalled, and in some states have begun to erode Medicaid, experienced upticks of 1 percentage point in The 2019 State Scorecard found that the historic gains made from the end of 2016 to the end of 2017. People with low by states in expanding health insurance coverage and income made the greatest gains (Appendices C3 and C4). commonwealthfund.org their adult uninsured rate (Appendix C3).7 One notable exception was Louisiana, where Medicaid expansion took effect in July 2016. Louisiana experienced a 3 percentagepoint drop in its adult uninsured rate (from 15% to 12%) June 2019 Exhibit 4 2019 Scorecard on State Health System Performance Growth in deaths from suicide, alcohol, and drug overdose differ across states 6 Exhibit 4. Growth in deaths from suicide, alcohol, and drug overdose differ across states Suicide Drug overdose Alcohol Percent change 2005–2017 3%–48% (44 states) Percent change 2005–2017 3%–48% (27 states) Percent change 2005–2017 16%–47% (13 states) 52%–87% (6 states) 51%–96% (22 states) 53%–86% (10 states) 100% or more (0 states) 119% (1 state) 107%–450% (26 states) Note: Growth is measured as the percent change in deaths per 100,000 between 2005 and 2017. D.C. not counted in state tallies. Map categories are fixed for all three death Notes: is measured as the percent change deaths 100,000 between 2005 and 2017. D.C. not counted in state tallies. Map categories are fixed for all three causes at Growth 0%–49% increase, 50%–99% increase, andin100% orper more increase. death causes at 0%–49% increase, 50%–99% increase, and 100% or more increase. Data: 2005–2017 National Vital Statistics System (NVSS), via CDC WONDER. Data: 2005–2017 National Vital Statistics System (NVSS), via CDC WONDER. Exhibit 5 Source: David C. Radley, Sara R. Collins, and Susan L. Hayes, 2019 Scorecard on State Health System Performance (Commonwealth Fund, June 2019). Cost barriers to receiving carefellfell as uninsured fellACA coverage Exhibit 5. Cost barriers to receiving care as uninsured rates fellrates following following ACA coverage expansions expansions Uninsured adults Less than 10% 10%–14% 15% or more Adults who went without care because of costs 2013 2014 2015 2016 2017 Notes: Adults who went without care is limited to adults ages 18–64 in this exhibit, thou the Scorecard ranks states on a version of this measure that includes all adults age Notes: Adults who went without care is limited to adults ages 18–64 in this exhibit, though the Scorecard ranks states on a version of this measure that includes all adults age 18 and older. 18 and older. Data: Uninsured (ages 19–64): U.S. Census Bureau, 2013–2017 One-Year American Community Surveys, Public Use Micro Sample (ACS PUMS); Cost barriers (ages 18–64): Data: Uninsured (ages 19–64): U.S. Census Bureau, 2013–2017 2013–2017 Behavioral Risk Factor Surveillance System (BRFSS).One-Year American Community Surveys, Public Use Micro Sample (ACS PUMS); Cost barriers (ages 18–64): 2013–2017 Behavioral Risk Factor Surveillance System (BRFSS). commonwealthfund.org Source: David C. Radley, Sara R. Collins, and Susan L. Hayes, 2019 Scorecard on State Health System Performance (Commonwealth Fund, June 2019). June 2019 2019 Scorecard on State Health System Performance 7 Medicaid makes a difference in lowering uninsured rates expansions, with states that expanded Medicaid seeing the States’ decisions about whether to expand their Medicaid rates among low-income adults did not change much largest drops. After falling through 2015, state uninsured programs have had stark implications for their uninsured between 2016 and 2017 (Exhibit 7). rates. This is apparent in the sixfold variation across state The notable exceptions to this trend were three states that uninsured rates in 2017, ranging from a low of 4 percent in Massachusetts (which expanded Medicaid along with coverage enhancements like extra subsidies) to a high of 24 percent in Texas (which did not expand) (Exhibit 6, Appendix C2). Among the 17 states that have yet to expand Medicaid, five had the highest uninsured rates, ranging from 18 percent to 24 percent. In states that recently expanded Medicaid, uninsured rates among low-income adults dropped substantially in 2017 expanded Medicaid in 2015 or later: Alaska (September 2015), Louisiana (July 2016), and Montana (January 2016). Uninsured rates among low-income adults in these states dropped by 8, 6, and 4 percentage points, respectively, from the end of 2016 to the end of 2017. These gains suggest the potential for improving uninsured rates among low-income adults in the latest batch of states that have either expanded Medicaid (Maine and Virginia in 2019) or are poised to (Idaho, Nebraska, and Utah passed ballot initiatives in November 2018 to expand the program). In contrast, the failure of a November ballot initiative in Montana to permanently All states saw reductions in uninsured rates among reauthorize the state’s full Medicaid expansion, which was low-income adults following the ACA’s 2014 coverage due to “sunset” this summer, and subsequent legislation Exhibit 6 Five of the 17 states that have yet to expand Medicaid had the Exhibit 6. Five of the 17 states that have yet to expand Medicaid had the highest adult highest rates in 2017 uninsuredadult rates inuninsured 2017 Percent 30 Medicaid expansion states as of January 1, 2017 Nonexpansion states as of January 1, 2017 20 10 Massachusetts District of Columbia Hawaii Iowa Minnesota Rhode Island Vermont Kentuck y Michigan Pennsylvan ia Wisconsin Connecticut Delaware Maryland New Hampshire New York Ohio North Dakota Washington West Virginia California Colorado Illi nois Oregon Indiana New Jersey Arkansas Kansas Louisi ana Maine Nebraska Utah Virginia Missouri Montana New Mexico South Dakota Arizona Tennessee Alabama Nevada Idaho North Carolina South Carolina Wyoming Alask a Mississippi Florida Georgia Ok lahoma Texas 0 Note: As of January 1, 2017, there were 19 states that had not expanded Medicaid. Maine and Virginia implemented Medicaid expansion in 2019; Idaho, Nebraska, and Utah Note: As of January 1, 2017, there were 19 states thatMedicaid had not expanded Medicaid. Maine and Virginia implemented expansion in 2019; Idaho, Nebraska, and Utah passed ballot initiatives in November 2018 to expand but have not yet implemented a full expansion; Utah Medicaid made adults up to 100% of poverty eligible. Adults with passed ballot initiatives in November 2018for to Medicaid expand Medicaid but have not yet implemented a full expansion; Utah made adults up to 100% of poverty eligible. Adults with incomes up to 100% of poverty are eligible in Wisconsin. incomes up to 100% of poverty are eligible for Medicaid in Wisconsin. Data: U.S. Census Bureau, 2017 One-Year American Community Surveys, Public Use Micro Sample (ACS PUMS). Data: U.S. Census Bureau, 2017 One-Year American Community Surveys. Public Use Micro Sample (ACS PUMS). Source: David C. Radley, Sara R. Collins, and Susan L. Hayes, 2019 Scorecard on State Health System Performance (Commonwealth Fund, June 2019). commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance 8 Exhibit 7 States that more recently implemented Medicaid expansion saw Exhibit 7. States that morein recently implemented Medicaid expansion sawin the2017 biggest drops the biggest drops uninsured low-income adults in uninsured low-income adults in 2017 Percent Medicaid expansion states as of January 1, 2017 50 40 2017 Nonexpansion states as of January 1, 2017 Jan. July 2016 2016 Sept. 2015 2016 30 20 10 Ma s Di st sac h ric t o V u se f C erm tts ol o um n t H a b ia wa W Ke Io ii es nt wa t V uc Mi irgi ky c n R h Ne h ig ia od w Y an e o De Isla rk l n M Pe i n awa d nn ne r e sy s o l t Co v an a nn O ia ec hio W O ticu as re t h go Ar ingt n Cakan on l if sa Ne Coloorn s M w a ra ia H a ry d o m lan ps d h Il ir Ne Mo lino e w nta is M Lo ex n a u i No isiaco rth In d na Da iana Ar kot iz a Ne Ne ona w vad Je a r Al sey as ka W isc o Te Mnsi n n n ain es e s So M U ee ut i s t ah h so D W ak u ri yo o t Al m i a ab ng am So I ut K d ah a h an o C No N aro sas rth eb lin Ca raska r a V i o lin rg a Mi Flo in ia ss ri d iss a i OkGeo p pi l ah r g o ia Tema xa s 0 Notes: Low-income adults defined as adults ages 19–64 living in a household with income <200% of the federal poverty level. Medicaid expansion states are those states Notes: Low-income adults defined as adults agesStates 19–64arranged living in ainhousehold with 2017 income <200% of the federal poverty level. Medicaid expansion states are those states that that expanded Medicaid by January 1, 2017. order of their rate. expanded January 1, 2017. States arranged in order of their 2017 rate. Data: U.S.Medicaid Census by Bureau, 2017 1-Year American Community Survey, American FactFinder and 2016 1-Year American Community Surveys, Public Use Micro Sample (ACS PUMS). Data: U.S. Census Bureau, 2017 1-Year American Community Survey, American FactFinder and 2016 1-Year American Community Surveys, Public Use Micro Sample (ACS PUMS). Source: David C. Radley, Sara R. Collins, and Susan L. Hayes, 2019 Scorecard on State Health System Performance (Commonwealth Fund, June 2019). that would impose work requirements for enrollees, could endanger recent gains made there.8 In Wyoming, Montana’s neighbor — which has not expanded its Medicaid program — a third of low-income adults were uninsured in 2017. Uninsured rates among people of color are also high in several of the states that have yet to expand Medicaid and are home to large African American and Hispanic populations. In Florida, Georgia, and Texas, for example, about 20 percent of black adults were uninsured in 2017, above the U.S. average of 14 percent (Appendix C3). More than a third of Hispanic adults in Texas and close to half of Hispanic adults in Georgia were uninsured in 2017. By contrast, uninsured rates among Hispanic adults in New York and in California, two states that did expand Medicaid, were 16 percent and 17 percent, respectively.9 commonwealthfund.org Cost barriers to care on the rise As the progress in expanding health coverage stalled, so too did gains in people’s ability to access health care. Between 2016 and 2017, a dozen states had increases of at least 2 percentage points in the share of adults ages 18 to 64 who reported they had not gone to the doctor when needed because of cost (Exhibit 8).10 But it’s also worth noting that as with uninsured rates among low-income adults, some states that expanded Medicaid after 2014 saw a decrease in the share of adults in this income group who skipped needed care because of cost between 2016 and 2017. In Alaska, for example, the rate of low-income adults who went without care because of cost dropped from 31 percent in 2016 to 13 percent in 2017; in Louisiana, the rate dropped from 37 percent to 28 percent (Appendix C4). June 2019 2019 Scorecard on State Health System Performance Exhibit 8 9 The share of adults ages 18–64 who skipped needed care because Exhibit 8. The share of adults 18–64 who skipped care because of cost climbed of cost climbed by 2ages percentage pointsneeded or more in a dozen statesby 2 percentage points or more in a dozen states between 2016 and 2017, eroding earlier gains between 2016 and 2017, eroding earlier gains Percent 24 States with little or no change States with an Increase* 2017 2016 16 8 Ha No w rth I aii Da o wa Di M st as V e ko ric sa rm ta t o ch o f C us nt o e M lu tts Co i nn mb n e ia Ne W a n ec s ota w sh tic H a in ut m gt W ps on isc h i Ma on re s Ne ry la i n w nd Y Il li ork no Pe Ca Oh is l i nn fo io sy rn Co lv an ia Ke lo ra ia n d Mo tu c o nt ky K an Ne an a sa Mi bras s ch ka i Al gan In ask d a V i ian Mi rgin a s ia Ar sou iz o ri n I W W y d ah a es om o tV i ir ng Ge gin So o ia u N r No th ev gia rth Car ada Ca o lin Al ro li a Lo aba n a ui ma sia Mi Flo na ss ri d iss a ip pi So u R h th D od ak e I ot sla a nd Or Ut a e De g h law on Ne M ar e a Te w J e in e Ne n n rse w ess y M e A ex e Okrkan ico l ah sa om s Te a xa s 0 Note:States Statesare arearranged arrangedininrank rankorder order based their 2016 value. * Rate increase refers to change between 2016 2017 at least 2 percentage points. Adults who Note: based onon their 2016 value. * Rate increase refers to change between 2016 andand 2017 of atof least 2 percentage points. Adults who went went without is limited to ages adults ages 18–64 in this exhibit, the Scorecard rankson states on a of version of this measure that includes adults age 18 and older. without care is care limited to adults 18–64 in this exhibit, thoughthough the Scorecard ranks states a version this measure that includes all adultsall age 18 and older. Data: 2016 and 2017 Behavioral Risk Factor Surveillance System (BRFSS). Data: 2016 and 2017 Behavioral Risk Factor Surveillance System (BRFSS). Source: David C. Radley, Sara R. Collins, and Susan L. Hayes, 2019 Scorecard on State Health System Performance (Commonwealth Fund, June 2019). Per capita spending growth in employer plans is outpacing that in Medicare private insurance. Insurers and employers have tried to Stalled progress in expanding health insurance coverage insurance and whether to get health care. lower premiums by increasing deductibles and other cost-sharing for enrollees. Health care costs thus ultimately drive both consumers’ decisions about whether to enroll in and access to care relates to rising health care costs as private health plans are rising and people covered by such Employee premium contributions are high relative to median income in many states plans are increasingly exposed to high deductibles and More than half of the U.S. population under age 65 — about well as state and federal policies. In particular, the costs of out-of-pocket costs. As of the end of 2018, 30 million adults remained uninsured and an estimated 44 million people had insurance but had such high deductibles and out-of-pocket costs relative to their income that they were considered to be underinsured.11 People with individual-market plans were underinsured at the highest rates, but the greatest recent growth occurred among people with employer plans. 158 million people — get their health insurance through an employer.12 The amount that employees contribute to their employer coverage is rising faster than median income in most states.13 In 2017, employee premium contributions as a share of median income was 7 percent nationally (Appendix C2). This share increased in 19 states by 0.6 percentage points or more between 2013 and 2017, meeting A key factor in both uninsured and underinsured rates is the Scorecard’s definition of worsening. Earlier research the overall rate of growth in U.S. health care costs, especially indicates that these higher premiums are not buying more compared with slow growth in U.S. median income. Health generous health plans; deductibles are also growing in care costs are the primary driver of premium growth in most states.14 commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance 10 Families spending the largest amount of their income on What accounts for state variation in costs and premiums employer premiums live in the South and Southwest. In in employer health plans? There is growing evidence that 11 states (Arizona, Delaware, Florida, Georgia, Louisiana, prices paid by private insurers to health care providers, Mississippi, Nevada, New Mexico, North Carolina, especially hospitals, rather than people’s use of health Oklahoma, and Texas), premium contributions were 8 care services, are the primary driver of cost and premium percent of median income or more, with a high of 10.2 growth.15 For example, the Health Care Cost Institute percent in Louisiana (Exhibit 9, Appendix C2). recently found that between 2013 and 2017, prices for States with higher employer premiums also have higher health care costs percent while utilization fell by 5 percent.16 The analysis States with the highest average employer premiums (both inpatient services paid by private insurers climbed by 16 found similar patterns for outpatient and professional services as well as prescription drugs. employer and employee contributions) also tended to There is also evidence that prices explain the wide health have the highest per-enrollee health care costs (Exhibit 10). care spending gap between the United States and other Medical costs comprise the largest share of premiums (80% wealthy countries.17 Other research has found that greater to 95%), so it is not surprising that states with higher costs spending in the United States does not result in better also had higher premiums. health outcomes than in countries that spend less.18 Exhibit 9 Exhibit In 11 states, averageemployee employee health insurance contributions were 8 percent of In 119.states, average health insurance contributions median or more 2017 wereincome 8 percent ofinmedian income or more in 2017 Average employee share of premium as percent of median state incomes 4.8%–5.9% (16 states + D.C.) 6.0%–7.7% (23 states) 8.0%–10.2% (11 states) Data: Employee premium PanelSurvey–Insurance Survey–Insurance Component (MEPS-IC, 2017); Median household income: Population Data: Employee premiumshare: share:Medical Medical Expenditure Expenditure Panel Component (MEPS-IC, 2017); Median household income: CurrentCurrent Population Survey Survey (2017–18). (2017–18). Source: David C. Radley, Sara R. Collins, and Susan L. Hayes, 2019 Scorecard on State Health System Performance (Commonwealth Fund, June 2019). commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance 11 Exhibit 10 Higher premiums employer coverage is associated with Exhibit 10. Higher premiumsfor for employer coverage is associated with higher per-person higher2016  per-person spending, 2016 spending, Average premiums for employer coverage $20,000 State values $19,000 AK U.S. average $18,000 $17,000 MA $16,000 MD $15,000 RI IL NH CT NY WY IN WI MI WV HI $14,000 MS $13,000 $12,000 $2,000 $3,000 IA AR NE AL r = 0.74 NV $4,000 $5,000 $6,000 $7,000 $8,000 Average per-enrollee spending among individuals with employer coverage Note: X- and Y-axes do not start at $0. Abbreviations left off some states clustered near the U.S. average for legibility. Note: X- and Y-axes do not start at $0. Abbreviations left off some states clustered near the U.S. average for legibility. Data: Employer coverage per-enrollee spending: 2016 Truven MarketScan Database, analysis by Michael E. Chernew, Harvard Medical School; Premiums for employer Data:coverage: Employer coverage per-enrollee 2016 Truven MarketScan Database, Medical Expenditure Panelspending: Survey–Insurance Component (MEPS-IC, 2017). analysis by Michael E. Chernew, Harvard Medical School; Premiums for employer coverage: Medical Expenditure Panel Survey–Insurance Component (MEPS-IC, 2017). Source: David C. Radley, Sara R. Collins, and Susan L. Hayes, 2019 Scorecard on State Health System Performance (Commonwealth Fund, June 2019). Per-enrollee costs grew faster in employer plans than in Medicare in most places Recent research indicates that per capita costs in private regions. Differences were widest in the Mid-Atlantic and Great Lakes states (Exhibit 11, Appendix E2). that prices are a likely culprit. Cooper and colleagues Growth in per-enrollee costs grew faster in employer plans than in Medicare in 31 states found that between 2007 and 2014, health spending per Our analysis of cost trends at the state level between 2013 insured enrollee in employer plans increased more rapidly and 2016 found that per-enrollee spending growth in and showed much more variability than per-beneficiary employer plans outpaced that of Medicare in 31 states. spending in Medicare. Medicare sets prices for providers Per-beneficiary spending in Medicare climbed by 2.5 percent while prices in private plans are usually the result of nationally, but ranged from a 1.5 percent decrease in Ohio to confidential negotiation between providers and insurers or a 12.1 percent increase in Alaska (Exhibit 12, Appendix E2). employers. A recent RAND analysis of a sample of hospitals Alaska was the only state where the growth rate exceeded in 25 states found that case-mix adjusted hospital prices 10 percent. insurance are rising faster than those in Medicare and 19 paid by private insurers and employers were 241 percent higher than Medicare prices in 2017.20 Per-enrollee spending among adults with employer coverage grew 3.9 percent between 2013 and 2016, but with more Our analysis of another database of employer health variation across states (Appendix E2). Per-enrollee spending insurance claims identified similar patterns across regions. increased by 10 percent or more in nine states, ranging from Growth in per-enrollee spending among working-age adults 10.1 percent in Wyoming to 16.2 percent in Alaska. Spending with employer coverage outpaced growth in per-enrollee decreased in nine states, ranging from a drop of 18 percent Medicare spending between 2013 to 2016 in five of eight in Mississippi to a decline of 1.2 percent in Massachusetts. commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance Exhibit 11 12 Cumulative growth in per-enrollee spending among adults with employer Exhibit 11. Cumulative in per-enrollee spending among adultsin with employer insurance outpacedgrowth per capita Medicare spending growth five of eightinsurance outpaced per2013–2016 capita Medicare spending growth in five of eight regions in 2013–2016 regions in Employer insurance Mid-Atlantic Great Lakes Medicare Plains New England 8 8 8 8 4 4 4 4 0 0 0 0 -4 2013 2014 2015 2016 -4 Rocky Mountain 2013 2014 2015 2016 -4 2013 2014 2015 2016 -4 West Southwest Southeast 8 8 8 8 4 4 4 4 0 0 0 0 -4 2013 2014 2015 2016 -4 2013 2014 2015 2016 -4 2013 2014 2015 2016 2013 2014 2015 2016 -4 2013 2014 2015 2016 Data: Employer coverage: 2016 Truven MarketScan Database, analysis by Michael E. Chernew, Harvard Medical School; Medicare: 2016 administrative claims via May 2018 Data: Employer coverage: 2016 Truven MarketScan Database, analysis by Michael E. Chernew, Harvard Medical School; Medicare: 2016 administrative claims via May CMS Geographic Variation Public Use File. 2018 CMS Geographic Variation Public Use File. Exhibit 12 Source: David C. Radley, Sara R. Collins, and Susan L. Hayes, 2019 Scorecard on State Health System Performance Cumulative change inFund, per enrollee spending, 2013–2016 (Commonwealth June 2019). Exhibit 12. Cumulative change in per enrollee spending, 2013–2016  Percent change Employer coverage Medicare 20 15 10 5 0 -5 -10 -15 Pe nn O s So y lv ahio ut F n i R hh Ca lori da od ro a e lin Ke Isla a n n Lo tu d Ne u is cky w ian Mi J ers a Ma W ch i ey ss isc gan ac on Te hu s si n n n et e ts Ge sse o e V i r gi Di rg a st ric I in t o I l linoia f C n d is Co o lu ian nn m a ec b ia W Mar ticu as y la t h n Deingt d law on Ne ar e Ar vad iz o a n C Te a Ne al if xas o w H a Urn ia m ta Ne psh h w ir W Co Y o e es lo rk t V rad i o Mi rgin ss ia o No A Io u ri rth lab wa C a Mi aro m a ss lin iss a ip No Id a pi rth H a h o Da wai k i K ot Mo an s a nt as a Mi Ma n a nn in e e Ne V er s ot w mo a M n So Ar ex t ut ka ico h ns Da as O ko Ok re ta l a go Ne h o n m W bras a yo k m a Al ing as ka -20 Data: MarketScan Database, analysis by Michael E. Chernew, Harvard Medical School; Medicare: 2013–2016 administrative claims Data:Employer Employercoverage: coverage:2013–2016 2013–2016Truven Truven MarketScan Database, analysis by Michael E. Chernew, Harvard Medical School; Medicare: 2013–2016 administrative via May 2018 CMS Geographic VariationVariation Public Use File. Use File. claims via May 2018 CMS Geographic Public commonwealthfund.org Source: David C. Radley, Sara R. Collins, and Susan L. Hayes, 2019 Scorecard on State Health System Performance (Commonwealth Fund, June 2019). June 2019 2019 Scorecard on State Health System Performance Differences in prices paid to providers likely drive much of the interstate variation in employer health plan costs and premiums What drives the considerable variation in per-enrollee spending levels in Medicare and employer plans? Exhibit 13 compares spending among Medicare beneficiaries and those with employer coverage in the same state. Spending for each group is shown as the degree to which it diverges from the U.S. median. 13 Since prices are fixed in the Medicare program with adjustments such as hospital type and regional characteristics, most of the state variation in per-beneficiary Medicare spending arises from differences in the amount of services beneficiaries in each state use.21 In contrast, recent research suggests that much of the observed variation in per-enrollee spending in private health plans may stem from provider price variation resulting from local contract negotiations. Per-enrollee Medicare spending in Hawaii was 34 percent less than the U.S. median, whereas spending was 24 percent higher than the median in Louisiana. In employer plans, spending per member in Alaska was nearly 70 percent higher than the U.S. median, while in Mississippi per-member spending was about 30 percent lower than the median. Exhibit 13 Per-enrollee spending among adults with employer coverage and Exhibit 13. Per-enrollee spending among adults with employer coverage and Medicare, Medicare, relative to for theeach U.S. median relative to the U.S. median group, 2016 for each group, 2016 70% 60% Employer coverage Medicare 50% 40% 30% 20% 10% 0% -10% -20% -30% Ha w A ai Or lask i Mo eg a o W nta n yo n m a Ne V er in m g W w M on as ex t h i So ingt co ut Id on h a D h Co ako o lo ta Ne W rad w is Io wo H a co a m ns NoMi n psh i n rth ne ire Das ota k Ma ota in U e So Ariz t ah o u No th V irg na rth Car in i C o li a Nearo l na i Ca bra n a l if ska o R h N rn od ev ia e a De Isla da la n W Ma wa d es ry r e t V la Di ir nd st Ge gin ric t o M or ia f C i ss gia o l ou Ma u r ss K mb i ac an ia h s Ar u se as ka tt Co In n sas nn dia s Te ec na n n tic u Pe ess t nn O ee s h Ney lv a io n Ke w Y ia nt ork u I ck Al l lino y a M ba is Ne i ch m a w ig Ok J e an r Mi l ah sey ss om iss a ip Te pi x F Lo lor as u i i da sia na -40% Data: Employer coverage: 2016 Truven MarketScan Database, analysis by Michael E. Chernew, Harvard Medical School; Medicare: 2016 administrative claims via May 2018 Data: Employer coverage: Truven MarketScan Database, analysis by Michael E. Chernew, Harvard Medical School; Medicare: 2016 administrative claims via CMS Geographic Variation Public2016 Use File. May 2018 CMS Geographic Variation Public Use File. Source: David C. Radley, Sara R. Collins, and Susan L. Hayes, 2019 Scorecard on State Health System Performance (Commonwealth Fund, June 2019). commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance 14 CONCLUSION The 2019 Scorecard on State Health System Performance shows that states and the federal government face important challenges in promoting affordable health care and the best possible health outcomes for people across the country. The widespread gains in expanding health insurance coverage and access to care following the 2010 passage of the Affordable Care Act have largely stalled since 2015; in 16 states, these coverage gains slightly eroded between 2016 and 2017. There are several reasons for this stalled progress and backsliding: lack of Medicaid expansion in 17 states; the fact that individualmarket insurance remains unaffordable for many, including those with incomes just over the eligibility threshold for marketplace subsidies (about $48,560 for an individual); and growing out-of-pocket costs for many with private plans, including employer plans. What’s more, recent congressional and executive actions related to the individual health insurance market and Medicaid have curtailed enrollment in both. Finally, undocumented immigrants are ineligible for subsidized coverage. At the same time, health care costs in employer plans continue to grow at a faster National gains if all states achieved top rates* of performance: 18 million more adults and children insured, beyond those who already gained coverage through the ACA 14 million fewer adults skipping care because of its cost clip than median income, leaving many families paying more for their insurance but getting less. Most alarming, in some states residents now face shorter life expectancies than just a few years ago, in part because of unrelenting increases in deaths linked to suicide, alcohol, and drug overdose. All states can improve, including those that topped our Scorecard rankings. Indeed, many states are already taking important steps to expand access to high-quality care by: Expanding access to care • Expanding Medicaid eligibility –– As of June 2019, 33 states and the District of Columbia have expanded eligibility for their Medicaid programs to more low-income adults. In November 2018, voters in Idaho, Nebraska, and Utah passed ballot initiatives to do so, but lawmakers in these states have since taken steps to restrict the expansion. –– However, 15 states, including eight that expanded Medicaid eligibility, 27 million more adults with a usual source of care 11 million more adults receiving recommended cancer screenings 808,000 more young children receiving all recommended vaccines have approved or pending waivers that allow them to make work status a requirement for Medicaid coverage. This will likely further erode coverage gains among adults with low incomes. Two of the approved waivers, in Arkansas and Kentucky, were blocked by court rulings, but not before * Performance benchmarks set at the level achieved by the top-performing state with available data for this indicator. more than 18,000 Arkansans lost their health coverage.22 commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance 15 • Ensuring well-functioning individual insurance markets23 –– The Affordable Care Act’s reinsurance program, which protected insurers against unexpectedly high claims and helped to reduce marketplace premiums, expired at the end of 2016. Seven states are now operating their own reinsurance programs to stabilize and strengthen their individual insurance market; Alaska’s program reduced premiums by 20 percent in 2018.24 Additional states are seeking federal approval to establish reinsurance programs. Several congressional bills include proposals for reinstating a federal reinsurance program.25 Taking steps to mitigate health care cost growth National gains if all states achieved top rates* of performance: 10 million more children would receive recommended annual medical and dental visits • Some health reform bills recently introduced in Congress propose to lower U.S. health care costs by paying providers at or near Medicare rates.26 The health reform bills that would use Medicare payment rates include singlepayer or Medicare-for-All proposals, as well as those that give consumers a choice of enrolling in a Medicare-like public plan. Some states are 296,000** fewer hospital readmissions attempting similar reforms. Washington will launch a public-plan option in 2021 that will cap what providers are paid at 160 percent of Medicare rates. Some states including New Mexico are crafting a Medicaid buy-in option. But paying providers in employer and other private insurance plans at or near Medicare rates could be put in place without a public plan or singlepayer system.27 • Several states are using value-based purchasing in their Medicaid and state employee benefits programs in order to promote higher-quality, lower- 6.7 million** fewer emergency room visits for nonemergency care or conditions treatable with primary care cost care.28 • Colorado, Michigan, and Oklahoma are changing the way they pay for prescription drugs in Medicaid by requesting federal waivers to negotiate with drugmakers based on how well the drug works, rather than accepting market pricing.29 • Some states are promoting secure and efficient platforms for health care 90,000 fewer deaths before age 75 from treatable diseases providers, health plans, and state programs to exchange information in order to monitor and improve health care quality.30 Promoting the best possible outcomes • Several states are working to build an adequate primary care workforce, especially in underserved areas, by offering tuition assistance, changing the scope of practice laws, raising the primary care reimbursement rate, and *P erformance benchmarks set at the level achieved by the top-performing state with available data for this indicator. ** Estimate based on working-age population, ages 18–64, with employersponsored insurance, and Medicare beneficiaries age 65 and older. other steps. 31 commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance Working in partnership with the federal government, states have an opportunity to do more in developing and implementing new initiatives to curb the opioid crisis. State efforts to counter the surge in drug overdose deaths include improving access to opioid overdose reversal medications such as naloxone — efforts that have been bolstered by Medicaid expansion — and passed legislation that sets guidelines or limits for opioid prescriptions.32 These are important steps, but there is more to be done in preventing and treating opioid use disorder and responding to overdoses. Reversing the upward trend in deaths from suicide, alcohol, and drug overdose will require greater cooperation across sectors, at both the state and federal level, including the public health, care delivery, and criminal justice systems.33 commonwealthfund.org 16 Ultimately, national improvement in health system performance will require the support of the federal government. States with fewer resources and those that are less engaged in efforts to expand insurance coverage, reduce health care costs, and improve care quality will continue to lag others. Some states that have taken steps to improve, for example by implementing reinsurance programs to lower premiums, are struggling to finance their efforts over the long term. While many states have assumed greater responsibility for improving health system performance in recent years, they will need a strong federal partnership to build and sustain their progress. June 2019 2019 Scorecard on State Health System Performance 17 2019 state rankings on health system performance Which states lead the overall rankings? What are the leading states by region? Hawaii, Massachusetts, Minnesota, Washington, Connecticut, and Vermont (See Scorecard Methods for states in each region) Great Lakes Wisconsin Mid-Atlantic New York Which states are ranked at the bottom? New England Massachusetts Arkansas, Nevada, Texas, Oklahoma, and Mississippi Plains Minnesota Rocky Mountain Colorado Southeast Virginia Southwest Arizona West Hawaii Exhibit 14 Exhibit 14. Overall health system performance Overall health system performance Better performance 1.1 HI 0.9 0.7 0.5 MA MN WA CT VT RI IA CO NH UT 0.3 0.1 ME WI CA NY ND OR ID MD NJ PA NE DC SD MI U.S. AVERAGE MT DE IL -0.1 VA AK KS AZ OH NC -0.3 NM IN WY AL TN -0.5 -0.7 KY SC GA MO FL LA WV AR NV TX OK MS -0.9 -1.1 Worse performance Note: States are arranged in rank order from left (best) to right (worst), based on their overall 2019 State Scorecard rank. States are arranged in rank order from left (best) to right (worst), based on their overall 2019 State Scorecard rank. Source: David C. Radley, Sara R. Collins, and Susan L. Hayes, 2019 Scorecard on State Health System Performance (Commonwealth Fund, June 2019). commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance 18 Exhibit 15 More15. improvement than decline Exhibit More improvement than decline Rhode Island MOST IMPROVED Improved over five-year period SC UT 9 MA NM NV NH HI NE DE INDICATORS WORSENED GA VT WY OK ND OH ID NC FL TX VA OR IA MT CA WI AL MN IN ME AZ CO SD AK NJ PA MS IL KS MI TN DC MD LA NY CT KY WV AR WA Worsened over five-year period MO INDICATORS IMPROVED 21 7 16 Notes: Based on 5-year trends for 45 of 47 total indicators (Disparity dimension not included); trend data are not available for all indicators. Bar length equals the total Notes: Based on five-year trends for 45 of 47 indicators (Disparity not included); trenddeviations data are (StDev) not available for alldistribution. indicators. Bar length equals number of indicators with any improvement ortotal worsening with an absolutedimension value greater than 0.5 standard of the state the total number of indicators with any improvement or worsening with an absolute value greater than 0.5 standard deviations (StDev) of the state distribution. Source: David C. Radley, Sara R. Collins, and Susan L. Hayes, 2019 Scorecard on State Health System Performance (Commonwealth Fund, June 2019). Which states moved up the most in the rankings between 2013 and 2017, and which states dropped? California had the largest jump in rankings, up 12 spots. New York and Washington each moved up 10 spots in the rankings, and Rhode Island rose nine spots. Delaware fell 17 spots in the rankings, while Wyoming, Virginia, and Maryland fell 11, nine, and seven spots, respectively. commonwealthfund.org Which states improved on the most indicators? Rhode Island improved on 21 of 45 indicators we track over time, the most of any state. Missouri, Washington, and West Virginia each improved on 19 indicators. Delaware, Hawaii, New Mexico, and Wyoming each got worse on more indicators than they improved on. What’s the trend? On balance, the 2019 State Scorecard finds more improvement than decline between 2013 and 2017, but trends are mixed. Almost all states improved on more indicators than they worsened, but no state improved on a majority of indicators. Most states (42) saw little or no change on more indicators than they improved on. June 2019 2019 Scorecard on State Health System Performance 19 SCORECARD METHODS The Commonwealth Fund’s 2019 Scorecard on State Health System Performance evaluates states on 47 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 care. • 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 (13 indicators; including several measures reported separately for distinct age groups): includes indicators of hospital and emergency department use that might be reduced with timely and effective care and follow-up care, as well as estimates of per-person spending among Medicare beneficiaries and working-age adults with employer-sponsored insurance. • Healthy Lives (12 indicators): includes measures of premature death, health status, health risk behaviors including smoking and obesity, and tooth loss. DISPARITIES BASED ON INCOME. The Scorecard reports on performance differences within states associated with individuals’ income level for 19 of the 47 indicators. For each indicator, we measure the difference between rates for a state’s low-income population (generally less than 200% of the federal poverty level) and higher-income population (generally 400% or more of the federal poverty level). States are ranked on the relative magnitude of the resulting disparities in performance. The following principles guided the development of the Scorecard: PERFORMANCE METRICS. The 47 metrics selected for this report span health care system performance, representing important commonwealthfund.org dimensions and measurable aspects of care. Where possible, indicators align with those used in previous state scorecards. Several indicators used in previous versions of the scorecard have been dropped either because all states improved to the point where no meaningful variations existed (e.g., measures that assessed hospitals on processes of care) or the data to construct the measures were no longer available. New indicators have been added to the scorecard series over time in response to evolving priorities. See the box on page 21 for more detail on changes in indicators. MEASURING CHANGE OVER TIME. We were able to track performance over time for 45 of the 47 indicators. Not all indicators could be trended because of changes in the underlying data or measure definitions. June 2019 2019 Scorecard on State Health System Performance There were generally four to five years between indicators’ baseline and current-year data observation, though the starting and ending points depended on data availability. We chose this short time horizon to capture the immediate effects of changes relative to the policy and delivery system environment, such as coverage expansions under the Affordable Care Act and other reforms. We considered a change in an indicator’s value between the baseline and current year data points to be meaningful if it was at least onehalf (0.5) of a standard deviation larger than the indicator’s combined distribution over the two time points — a common approach used in social science research. To assess change over time in the disparity dimension, we count how often the disparity narrowed within a state, so long as there was also an improvement in the observed rate for the state’s low-income population. DATA SOURCES. Indicators draw from publicly available data sources, including governmentsponsored surveys, registries, publicly reported quality indicators, vital statistics, mortality data, and administrative databases. The most current data available were used in this report whenever possible. Appendix H provides detail on the data sources and time frames. SCORING AND RANKING METHODOLOGY. For each indicator, a state’s standardized z-score is calculated by subtracting the 51-state average (including the District of Columbia as if it were a state) from the state’s observed rate, and then dividing by the standard deviation of all observed state rates. States’ standardized z-scores are averaged across all indicators within the performance dimension, and dimension scores are averaged into an overall commonwealthfund.org 20 score. Ranks are assigned based on the overall score. This approach gives each dimension equal weight, and within each dimension it weights all indicators equally. The z-score more precisely portrays differences in performance across states (see Exhibit 14 on page 17) than the simple ranking approach used in our scorecards prior to 2018. It is also better suited to accommodate the different scales used across scorecard indicators (e.g., percentages, dollars, and populationbased rates). This method also aligns with methods used in the Commonwealth Fund’s international health system rankings. As in previous scorecards, if historical data were not available for a particular indicator in the baseline period, the current year data point was used as a substitute, thus ensuring that ranks in each time period were based on the same number of indicators. REGIONAL COMPARISONS. The Scorecard groups states into the eight regions used by the Bureau of Economic Analysis to measure and compare economic activity. The regions are: Great Lakes (Illinois, Indiana, Michigan, Ohio, Wisconsin); Mid-Atlantic (Delaware, District of Columbia, Maryland, New Jersey, New York, Pennsylvania); New England (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont); Plains (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota); Rocky Mountain (Colorado, Idaho, Montana, Utah, Wyoming); Southeast (Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, West Virginia); Southwest (Arizona, New Mexico, Oklahoma, Texas); and West (Alaska, California, Hawaii, Nevada, Oregon, Washington). June 2019 2019 Scorecard on State Health System Performance METHODOLOGICAL CHANGES FROM THE 2018 STATE SCORECARD • The Centers for Medicare and Medicaid Services (CMS) changed the way it reports survey responses from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) in its Hospital Compare public use data. This change impacted one of the measures we used to evaluate hospitalized patients’ experiences. Rather than constructing our own composite of hospitalized patients’ experiences, as was done in the 2018 State Scorecard, we substituted a CMSconstructed composite summary of hospitals’ HCAHPS scores. This composite has a 100-point scale, with 100 points representing the highest possible patient experience summary score. We convert this into a measure suitable for use in the 2019 State Scorecard by calculating the share of hospitals in a state with HCAHPS patient experience summary scores lower than the national median. • The 2018 State Scorecard reported deaths from suicide, alcohol, and drug overdose in a single composite, referred to as “deaths of despair.” In 2019, we report each component separately to better capture variations among states in the underlying causes of death. commonwealthfund.org 21 • In previous years, the indicator measuring “high out-of-pocket medical spending relative to income” included over-the-counter drug costs. Since these costs were excluded from the most recent data (2016–17), we also removed them from our baseline estimate (2013– 14) for comparability. • Several indicators in the 2018 State Scorecard were grouped and reported for separate age stratifications within the same measurement construct (e.g., potentially avoidable emergency department visits among working-age adults and Medicare beneficiaries). An adjustment was made to down-weight each age group within the construct for scoring. The same data are used in the 2019 State Scorecard, but we no longer make the scoring adjustment. Sensitivity analyses indicate that this change has no impact on state rankings. Data in the 2019 State Scorecard are generally comparable with those in the 2018 State Scorecard. However, because of changes in indicators and methodology, rankings in these two scorecards are not comparable to those reported in previous scorecard editions. June 2019 2019 Scorecard on State Health System Performance 22 NOTES 1. Anne Case and Angus Deaton, “Rising Morbidity and Mortality in Midlife Among White Non-Hispanic Americans in the 21st Century,” Proceedings of the National Academy of Sciences of the United States of America 112, no. 49 (Dec. 8, 2015): 15078–83. 2. Kenneth D. Kochanek et al., Mortality in the United States, 2016, NCHS Data Brief no. 293 (National Center for Health Statistics, Dec. 2017). 3. The Scorecard groups states into the eight regions used by the Bureau of Economic Analysis to measure and compare economic activity. The regions are: Great Lakes (Illinois, Indiana, Michigan, Ohio, Wisconsin); Mid-Atlantic (Delaware, District of Columbia, Maryland, New Jersey, New York, Pennsylvania); New England (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont); Plains (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota); Rocky Mountain (Colorado, Idaho, Montana, Utah, Wyoming); Southeast (Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, West Virginia); Southwest (Arizona, New Mexico, Oklahoma, Texas); and West (Alaska, California, Hawaii, Nevada, Oregon, Washington). 4. Alaska, Arkansas, Colorado, Hawaii, Idaho, Iowa, Kansas, Minnesota, Mississippi, New Mexico, Texas, Utah, and Washington. 5. 2005 was selected as the baseline in this comparison because it was the last year in which drug deaths were lower than suicide deaths, and the last point from which the 2017 rate was more than double. 6. 2016 data are not reported in the Scorecard Appendices, but can be found in the Commonwealth Fund’s online Health System Data Center. 7. In its analysis of state uninsured rates among the total civilian noninstitutionalized population, the U.S. Census Bureau found statistically significant upticks of between 0.3 and 1 percentage point in 14 states between 2016 and 2017. Edward R. Berchick, Emily Hood, and Jessica C. Barnett, Health Insurance Coverage in the United States: 2017, Current Population Reports, P60-264 (U.S. Census Bureau, Sept. 2018). commonwealthfund.org 8. Akeiisa Coleman, Rachel Nuzum, and Susan L. Hayes, “Medicaid Expansion Across the Country: A Check-In on Recent Ballot Initiatives,” To the Point (blog), Commonwealth Fund, Feb. 25, 2019; and Amy Beth Hanson, “Medicaid Expansion Bill Signed by Montana Governor,” Governing, May 13, 2019. 9. See the Commonwealth Fund’s online Health System Data Center. 10. Exhibit 7 on page 8 uses data that are limited to the working-age adult population ages 18–64, and these are the values discussed here and shown in Appendix C4. Note that states are ranked on a version of this indicator that includes all adults age 18 and older. These rates can be found in Appendix C2. 11. Robin A. Cohen, Emily P. Terlizzi, and Michael E. Martinez, Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, 2018 (National Center for Health Statistics, May 2019). 12. Analysis of the 2018 U.S. Current Population Survey by Ougni Chakraborty and Sherry Glied of New York University for the Commonwealth Fund. 13. Sara R. Collins and David C. Radley, The Cost of Employer Insurance Is a Growing Burden for MiddleIncome Families (Commonwealth Fund, Dec. 2018). 14. Collins and Radley, Cost of Employer Insurance, 2018. 15. Zack Cooper et al., “Variation in Health Spending Growth for the Privately Insured from 2007 to 2014,” Health Affairs 38, no. 2 (Feb. 2019): 230–36; Zack Cooper et al., “Hospital Prices Grew Substantially Faster than Physician Prices for Hospital-Based Care in 2007–14,” Health Affairs 38, no. 2 (Feb. 2019): 184–89; and Andrea M. Sisko et al., “National Health Expenditure Projections, 2018–27: Economic and Demographic Trends Drive Spending and Enrollment Growth,” Health Affairs 38, no. 3 (Mar. 2019): 491–501. 16. Health Care Cost Institute, 2017 Health Care Cost and Utilization Report (HCCI, Feb. 2019). June 2019 2019 Scorecard on State Health System Performance 17. Gerard F. Anderson, Peter S. Hussey, and Varduhi Petrosyan, “It’s Still the Prices, Stupid: Why the U.S. Spends So Much on Health Care, and a Tribute to Uwe Reinhardt,” Health Affairs 38, no. 1, (Jan. 2019): 87–95. 23 Costs, Invited Testimony, U.S. House of Representatives Committee on Rules, Hearing on “Medicare for All Act of 2019,” Apr. 30, 2019. 20. Chapin White and Christopher Whaley, Prices Paid to Hospitals by Private Health Plans Are High Relative to Medicare and Vary Widely (RAND Corporation, May 2019). 28. Bailit Health, The Role of State Medicaid Programs in Improving the Health Care System (National Association of Medicaid Directors, Mar. 2016); Michael Bailit, Megan Burns, and Mary Beth Dyer, Value-Based-Innovation by State Public Employee Health Benefits Programs (Bailit Health, for State Health and Value Strategies, Princeton University Woodrow Wilson School of Public and International Affairs, Nov. 2017); and Trish Riley et al., Cross-Agency Strategies to Curb Health Care Costs: Leveraging State Purchasing Power (National Academy for State Health Policy, Apr. 2019). 21. Uwe E. Reinhardt, “How Medicare Sets Hospital Prices: A Primer,” New York Times, Nov. 26, 2010. 29. “CMS OKs Colorado’s Waiver for Medicaid Value-Based Purchasing,” Modern Healthcare, Feb. 25, 2019. 22. Collins, Bhupal, and Doty, Health Insurance Coverage Eight Years, 2019. 30. National Governors Association, Getting the Right Information to the Right Health Care Providers at the Right Time: A Road Map for States to Improve Health Information Flow Between Providers (NGA Center for Best Practices, Dec. 2016). 18. Eric C. Schneider et al., Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care (Commonwealth Fund, July 2017). 19. Cooper et al., “Variation in Health Spending Growth,” 2019. 23. Sabrina Corlette, Kevin Lucia, and Maanasa Kona, “States Step Up to Protect Consumers in Wake of Cuts to ACA Cost-Sharing Reduction Payments,” To the Point (blog), Commonwealth Fund, Oct. 27, 2017; and Justin Giovannelli and Ashley Williams, “Regulation of Narrow Networks: With Federal Protections in Jeopardy, State Approaches Take on Added Significance,” To the Point (blog), Commonwealth Fund, Feb. 2, 2017. 24. What Is Your State Doing to Affect Access to Adequate Health Insurance?, interactive map (Commonwealth Fund, last updated May 30, 2019). 25. Collins, Bhupal, and Doty, Health Insurance Coverage Eight Years, 2019; and David Blumenthal et al., “States Take the Lead on Reinsurance to Stabilize the ACA Marketplaces,” To the Point (blog), Commonwealth Fund, May 22, 2018. 31. National Conference of State Legislatures, Primary Care Workforce: Health Care Safety-Net Toolkit for Legislators (NCSL, 2013). 32. Richard G. Frank and Carrie E. Fry, “The Impact of Expanded Medicaid Eligibility on Access to Naloxone,” Addiction, published online Apr. 14, 2019; and National Conference of State Legislators, “Prescribing Policies: States Confront Opioid Overdose Epidemic,” NCSL, last updated Oct. 31, 2018. 33. National Governors Association, Finding Solutions to the Prescription Opioid and Heroin Crisis: A Road Map for States (NGA Center for Best Practices, July 2016). 26. Sara R. Collins and Roosa Tikkanen, “The Many Varieties of Universal Coverage,” Commonwealth Fund, last updated Apr. 24, 2019. 27. Sara R. Collins, Status of U.S. Health Insurance Coverage and the Potential of Recent Congressional Health Reform Bills to Expand Coverage and Lower Consumer commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance ABOUT THE AUTHORS David C. Radley, Ph.D., M.P.H., is senior scientist for the Commonwealth Fund’s Tracking Health System Performance initiative, working on the Scorecard project. Dr. Radley and his team develop national, state, and substate regional analyses on health care system performance and related insurance and care system market structure analyses. He is also a senior study director at Westat, a research firm that supports the Scorecard project. Previously, he was associate in domestic health policy for Abt Associates, with responsibility for a number of projects related to measuring long-term care quality and evaluating health information technology initiatives. Dr. Radley received his Ph.D. in health policy from the Dartmouth Institute for Health Policy and Clinical Practice, and holds a B.A. from Syracuse University and an M.P.H. from Yale University. Sara R. Collins, Ph.D., is vice president for Health Care Coverage and Access at the Commonwealth Fund. An economist, Dr. Collins joined the Fund in 2002 and has led the Fund’s national program on health insurance since 2005. Since joining the Fund, she has led several national surveys on health insurance and authored numerous reports, issue briefs, and journal articles on health insurance coverage and policy. She has provided invited testimony before several Congressional committees and subcommittees. Prior to joining the Fund, Dr. Collins was associate director/senior research associate at the New York Academy of Medicine. Earlier in her 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 Office of the Public Advocate. Dr. Collins holds a Ph.D. in economics from George Washington University. Susan L. Hayes, M.P.A., is senior researcher for the Commonwealth Fund’s Tracking Health System Performance initiative. In this role she supports the Scorecard project, actively participating in the selection/ development, research, and analysis of national, state, local, and special-population-level health system performance measures, and coauthoring Scorecard reports and related publications. Ms. Hayes holds an M.P.A. from New York commonwealthfund.org 24 University’s Wagner School of Public Service, where she won the Martin Dworkis Memorial Award for academic achievement and public service. She graduated from Dartmouth College with an A.B. in English and began a distinguished career in journalism, working as an editorial assistant at PC Magazine and a senior editor at National Geographic Kids and later at Woman’s Day magazine. Following that period, Ms. Hayes was a freelance health writer and a contributing editor to Parent & Child magazine and cowrote a book on raising bilingual children with a pediatrician at Tufts Medical Center. Editorial support was provided by Martha Hostetter. ACKNOWLEDGMENTS We owe our sincere appreciation to all of the researchers who developed indicators and conducted data analyses for this Scorecard. These include: Michael E. Chernew, Ph.D., and Andrew Hicks, Department of Health Care Policy, Harvard Medical School; Sherry Glied, Ph.D., and Ougni Chakraborty, New York University Robert F. Wagner Graduate School of Public Service; Ashish Jha, M.D., M.P.H., and Jie Zheng, Ph.D., Harvard School of Public Health; and Vincent Mor, Ph.D., Emily Gadbois, Ph.D., Brown University. We acknowledge Mental Health America for data reported in The State of Mental Health in America. We also would like to thank the following Commonwealth Fund staff: David Blumenthal, M.D., Donald Moulds, Eric Schneider, M.D., Melinda Abrams, and Rachel Nuzum for providing constructive guidance throughout; and the Fund’s communications and support teams, including Barry Scholl, Chris Hollander, Deborah Lorber, Martha Hostetter, Bethanne Fox, Josh Tallman, Jen Wilson, Paul Frame, Samantha Chase, Herman Bhupal, and Munira Gunja for their guidance, editorial and production support, and public dissemination efforts. Finally, the authors wish to acknowledge Caroline Broder and Maya Brod of Burness for their assistance with media outreach, and Westat for its support of the research unit, which enabled the analysis and development of the Scorecard report. June 2019 2019 Scorecard on State Health System Performance 25 For more information about this report, please contact: David C. Radley, Ph.D., M.P.H. Senior Scientist, Westat and the Commonwealth Fund Health System Scorecard Project drcmwf.org Support for this research was provided by the Commonwealth Fund. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund or its directors, officers, or staff. To learn more about new publications when they become available, visit the Fund’s website and register to receive email alerts. commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance 26 APPENDIX A1. State Scorecard Years and Databases Appendix A1. State Scorecard Data YearsData and Databases Indicator Access and Affordability Past year Current year Database 1 Uninsured adults 2013 2017 American Community Survey, Public Use Microdata Sample (ACS PUMS) 2 Uninsured children 2013 2017 American Community Survey, Public Use Microdata Sample (ACS PUMS) 3 Adults without a usual source of care 2013 2017 Behavioral Risk Factor Surveillance System (BRFSS) 4 Adults who went without care because of cost 2013 2017 Behavioral Risk Factor Surveillance System (BRFSS) 5 High out-of-pocket medical spending 2013-14 2016-17 6 Employee insurance costs as a share of median income 2013 2017 Medical Expenditure Panel Survey Insurance Component (MEPS-IC) 7 Adults without a dental visit 2012 2016 Behavioral Risk Factor Surveillance System (BRFSS) 8 Adults without all recommended cancer screenings 2012 2016 Behavioral Risk Factor Surveillance System (BRFSS) 9 Adults without all recommended vaccines 2013 2017 Behavioral Risk Factor Surveillance System (BRFSS) 10 Diabetic adults without an annual hemoglobin A1c test 2015 2016 Truven MarketScan 11 Elderly patients who received a high-risk prescription drug -- 2015 Medicare Part D Claims 12 Children without a medical home 2016 2017 National Survey of Children’s Health (NSCH) 13 Children without a medical and dental preventive care visit 2016 2017 National Survey of Children’s Health (NSCH) 14 Children who did not receive needed mental health care 2016 2017 National Survey of Children’s Health (NSCH) 15 Children without all recommended vaccines 2012 2016 National Immunization Survey (NIS) 16 Hospital 30-day mortality Current Population Survey Annual Social and Economic Supplement (CPS ASEC) Prevention and Treatment 17 Central line–associated blood stream infection (CLABSI) 18 Hospitals with lower-than-average patient experience ratings 19 07/2010 - 06/2013 07/2014 - 06/2017 CMS Hospital Compare 2015 2016 CDC Healthcare-Associated Infections (HAI) Progress Report -- 2017 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), via CMS Hospital Compare Home health patients without improved mobility 2013 2017 Outcome and Assessment Information Set (OASIS), via CMS home Health Compare 20 Nursing home residents with an antipsychotic medication 2013 2017 21 Adults with any mental illness reporting unmet need 2009-11 2014-16 National Survey on Drug Use and Health (NSDUH), via State of Mental Health in America Adults with any mental illness who did not receive treatment 2009-11 2014-16 National Survey on Drug Use and Health (NSDUH), via State of Mental Health in America 2012 2015 Healthcare Cost and Utilization Project (HCUP), via AHRQ National Healthcare Quality Report 22 Minimum Dataset (MDS), via CMS Nursing Home Compare Avoidable Hospital Use and Cost 23 Hospital admissions for pediatric asthma Potentially avoidable emergency department visits 24 Ages 18–64, per 1,000 employer-insured enrollees 2015 2016 Truven MarketScan 25 Age 65 and older, per 1,000 Medicare beneficiaries 2012 2015 Chronic Conditions Data Warehouse (CCW), via CMS Geographic Variation Public Use File Admissions for ambulatory care–sensitive conditions 26 Ages 18–64, per 1,000 employer-insured enrollees 2015 2016 Truven MarketScan 27 Ages 65 and older, per 1,000 Medicare beneficiaries 2013 2017 Chronic Conditions Data Warehouse (CCW), via CMS Geographic Variation Public Use File 30-day hospital readmissions 28 Ages 18–64, per 1,000 employer-insured enrollees 2015 2016 Truven MarketScan 29 Age 65 and older, per 1,000 Medicare beneficiaries 2013 2017 Chronic Conditions Data Warehouse (CCW), via CMS Geographic Variation Public Use File 30 Skilled nursing facility patients with a hospital readmission 2012 2016 Residential History File 31 Nursing home residents with a hospital admission 2012 2016 Residential History File 32 Home health patients with a hospital admission 2013 2017 Medicare Claims, via CMS Home Health Compare 33 Adults with inappropriate lower-back imaging 2015 2016 Truven MarketScan 34 Employer-sponsored insurance spending per enrollee 2013 2016 Truven MarketScan 35 Medicare spending per beneficiary 2013 2017 Chronic Conditions Data Warehouse (CCW), via CMS Geographic Variation Public Use File Healthy Lives 36 Mortality amenable to health care 2010-11 2014-15 37 Breast cancer deaths 2013 2017 CDC National Vital Statistics System (NVSS): WONDER CDC National Vital Statistics System (NVSS): Restricted Use Mortality Microdata 38 Colorectal cancer deaths 2013 2017 CDC National Vital Statistics System (NVSS): WONDER 39 Suicide deaths 2013 2017 CDC National Vital Statistics System (NVSS): WONDER 40 Alcohol deaths 2013 2017 CDC National Vital Statistics System (NVSS): WONDER 41 Drug poisoning deaths 2013 2017 CDC National Vital Statistics System (NVSS): WONDER 42 Infant mortality 2012 2016 CDC National Vital Statistics System (NVSS): WONDER 43 Adults who report fair or poor health 2013 2017 Behavioral Risk Factor Surveillance System (BRFSS) 44 Adults who smoke 2013 2017 Behavioral Risk Factor Surveillance System (BRFSS) 45 Adults who are obese 2013 2017 Behavioral Risk Factor Surveillance System (BRFSS) 46 Children who are overweight or obese 2016 2017 National Survey of Children’s Health (NSCH) 47 Adults who have lost six or more teeth 2012 2016 Behavioral Risk Factor Surveillance System (BRFSS) Note: (--) Previous data not available or its definition is not comparable over time. Note: (--) Previous data not available or its definition is not comparable over time. commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance 27 APPENDIX of Indicators theScorecard Scorecard State Health System Performance Appendix A2.A2. ListList of Indicators in thein State onon Health System Performance Data years represented Indicator Access and Affordability Baseline 2019 Scorecard U.S. average rate Baseline Range of state performance 2019 Scorecard Baseline 2019 Scorecard 4 - 24 1 Uninsured adults 2013 2017 20% 12% 5 - 30 2 Uninsured children 2013 2017 8% 5% 2 - 14 1 - 11 3 Adults without a usual source of care 2013 2017 24% 23% 12 - 35 12 - 34 4 Adults who went without care because of cost 8 - 20 5 High out-of-pocket medical spending 6 7 2013 2017 16% 14% 7 - 22 2013-14 2016-17 11% 10% 7 - 17 5 - 15 Employee insurance costs as a share of median income 2013 2017 6.5% 6.9% 4.4 - 9 4.8 - 10.2 Adults without a dental visit 2012 2016 15% 16% 10 - 20 10 - 20 24 - 40 Prevention and Treatment 8 Adults without all recommended cancer screenings 2012 2016 31% 32% 21 - 40 9 Adults without all recommended vaccines 2013 2017 64% 62% 53 - 72 54 - 69 10 Diabetic adults without an annual hemoglobin A1c test 2015 2016 16.9% 12.0% 11 - 23.7 5.6 - 22.5 11 Elderly patients who received a high-risk prescription drug -- 2015 -- 11% -- 5 - 16 12 Children without a medical home 2016 2017 51% 51% 40 - 66 39 - 64 13 Children without a medical and dental preventive care visit 2016 2017 32% 32% 20 - 41 18 - 43 14 Children who did not receive needed mental health care 2016 2017 18% 22% 5 - 34 4 - 48 15 Children without all recommended vaccines 2012 2016 32% 29% 20 - 40 15 - 42 16 Hospital 30-day mortality 2010-13 2014-17 13.2% 13.9% 12.2 - 14.1 12.8 - 15.1 17 Central line–associated blood stream infection (CLABSI) 2015 2016 0.99 0.89 0.32 - 1.43 0.36 - 1.14 18 Hospitals with lower-than-average patient experience ratings -- 2017 -- 45.0% -- 9 - 100 19 Home health patients without improved mobility 2013 2017 39.0% 25.0% 34 - 51 20 - 35 20 Nursing home residents with an antipsychotic medication 2013 2017 21.0% 15.0% 11 - 27 7 - 20 21 Adults with any mental illness reporting unmet need 2009-11 2014-16 21.0% 21.0% 14 - 30 16 - 26 22 Adults with any mental illness who did not receive treatment 2009-11 2014-16 59.0% 56.0% 45 - 73 42 - 68 2012 2015 142.9 87.2 27.6 - 231.5 21.7 - 183.4 Avoidable Hospital Use and Cost 23 Hospital admissions for pediatric asthma Potentially avoidable emergency department visits 24 Ages 18–64, per 1,000 employer-insured enrollees 2015 2016 159.0 142.2 130 - 203.4 115.9 - 186.8 25 Age 65 and older, per 1,000 Medicare beneficiaries 2012 2015 187.8 196.9 130.8 - 247.9 138.3 - 250.8 Admissions for ambulatory care–sensitive conditions 26 Ages 18–64, per 1,000 employer-insured enrollees 2015 2016 4.6 5.3 3.3 - 6.1 5.6 - 7.9 27 Ages 65 and older, per 1,000 Medicare beneficiaries 2013 2017 47.7 43.9 24.3 - 72.4 21.7 - 60.1 30-day hospital readmissions 28 Ages 18–64, per 1,000 employer-insured enrollees 2015 2016 2.9 3.1 1.2 - 5.5 2.4 - 3.6 29 Age 65 and older, per 1,000 Medicare beneficiaries 2013 2017 43.5 41.0 21.4 - 57.2 19.7 - 51.5 11 - 24 30 Skilled nursing facility patients with a hospital readmission 2012 2016 20% 19% 13 - 26 31 Nursing home residents with a hospital admission 2012 2016 17% 15% 7 - 30 5 - 28 32 Home health patients with a hospital admission 2013 2017 16% 16% 14 - 18 14 - 18 33 Adults with inappropriate lower-back imaging 2015 2016 71.1% 68.9% 59.2 - 83.7 57.7 - 76.5 34 Employer-sponsored insurance spending per enrollee 2013 2016 $4,697 $4,882 $3,117 - $7,186 $3,255 - $8,042 35 Medicare spending per beneficiary 2013 2017 $9,081 $9,534 $5,674 - $10,991 $6,195 - $11,257 36 Mortality amenable to health care 2010-11 2014-15 85.3 84.3 57.1 - 133.2 54.7 - 142.4 37 Breast cancer deaths 2013 2017 20.8 19.9 15.5 - 29.8 15.6 - 25.5 38 Colorectal cancer deaths 2013 2017 14.6 12.9 10.9 - 19.8 9.3 - 16.4 39 Suicide deaths 2013 2017 12.6 14.0 5.7 - 23.7 6.6 - 28.9 40 Alcohol deaths 2013 2017 8.2 9.6 4.5 - 22.7 5.5 - 30.6 41 Drug poisoning deaths 2013 2017 13.8 21.7 2.8 - 32.2 8.1 - 57.8 42 Infant mortality 2012 2016 6.0 5.9 4.2 - 8.9 3.5 - 9 43 Adults who report fair or poor health 2013 2017 16% 17% 10 - 22 9 - 24 44 Adults who smoke 2013 2017 18% 16% 10 - 27 9 - 26 45 Adults who are obese 2013 2017 29% 31% 22 - 37 23 - 40 Healthy Lives 46 Children who are overweight or obese 2016 2017 31% 31% 19 - 38 21 - 41 47 Adults who have lost six or more teeth 2012 2016 10% 10% 6 - 23 6 - 21 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. * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance 28 APPENDIX National and Regional Performance Appendix A3. A3. National and Regional Performance Benchmarks Benchmarks National Indicator Access and Affordability Rate Best state(s)a Great Lakes Best state(s)a Rate Mid-Atlantic Best state(s)a Rate New England Best Rate state(s)a Plains Best Rate state(s)a Rocky Moun B Rate sta 1 Uninsured adults 4% MA 7 MI, WI 5 DC 4 MA 6 IA, MN 10 C 2 Uninsured children 1% MA 3 IL, MI 3 DE, NY 1 MA 3 IA, MN 4 C 3 Adults without a usual source of care 12% RI 15 MI 15 PA 12 RI 17 IA 25 4 Adults who went without care because of cost 8% HI, IA, ND 11 MI, OH, WI 10 MD, PA 9 MA, VT 8 IA, ND 11 5 High out-of-pocket medical spending 5% DC 8 WI 5 DC 6 RI 8 MN 12 6 Employee insurance costs as a share of median income 4.8% MI 4.8 MI 5.6 DC 5.4 MA 5.1 IA 5.0 U 7 Adults without a dental visit 10% CT 12 WI 13 NJ 10 CT 12 IA, MN 14 U M CO, Prevention and Treatment 8 Adults without all recommended cancer screenings 24% CT 28 WI 25 DC 24 CT 29 MN 32 C 9 Adults without all recommended vaccines 54% SD 61 OH 55 MD 55 RI 54 SD 57 C 10 Diabetic adults without an annual hemoglobin A1c test 5.6 MN 10.1 MI 10.8 MD 9.2 ME 5.6 MN 10.3 M 11 Elderly patients who received a high-risk prescription drug 5% HI 8 WI 8 NY, PA 7 MA 7 MN, SD 9 M 12 Children without a medical home 39% VT 45 IN, OH 45 MD 39 VT 41 NE 49 C 13 Children without a medical and dental preventive care visit 18% CT 31 IN, MI, WI 21 DC 18 CT 24 IA 22 C 14 Children who did not receive needed mental health care 4% NE, RI 5 IN 6 PA 4 RI 4 NE 8 M 15 Children without all recommended vaccines 15% MA 21 WI 22 DE 15 MA 19 NE 24 C 16 Hospital 30-day mortality 12.8% MA 13.3 OH 13.0 DE 12.8 MA 13.6 MN 13.8 C 17 Central line–associated blood stream infection (CLABSI) 0.36 WY 0.70 IL 0.82 NJ 0.68 VT 0.64 IA 0.36 W 18 Hospitals with lower-than-average patient experience ratings 9% ID 18 WI 33 DE 15 NH 14 KS 9 19 Home health patients without improved mobility 20% AL, MS 26 MI, OH, WI 22 MD 24 MA 24 KS, MO, ND 21 U 20 Nursing home residents with an antipsychotic medication 7% HI 13 MI, WI 11 DC, NJ 15 NH 14 MN 13 W 21 Adults with any mental illness reporting unmet need 16% HI 18 WI 20 NJ, NY 17 ME, RI 17 NE 21 MT, U 22 Adults with any mental illness who did not receive treatment 42% ME 53 MI, OH, WI 48 DE 42 ME 43 MN 54 21.7 VT 62.1 93.3 MD 21.7 VT 42.0 NE 44.3 M CO Avoidable Hospital Use and Cost 23 Hospital admissions for pediatric asthma WI Potentially avoidable emergency department visits 24 Ages 18–64, per 1,000 employer-insured enrollees 115.9 UT 141.9 MI 122.4 NY 125.6 MA 125.9 SD 115.9 U 25 Age 65 and older, per 1,000 Medicare beneficiaries 138.3 HI 193.8 WI 178.8 NY 173.5 VT 155.1 SD 151.4 U Admissions for ambulatory care–sensitive conditions 26 Ages 18–64, per 1,000 employer-insured enrollees 5.6 WA 6.7 WI 6.2 NY 6.1 MA 6.2 MN 5.8 C 27 Ages 65 and older, per 1,000 Medicare beneficiaries 21.7 HI 36.6 WI 41.9 MD 34.8 VT 35.3 MN 23.3 U U 30-day hospital readmissions 28 Ages 18–64, per 1,000 employer-insured enrollees 2.4 UT 3.2 OH 3.0 MD 2.7 ME 3.0 ND 2.4 29 Age 65 and older, per 1,000 Medicare beneficiaries 19.7 HI 33.5 WI 36.6 DE 30.6 VT 30.7 SD 22.6 11% AK 17 WI 19 5% HI 11 WI 12 PA 8 14% AK, CA, ID, UT 16 IL 15 DC, MD 16 30 Skilled nursing facility patients with a hospital readmission DC, DE, MD, PA 16 31 Nursing home residents with a hospital admission 32 Home health patients with a hospital admission 33 Adults with inappropriate lower-back imaging 57.7% AL 67.8 IL 66.5 MD 66.8 34 Employer-sponsored insurance spending per enrollee $3,255 MS 4,904 IL 3,819 MD 4,242 35 Medicare spending per beneficiary $6,195 HI 9,850 IL 9,205 DE ME, VT 13 U 15 ND, NE, SD ID RI 7 MN 9 CT, ME, VT 15 ND 14 RI 64.5 MO 68.9 M RI 3,851 IA 4,537 U 7,626 VT 8,120 SD 7,552 M U C ID Healthy Lives 36 Mortality amenable to health care 54.7 MN 69.4 WI 73.1 NJ 57.7 NH 54.7 MN 60.7 37 Breast cancer deaths 15.6 HI 17.4 WI 17.9 NY 16.3 NH 16.7 MN 16.5 38 Colorectal cancer deaths 9.3 CT 11.6 WI 12.2 NY 9.3 CT 10.2 ND 9.8 UT 39 Suicide deaths 6.6 DC 15.4 WI 6.6 DC 9.5 MA 13.8 MN 20.3 C 40 Alcohol deaths 5.5 MD 11.2 WI 5.5 MD 8.2 CT 7.9 MO 9.3 U 41 Drug poisoning deaths 8.1 NE 21.2 WI 19.4 NY 23.2 VT 8.1 NE 11.7 M 42 Infant mortality 3.5 VT 6.3 WI 4.0 NJ 3.5 VT 4.9 SD 4.8 C 43 Adults who report fair or poor health 9% DC 16 WI 9 DC 12 CT 11 MN 12 U 44 Adults who smoke 9% UT 16 WI 14 DC, MD, NJ, NY 13 CT 14 MN 9 U 45 Adults who are obese 23% CO, DC 33 WI 23 DC 26 MA 28 MN 23 C 46 Children who are overweight or obese 21% CT 26 WI 29 DE, PA 21 CT 22 ND 23 47 Adults who have lost six or more teeth 6% CA, DC, HI, UT 10 WI 6 DC 7 CT 7 MN, NE 6 commonwealthfund.org June 2019 W U 2019 Scorecard on State Health System Performance 29 APPENDIX National and Regional Performance Appendix A3. A3. National and Regional Performance Benchmarks Benchmarks (continued) nal t state(s)a Great Lakes Rate Indicator Best state(s)a Mid-Atlantic Best state(s)a Rate New England Best Rate state(s)a Plains National Rocky Mountain Great Lakes Southeast Mid-Atlantic Southwest New England West Plains Best Best Best Best Best Best a a a Rate Best state(s) state(s) RateRate state(s) Bestastate(s) Ratea Rate state(s)aBest state(s) Rate a BestRate state(s)astate(s) Rate Rate state(s)astate(s)a Rocky Moun B Rate sta Access and Affordability MA 1 7Uninsured MI,adults WI 5 DC 4 MA 4% 6 IA, MN MA 10 7 CO MI, WI 13 KY5 MA 2 3Uninsured IL, MI children 3 DE, NY 1 MA 1% 3 IA, MN MA 4 3 CO IL, MI 5 AL, LA,3WV RI 3 15Adults without MI a usual source15of care PA 12 RI 12% 17 IA RI MI 25 HI, IA, ND 4 11AdultsMI, who OH, went WI without care 10because MD, of PA cost 9 MA, VT 8% 8 DC 5 6 RI 5% 8 MI 6 4.8EmployeeMI insurance costs as 5.6a share ofDC median income 5.4 MA CT 7 12Adults without WI a dental visit 13 10 CT 8High out-of-pocket WI medical spending 5 DC NJ IA, HI,ND IA, ND 25 15 ID 11 11 MT MI, OH, WI CO, 8 ID, MT WI DC 13 NM 4 MA 5 HI6 IA, MN 10 C DE, NY 5 NM 1 MA 2 HI3 IA, MN 4 C KY 15 PA 25 OK12 RI 17 HI 17 IA 25 14 KY 10 MD, PA14 AZ, NM9 8 KY5 DC MNDC 12 4.8% 5.1 IA MI 5.0 4.8 UT MI 8.0 WV 5.6 10% 12 IA, MN CT 14 12 UT WI 17 VA 13 MA, VT 8 HI8 IA, ND 11 NM 6 RI 7 HI8 MN 12 DC 8.0 TX5.4 MA 5.1 WA 5.1 IA 5.0 U NJ 17 AZ 10 CT 12 HI 12 IA, MN 14 U 8 M CO, Prevention and Treatment CT 8 28Adults without WI all recommended 25 cancerDC screenings 24 CT 24% 29 MNCT 32 28 CO WI 35 NC 25 DC 35 AZ 24 CT 26 HI 29 MN 32 C SD 9 61Adults without OH all recommended 55 vaccines MD 55 RI 54% 54 SDSD 57 61 CO OH 58 NC, VA, 55 WV MD 58 OK55 RI 57 WA 54 SD 57 C MN 10 10.1Diabetic adults MI without an annual 10.8 hemoglobin MD A1c test 9.2 ME 5.6 MNMN 10.3 10.1 MT MI 9.6 10.8 NC MD 9.6 TX9.2 ME 7.1 WA 5.6 MN 10.3 M HI 11 8Elderly patients WI who received8a high-risk NY,prescription PA drug 7 MA 5% 7 MN, SD HI WI 11 VA8 NY, PA11 NM 7 MA 5 HI7 MN, SD 9 M VT 12 45ChildrenIN, without OH a medical home 45 39 VT 39% 41 NEVT 49 45 CO IN, OH 54 NC 45 MD 54 OK39 VT 44 WA 41 NE 49 C CT 13 31Children IN,without MI, WI a medical and 21 dental preventive DC care visit18 CT 18% 24 IACT 22 31 CO IN, MI, WI 34 VA,21 WV DC 34 AZ 18 CT 28 WA 24 IA 22 C 14 4 RI 4% 4 NE NE, RI 15 MA 15% 19 NE, RI MD 5Children who IN did not receive needed 6 mental PA health care 9 8 8 MT 5 MT IN 9 WV6 PA 9 OK 4 RI 10 OR4 NE 8 M NEMA 24 21 CO WI 30 NC 22 DE 30 AZ 15 MA 24 WA 19 NE 24 C MA 15 21Children without WI all recommended 22 vaccines DE MA 16 13.3Hospital 30-day OH mortality 13.0 12.8 MA 12.8% 13.6 MNMA 13.8 13.3 CO OH 13.7 13.0 LA DE13.7 AZ,12.8 TX MA 13.4 13.6 CA MN 13.8 C WY 17 0.70Central line–associated IL blood 0.82stream infection NJ (CLABSI) 0.68 VT 0.64 0.36 IAWY 0.36 0.70 WY IL 0.76 0.82 VA NJ 0.76 AZ 0.68 VT 0.53 0.64 HI IA 0.36 W ID 18 18Hospitals WI with lower-than-average 33 patient DE experience ratings 15 NH 9% 14 KSID 9 18 ID WI 33 LA 33 DE 33 TX 15 NH 21 OR 14 KS 9 19 26HomeMI, health OH, WI patients without 22improvedMD mobility AL, MS DE 24 MA 21 26 UT MI, OH, WI 24 AL,22 MS MD 24 OK24 MA 26 WA 24 KS, MO, ND 21 U HI 20 13Nursing MI, home WI residents with11 an antipsychotic DC, NJ medication15 NH 7% 14 MNHI 13 13 WY 14 NC 11 DC, NJ 14 AZ 15 NH 7 HI 14 MN 13 W HI 21 18Adults with WIany mental illness20 reporting NJ,unmet NY need ME, RI 16% 17 NEHI 21 18 MT, UT, WY WI 17 AL 20 NJ, NY 17 TX 17 ME, RI 16 HI 17 NE 21 MT, U ME 22 53AdultsMI, with OH, any WImental illness48 who did not DEreceive treatment 42 ME 42% 43 MNME 54 53CO, MTMI, OH, WI 55 KY,48 NC DE 55 OK42 ME 54 WA 43 MN 54 21.7 VT 42.0 21.7 NEVT 44.3 62.1 MT WI 67.6 93.3 TN MD67.6 TX 21.7 VT 46.3 42.0 OR NE 44.3 M UT 24141.9 Ages 18–64, per 1,000122.4 employer-insured MI NY enrollees 125.6 MA 125.9 115.9 SDUT 115.9141.9 UT MI 143.5 122.4 KY NY 143.5 125.6 NM MA 117.7 125.9 CA SD 115.9 U HI 25193.8 Age 65WI and older, per 1,000 178.8MedicareNY beneficiaries 173.5 VT 155.1 138.3 SDHI 151.4193.8 UT WI 191.0 178.8 SC NY 191.0 173.5 AZ VT 138.3 155.1 HI SD 151.4 U 17 20% 24 KS, MO, AL,ND MS MI, WI CO Avoidable Hospital Use and Cost VT 23 62.1Hospital admissions WI for pediatric 93.3 asthma MD Potentially avoidable emergency department visits Admissions for ambulatory care–sensitive conditions WA 26 6.7 Ages 18–64, per 1,000 employer-insured WI 6.2 NY enrollees 6.1 MA 6.2 5.6 MNWA 5.8 6.7 CO WI 6.4 NC 6.2 NY 6.4 AZ6.1 MA 5.6 WA 6.2 MN 5.8 C HI 27 36.6 Ages 65WIand older, per 1,000 41.9 Medicare MDbeneficiaries 34.8 VT 35.3 21.7 MNHI 23.3 36.6 UT WI 28.3 41.9 SC MD28.3 AZ 34.8 VT 21.7 35.3 HI MN 23.3 U UT 28 3.2 Ages 18–64, OH per 1,000 employer-insured 3.0 MD enrollees 2.7 ME 3.0 2.4 NDUT 2.4 3.2 UT OH 3.0 AL 3.0 MD 3.0 NM2.7 ME 2.7 WA 3.0 ND 2.4 U HI 29 33.5 Age 65WI and older, per 1,000 36.6MedicareDE beneficiaries 30.6 VT 30.7 19.7 SDHI 22.6 33.5 UT WI 28.6 36.6 SC DE28.6 NM 30.6 VT 19.7 30.7 HI SD 22.6 AK 30 17Skilled nursing WI facility patients 19withDC, a hospital DE, MD, readmission PA 16 13 17ID, UT WI 18 NM16 ME, VT 11 AK 15 ND, NE, SD HI 31 11Nursing home WI residents with12 a hospitalPA admission 9 11 CO WI 7 VA 12 14 16ID, UT IL 15 FL 15 DC, MD15 30-day hospital readmissions CA, ID, UT 32 16Home health IL patients with a 15 hospital admission DC, MD ME, VT 11% 15 ND, NE,AK SD 8 RI 5% 7 16 CT, ME, VT 14% 15 MNHI AK,ND CA, ID, UT NC, TN, 19 VADC, DE, MD,18 PA PA 7 AZ 8 RI 5 AZ, NM, OK, 16 TXCT, ME, VT 14 13 HI7 MN 9 AK,15 CA ND 14 U ID C ID AL 33 67.8Adults withILinappropriate lower-back 66.5 imaging MD 66.8 RI 57.7% 64.5 MOAL 68.9 67.8 MT IL 64.2 66.5 AL MD64.2 TX 66.8 RI 62.4 64.5 NV MO 68.9 M MS 344,904Employer-sponsored IL insurance 3,819 spending MDper enrollee4,242 RI $3,255 3,851 IAMS 4,5374,904 UT IL 4,624 3,819 MS MD 4,624 4,242 AZ RI 3,299 3,851 HI IA 4,537 U HI 359,850Medicare spending IL per beneficiary 9,205 SDHI 7,5529,850 MT IL 7,729 9,205 VA DE 7,729 7,626 NM VT 6,195 8,120 HI SD 7,552 M U DE 7,626 VT $6,195 8,120 Healthy Lives MN 36 69.4Mortality amenable WI to health 73.1 care NJ 57.7 NH 54.7 MNMN 60.7 69.4 UT WI 73.5 73.1 VA NJ 73.5 AZ 57.7 NH 62.4 54.7 WA MN 60.7 HI 37 17.4Breast cancer WI deaths 17.9 NY 16.3 NH 16.7 15.6 MNHI 16.5 17.4 WY WI 18.1 17.9 FL NY18.1 AZ 16.3 NH 15.6 16.7 HI MN 16.5 CT 38 11.6ColorectalWI cancer deaths 12.2 NY 9.3 CT 10.2 9.3 NDCT WI 12.2 12.2 NC NY12.2 AZ9.3 CT 11.2 10.2 HI ND 9.8 UT 9.8 11.6UT, WY W DC 39 15.4Suicide deaths WI 6.6 DC 9.5 MA 13.8 6.6 MNDC 20.3 15.4 CO WI 13.4 VA 6.6 DC13.4 TX9.5 MA 10.5 13.8 CA MN 20.3 C MD 40 11.2Alcohol deaths WI 5.5 MD 8.2 CT 7.9 5.5 MOMD 9.3 11.2 UT WI 7.9 MS 5.5 MD 7.9 TX8.2 CT 5.8 7.9 HI MO 9.3 U NE 41 21.2Drug poisoning WI deaths 19.4 NY 23.2 VT 8.1 NENE 11.7 21.2 MT WI 10.5 19.4 MS NY10.5 TX 23.2 VT 11.7 CA 8.1 NE 11.7 M VT 42 6.3Infant mortality WI 4.0 NJ 3.5 VT 4.9 3.5 SDVT 4.8 6.3 CO WI 5.3 VA 4.0 NJ 5.3 AZ3.5 VT 4.2 CA 4.9 SD 4.8 C DC 43 16Adults who WIreport fair or poor9health DC 12 CT 9% 11 MNDC 12 16 UT WI 18 VA9 DC 18 AZ 12 CT 13 HI 11 MN 12 U UT 44 16Adults who WIsmoke 14 DC, MD, NJ, NY 13 CT 9% 14 MNUT 9 16 UT WI 16 AZ, TX 13 CT 11 CA 14 MN 9 U 45 33Adults who WIare obese 23 DC 26 MA 23% 28 MN CO, DC 23 33 CO WI 30 FL 23 DC 30 NM26 MA 25 CA,28HI MN 23 C 21 CT 21% 22 NDCT 23 26 ID WI 24 AR 29 DE, PA24 AZ 21 CT 24 AK,22 OR ND 23 7 CT 6% 7 6 10 UT WI 7 VA6 TX 7 CT 6 CA, 7HI MN, NE 6 CO, DC CT DC, HI, UT 46 26Children who WI are overweight29 or obeseDE, PA 47 10Adults who WIhave lost six or more 6 teeth DC commonwealthfund.org CA, MN,DC, NEHI, UT FL,14 VA DC, MD, NJ,16 NY DC 7 June 2019 U 2019 Scorecard on State Health System Performance 30 Appendix Change in State Health System Performance by Indicator APPENDIX A4. A4. Change in State Health System Performance by Indicator Indicator (arranged by number of states with improvement within dimension) Number of states that: • Access and Affordability Improved • a • No Change b Worseneda 0 Uninsured adults Uninsured children Adults without a usual source of care Adults who went without care because of cost High out-of-pocket medical spending Employee insurance costs as a share of median income Adults without a dental visit 47 4 32 1 18 12 2 37 32 1 18 21 3 27 5 19 27 7 9 35 Prevention and Treatment Adults without all recommended cancer screenings 2 Adults without all recommended vaccines Diabetic adults without an annual hemoglobin A1c test Children without a medical home Children without a medical and dental preventive care visit Children who did not receive needed mental health care Children without all recommended vaccines Hospital 30-day mortality 1 Central line–associated blood stream infection (CLABSI) Home health patients without improved mobility Nursing home residents with an antipsychotic medication Adults with any mental illness reporting unmet need Adults with any mental illness who did not receive treatment 8 41 14 4 33 45 10 6 16 25 15 11 25 16 17 18 25 9 17 50 27 4 20 51 50 20 1 17 14 23 7 21 Avoidable Hospital Use and Cost Hospital admissions for pediatric asthma Potentially avoidable emergency department visits ages 18–64 Potentially avoidable emergency department visits age 65 and older Preventable hospitalizations ages 18–64 Preventable hospitalizations age 65 and older Hospital 30-day readmission rate ages 18–64 Hospital 30-day readmission rate age 65 and older Skilled nursing facility patients with a hospital readmission Nursing home residents with a hospital admission Home health patients with a hospital admission Adults with inappropriate lower-back imaging Employer-sponsored insurance spending per enrollee Medicare spending per beneficiary 28 23 44 4 7 16 31 49 2 11 40 2 24 25 6 45 19 32 17 34 11 9 31 21 30 1 12 38 21 30 Healthy Lives Mortality amenable to health care Breast cancer deaths 20 Colorectal cancer deaths Suicide deaths Alcohol deaths 21 Drug poisoning deaths 1 8 Infant mortality Adults who report fair or poor health 3 Adults who smoke 23 Adults who are obese 13 Children who are overweight or obese 8 Adults who have lost six or more teeth 1 50 5 26 39 12 17 34 17 34 29 8 35 18 30 32 19 28 12 26 42 1 Notes: Only Scorecard indicators with trends are shown. Trend data generally reflect the two- to three-year period ending in 2015 or 2016—refer to Appendix 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 between the baseline and current time periods of at least 0.5 standard deviations. (b) Includes the number of states with no change or Notes: Only Scorecard indicators with trends are shown. Trend data generally reflect the two- to three-year period ending in 2015 or 2016—refer to Appendix Exhibit A1 for additional detail without data forfor this to assess change over (trend datasufficient were not available all subpopulation indicators). For purposes of this analysis wetime. count District of Columbia as a state. (a) Improvement or worsening refers to a change between the baseline and current time periods of at least 0.5 standard deviations. (b) Includes the number of states with no change or without sufficient data for this subpopulation to assess change over time. commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance 31 APPENDIX Impact if All States Achieved Top top State Raterate Appendix A5. A5.National NationalCumulative cumulative impact if all states achieved state Indicator If all states improved their performance to the level of the best-performing state for this indicator, then: Insured adults 15,517,664 more adults (ages 19–64) would be covered by health insurance (public or private), and therefore would be more likely to receive health care when needed. Insured children 3,124,225 more children (ages 0–18) would be covered by health insurance (public or private), and therefore would be more likely to receive health care when needed. Went without care because of cost 14,951,586 fewer adults (age 18 and older) would go without needed health care because of cost. High out-of-pocket medical spending 13,603,821 fewer individuals would be burdened by high out-of-pocket spending on medical care. Adult usual source of care 27,411,240 more adults (age 18 and older) would have a usual source of care to help ensure that care is coordinated and accessible when needed. Adult cancer screening 11,714,671 more adults would receive age- and gender-appropriate recommended cancer screenings, including tests for colon, breast, and cervical cancers. Adult vaccines 19,935,447 more adults would receive age- appropriate recommended vaccines. Children with a medical home 8,875,559 Children vaccines 808,883 Children with preventive medical and dental visits 10,354,819 Medicare received a high-risk drug 210,760 Preventable hospital admissions among children 48,446 Hospital readmissions 296,928 Potentially avoidable emergency department visits 6,767,282 Mortality amenable to health care 90,162 Breast cancer deaths 7,083 Colon cancer deaths 11,634 fewer individuals would die from colon cancer. Suicides 23,914 fewer individuals would take their own lives. Adults who smoke 17,443,517 fewer adults would smoke, reducing their risk of lung and heart disease. Adults who are obese 15,849,074 fewer adults would be obese, with body weights that increase their risk for disease and long-term complications. Children who are overweight or obese 3,379,093 fewer children (ages 10–17) would be overweight or obese, thus reducing the potential for poor health as they transition into adulthood. commonwealthfund.org more children (ages 0–17) would have a medical home to help ensure that care is coordinated and accessible when needed. more children (ages 19–35 months) would receive all recommended vaccines. more children (ages 0–17) would receive annual preventive medical and dental care visits each year. fewer Medicare beneficiaries would receive an inappropriately prescribed medication. fewer children (ages 2–17) would be hospitalized for asthma exacerbations. fewer employer-insured adults and elderly Medicare beneficiaries would experience a hospital readmission within 30 days of discharge. fewer employer-insured adults and elderly Medicare beneficiaries would seek care in emergency departments for nonemergent or primary-care-treatable conditions. fewer premature deaths (before age 75) might occur from causes that are potentially treatable or preventable with timely and appropriate health care. fewer women would die from breast cancer. June 2019 2019 Scorecard on State Health System Performance 32 APPENDIX B0. State Scorecard Summary of Health System Performance Across Dimensions 1 2 3 4 5 5 7 8 9 10 11 12 12 14 14 16 17 18 18 20 21 22 23 23 25 26 27 28 29 30 30 32 33 34 35 36 37 38 38 40 41 42 43 44 45 45 47 48 49 50 51 Hawaii Massachusetts Minnesota Washington Connecticut Vermont Rhode Island Iowa Colorado New Hampshire Utah Maine Wisconsin California New York North Dakota Oregon Idaho Maryland New Jersey Pennsylvania Nebraska District of Columbia South Dakota Michigan Montana Delaware Illinois Virginia Alaska Kansas Arizona Ohio North Carolina New Mexico Indiana Wyoming Alabama Tennessee Kentucky South Carolina Georgia Missouri Florida Louisiana West Virginia Arkansas Nevada Texas Oklahoma Mississippi commonwealthfund.org Ac Baseline Ranking Ac Current Ranking ce Af ss fo an rd d ab ili Pr ty ev e T r nt ea io tm n a en nd Av t oi d Co ab st le Us ea He nd al th yL iv es Di sp ar ity Top quartile Second quartile Third quartile Appendix State Scorecard Summary of Health System Performance Across Dimensions BottomB0. quartile Data not available ce Af ss fo an rd d ab ili Pr ty ev Tr ent ea io tm n a en nd Av t oi Co dab st le Us ea He nd al th yL iv es Di sp ar ity Overall performance 1 1 1 1 1 1 1 1 1 3 1 2 1 1 1 1 1 3 2 1 1 1 2 4 1 1 2 3 1 5 1 2 2 1 1 5 1 1 2 3 1 7 1 2 2 2 1 8 3 1 1 1 1 9 1 1 3 2 1 10 3 1 2 1 3 11 2 3 1 2 1 12 1 2 3 2 1 12 2 1 1 2 3 14 2 1 1 3 3 14 2 2 2 1 2 16 2 2 2 1 4 17 3 2 1 1 3 18 2 2 3 2 1 19 2 1 2 3 2 20 1 3 1 3 2 20 3 1 3 2 2 22 1 3 2 4 2 23 3 2 3 2 2 24 1 3 3 4 2 25 3 3 2 1 3 26 2 3 3 3 2 26 2 3 3 4 3 28 3 2 4 2 2 29 4 3 2 1 3 30 2 3 4 3 3 30 4 2 2 1 4 30 2 4 4 4 2 33 4 3 4 2 2 34 4 4 1 2 4 35 3 4 4 3 3 35 4 2 3 2 4 37 3 4 3 3 3 38 3 4 4 3 3 39 2 4 4 4 2 40 4 4 4 2 4 41 4 3 4 3 4 42 3 3 4 4 3 43 4 3 3 4 4 44 4 4 1 4 4 45 3 4 3 4 3 46 3 4 4 3 4 47 4 4 2 3 4 48 4 2 4 4 4 49 4 4 4 4 4 50 4 4 3 4 4 51 Hawaii Massachusetts Minnesota Vermont New Hampshire Utah Iowa Connecticut Maine Delaware Maryland Colorado Wisconsin North Dakota Washington Rhode Island Nebraska South Dakota Pennsylvania Idaho Virginia New Jersey Oregon New York Montana California Wyoming Illinois Michigan District of Columbia Kansas New Mexico Ohio North Carolina Alaska Arizona Alabama South Carolina Georgia Indiana Missouri Tennessee Texas Kentucky Florida West Virginia Nevada Arkansas Oklahoma Louisiana Mississippi 1 1 1 1 1 1 1 1 3 1 1 1 1 1 1 1 1 2 1 3 1 1 2 3 2 3 1 1 2 2 1 2 2 2 2 1 2 2 1 1 2 1 3 1 2 1 1 3 2 1 1 1 1 1 2 3 2 2 2 1 1 2 2 2 1 2 1 3 1 4 2 1 1 4 3 2 3 1 2 2 2 2 3 1 4 2 2 2 1 3 1 2 3 3 1 3 2 2 3 2 2 3 2 3 1 2 1 2 1 3 3 3 3 4 2 2 3 1 2 1 4 3 3 3 2 3 2 1 1 3 3 3 1 2 1 2 2 2 4 3 2 2 4 2 1 1 3 2 2 4 2 2 4 3 3 4 3 3 2 4 2 4 3 4 3 3 3 4 2 2 4 4 1 1 3 4 4 4 4 4 3 3 1 2 3 3 4 3 3 3 4 4 4 3 2 3 4 4 4 2 3 4 4 2 2 4 3 4 3 3 4 4 4 4 4 3 3 3 4 4 4 4 3 4 4 3 4 4 4 3 4 4 4 3 4 4 3 2 3 4 4 2 3 4 4 4 4 4 4 4 4 4 4 4 4 June 2019 2019 Scorecard on State Health System Performance 33 APPENDIX of State Rankings in Current and Previous Scorecards AppendixB1. B1.Summary Summary of State Rankings in Current and Previous Scorecards 2019 Scorecard rankings State Overall ranking Access and Affordability Prevention and Treatment Avoidable Use and Cost Healthy Lives Disparity Overall ranking in the baseline time perioda Alabama 38 35 30 34 46 36 37 Alaska 30 39 38 8 36 14 35 Arizona 32 44 41 10 20 16 35 Arkansas 47 37 47 38 45 50 48 California 14 22 35 14 5 4 26 Colorado 9 31 10 5 10 11 12 Connecticut 5 6 9 27 1 22 8 Delaware 27 20 13 28 35 28 10 District of Columbia 23 8 21 44 28 23 30 Florida 44 47 44 49 31 32 45 Georgia 42 46 40 32 37 43 39 Hawaii Hawaii 1 2 5 1 3 1 1 Idaho Idaho 18 35 33 3 17 8 20 Illinois Illinois 28 18 31 40 29 29 28 Indiana Indiana 36 27 34 36 41 43 40 Iowa Iowa 8 5 2 13 22 19 7 Kansas Kansas 30 23 29 35 27 40 30 Kentucky Kentucky 40 23 20 48 49 40 44 Louisiana Louisiana 45 43 48 47 47 9 50 Maine Maine 12 14 7 16 30 12 9 Maryland Maryland 18 14 11 20 25 35 11 Massachusetts Massachusetts 2 1 1 31 4 7 2 Michigan Michigan 25 10 17 41 32 26 29 Minnesota Minnesota 3 9 3 11 2 5 3 Mississippi Mississippi 51 45 46 50 50 34 51 Missouri Missouri 43 33 37 45 38 51 41 Montana Montana 26 32 36 7 26 25 25 Nebraska Nebraska 22 29 14 21 12 31 17 Nevada Nevada 48 50 51 38 39 24 47 New Hampshire New Hampshire 10 4 8 18 9 38 5 New Jersey New Jersey 20 19 22 30 12 21 22 New Mexico New Mexico 35 40 49 16 42 3 30 New York New York 14 17 26 36 7 2 24 North Carolina North Carolina 34 42 15 24 33 46 34 North Dakota North Dakota 16 21 24 9 16 19 14 Ohio Ohio 33 16 25 42 43 42 33 Oklahoma Oklahoma 50 49 42 46 48 45 49 Oregon Oregon 17 23 39 6 14 17 23 PennsylvaniaPennsylvania 21 12 19 33 34 9 19 Rhode IslandRhode Island 7 3 5 26 11 13 16 South Carolina South Carolina 41 41 42 25 40 47 38 South Dakota South Dakota 23 28 16 15 20 32 18 Tennessee Tennessee 38 38 27 29 44 39 42 Texas Texas 49 51 45 42 23 48 43 Utah Utah 11 34 31 2 5 15 5 Vermont Vermont 5 7 4 12 14 17 4 Virginia Virginia 29 30 23 22 19 49 20 Washington Washington 4 13 18 3 8 6 14 West VirginiaWest Virginia 45 26 27 51 51 30 46 Wisconsin Wisconsin 12 11 11 23 18 27 12 Wyoming Wyoming 37 48 50 18 23 37 26 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 as reported in our 2017 State Scorecard and should not be compared to the 2017 ranking because of changes in the underlying set of performance indicators evaluated in the two reports. Notes: (a) The baseline period generally reflects two to three years prior to the time of observation for the latest year of data available. This is not the same ranking as reported in our 2017 State Scorecard and should not be compared to the 2017 ranking because of changes in the underlying set of performance indicators evaluated in the two reports. commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance 34 APPENDIX B2. Summary of Indicator Rankings by Stateby State Appendix Exhibit B2. Summary of Indicator Rankings Overall ranking State No. of indicators scored (of 47) Top 5 states Top quartile 2nd quartile 3rd quartile No. of indicators Bottom Bottom 5 with trend quartile states (of 45) No. of No. of indicators indicators improved worsened 38 Alabama 46 5 8 7 9 22 11 44 30 Alaska 46 9 11 11 9 15 10 41 32 Arizona 47 3 8 16 12 11 3 45 47 Arkansas 47 2 4 8 11 24 11 45 14 California 47 10 17 10 12 8 2 45 9 Colorado 47 9 20 16 7 4 0 45 5 Connecticut 47 12 23 10 9 5 0 45 27 Delaware 46 3 10 16 13 7 2 44 23 District of Columbia 39 12 14 7 5 13 8 35 44 Florida 47 1 4 8 13 22 9 45 42 Georgia 47 1 5 7 18 17 5 45 1 Hawaii 47 25 29 12 4 2 2 43 18 Idaho 46 8 15 10 10 11 4 44 28 Illinois 47 1 7 13 20 7 2 45 36 Indiana 47 1 5 11 19 12 2 45 8 Iowa 47 10 22 19 3 3 3 45 30 Kansas 47 1 3 21 17 6 2 45 40 Kentucky 47 1 5 15 6 21 14 45 45 Louisiana 46 2 4 11 8 23 18 44 12 Maine 46 6 12 21 8 5 0 44 18 Maryland 46 7 19 10 13 4 2 45 2 Massachusetts 47 17 29 7 6 5 2 45 25 Michigan 47 3 8 17 17 5 2 45 3 Minnesota 47 13 28 11 6 2 0 45 51 Mississippi 46 3 7 1 9 29 23 44 43 Missouri 47 0 4 8 24 11 5 45 26 Montana 47 4 15 16 7 9 6 45 22 Nebraska 47 10 15 15 10 7 5 45 48 Nevada 46 1 4 6 12 24 14 44 10 New Hampshire 46 11 22 15 4 5 3 44 20 New Jersey 47 7 12 17 11 7 3 45 35 New Mexico 47 2 6 8 19 14 11 44 14 New York 47 8 15 16 10 6 3 45 34 North Carolina 47 2 9 13 16 9 1 45 16 North Dakota 47 7 17 14 9 7 1 43 33 Ohio 47 0 5 17 11 14 1 45 50 Oklahoma 47 1 2 10 7 28 18 45 17 Oregon 47 8 16 15 8 8 4 45 21 Pennsylvania 47 4 12 12 18 5 3 44 7 Rhode Island 45 15 21 12 5 7 2 43 41 South Carolina 40 0 2 9 18 11 3 38 23 South Dakota 47 7 15 12 16 4 2 45 38 Tennessee 46 4 6 8 15 17 4 44 49 Texas 47 4 8 5 13 21 12 45 11 Utah 46 15 19 11 11 5 3 44 5 Vermont 46 10 23 13 8 2 1 44 29 Virginia 47 1 8 23 11 5 1 45 4 Washington 47 9 26 12 5 4 1 45 45 West Virginia 47 2 6 8 10 23 14 45 12 Wisconsin 46 5 16 18 8 4 2 44 37 Wyoming 46 5 11 8 12 15 11 44 Notes: Improvement or worsening refers to a change between the baseline and current time periods of at least 0.5 standard deviations. 14 15 15 18 14 15 18 11 17 13 11 11 13 16 15 14 16 18 18 15 17 9 17 15 16 19 14 11 11 10 16 10 18 13 13 13 13 14 16 21 9 16 17 14 10 13 14 19 19 15 13 7 11 8 9 5 8 6 13 4 6 8 12 7 7 9 9 11 9 7 9 12 8 3 5 10 11 10 10 8 10 8 16 10 10 11 6 10 9 7 7 9 11 7 6 7 9 10 5 13 8 14 Net change 7 4 7 9 9 7 12 -2 13 7 3 -1 6 9 6 5 5 9 11 6 5 1 14 10 6 8 4 1 3 0 8 -6 8 3 2 7 3 5 9 14 0 5 10 8 3 4 4 14 6 7 -1 Notes: Improvement or worsening refers to a change between the baseline and current time periods of at least 0.5 standard deviations. commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance 35 APPENDIX C1. Access & Affordability: Dimension and Indicator Ranking 1 2 3 4 5 6 7 8 9 10 11 12 13 14 14 16 17 18 19 20 21 22 23 23 23 26 27 28 29 30 31 32 33 34 35 35 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 Massachusetts Hawaii Rhode Island New Hampshire Iowa Connecticut Vermont District of Columbia Minnesota Michigan Wisconsin Pennsylvania Washington Maine Maryland Ohio New York Illinois New Jersey Delaware North Dakota California Kansas Kentucky Oregon West Virginia Indiana South Dakota Nebraska Virginia Colorado Montana Missouri Utah Alabama Idaho Arkansas Tennessee Alaska New Mexico South Carolina North Carolina Louisiana Arizona Mississippi Georgia Florida Wyoming Oklahoma Nevada Texas commonwealthfund.org 1 1 1 1 1 1 1 1 1 1 1 1 2 3 1 1 1 2 2 1 2 2 3 1 2 2 2 3 3 3 2 3 3 3 4 4 3 3 4 3 4 4 3 3 4 4 4 4 4 4 4 1 1 1 1 1 1 0 0 1 1 2 3 1 2 2 2 1 1 2 1 4 1 3 2 1 1 3 3 3 3 2 3 3 4 1 3 3 2 4 3 3 3 1 4 3 4 4 4 4 4 4 ta us ul ua be ts w ls ca h ou us o w rc eo e eo nt Hi f f co w gh i st th sp o u o ut en t-o ca di f-p ng o re ck Em e tm p sh loy ed e ar e ic e o in al f m su Ad r ed an ul ia ce ts n co w in ith co sts ou m as e ta a de nt al vi si t ou 1 1 1 1 1 1 1 4 3 1 2 1 3 1 1 2 1 2 2 2 4 3 2 2 3 2 2 3 2 3 4 4 3 4 2 3 2 3 4 4 3 2 2 4 3 4 4 4 3 4 4 Ad Ad u ca lts w re it h ch ur ed Un in s Un in s ur ed ad u lts Top quartile Second quartile Third quartile Bottom quartile Data not available ild re n Appendix C1. Access & Affordability: Dimension and Indicator Ranking Overall performance 1 1 2 1 1 1 1 1 1 1 1 1 1 2 1 1 2 2 3 3 1 2 2 2 3 3 3 1 2 3 3 1 3 3 4 3 4 3 2 3 3 4 4 3 4 4 4 3 4 4 4 1 1 1 2 2 2 2 1 1 2 1 1 1 2 2 2 1 2 1 2 2 1 2 2 3 2 2 3 4 2 4 4 3 4 4 4 4 4 1 1 4 4 3 4 3 2 3 4 3 2 3 1 1 3 1 1 2 2 1 1 1 2 3 1 2 2 2 3 1 2 4 1 3 2 3 3 3 2 3 2 3 1 2 2 1 3 2 3 3 3 4 4 4 4 4 4 4 4 3 4 4 4 1 1 1 1 1 1 1 2 1 2 1 2 2 1 2 2 2 3 1 2 2 3 2 4 2 3 3 1 2 2 3 2 3 2 3 3 3 4 2 4 4 2 4 3 4 3 3 2 4 4 4 June 2019 2019 Scorecard on State Health System Performance 36 APPENDIX Access & Affordability: Dimension Ranking Ranking and Indicator AppendixC2. C2. Access & Affordability: Dimension andRates Indicator Rates Adults ages 19–64 uninsured United States Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 2013 20% 20 24 24 24 24 19 13 14 8 29 26 10 23 18 19 12 18 21 25 16 14 5 16 11 25 18 23 15 27 16 19 28 15 23 14 16 25 21 14 17 23 17 20 30 18 10 17 20 20 13 18 2017 12% * 15 18 14 12 10 10 8 8 5 19 19 5 16 10 11 6 12 7 12 12 8 4 7 6 18 13 13 12 15 8 11 13 8 16 9 8 20 10 7 6 16 13 14 24 12 6 12 9 9 7 16 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Children ages 0–18 uninsured 2013 8% 5 12 13 6 8 9 4 5 3 12 10 3 9 5 9 5 7 6 6 5 5 2 5 6 8 7 11 6 14 4 6 9 4 6 8 5 11 7 5 6 7 7 6 13 9 -6 7 5 5 7 2017 5% * 3 10 8 5 3 4 3 3 -7 7 2 5 3 6 3 5 4 3 4 4 1 3 3 5 5 6 6 8 3 4 5 3 5 7 4 8 3 5 2 5 6 4 11 7 -5 3 3 4 10 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Adults age 18 and older who went without care because Adults without a usual source of care of cost in past year 2013 24% 2017 23% 2013 16% 22 33 32 23 29 24 15 14 24 27 28 15 28 20 20 19 22 22 26 13 21 12 17 27 23 21 30 21 35 12 19 31 19 27 27 19 26 26 14 16 24 24 23 33 28 13 24 28 23 19 31 21 31 27 20 24 26 15 18 26 28 28 17 25 18 19 17 22 18 22 13 17 14 15 25 24 24 29 20 34 13 21 29 17 21 29 19 25 23 15 12 23 24 23 32 29 13 23 24 19 18 32 16 14 17 21 16 15 12 12 11 21 20 9 16 14 16 10 14 19 20 10 13 9 15 10 22 16 14 13 17 12 15 18 15 18 7 15 17 18 12 14 19 10 18 19 15 9 15 15 18 12 14 Change States Improved 47 32 12 States Worsened 0 1 2 Notes: * Denotes a change of at least 0.5 standard deviations. — Indicates that estimates are not available. * * * * * * * * * * * * * * 2017 14% * 17 12 14 16 12 13 10 13 11 16 17 8 14 12 13 8 12 12 17 12 10 9 11 10 18 14 11 12 17 10 14 14 12 16 8 11 17 13 10 12 15 10 15 20 14 9 14 11 15 11 15 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 32 1 High out-of-pocket medical spending 2013-14 2016-17 11% 10% 13 14 12 16 9 10 10 9 8 11 11 8 17 9 12 12 10 12 13 11 7 7 11 9 15 12 15 12 13 9 9 10 8 14 12 10 12 15 9 9 11 14 17 12 14 9 9 10 12 12 13 12 8 12 13 8 12 9 9 5 11 10 7 12 9 10 10 10 9 11 9 9 8 10 8 11 11 12 13 10 9 8 8 7 14 10 9 11 11 8 6 12 11 12 11 13 10 10 8 10 8 15 201 6.5 * * * * * * * * * * * * * * * * * * * * * * * * 21 3 Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. — Indicates that estimates are not available. commonwealthfund.org Emplo costs med June 2019 6 5 8 7 7 5 5 7 6 9 7 4 5 6 6 5 6 7 8 6 5 5 5 4 8 6 5 6 8 4 5 7 6 7 4 5 7 6 5 5 7 6 7 7 4 5 5 5 5 5 4 2019 Scorecard on State Health System Performance 37 APPENDIX Access & Affordability: Dimension Ranking Ranking and Indicator (continued) d Indicator Appendix RatesC2. C2. Access & Affordability: Dimension andRates Indicator Rates Adults age 18 and older who went out a without care because of care of cost in past year High Adults out-of-pocket ages 19–64 medical uninsured spending 2017 23% 2013-14 2013 2016-17 2017 20% 11% 12% 10% * . 21 31 27 20 24 26 15 18 26 28 28 17 25 18 19 17 22 18 22 13 17 14 15 25 24 24 29 20 34 13 21 29 17 21 29 19 25 23 15 12 23 24 23 32 29 13 23 24 19 18 32 12 2 2013 2017 United 16%States 14% * * * * * * * * * * * * * * * Alabama 16 17 Alaska 14 12 Arizona17 14 Arkansas 21 16 California 16 12 Colorado 15 13 Connecticut 12 10 Delaware 12 13 District 11 of Columbia 11 Florida 21 16 Georgia20 17 Hawaii 9 8 Idaho 16 14 Illinois 14 12 Indiana16 13 Iowa 10 8 Kansas14 12 Kentucky 19 12 Louisiana 20 17 Maine 10 12 Maryland 13 10 Massachusetts 9 9 Michigan 15 11 Minnesota 10 10 Mississippi 22 18 Missouri16 14 Montana 14 11 Nebraska 13 12 Nevada17 17 New Hampshire 12 10 New Jersey 15 14 New Mexico 18 14 New York 15 12 North Carolina 18 16 North Dakota 7 8 Ohio 15 11 Oklahoma 17 17 Oregon18 13 Pennsylvania 12 10 Rhode Island 14 12 South Carolina 19 15 South Dakota 10 10 Tennessee 18 15 Texas 19 20 Utah 15 14 Vermont9 9 Virginia15 14 Washington 15 11 West Virginia 18 15 Wisconsin 12 11 Wyoming 14 15 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 20 13 24 14 24 12 24 16 249 19 10 13 10 149 88 29 11 26 11 108 23 17 189 19 12 12 12 18 10 21 12 25 13 16 11 147 57 16 11 119 25 15 18 12 23 15 15 12 27 13 169 199 28 10 158 23 14 14 12 16 10 25 12 21 15 149 179 23 11 17 14 20 17 30 12 18 14 109 179 20 10 20 12 13 12 18 13 15 12 * 188 ** 14 12 * 12 13 ** 108 * 10 12 ** 89 * 89 * 55 * 19 11 * 19 10 * 57 * 16 12 ** 109 * 11 10 ** 10 6 ** 12 10 * 79 ** 12 11 ** 129 ** 89 ** 48 10 7 * 68 * 18 11 ** 13 11 * 13 12 ** 12 13 15 10 ** 89 * 118 * 138 ** 87 * 16 14 * 10 9 ** 89 * 20 11 * 10 11 ** 78 * 66 ** 16 12 * 13 11 ** 14 12 ** 24 11 * 12 13 * 10 6 * 12 10 * 98 ** 10 9 ** 78 ** 16 15 * Adults age 18 and Employee insurance older who went Children 0–18 Adults Adultswithout withoutaa without care because costs asages a share of median uninsured income usualdental source visit of care of cost in past year 2013 2013 6.5% 8% 2017 2017 6.9% 5% * 2013 2012 24% 15% 6.5 5 5.9 12 8.0 13 7.2 6 7.0 8 5.1 9 5.9 4 7.6 5 6.2 3 9.0 12 7.2 10 4.4 3 5.7 9 6.4 5 6.5 9 5.5 5 6.3 7 7.4 6 8.1 6 6.9 5 5.4 5 5.5 2 5.9 5 4.9 6 8.5 8 6.3 7 5.4 11 6.0 6 8.0 14 4.9 4 5.2 6 7.7 9 6.6 4 7.8 6 4.9 8 5.5 5 7.9 11 6.2 7 5.2 5 5.8 6 7.1 7 6.8 7 7.5 6 7.9 13 4.6 9 5.7 -5.7 6 5.0 7 5.0 5 5.0 5 4.9 7 6.9 3 * 7.2 10 ** 8.8 8 ** 7.5 5 7.2 3 * 5.6 4 * 5.9 3 8.5 3 ** 5.6 -- * 8.0 7 ** 8.0 7 ** 5.3 2 * 5.9 5 * 5.5 3 ** 6.0 6 * 5.1 3 * 6.0 5 * 7.3 4 * 10.2 3 ** 6.2 4 * 6.2 4 * 5.4 1 4.8 3 ** 5.4 3 * 8.6 5 * 6.3 5 * 6.1 6 ** 5.9 6 8.2 8 * 5.6 3 * 5.9 4 ** 9.3 5 ** 7.6 3 * 8.2 5 5.5 7 5.7 4 8.1 8 * 6.4 3 * 6.6 5 * 6.9 2 ** 7.7 5 ** 6.9 6 7.6 4 * 8.0 11 * 5.0 7 * 6.1 -6.9 5 * 5.1 3 * 6.4 3 ** 6.0 4 * 6.4 10 ** 22 18 33 14 32 17 23 19 29 16 24 16 15 11 14 12 24 16 27 18 28 16 15 15 28 13 20 15 20 15 19 12 22 13 22 16 26 20 13 13 21 13 12 11 17 14 27 11 23 19 21 15 30 17 21 15 35 20 12 10 19 15 31 18 19 15 27 15 27 15 19 14 26 18 26 15 14 13 16 12 24 18 24 11 23 17 33 18 28 16 13 11 24 12 28 14 23 18 19 12 31 15 2017 2016 23% 16% 21 16 * 31 15 27 17 * 20 16 ** 24 16 * 26 16 15 10 18 14 ** 26 14 * 28 17 28 17 17 12 * 25 16 ** 18 17 * 19 16 17 12 22 14 18 18 ** 22 20 * 13 13 17 15 ** 14 12 15 14 25 12 24 18 24 17 ** 29 15 * 20 14 34 19 13 11 21 13 * 29 19 17 15 21 15 * 29 14 19 15 25 18 23 14 * 15 15 * 12 11 * 23 18 24 13 * 23 18 32 19 29 14 * 13 12 23 14 * 24 15 * 19 17 * 18 12 32 15 Change States Improved 32 47 21 325 127 States Worsened 1 03 19 1 29 Notes: * Denotes a change of at least 0.5 standard deviations. — Indicates that estimates are not available. 2013 16% 16 14 17 21 16 15 12 12 11 21 20 9 16 14 16 10 14 19 20 10 13 9 15 10 22 16 14 13 17 12 15 18 15 18 7 15 17 18 12 14 19 10 18 19 15 9 15 15 18 12 14 2017 14% * 17 12 14 16 12 13 10 13 11 16 17 8 14 12 13 8 12 12 17 12 10 9 11 10 18 14 11 12 17 10 14 14 12 16 8 11 17 13 10 12 15 10 15 20 14 9 14 11 15 11 15 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 32 1 High out-of-pocket medical spending 2013-14 2016-17 11% 10% 13 14 12 16 9 10 10 9 8 11 11 8 17 9 12 12 10 12 13 11 7 7 11 9 15 12 15 12 13 9 9 10 8 14 12 10 12 15 9 9 11 14 17 12 14 9 9 10 12 12 13 12 8 12 13 8 12 9 9 5 11 10 7 12 9 10 10 10 9 11 9 9 8 10 8 11 11 12 13 10 9 8 8 7 14 10 9 11 11 8 6 12 11 12 11 13 10 10 8 10 8 15 201 6.5 * * * * * * * * * * * * * * * * * * * * * * * * 21 3 Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. — Indicates that estimates are not available. commonwealthfund.org Emplo costs med June 2019 6 5 8 7 7 5 5 7 6 9 7 4 5 6 6 5 6 7 8 6 5 5 5 4 8 6 5 6 8 4 5 7 6 7 4 5 7 6 5 5 7 6 7 7 4 5 5 5 5 5 4 2019 Scorecard on State Health System Performance 38 AppendixC3.C3. Uninsured Adults agesby19-64 byand Income and by Race/Ethnicity APPENDIX Uninsured Adults Ages 19–64 Income by Race/Ethnicity Low-Income (< 200% FPL) Total Population United States Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Race/Ethnicity (2017 only) 2013 20% 2016 12% 2017 12% 2013 38% 2016 23% 2017 23% Black 14% Hispanic 25% Other 10% White 8% 20 24 24 24 24 19 13 14 8 29 26 10 23 18 19 12 18 21 25 16 14 5 16 11 25 18 23 15 27 16 19 28 15 23 14 16 25 21 14 17 23 17 20 30 18 10 17 20 20 13 18 14 18 14 12 10 10 7 8 5 18 18 5 15 9 11 6 12 7 15 11 8 4 8 6 18 13 12 12 15 9 11 13 9 15 9 8 20 9 8 6 15 12 14 23 12 5 12 9 8 7 15 15 18 14 12 10 10 8 8 5 19 19 5 16 10 11 6 12 7 12 12 8 4 7 6 18 13 13 12 15 8 11 13 8 16 9 8 20 10 7 6 16 13 14 24 12 6 12 9 9 7 16 37 46 41 40 41 35 28 26 12 46 46 21 37 36 37 26 37 38 42 26 30 11 30 23 39 36 40 35 47 34 43 43 26 42 28 30 42 37 29 32 39 36 37 52 35 14 38 40 35 26 37 27 34 22 18 19 19 14 15 8 31 35 10 27 19 21 11 27 11 26 20 18 6 14 11 31 26 23 29 26 20 25 20 15 29 20 14 35 15 15 10 27 26 24 42 24 7 29 16 11 15 26 27 26 23 18 18 18 16 14 8 32 35 12 27 19 21 12 26 12 20 23 18 7 13 14 31 26 19 27 25 18 25 19 13 31 21 15 35 16 14 13 30 28 25 43 25 7 27 17 12 14 33 16 -10 10 8 11 9 7 5 21 19 --11 15 -15 9 13 -7 6 10 9 21 18 -14 13 -11 -9 16 -11 23 -9 -18 -15 20 --15 10 9 10 -- 45 -22 35 17 21 20 26 12 27 45 7 35 24 29 19 28 30 38 -32 7 18 25 39 25 -32 25 -26 15 16 44 -22 38 25 17 17 43 -43 37 33 -31 27 -20 34 14 31 14 18 6 9 8 8 -16 17 5 15 8 12 13 13 12 16 18 6 5 7 9 24 18 30 17 12 13 8 22 9 14 26 8 30 9 9 11 16 40 13 15 12 -10 7 -11 18 12 14 9 9 6 7 5 5 3 15 14 6 14 6 9 5 9 6 10 11 4 3 6 4 15 11 11 9 10 8 6 8 5 12 7 7 15 8 6 4 13 9 12 14 8 6 9 6 9 5 14 Notes: — Indicates that estimates are not available. Notes: — Indicates that estimates are not available. commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance 39 AppendixC4.C4. Adults Who Went Care Without Care Because of Costs Income and APPENDIX Adults Agesages 18–6418-64 Who Went Without Because of Cost by Income and byby Race/Ethnicity   by Race/Eth Low-Income (< 200% FPL) Total Population United States Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Race/Ethnicity (2017 only) 2013 19% 2016 15% 2017 16% 2013 33% 2016 26% 2017 26% Black 19% Hispanic 22% Other 14% White 13% 19 16 20 25 18 17 14 14 12 26 23 10 19 16 18 12 16 22 23 12 15 10 18 12 25 19 16 15 20 14 18 21 17 21 8 17 20 22 14 17 23 11 21 22 17 11 18 18 22 14 17 19 14 16 18 13 14 11 13 10 21 19 8 17 13 15 9 14 14 20 13 12 10 14 11 22 16 14 14 19 12 14 14 13 19 9 13 18 13 13 12 19 10 14 20 13 10 15 12 17 12 17 19 13 17 20 14 15 12 15 11 21 19 9 16 14 15 9 14 14 20 15 12 10 13 11 21 16 13 14 20 11 16 16 13 18 9 13 20 15 12 14 18 12 17 22 15 10 16 13 18 12 17 37 26 37 39 29 33 24 26 17 41 39 18 34 31 36 24 34 39 40 16 30 19 29 24 38 36 30 31 32 34 33 32 28 40 19 28 38 41 27 29 38 23 33 39 33 18 34 35 38 23 33 38 31 25 26 21 23 17 23 21 35 35 18 32 20 27 18 30 21 37 22 24 16 20 18 37 33 22 30 29 23 25 20 18 37 17 21 33 20 22 21 32 18 25 36 24 13 38 19 22 20 27 32 13 21 28 21 24 21 22 12 31 33 18 29 22 26 16 31 19 28 19 25 15 19 18 33 30 21 28 34 21 24 19 20 35 21 17 32 25 18 22 30 30 23 40 26 11 33 19 22 26 37 21 -16 20 16 10 12 14 12 20 20 9 -15 18 18 23 11 23 -12 12 18 20 24 25 -23 13 -19 -14 21 19 17 25 13 15 14 20 -21 27 --19 17 16 12 -- 12 16 21 36 18 21 21 26 21 24 24 11 21 19 24 19 20 24 32 30 29 18 18 22 -20 11 21 29 11 27 19 20 30 21 19 24 17 15 24 26 22 18 27 21 11 26 21 -17 25 27 9 14 21 8 16 13 8 14 18 12 9 22 12 21 11 14 18 21 32 13 9 15 12 22 17 16 19 17 13 12 12 14 19 17 21 19 19 13 19 25 18 32 20 21 9 13 13 23 20 17 19 14 14 17 11 13 10 14 7 18 18 9 15 12 13 8 13 14 17 14 8 9 12 10 19 15 13 12 16 11 11 12 10 16 7 11 19 14 11 11 16 10 15 18 13 10 14 11 17 11 17 Notes: — Indicates that estimates are not available. Notes: — Indicates that estimates are not available. commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance 40 APPENDIX D1. Prevention & Treatment: Dimension and Indicator Ranking Appendix D1. Prevention & Treatment: Dimension and Indicator Ranking Top quartile Second quartile Third quartile Bottom quartile Data not available 1 2 3 4 5 5 7 8 9 10 11 11 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 27 29 30 31 31 33 34 35 36 37 38 39 40 41 42 42 44 45 46 47 48 49 50 51 Massachusetts Iowa Minnesota Vermont Hawaii Rhode Island Maine New Hampshire Connecticut Colorado Maryland Wisconsin Delaware Nebraska North Carolina South Dakota Michigan Washington Pennsylvania Kentucky District of Columbia New Jersey Virginia North Dakota Ohio New York Tennessee West Virginia Kansas Alabama Illinois Utah Idaho Indiana California Montana Missouri Alaska Oregon Georgia Arizona Oklahoma South Carolina Florida Texas Mississippi Arkansas Louisiana New Mexico Wyoming Nevada commonwealthfund.org Ad ul ca t s w nc i t er ho sc u t re a en ll r Ad in ec ul gs o m va ts w m cc i t en i n ho de es u ta d ll Di re ab c om an eti m nu c a en d al u de he l t s d m w El o g ith de lo o b i ut hi rl y n an gh p a A1 -ri tie ct sk n es t pr s w t es h Ch o cr ild i p re re t i o ce n n ive wi dr d th ug a ou t Ch am ild ed d e re ic al nt n w ho al it p r ho m ev ut e en a Ch m tiv ild e c ed i ne r e ar ca ed n w ev l a ed ho i s nd m d it i en d Ch t a no lh t ild ea rec re re lth ei co n w m it ca ve m ho re en u de t a Ho d ll sp va ita cc in l3 es 0da ym Ce or nt ta lit st ral y re l i n am e –a in s fe so ct c Ho io iat sp n ed i (C av ta LA blo er ls a B o w Overall performance 1 2 1 2 1 1 1 1 1 2 1 1 1 3 1 3 2 2 2 2 1 2 1 4 2 2 2 3 3 2 3 2 4 4 1 4 3 4 3 3 3 4 2 2 4 4 4 2 4 4 4 2 1 1 2 2 1 2 1 1 1 1 3 1 1 1 1 3 1 1 2 3 2 1 2 2 2 3 1 3 3 3 3 4 4 3 2 2 4 4 4 4 2 3 4 4 4 2 4 3 4 4 1 1 1 2 3 4 1 4 3 2 2 2 4 4 1 2 2 1 4 1 0 3 1 1 3 3 1 4 3 2 3 2 3 3 4 2 3 3 4 1 2 2 0 4 1 1 3 4 3 4 4 1 1 1 1 1 1 2 2 2 3 2 1 2 1 3 1 2 2 1 4 3 2 3 1 3 1 4 4 2 4 2 3 3 3 2 2 3 2 3 4 3 4 4 3 4 4 4 4 3 2 3 1 1 2 1 2 3 1 1 1 2 1 4 4 1 1 2 3 1 4 2 2 3 2 1 1 3 2 2 2 2 2 2 4 1 4 3 2 3 2 4 4 4 3 4 4 3 4 3 4 3 4 1 1 3 2 2 1 1 1 1 1 1 2 1 3 3 3 2 2 1 2 1 1 1 4 4 2 2 1 3 4 4 3 3 2 3 3 4 4 2 2 3 4 3 4 4 3 4 2 4 3 4 2 1 2 1 2 1 2 3 1 3 3 0 3 1 3 1 2 3 1 3 2 4 4 1 3 3 0 1 3 2 2 4 2 1 3 1 2 2 2 4 4 1 4 4 4 4 4 4 3 3 0 1 2 2 1 2 1 2 1 1 1 2 1 1 1 1 3 3 1 2 2 3 3 4 3 3 2 4 4 1 1 2 2 2 3 4 4 4 3 4 1 3 4 3 4 3 3 3 4 3 4 2 1 4 1 3 2 1 3 2 1 2 1 3 1 4 3 3 1 4 1 3 1 1 2 3 1 1 3 2 4 3 1 3 4 3 1 4 2 3 4 3 2 3 3 2 2 4 4 2 2 4 3 1 1 3 1 1 4 3 3 4 1 4 2 4 2 4 2 2 1 3 2 3 2 1 2 2 4 2 3 2 4 1 2 1 4 3 1 3 3 1 4 1 2 4 3 3 3 4 4 4 1 3 June 2019 3 2 1 2 3 4 2 1 3 1 0 1 2 1 3 1 3 3 3 2 4 4 3 3 2 4 2 4 1 2 3 1 1 1 4 4 3 2 1 3 4 2 2 4 2 3 2 1 4 4 4 2019 Scorecard on State Health System Performance 41 APPENDIX D1. Prevention & Treatment: Dimension and Indicator Ranking (continued) ankingAppendix D1. Prevention & Treatment: Dimension and Indicator Ranking Ch am ild ed d e re ic al nt n w ho al it p r ho m ev ut e en a Ch tiv m ild e c ed i ne r e ar ca ed n w ev l a ed ho i s nd m d it en id Ch n ta o lh t ild ea rec re re lth ei co n w m it ca ve m ho re en u de t a Ho d ll sp va ita cc in l3 es 0da ym ACde or nut ta l lit csat trsalw y rne lin caem the r s o– ua icn st rfe sao ecnt llcri AHdo iion eat uslp ng ceod s(C mb vaav tistaw L A mlo eccr lis t a BS eond w i h n g ra e oit I) d e tin sp uht d a l a o t DHio gs ien lwl re amb t e erc-t xp ohma aimn ethi er nmnpur cea ie en l d oalv tuh nc d hede ltpsa e ed mm w t i ENlu oog ietnh bloi tos dre s lbit uw hani rilnyg iyn tiat gthi pha A1 nho p-rs otim c t ut iysc ene es khp trs t ort ews eisc ihd CAhd o cmr en iuldl ipe rets re trsew dti cew p o ni ocna ivi tdio tehd rt wthit in ahn run aan o g u yu g ta nm m CAhd em iuldl et ntea ne dl il dweh trsew ed clanl not niwt ehs adli hita osm dp hno rneo yu e vte m ta Ch nret em ild cive ntea eivc dl i ne r e eat cllan ed n w rree le ed ho vait asns smi d m d te i en d nt Ch t a no lh t ild r ea ec re re lth ei co n w m it ca ve m ho re en u de t a Ho d ll sp va ita cc in l3 es 0da ym Ce or Cen ta t lit st ntrral y a r l St ea l Lin re m ine– amin e-as Infec asssooc Ho fe tio cia ct n iatte sp io (C e d av ita n L db er ls (C A Bllo a L B oo w Overall performance Top quartile Second quartile Third quartile Bottom quartile Data not available 1 1 3 2 2 1 1 1 1 1 1 2 1 3 3 3 2 2 1 2 1 1 1 4 4 2 2 1 3 4 4 3 3 2 3 3 4 4 2 2 3 4 3 4 4 3 4 2 4 3 4 21 12 23 14 25 15 27 38 19 3 10 3 11 0 11 3 13 1 14 3 15 1 16 2 17 3 18 1 19 3 20 2 21 4 22 4 23 1 24 3 25 3 26 0 27 1 27 3 29 2 30 2 31 4 31 2 33 1 34 3 35 1 36 2 37 2 38 2 39 4 40 4 41 1 42 4 42 4 44 4 45 4 46 4 47 4 48 3 49 3 50 0 51 1 1 Massachusetts 2 Iowa 4 2 Minnesota 1 1 Vermont 3 2 Hawaii2 1 Rhode Island 1 2 Maine 3 New1Hampshire 2 1 1 Connecticut 1 Colorado 2 2 Maryland 1 1 Wisconsin 3 1 Delaware 1 1 Nebraska 4 1 North Carolina 3 3 South Dakota 3 3 Michigan 1 1Washington 4 2 1 Pennsylvania 2 Kentucky 3 District 3of Columbia 1 3New Jersey 1 4 Virginia 2 3 North Dakota 3 3 Ohio 1 2 New York 1 4Tennessee 3 4 West Virginia 2 1 Kansas 4 1 Alabama 3 2 Illinois 1 2 Utah 3 2 Idaho 4 3 Indiana 3 4 California 1 4 Montana 4 4 Missouri2 3 Alaska 3 4 Oregon 4 1 Georgia 3 3 Arizona 2 4 Oklahoma 3 3 South Carolina 3 4 Florida 2 3 Texas 2 3 Mississippi4 3 Arkansas 4 4 Louisiana 2 3New Mexico 2 4 Wyoming 4 2 Nevada 3 commonwealthfund.org 1 12 31 12 1 41 31 31 41 12 41 21 41 23 41 23 2 12 32 2 31 2 1 24 2 42 2 3 23 42 13 2 14 4 31 14 3 34 13 43 13 24 42 32 34 34 4 42 4 14 34 32 21 1 2 32 41 2 1 31 1 01 13 21 1 31 1 3 31 31 2 43 42 31 32 2 42 23 41 13 23 3 13 14 14 43 42 32 24 14 34 4 2 23 4 24 34 2 14 43 4 4 21 21 41 42 43 24 31 24 43 2 12 32 34 24 21 32 32 31 24 1 20 23 31 21 3 3 1 14 23 12 3 12 13 3 34 42 23 43 4 1 32 2 10 14 41 1 13 24 3 4 4 41 21 1 31 1 31 42 2 32 23 12 1 12 41 13 31 12 2 31 4 13 12 23 31 3 1 34 24 42 4 42 3 43 23 12 2 43 12 23 4 13 4 14 23 34 4 24 34 3 12 3 1 1 32 1 12 13 1 41 21 32 31 14 24 1 41 2 23 41 34 2 42 23 42 1 21 23 2 32 2 12 32 2 4 41 24 23 42 13 42 24 24 24 23 14 14 43 4 23 34 23 4 1 1 13 12 42 1 1 1 21 21 31 2 1 3 13 23 2 2 21 12 41 31 21 4 24 32 32 1 3 4 24 3 3 2 43 23 14 4 2 42 43 24 43 4 4 3 34 42 34 3 4 2 1 2 1 2 1 2 3 1 3 3 0 3 1 3 1 2 3 1 3 2 4 4 1 3 3 0 1 3 2 2 4 2 1 3 1 2 2 2 4 4 1 4 4 4 4 4 4 3 3 0 1 2 2 1 2 1 2 1 1 1 2 1 1 1 1 3 3 1 2 2 3 3 4 3 3 2 4 4 1 1 2 2 2 3 4 4 4 3 4 1 3 4 3 4 3 3 3 4 3 4 2 1 4 1 3 2 1 3 2 1 2 1 3 1 4 3 3 1 4 1 3 1 1 2 3 1 1 3 2 4 3 1 3 4 3 1 4 2 3 4 3 2 3 3 2 2 4 4 2 2 4 3 1 1 3 1 1 4 3 3 4 1 4 2 4 2 4 2 2 1 3 2 3 2 1 2 2 4 2 3 2 4 1 2 1 4 3 1 3 3 1 4 1 2 4 3 3 3 4 4 4 1 3 June 2019 3 2 1 2 3 4 2 1 3 1 0 1 2 1 3 1 3 3 3 2 4 4 3 3 2 4 2 4 1 2 3 1 1 1 4 4 3 2 1 3 4 2 2 4 2 3 2 1 4 4 4 2019 Scorecard on State Health System Performance 42 Appendix D2. & Treatment: Treatment:Dimension DimensionRanking Rankingand andIndicator IndicatorRates Rates APPENDIX D2. Prevention Prevention & Adults without all recommended cancer screenings United States Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Adults without all recommended vaccines Elderly patients who received a high-risk Diabetic adults prescription without an annual hemoglobin A1c test drug Children without a Children who di medical and dental receive need preventive care visit mental health 2012 2016 2013 2017 2015 2015 2016 2017 2016 2017 2016 201 31% 32% 64% 62% 16.9 12.0 * 11 51% 51% 32% 32% 18% 22 32 37 37 39 27 31 25 25 25 32 28 30 39 33 37 29 32 35 33 27 25 21 29 27 37 34 40 34 37 25 31 37 28 29 36 33 39 33 31 24 32 32 33 34 32 27 28 31 34 29 39 32 36 35 36 28 32 24 28 25 33 34 26 40 34 37 31 34 33 32 29 29 26 31 29 36 35 38 35 36 27 31 40 31 28 36 33 40 34 33 26 33 34 33 37 33 30 29 32 35 28 40 62 67 69 63 66 58 63 57 64 72 68 57 68 66 67 56 60 62 61 59 58 53 67 56 65 60 63 57 71 61 66 64 65 56 61 62 59 67 63 58 63 53 58 66 65 58 59 61 58 65 68 62 66 65 61 62 57 56 57 62 65 65 59 66 64 65 56 63 61 67 58 55 59 64 56 66 58 61 55 69 57 61 62 61 57 60 61 58 65 57 55 62 54 64 65 64 59 57 57 57 63 65 15.2 16.4 15.9 17.7 19.2 16.6 20.9 20.8 -18.9 14.8 15.2 16.4 17.8 18.4 15.1 16.2 14.4 17.0 16.8 16.4 16.3 15.5 11.0 14.8 17.9 16.0 18.5 19.6 20.9 18.6 19.6 21.2 13.4 14.6 18.4 15.8 16.0 18.9 23.7 -13.2 13.5 15.0 15.2 19.3 14.2 12.7 19.6 13.7 22.4 10.4 11.5 10.7 13.2 15.2 10.5 13.1 14.8 -13.3 9.7 11.8 12.8 12.2 12.2 9.1 12.0 8.9 18.7 9.2 10.8 10.0 10.1 5.6 9.3 13.2 10.3 17.2 15.6 14.8 13.2 12.2 12.9 7.5 9.2 12.0 10.1 14.3 14.2 16.2 -10.3 9.0 9.6 10.9 10.4 10.0 7.1 15.1 10.5 22.5 15 10 12 13 10 11 9 10 11 12 14 5 11 9 11 8 10 14 16 10 10 7 9 7 16 11 9 8 12 9 9 11 8 12 8 11 16 11 8 8 15 7 14 13 11 8 11 10 13 8 10 49 52 55 52 58 51 46 48 51 58 51 50 50 50 47 42 49 46 51 46 42 42 50 45 49 51 47 45 66 42 50 55 48 46 49 48 55 49 45 50 49 46 46 59 43 40 51 52 48 48 48 50 52 56 57 56 49 43 55 46 59 54 49 55 48 45 45 50 48 53 42 45 40 51 48 52 48 52 41 64 42 52 58 51 45 45 45 54 47 58 52 51 50 47 56 50 39 46 44 50 54 53 32 37 31 41 39 29 23 28 26 38 28 31 33 28 32 30 36 33 32 22 26 22 33 35 41 38 32 35 38 21 26 28 31 27 41 32 36 33 26 28 25 39 34 36 34 20 28 27 28 31 34 35 37 34 36 33 22 18 26 21 35 29 29 32 38 31 24 32 31 31 23 24 21 31 34 32 42 33 34 41 23 24 35 27 33 36 36 43 30 25 23 33 34 28 37 32 27 26 28 26 31 33 * * * * * * * * * * * * * * * * * * * * * * * * * * * * 2016 Children without a medical home * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Change States Improved 2 14 45 States Worsened 8 4 0 Notes: * Denotes a change of at least 0.5 standard deviations. — Indicates that estimates are not available. 10 16 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 15 11 Notes: * Denotes a change of at least 0.5 standard deviations. — Indicates that estimates are not available. commonwealthfund.org June 2019 19 24 22 15 16 27 15 9 16 18 34 23 13 15 18 7 14 18 25 17 11 13 7 9 22 22 8 20 26 5 23 9 17 30 10 15 11 10 13 16 19 17 15 24 18 16 14 20 24 9 7 2019 Scorecard on State Health System Performance 43 Appendix D2. & Treatment: Treatment:Dimension DimensionRanking Rankingand andIndicator IndicatorRates Rates APPENDIX D2. Prevention Prevention & (continued) without a home 2017 Central line–associated Elderly patients whobloodstream received a Hospitals with Nursing h infections (CLABSI), Children without a Children Adults without who didall not Children Adults without withoutall all Diabetic adults high-risk Home without health a Children residents who diw lower-than- Children Standardized Children medical and dental recommended receive needed recommended without Hospital an30-day annual prescription without a medical patients and dental without receive antipsych need average patient preventive care visit mental cancer screenings health care vaccines hemoglobin mortality A1c test Infection drug Ratio medical experience homeratings preventive improved care mobility visit mentalmedicat health 07/2010 07/2014 20152016- 2017 2012 2016 2016 2017 2013 2012 2017 2016 51% United 32%States 32% 31% 18% 32% 22% 64% 32 62% 29 * 13.2% 16.9 50 52 56 57 56 49 43 55 46 59 54 49 55 48 45 45 50 48 53 42 45 40 51 48 52 48 52 41 64 42 52 58 51 45 45 45 54 47 58 52 51 50 47 56 50 39 46 44 50 54 53 Alabama 32 35 Alaska 37 37 Arizona31 34 Arkansas 41 36 California 39 33 Colorado 29 22 Connecticut 23 18 Delaware 28 26 District of 26Columbia 21 Florida 38 35 Georgia28 29 Hawaii 31 29 Idaho 33 32 Illinois 28 38 Indiana 32 31 Iowa 30 24 Kansas 36 32 Kentucky 33 31 Louisiana 32 31 Maine 22 23 Maryland 26 24 Massachusetts 22 21 Michigan 33 31 Minnesota 35 34 Mississippi 41 32 Missouri38 42 Montana32 33 Nebraska 35 34 Nevada38 41 New Hampshire 21 23 New Jersey 26 24 New Mexico 28 35 New York 31 27 North Carolina 27 33 North Dakota 41 36 Ohio 32 36 Oklahoma 36 43 Oregon33 30 Pennsylvania 26 25 Rhode Island 28 23 South Carolina 25 33 South Dakota 39 34 Tennessee 34 28 Texas 36 37 Utah 34 32 Vermont 20 27 Virginia 28 26 Washington 27 28 West Virginia 28 26 Wisconsin 31 31 Wyoming 34 33 32 19 37 24 37 22 39 15 27 16 31 27 25 15 25 9 25 16 32 18 28 34 30 23 39 13 33 15 37 18 29 7 32 14 35 18 33 25 27 17 25 11 21 13 29 7 27 9 37 22 34 22 40 8 34 20 37 26 25 5 31 23 37 9 28 17 29 30 36 10 33 15 39 11 33 10 31 13 24 16 32 19 32 17 33 15 34 24 32 18 27 16 28 14 31 20 34 24 29 9 39 7 32 12 36 11 35 25 36 31 28 24 32 16 24 6 28 23 25 11 33 34 31 26 11 40 13 34 13 37 5 31 9 34 19 33 17 32 26 29 10 29 20 26 11 31 11 29 13 36 28 35 12 38 8 35 4 36 -27 14 31 41 40 18 31 24 28 16 36 7 33 23 40 9 34 10 33 6 26 4 33 48 34 9 33 -37 40 33 38 30 9 29 35 32 24 35 9 28 -40 24 62 32 67 40 69 32 63 34 66 33 58 28 63 23 57 27 64 27 72 31 68 25 57 20 68 37 66 31 67 39 56 25 60 35 62 32 61 32 59 27 58 33 53 26 67 30 56 34 65 23 60 36 63 34 57 27 71 35 61 20 66 29 64 28 65 36 56 25 61 28 62 33 59 39 67 33 63 32 58 28 63 28 53 36 58 27 66 35 65 27 58 37 59 30 61 35 58 39 65 25 68 33 62 29 66 31 65 30 61 32 62 35 57 24 56 24 57 22 62 32 65 33 65 23 59 25 66 26 64 29 65 31 56 27 63 24 61 25 67 33 58 29 55 26 59 15 64 30 56 26 66 30 58 33 61 36 55 19 69 28 57 22 61 30 62 32 61 28 57 22 60 32 61 32 58 33 65 42 57 26 55 24 62 30 54 30 64 33 65 31 64 28 59 23 57 34 57 24 57 35 63 21 65 37 * * 15.2 13.7 16.4 13.7 15.9 13.1 17.7 14.1 19.2 13.0 16.6 12.9 20.9 13.0 20.8 12.2 12.4 -18.9 13.1 14.8 13.4 15.2 13.4 16.4 13.6 17.8 12.9 18.4 13.4 15.1 13.4 16.2 13.0 14.4 13.3 17.0 13.3 16.8 13.4 16.4 12.8 16.3 12.4 15.5 13.0 11.0 12.8 14.8 13.4 17.9 13.2 16.0 13.2 18.5 13.3 19.6 13.8 20.9 13.3 18.6 12.7 19.6 13.3 21.2 13.1 13.4 13.7 14.6 12.7 18.4 12.9 15.8 13.2 16.0 13.9 18.9 12.9 23.7 13.2 13.5 -13.2 13.1 13.5 15.0 13.0 15.2 13.5 19.3 13.8 14.2 13.5 12.7 13.9 19.6 13.2 13.7 13.5 22.4 13.0 10 16 2016 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** * * * ** * * * ** * * * ** * * * * * * ** ** * * * * * * ** * ** * * * * * * * * * * * * * * ** * * ** ** * * * * * * * * * ** * * * * ** ** * ** * * * ** * * ** 2015 2015 2016 13.9% 12.0 * * 10.4 14.3 11.5 14.4 10.7 13.7 13.2 15.1 15.2 13.4 10.5 13.8 13.1 13.4 14.8 13.0 13.2 -13.3 13.8 14.1 9.7 11.8 13.8 12.8 14.5 12.2 13.6 12.2 14.1 14.8 9.1 12.0 14.6 14.3 8.9 18.7 13.7 14.1 9.2 10.8 13.6 10.0 12.8 10.1 13.6 13.6 5.6 14.6 9.3 13.2 14.0 10.3 14.6 17.2 14.8 15.6 14.2 14.8 13.7 13.2 13.1 12.2 14.0 12.9 13.6 14.3 7.5 14.2 9.2 12.0 13.3 10.1 14.3 14.3 14.7 14.2 13.6 16.2 13.0 14.2 -10.3 14.4 14.3 9.0 13.7 9.6 10.9 14.4 10.4 14.4 10.0 13.8 14.6 7.1 15.1 14.0 10.5 14.2 22.5 14.8 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Change States Improved15 16 2 14 25 45 0 States Worsened 11 17 8 4 9 50 0 Notes: * Denotes a change of at least 0.5 standard deviations. — Indicates that estimates are not available. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 0.99 11 0.89 * 1.41 1.09 0.85 1.10 0.97 0.90 1.16 1.05 1.16 1.10 1.17 0.32 0.64 0.82 1.12 0.93 0.80 1.07 1.43 0.80 1.12 0.75 0.94 0.78 1.11 1.06 0.93 1.16 0.95 1.04 1.13 1.00 1.07 1.06 0.79 0.88 0.95 0.80 0.94 1.07 1.10 0.65 0.90 0.97 0.82 1.13 0.92 0.87 0.74 0.77 0.67 1.12 0.87 0.76 1.00 0.94 0.72 1.03 0.97 0.95 0.91 1.14 0.53 0.39 0.70 0.99 0.64 0.85 0.77 1.13 0.93 1.10 0.76 0.78 0.86 0.92 0.93 0.69 0.78 0.94 0.96 0.82 1.05 0.98 1.04 0.84 0.84 0.82 0.68 0.95 1.03 0.96 0.77 0.78 0.87 0.84 0.68 0.68 0.71 0.86 0.80 0.36 15 10 12 13 10 11 9 10 11 12 14 5 11 9 11 8 10 14 16 10 10 7 9 7 16 11 9 8 12 9 9 11 8 12 8 11 16 11 8 8 15 7 14 13 11 8 11 10 13 8 10 27 4 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 2016 2017 2017 51% 45% 51% 32%39% 49 52 55 52 58 51 46 48 51 58 51 50 50 50 47 42 49 46 51 46 42 42 50 45 49 51 47 45 66 42 50 55 48 46 49 48 55 49 45 50 49 46 46 59 43 40 51 52 48 48 48 38 50 29 52 64 56 34 57 58 56 12 49 52 43 33 55 100 46 63 59 42 54 45 49 55 9 44 48 21 45 32 45 14 50 38 48 20 53 41 42 -45 47 40 42 51 23 48 43 52 45 48 56 52 21 41 79 64 15 42 70 52 77 58 76 51 44 45 50 45 38 45 40 54 21 47 50 58 55 52 37 51 17 50 41 47 33 56 26 50 33 39 51 46 48 44 68 50 18 54 62 53 32 37 31 41 39 29 23 28 26 38 28 31 33 28 32 30 36 33 32 22 26 22 33 35 41 38 32 35 38 21 26 28 31 27 41 32 36 33 26 28 25 39 34 36 34 20 28 27 28 31 34 10 16 2016 2013 2017 2017 * * * * * * * * * * * * * * * * * * * * * * * * * * 2016 2013 201 32%25% * 35 51 42 39 41 38 41 42 40 35 39 45 37 39 41 38 39 36 40 38 37 37 39 43 36 38 44 41 40 41 37 41 41 39 44 39 40 44 37 37 36 42 37 44 34 40 37 44 37 41 42 35 37 34 36 33 22 18 26 21 35 29 29 32 38 31 24 32 31 31 23 24 21 31 34 32 42 33 34 41 23 24 35 27 33 36 36 43 30 25 23 33 34 28 37 32 27 26 28 26 31 33 15 11 20* 35 27* 21* 27* 25* 29* 27 24* 22* 23 32 23 27* 27 25* 24* 22 25 26 22 24 26 29 20* 24* 30 25 28* 25 25 27* 26* 24* 24* 26* 24* 29* 24 25* 23* 27* 21* 30 21 28* 26 26 21 26 31 18%21% * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 51 0 Notes: * Denotes a change of at least 0.5 standard deviations. — Indicates that estimates are not available. commonwealthfund.org June 2019 19 24 22 15 16 27 15 9 16 18 34 23 13 15 18 7 14 18 25 17 11 13 7 9 22 22 8 20 26 5 23 9 17 30 10 15 11 10 13 16 19 17 15 24 18 16 14 20 24 9 7 22 13 20 24 17 17 21 17 16 22 22 11 20 25 21 20 22 22 27 21 16 22 15 16 25 24 18 23 21 21 16 19 19 16 19 23 23 18 19 18 17 19 24 27 25 20 20 19 18 16 18 22 2019 Scorecard on State Health System Performance Appendix D2. & Treatment: Treatment:Dimension DimensionRanking Rankingand andIndicator IndicatorRates Rates APPENDIX D2. Prevention Prevention & (continued) als with -thanHome health e patient patients without ce ratings improved mobility 17 44 2013 Nursing home Adults without all residents with an recommended antipsychotic cancer medication screenings 2017 2012 2013 5% United 39%States 25% * 38 29 64 34 58 12 52 33 100 63 42 45 9 44 21 32 14 38 20 41 -47 42 23 43 45 56 21 79 15 70 77 76 44 50 38 40 21 50 55 37 17 41 33 26 33 51 48 68 18 62 Alabama 35 20 Alaska 51 35 Arizona42 27 Arkansas 39 21 California 41 27 Colorado 38 25 Connecticut 41 29 Delaware 42 27 District of 40Columbia 24 Florida 35 22 Georgia39 23 Hawaii 45 32 Idaho 37 23 Illinois 39 27 Indiana 41 27 Iowa 38 25 Kansas 39 24 Kentucky 36 22 Louisiana 40 25 Maine 38 26 Maryland 37 22 Massachusetts 37 24 Michigan 39 26 Minnesota 43 29 Mississippi 36 20 Missouri38 24 Montana44 30 Nebraska 41 25 Nevada40 28 New Hampshire 41 25 New Jersey 37 25 New Mexico 41 27 New York 41 26 North Carolina 39 24 North Dakota 44 24 Ohio 39 26 Oklahoma 40 24 Oregon44 29 Pennsylvania 37 24 Rhode Island 37 25 South Carolina 36 23 South Dakota 42 27 Tennessee 37 21 Texas 44 30 Utah 34 21 Vermont 40 28 Virginia 37 26 Washington 44 26 West Virginia 37 21 Wisconsin 41 26 Wyoming 42 31 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 31% 21% 32 22 37 13 37 20 39 24 27 17 31 17 25 21 25 17 25 16 32 22 28 22 30 11 39 20 33 25 37 21 29 20 32 22 35 22 33 27 27 21 25 16 21 22 29 15 27 16 37 25 34 24 40 18 34 23 37 21 25 21 31 16 37 19 28 19 29 16 36 19 33 23 39 23 33 18 31 19 24 18 32 17 32 19 33 24 34 27 32 25 27 20 28 20 31 19 34 18 29 16 39 18 2016 2017 2009-11 2013 2014-16 2017 32% 15% * 32 19 36 12 35 14 36 15 28 11 32 15 24 16 28 14 25 11 33 15 34 19 26 7 40 18 34 19 37 15 31 15 34 19 33 19 32 17 29 18 29 13 26 18 31 13 29 14 36 19 35 19 38 15 35 18 36 16 27 15 31 11 40 16 31 12 28 13 36 17 33 16 40 20 34 15 33 16 26 16 33 14 34 17 33 17 37 16 33 16 30 17 29 15 32 15 35 15 28 13 40 13 Adults with any Adults without mental illnessall recommended reporting unmet vaccines need * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 64% 21% 62% 21% 62 21 67 22 69 30 63 28 66 21 58 23 63 25 57 16 64 24 72 20 68 20 57 14 68 23 66 22 67 23 56 18 60 30 62 19 61 23 59 16 58 20 53 21 67 23 56 25 65 21 60 27 63 24 57 16 71 22 61 24 66 15 64 25 65 17 56 22 61 17 62 20 59 18 67 26 63 21 58 27 63 22 53 17 58 16 66 20 65 23 58 24 59 22 61 26 58 26 65 22 68 17 62 17 66 18 65 21 61 23 62 20 57 22 56 21 57 21 62 26 65 19 65 21 59 16 66 25 64 22 65 25 56 19 63 21 61 20 67 20 58 17 55 22 59 19 64 20 56 22 66 23 58 24 61 21 55 17 69 26 57 25 61 20 62 22 61 20 57 24 60 19 61 20 58 20 65 25 57 22 55 17 62 21 54 20 64 21 65 17 64 21 59 19 57 24 57 24 57 22 63 18 65 21 Elderly patients Adults with any who received a Diabetic adults high-risk mental illness who without annual prescription did notan receive hemoglobin treatment A1c test drug 2009-11 2015 2014-16 2016 16.9 59% * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 15.2 59 16.4 67 15.9 59 17.7 58 19.2 64 16.6 55 20.9 58 20.8 58 65 -18.9 63 14.8 59 15.2 73 16.4 54 17.8 58 18.4 57 15.1 55 16.2 49 14.4 55 17.0 65 16.8 47 16.4 57 16.3 49 15.5 60 11.0 57 14.8 67 17.9 56 16.0 51 18.5 53 19.6 68 20.9 57 18.6 68 19.6 55 21.2 61 13.4 59 14.6 55 18.4 54 15.8 60 16.0 56 18.9 54 23.7 47 54 -13.2 53 13.5 57 15.0 65 15.2 57 19.3 45 14.2 53 12.7 53 19.6 48 13.7 60 22.4 61 12.0 56% * 10.4 59 11.5 62 10.7 63 13.2 57 15.2 62 10.5 54 13.1 54 14.8 48 58 -13.3 61 9.7 59 11.8 68 12.8 56 12.2 54 12.2 55 9.1 46 12.0 56 8.9 51 18.7 61 9.2 42 10.8 56 10.0 49 10.1 53 5.6 43 9.3 57 13.2 52 10.3 54 17.2 56 15.6 63 14.8 46 13.2 57 12.2 56 12.9 57 7.5 51 9.2 58 12.0 53 10.1 55 14.3 55 14.2 54 16.2 48 60 -10.3 53 9.0 57 9.6 62 10.9 57 10.4 46 10.0 54 7.1 54 15.1 52 10.5 53 22.5 56 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Change States Improved 51 50 2 14 20 45 23 States Worsened 0 8 0 17 4 0 7 Notes: * Denotes a change of at least 0.5 standard deviations. — Indicates that estimates are not available. Children without a medical home Children without a Children who di medical and dental receive need preventive care visit mental health 2015 2016 2017 2016 2017 2016 201 11 51% 51% 32% 32% 18% 22 15 10 12 13 10 11 9 10 11 12 14 5 11 9 11 8 10 14 16 10 10 7 9 7 16 11 9 8 12 9 9 11 8 12 8 11 16 11 8 8 15 7 14 13 11 8 11 10 13 8 10 49 52 55 52 58 51 46 48 51 58 51 50 50 50 47 42 49 46 51 46 42 42 50 45 49 51 47 45 66 42 50 55 48 46 49 48 55 49 45 50 49 46 46 59 43 40 51 52 48 48 48 50 52 56 57 56 49 43 55 46 59 54 49 55 48 45 45 50 48 53 42 45 40 51 48 52 48 52 41 64 42 52 58 51 45 45 45 54 47 58 52 51 50 47 56 50 39 46 44 50 54 53 32 37 31 41 39 29 23 28 26 38 28 31 33 28 32 30 36 33 32 22 26 22 33 35 41 38 32 35 38 21 26 28 31 27 41 32 36 33 26 28 25 39 34 36 34 20 28 27 28 31 34 35 37 34 36 33 22 18 26 21 35 29 29 32 38 31 24 32 31 31 23 24 21 31 34 32 42 33 34 41 23 24 35 27 33 36 36 43 30 25 23 33 34 28 37 32 27 26 28 26 31 33 10 16 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 15 11 Notes: * Denotes a change of at least 0.5 standard deviations. — Indicates that estimates are not available. commonwealthfund.org June 2019 19 24 22 15 16 27 15 9 16 18 34 23 13 15 18 7 14 18 25 17 11 13 7 9 22 22 8 20 26 5 23 9 17 30 10 15 11 10 13 16 19 17 15 24 18 16 14 20 24 9 7 2019 Scorecard on State Health System Performance 45 APPENDIX E1. Prevention & Treatment: Dimension and Indicator Ranking Overall performance Ho Top quartile Second quartile Third quartile Bottom quartile Data not available sp p e ita di l a at d m ri c i as ssi Po th o n m s te a fo em nti r er ally ag ge av es nc o y i Po 18– d e d ab te 64 p a le rt em nti m en er ally tv ag ge av n is e6 c o its y d id 5 ab Pr a e ev nd p a le ag ent o ld rtm es ab er e nt 18 le vi – 6 ho si 4 sp ts Pr ita ev l i za ag ent tio e 6 ab ns l 5a e nd ho s ol pi Ho d e ta sp r liz at ra i ta io te l 3 ns ag 0es d a y 18 r – 6 ea Ho 4 dm sp is ra i ta si te l 3 on ag 0e 6 da 5a yr Sk nd ead ill ol m e d e i ss wi d t h nu r io n a h r si n os g fa p i t a ci Nu l r lity rs ea p ho i ng d m at sp h o is ien ita m si t s l a er on d m es Ho id i ss en m io ts ho e h n wi sp ea th l ita th a l a pa d m ti Ad en is t ul si s w on i lo ts w th we i t a r-b h in Appendix E1. Avoidable Hospital Use & Cost: Dimension and Indicator Ranking 1 2 3 3 5 6 7 8 9 10 11 12 13 14 15 16 16 18 18 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 36 38 38 40 41 42 42 44 45 46 47 48 49 50 51 Hawaii Utah Idaho Washington Colorado Oregon Montana Alaska North Dakota Arizona Minnesota Vermont Iowa California South Dakota Maine New Mexico New Hampshire Wyoming Maryland Nebraska Virginia Wisconsin North Carolina South Carolina Rhode Island Connecticut Delaware Tennessee New Jersey Massachusetts Georgia Pennsylvania Alabama Kansas Indiana New York Arkansas Nevada Illinois Michigan Ohio Texas District of Columbia Missouri Oklahoma Louisiana Kentucky Florida Mississippi West Virginia commonwealthfund.org 1 0 0 1 3 1 1 0 1 3 2 1 1 3 2 0 4 0 3 3 1 2 2 2 0 0 4 0 1 4 3 2 4 0 4 2 4 2 4 3 3 3 2 0 4 4 0 3 4 0 2 1 1 2 1 2 1 2 3 2 3 1 2 2 1 1 3 3 1 3 1 1 4 3 3 0 2 3 2 4 1 1 3 2 4 3 4 1 3 4 3 2 4 4 0 4 4 3 2 4 4 4 1 1 1 1 2 1 1 4 1 2 2 1 2 1 1 4 2 2 2 3 1 3 3 4 2 4 3 2 3 2 3 3 2 3 2 4 2 3 1 3 4 4 3 4 3 4 4 4 3 4 4 2 1 2 1 1 1 1 2 2 2 1 1 2 1 3 2 2 1 3 3 3 2 2 2 0 2 1 3 4 1 1 3 2 4 3 3 1 4 3 3 3 4 3 0 4 4 3 4 4 4 4 1 1 1 1 1 1 1 1 2 1 1 1 2 2 2 2 1 2 0 3 2 2 2 3 2 0 3 3 4 3 4 3 3 4 2 3 3 4 2 4 4 4 3 4 3 3 4 4 3 4 4 2 1 2 1 1 2 2 1 1 2 2 2 2 1 4 1 1 1 4 1 4 2 4 1 0 4 1 3 1 2 1 3 3 1 2 3 2 2 3 3 4 2 4 0 4 3 2 4 4 1 4 1 1 1 1 1 1 1 1 2 1 2 1 2 2 2 2 1 2 1 3 2 2 2 2 2 3 3 2 3 3 4 3 3 4 2 3 4 3 3 4 4 4 3 4 3 3 3 4 4 4 4 1 1 1 1 1 2 1 1 1 2 1 1 1 3 1 1 2 2 1 2 1 2 2 2 3 2 2 2 2 4 3 3 2 3 2 2 3 4 4 3 3 3 4 2 3 4 4 4 4 4 3 1 1 1 1 1 1 2 2 2 1 1 2 2 4 2 1 2 2 2 3 3 2 1 3 3 1 2 3 4 3 2 3 1 4 4 3 2 4 4 3 2 1 4 4 3 4 4 4 4 4 3 1 1 1 1 1 1 2 1 1 1 2 2 2 1 2 2 1 4 1 1 2 2 1 2 2 4 2 2 4 2 4 4 4 4 4 2 2 4 2 2 2 2 1 1 2 1 2 4 1 4 4 June 2019 3 3 3 4 3 4 3 3 3 2 4 4 4 4 4 4 4 2 3 2 4 2 4 1 0 2 3 3 1 2 3 1 3 1 4 1 3 1 1 2 2 2 1 0 1 2 1 2 1 1 2 2019 Scorecard on State Health System Performance 46 APPENDIX E1. Prevention & Treatment: Dimension and Indicator Ranking (continued) ator Ranking Appendix E1. Avoidable Hospital Use & Cost: Dimension and Indicator Ranking ld ita er li sp za ra i ta tio te l 3 ns ag 0es d a 18 y r – 6 ea Ho 4 dm sp is ra i ta si te l 3 on ag 0e 6 da 5a yr Sk nd ead ill ol m d e i ss wi ed t h nu r io n a h r si o s ng fa p i t a ci Nu l r lity rs ea p i ho ng d m at sp h o is ien ita m si t s l a er on es d m Ho is ide smp si nt on s pheo eitha wi dsip el a th ait ldtm railc h pi a aad sast smt ioe PAod him ss nsts tuel aio fow elom ntstiw n rith wee ali lt a ag rrg-eb yhaivn es nac oa i p y k PEom 18– dime dparbo tpe 64 paag lper rint ia einm nlotyi m g te seu aelr en l r y tv aegn gaen sapv o n is ero6 cce on its isd y l s 5 PMr leae dpe oarb eedv nd pn elde ad abge iecnatr o ld ritnmg ens aeb er ep net e1f slpe rv i8c– eh ia6 nod is r4y sip its nig Pr t a plei ev zra ag ent tio e 6 ab ns l 5a e nd ho s ol pi Ho d e ta sp r liz at ra i ta io te l 3 ns ag 0es d a y 18 r – 6 ea Ho 4 dm sp is ra i ta si te l 3 on ag 0e 6 da 5a yr Sk nd ead ill ol m e d e i ss wi d t h nu r io n a h r si n os g fa p i t a ci Nu l r lity rs ea p ho i ng d m at sp h o is ien ita m si t s l a er on d m es Ho id i ss en m io ts ho e h n wi sp ea th l ita th a l a pa d m ti Ad en is t ul si s w on i lo ts w th we i t a r-b h in Overall performance Top quartile Second quartile Third quartile Bottom quartile Data not available Ho state 2 1 2 1 1 2 2 1 1 2 2 2 2 1 4 1 1 1 4 1 4 2 4 1 0 4 1 3 1 2 1 3 3 1 2 3 2 2 3 3 4 2 4 0 4 3 2 4 4 1 4 11 12 13 13 15 16 17 18 29 1 10 2 11 1 12 2 13 2 14 2 15 2 16 1 16 2 18 1 18 3 20 2 21 2 22 2 23 2 24 2 25 3 26 3 27 2 28 3 29 3 30 4 31 3 32 3 33 4 34 2 35 3 36 4 36 3 38 3 38 4 40 4 41 4 42 3 42 4 44 3 45 3 46 3 47 4 48 4 49 4 50 4 51 1 Hawaii 1 1 Utah 1 1 Idaho 1 1 1 Washington 1 Colorado 1 2 Oregon 1 1 Montana 2 1 Alaska 2 1 North Dakota 2 2 Arizona 1 1 Minnesota 1 1 Vermont 2 1 Iowa 2 3 California 4 1 South Dakota 2 1 Maine 1 2New Mexico 2 New2Hampshire 2 1 Wyoming 2 2 Maryland 3 1 Nebraska 3 2 Virginia 2 2 Wisconsin 1 2 Carolina 3 North 3 Carolina 3 South 2 Rhode Island 1 2 2 Connecticut 2 Delaware 3 2Tennessee 4 4New Jersey 3 3 2 Massachusetts 3 Georgia 3 2 1 Pennsylvania 3 Alabama 4 2 Kansas 4 2 Indiana 3 3 New York 2 4 Arkansas 4 4 Nevada 4 3 Illinois 3 3 Michigan 2 3 Ohio 1 4 Texas 4 District 2of Columbia 4 3 Missouri 3 4 Oklahoma 4 4 Louisiana 4 4 Kentucky 4 4 Florida 4 4 Mississippi 4 3 West Virginia 3 commonwealthfund.org 1 1 0 1 0 1 1 3 1 2 1 1 0 1 1 3 2 2 1 2 1 1 3 2 2 0 1 4 4 0 1 3 1 3 2 1 2 1 2 2 2 0 4 0 2 4 2 0 4 1 2 4 4 3 4 2 4 4 0 4 2 2 4 4 2 2 4 2 3 2 3 2 3 1 2 1 0 2 4 1 4 2 0 4 3 1 4 4 0 4 2 3 1 3 1 3 2 4 1 3 2 4 1 3 2 3 3 2 2 3 4 1 4 2 4 2 4 1 4 1 4 3 4 3 2 1 3 2 1 4 1 2 4 4 3 1 3 0 2 3 3 2 1 4 2 1 3 1 1 3 3 2 1 4 4 3 1 4 3 1 1 3 1 4 2 3 2 2 4 1 4 0 1 4 2 4 1 3 2 1 4 1 4 2 4 1 2 1 4 1 2 1 2 3 1 3 1 4 3 1 2 3 2 3 1 1 2 4 1 3 1 3 4 3 2 4 2 4 2 1 3 4 1 2 3 4 3 3 4 0 2 1 4 4 3 2 1 3 3 2 2 3 3 1 2 1 3 2 4 4 2 1 3 1 3 1 4 2 4 4 3 0 4 2 3 2 4 2 4 1 4 3 1 4 4 1 2 2 1 1 2 1 1 1 1 1 2 2 2 2 1 1 2 2 1 1 3 2 1 2 2 1 1 3 3 2 3 2 1 2 2 2 0 2 3 1 3 3 4 4 1 3 1 3 3 2 4 3 3 4 1 4 3 4 3 4 3 4 4 3 3 0 3 4 4 4 3 4 4 4 3 4 1 1 1 1 1 1 1 1 2 1 1 1 2 2 2 2 1 2 0 3 2 2 2 3 2 0 3 3 4 3 4 3 3 4 2 3 3 4 2 4 4 4 3 4 3 3 4 4 3 4 4 2 1 2 1 1 2 2 1 1 2 2 2 2 1 4 1 1 1 4 1 4 2 4 1 0 4 1 3 1 2 1 3 3 1 2 3 2 2 3 3 4 2 4 0 4 3 2 4 4 1 4 1 1 1 1 1 1 1 1 2 1 2 1 2 2 2 2 1 2 1 3 2 2 2 2 2 3 3 2 3 3 4 3 3 4 2 3 4 3 3 4 4 4 3 4 3 3 3 4 4 4 4 1 1 1 1 1 2 1 1 1 2 1 1 1 3 1 1 2 2 1 2 1 2 2 2 3 2 2 2 2 4 3 3 2 3 2 2 3 4 4 3 3 3 4 2 3 4 4 4 4 4 3 rank 1 1 1 1 1 1 2 2 2 1 1 2 2 4 2 1 2 2 2 3 3 2 1 3 3 1 2 3 4 3 2 3 1 4 4 3 2 4 4 3 2 1 4 4 3 4 4 4 4 4 3 1 1 1 1 1 1 2 1 1 1 2 2 2 1 2 2 1 4 1 1 2 2 1 2 2 4 2 2 4 2 4 4 4 4 4 2 2 4 2 2 2 2 1 1 2 1 2 4 1 4 4 June 2019 3 3 3 4 3 4 3 3 3 2 4 4 4 4 4 4 4 2 3 2 4 2 4 1 0 2 3 3 1 2 3 1 3 1 4 1 3 1 1 2 2 2 1 0 1 2 1 2 1 1 2 2019 Scorecard on State Health System Performance 47 AppendixE2. E2. Avoidable Hospital Use & Cost: Dimension Indicator Rates APPENDIX Avoidable Hospital Use & Cost: Dimension Ranking andRanking Indicatorand Rates Hospital admissions for pediatric asthma (rate per 100,000) 2012 United States Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Change States Improved States Worsened 142.9 -61.9 124.7 80.6 95.8 129.1 136.3 --143.1 96.6 68.6 -119.5 102.4 71.2 160.4 151.8 203.0 76.3 136.9 141.1 94.0 82.3 -161.2 76.6 82.1 112.3 -162.7 -231.5 113.3 -127.9 189.1 41.0 -149.0 133.0 76.2 72.9 114.3 93.4 27.6 100.0 83.6 98.1 86.0 122.7 2015 87.2 * --84.4 69.0 86.8 100.4 103.4 --120.6 58.1 50.1 -85.3 62.5 46.8 103.8 85.3 --93.3 97.7 94.2 53.2 -110.1 44.3 42.0 109.7 -112.1 158.3 183.4 77.7 44.4 102.3 109.1 46.3 107.1 --62.2 49.9 67.6 -21.7 56.0 52.5 56.8 62.1 94.3 28 0 * * * * * * * * * * * * * * * * * * * * * * * * * * * * Potentially avoidable Potentially avoidable Preventable emergency emergency Preventable hospitalizations age Hosp department visits department visits age ages 18–64 (rate per 65 and older (rate per hospitalizations ages 65 and older (rate per readmis 1,000) 1,000) 18–64 (rate per 1,000) 1,000) 18–64 (r 2015 2016 2012 2015 2015 2016 2013 2017 2015 159.0 142.2 * 187.8 196.9 4.6 5.3 * 47.7 43.9 2.9 171.5 166.0 175.7 157.1 130.0 147.4 162.9 150.6 -177.6 164.0 137.6 133.5 154.4 171.5 151.1 160.8 151.2 173.9 172.4 148.5 142.1 159.4 139.2 182.6 203.4 144.6 140.3 186.7 155.5 145.3 149.2 155.0 159.2 161.7 177.0 172.3 137.1 158.6 157.9 -143.3 168.3 175.6 131.9 163.5 168.4 137.5 181.7 163.8 165.8 157.4 149.8 148.8 144.0 117.7 133.1 142.8 141.2 -163.8 149.9 122.3 137.9 142.4 151.7 134.6 145.0 136.4 150.3 150.2 131.7 125.6 141.9 127.6 155.0 186.8 136.4 131.7 184.9 131.7 125.6 143.5 122.4 142.5 133.1 158.3 157.4 124.8 140.3 135.9 -125.9 152.5 159.9 115.9 137.4 150.9 125.8 159.5 142.4 144.5 * * * * * * * * 191.7 204.7 177.9 185.0 166.9 172.7 189.3 159.0 247.9 178.9 200.6 130.8 162.1 192.0 199.9 183.6 172.9 218.7 236.3 232.5 192.9 208.9 214.2 180.5 230.9 196.7 158.5 152.6 165.4 192.2 170.3 169.9 172.6 197.4 187.2 218.7 211.1 161.9 186.7 187.7 176.4 168.3 199.8 185.6 146.9 186.6 193.2 157.3 226.5 182.1 168.9 199.5 212.9 191.0 200.2 173.8 177.4 207.9 179.0 242.2 199.0 197.1 138.3 172.9 199.3 209.7 186.2 188.7 236.3 238.3 219.3 193.6 207.9 222.9 185.7 246.2 209.4 163.3 157.5 164.3 183.1 179.6 193.5 178.8 217.1 168.2 230.2 236.5 166.7 193.5 212.2 188.8 155.1 204.9 198.3 151.4 173.5 195.3 175.0 250.8 193.8 177.9 6.0 4.4 4.6 5.3 3.6 3.5 3.9 5.2 -5.7 5.1 4.3 3.6 4.8 5.6 4.4 5.3 5.4 5.6 3.8 4.7 4.0 4.9 3.8 6.1 5.1 4.1 4.7 4.9 3.9 4.6 3.9 4.7 4.4 3.9 5.3 5.2 3.5 4.6 4.2 -4.2 5.7 5.3 4.0 4.1 4.6 3.3 5.5 4.3 5.0 7.9 6.5 6.4 7.3 5.9 5.8 6.2 7.1 -7.8 7.2 6.5 6.4 7.0 7.2 6.5 7.2 7.6 6.9 6.4 7.1 6.1 7.1 6.2 7.4 7.3 6.2 6.9 7.1 6.3 6.3 6.6 6.2 6.5 6.5 7.3 7.3 6.1 6.7 6.6 -6.8 7.3 7.2 6.3 6.3 6.7 5.6 7.9 6.7 6.9 * * * * * * * * 55.8 -32.8 55.0 37.1 28.7 48.1 47.9 52.4 49.2 48.4 24.3 27.7 50.9 54.6 42.4 46.2 72.4 66.8 43.8 48.4 53.1 53.7 36.9 66.2 50.7 35.6 42.1 37.7 42.4 50.1 37.5 49.0 44.9 -58.4 53.5 30.8 52.6 47.1 42.6 43.0 55.8 50.6 26.9 39.5 44.8 31.5 67.0 39.9 -- 56.4 25.9 28.3 50.3 35.9 25.1 43.4 44.1 51.6 47.8 45.0 21.7 25.0 50.0 48.6 37.6 40.4 60.1 57.7 38.2 41.9 52.1 52.0 35.3 58.2 47.2 30.5 36.5 38.9 40.8 46.0 30.1 44.5 44.6 40.8 50.6 48.9 28.0 48.4 -39.5 38.5 50.9 46.0 23.3 34.8 41.0 28.5 59.5 36.6 -- 1.2 2.6 3.3 3.0 2.4 2.3 2.4 2.7 3.9 2.9 2.8 2.5 3.2 3.1 2.7 2.9 3.0 3.0 2.1 2.6 2.8 3.4 3.1 2.9 3.5 3.3 3.0 3.6 2.3 3.2 2.9 5.5 2.6 2.7 3.4 3.2 2.7 3.1 3.4 3.4 1.9 3.4 1.4 3.2 2.5 2.2 3.0 3.2 2.9 44 0 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 4 16 * * * * * * * * * * * * * * * * * * * * 0 49 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 11 0 Notes: * Denotes a change of at least 0.5 standard deviations. Spending estimates exclude prescription drug costs and are adjusted for regional wage differences; Medicare estimates r Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. Spending estimates exclude prescription drug costs and are adjusted for regional wage differences; Medicare estimates reflect only the age 65+ Medicare fee-for-service population. — Indicates that estimates are not available. commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance 48 nking and Appendix Indicator E2. Rates Avoidable Hospital Use & Cost: Dimension Indicator Rates APPENDIX E2. Avoidable Hospital Use & Cost: Dimension Ranking andRanking Indicatorand Rates (continued) oidable Potentially avoidable Potentially avoidable cy Preventable emergency Hospital emergency 30-day Preventable its age Preventable Hospital admissions Hospital department 30-day visits readmission departmentrate visits age SkilledPreventable nursing facility hospitalizations Nursing home age Home Hosp he hospitalizations age age ate per hospitalizations ages 65for pediatric asthma ages 18–64rate (rateages per 65 65and andolder older(rate (rateper per hospitalizations and olderwith (ratea per readmis with a patients with aages 65residents and older (rate per readmission 18–64 (rate per 1,000) (rate1,000) per 100,000) 18–64 (rate 1,000) per 1,000) 1,000) 1,000) hospital 18–64 (rate readmission per 1,000) hospital1,000) admission 18–64 adm (r 2015 2015 2016 2016 96.9 015 United 4.6 States 5.3 * 142.9 47.7 43.9 87.2 * 159.0 2.9 142.2 3.1 99.5 12.9 91.0 00.2 73.8 77.4 07.9 79.0 42.2 99.0 97.1 38.3 72.9 99.3 09.7 86.2 88.7 36.3 38.3 19.3 93.6 07.9 22.9 85.7 46.2 09.4 63.3 57.5 64.3 83.1 79.6 93.5 78.8 17.1 68.2 30.2 36.5 66.7 93.5 12.2 88.8 55.1 04.9 98.3 51.4 73.5 95.3 75.0 50.8 93.8 77.9 Alabama 6.0 7.9 Alaska 4.4 6.5 Arizona 4.6 6.4 Arkansas 5.3 7.3 California 3.6 5.9 Colorado 3.5 5.8 Connecticut 3.9 6.2 Delaware 5.2 7.1 District--of Columbia-Florida 5.7 7.8 Georgia 5.1 7.2 Hawaii 4.3 6.5 Idaho3.6 6.4 Illinois4.8 7.0 Indiana 5.6 7.2 Iowa 4.4 6.5 Kansas 5.3 7.2 Kentucky 5.4 7.6 Louisiana 5.6 6.9 Maine3.8 6.4 Maryland 4.7 7.1 Massachusetts 4.0 6.1 Michigan 4.9 7.1 Minnesota 3.8 6.2 Mississippi 6.1 7.4 Missouri 5.1 7.3 Montana 4.1 6.2 Nebraska 4.7 6.9 Nevada 4.9 7.1 New Hampshire 3.9 6.3 New Jersey 4.6 6.3 New Mexico 3.9 6.6 New York 4.7 6.2 North4.4 Carolina 6.5 North3.9 Dakota 6.5 Ohio 5.3 7.3 Oklahoma 5.2 7.3 Oregon 3.5 6.1 Pennsylvania 4.6 6.7 Rhode4.2 Island 6.6 South Carolina --South4.2 Dakota 6.8 Tennessee 5.7 7.3 Texas5.3 7.2 Utah 4.0 6.3 Vermont 4.1 6.3 Virginia 4.6 6.7 Washington 3.3 5.6 West 5.5 Virginia 7.9 Wisconsin 4.3 6.7 Wyoming 5.0 6.9 * * * * * * * * 55.8-61.9 -32.8 124.7 55.0 80.6 37.1 95.8 28.7 129.1 48.1 136.3 47.9-52.4-49.2 143.1 48.4 96.6 24.3 68.6 27.7-50.9 119.5 54.6 102.4 42.4 71.2 46.2 160.4 72.4 151.8 66.8 203.0 43.8 76.3 48.4 136.9 53.1 141.1 53.7 94.0 36.9 82.3 66.2-50.7 161.2 35.6 76.6 42.1 82.1 37.7 112.3 42.4-50.1 162.7 37.5-49.0 231.5 44.9 113.3 ---58.4 127.9 53.5 189.1 30.8 41.0 52.6-47.1 149.0 42.6 133.0 43.0 76.2 55.8 72.9 50.6 114.3 26.9 93.4 39.5 27.6 44.8 100.0 31.5 83.6 67.0 98.1 39.9 86.0 122.7 -- 56.4-25.9-28.3 84.4 * 50.3 69.0 35.9 86.8 25.1 100.4 * 43.4 103.4 * 44.1-51.6-47.8 120.6 * 45.0 58.1 * 21.7 50.1 25.0-50.0 85.3 * 48.6 62.5* * 37.6 46.8 * 40.4 103.8* * 60.1 85.3* * 57.7--* 38.2--* 41.9 93.3* * 52.1 97.7 * 52.0 94.2 35.3 53.2 * 58.2--* 47.2 110.1 * 30.5 44.3 * 36.5 42.0* * 38.9 109.7 40.8-46.0 112.1 * 30.1 158.3* 44.5 183.4 * 44.6 77.7 * 40.8 44.4 50.6 102.3* * 48.9 109.1 * 28.0 46.3 48.4 107.1 ---39.5-38.5 62.2 50.9 49.9 * 46.0 67.6 * 23.3-34.8 21.7 41.0 56.0 * 28.5 52.5 * 59.5 56.8* * 36.6 62.1 * 94.3 -- * 171.5 1.2 166.0 2.6 175.7 3.3 157.1 3.0 130.0 2.4 147.4 2.3 162.9 2.4 150.6 2.7 ---177.6 3.9 164.0 2.9 137.6 2.8 133.5 2.5 154.4 3.2 171.5 3.1 151.1 2.7 160.8 2.9 151.2 3.0 173.9 3.0 172.4 2.1 148.5 2.6 142.1 2.8 159.4 3.4 139.2 3.1 182.6 2.9 203.4 3.5 144.6 3.3 140.3 3.0 186.7 3.6 155.5 2.3 145.3 3.2 149.2 2.9 155.0 5.5 159.2 2.6 161.7 2.7 177.0 3.4 172.3 3.2 137.1 2.7 158.6 3.1 157.9 3.4 ---143.3 3.4 168.3 1.9 175.6 3.4 131.9 1.4 163.5 3.2 168.4 2.5 137.5 2.2 181.7 3.0 163.8 3.2 165.8 2.9 4 16 2015 * * * * * * * * * * * * * * * * * * * * 2016 2013 2012 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Change States Improved 0 States Worsened 49 2017 2015 1128 00 157.4 2.5 * 149.8 3.0 * 148.8 3.2 144.0 3.1 117.7 3.0 * 133.1 2.9 * 142.8 2.9 * 141.2 3.3 * ---163.8 3.6 149.9 3.3 * 122.3 3.1 * 137.9 3.1 * 142.4 3.3 151.7 3.3 134.6 3.1 * 145.0 3.2 * 136.4 3.4 * 150.3 3.2 150.2 2.7 * 131.7 3.0 * 125.6 3.0 141.9 3.5 127.6 3.2 155.0 3.0 186.8 3.6 136.4 3.2 131.7 3.5 * 184.9 3.3 * 131.7 2.9 * 125.6 3.1 143.5 3.0 122.4 3.1 * 142.5 3.0 * 133.1 3.0 158.3 3.2 157.4 3.3 124.8 3.1 * 140.3 3.3 135.9 3.4 ---125.9 3.6 152.5 2.8 * 159.9 3.5 115.9 2.4 * 137.4 3.2 150.9 3.2 * 125.8 2.7 * 159.5 3.6 * 142.4 3.5 144.5 3.4 * 244 24 0 2013 2012 2017 2015 2012 2015 2016 2016 * 187.8 43.5 196.9 41.0 20% 4.6 19% 5.3 * * * * * * * * 43.9 191.7 26.1 204.7 33.2 177.9 44.7 185.0 38.0 166.9 26.5 172.7 46.0 189.3 40.1 159.0 56.0 247.9 49.2 178.9 40.9 200.6 21.4 130.8 24.8 162.1 49.6 192.0 44.2 199.9 34.0 183.6 38.6 172.9 57.2 218.7 50.7 236.3 36.1 232.5 52.2 192.9 45.6 208.9 54.8 214.2 36.9 180.5 50.4 230.9 45.9 196.7 28.5 158.5 33.4 152.6 36.9 165.4 33.7 192.2 49.3 170.3 30.9 169.9 51.3 172.6 39.1 197.4 35.4 187.2 52.7 218.7 43.2 211.1 26.2 161.9 48.8 186.7 43.8 187.7 36.9 176.4 31.7 168.3 46.1 199.8 41.5 185.6 25.3 146.9 29.3 186.6 42.7 193.2 30.6 157.3 55.8 226.5 36.6 182.1 29.5 168.9 45.5 199.5 24.1 212.9 29.7 191.0 43.9 200.2 37.9 173.8 25.2 177.4 43.4 207.9 36.6 179.0 48.3 242.2 48.1 199.0 40.1 197.1 19.7 138.3 23.2 172.9 47.2 199.3 40.4 209.7 31.1 186.2 37.7 188.7 50.7 236.3 45.1 238.3 34.7 219.3 42.4 193.6 48.3 207.9 51.5 222.9 37.2 185.7 47.4 246.2 44.5 209.4 25.9 163.3 33.4 157.5 40.8 164.3 35.4 183.1 45.1 179.6 28.6 193.5 47.0 178.8 37.8 217.1 34.4 168.2 46.0 230.2 41.8 236.5 25.6 166.7 44.9 193.5 45.1 212.2 33.7 188.8 30.7 155.1 42.7 204.9 41.1 198.3 22.6 151.4 30.6 173.5 37.9 195.3 28.7 175.0 51.5 250.8 33.5 193.8 26.7 177.9 22 6.0 4.4 -20 4.6 25 5.3 22 3.6 16 3.5 20 3.9 20 5.2 ---22 5.7 21 5.1 4.3 -14 3.6 23 4.8 20 5.6 17 4.4 19 5.3 22 5.4 26 5.6 17 3.8 22 4.7 19 4.0 23 4.9 17 3.8 24 6.1 22 5.1 13 4.1 16 4.7 23 4.9 16 3.9 24 4.6 18 3.9 23 4.7 20 4.4 16 3.9 21 5.3 23 5.2 17 3.5 21 4.6 21 4.2 20-15 4.2 21 5.7 22 5.3 14 4.0 16 4.1 21 4.6 17 3.3 23 5.5 17 4.3 15 5.0 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 64 016 * * * * * * * ** * * * * * * * * * * * * * * * * * 20 7.9* 11 6.5 19 6.4 22 7.3* 20 5.9* 15 5.8 19 6.2 19 7.1 19-21 7.8 20 7.2 13 6.5 13 6.4 20 7.0* 18 7.2* 16 6.5 17 7.2* 21 7.6 24 6.9* 16 6.4 19 7.1* 20 6.1 20 7.1* 16 6.2 22 7.4* 20 7.3* 14 6.2 15 6.9 24 7.1 17 6.3 21 6.3* 18 6.6 20 6.2* 19 6.5 15 6.5 20 7.3 22 7.3 17 6.1 19 6.7* 19 6.6* 20-15 6.8 19 7.3* 21 7.2 13 6.3 16 6.3 19 6.7* 15 5.6* 20 7.9* 17 6.7 15 6.9 19 0 049 2012 2013 2016 2017 2013 2015 * 17% 47.7 15% 43.9 16% 2.9 * * * * * * * * 55.8 21 ---32.8 9 55.0 26 37.1 20 28.7 10 48.1 16 47.9 19 52.4 -49.2 23 48.4 19 24.3 -27.7 11 50.9 22 54.6 19 42.4 15 46.2 20 72.4 24 66.8 30 43.8 12 48.4 17 53.1 14 53.7 18 36.9 7 66.2 29 50.7 20 35.6 12 42.1 16 37.7 20 42.4 14 50.1 21 37.5 13 49.0 17 44.9 18 15-58.4 15 53.5 24 30.8 8 52.6 16 47.1 10 42.6 20 43.0 15 55.8 22 50.6 23 26.9 11 39.5 15 44.8 20 31.5 13 67.0 19 39.9 12 13-- * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 56.4 19 25.9 13 28.3 7 50.3 23 * 35.9 19 25.1 9 43.4 13 * 44.1 16 * 51.6 19 47.8 21 45.0 16 * 21.7 5 25.0 11 50.0 17 * 48.6 17 * 37.6 14 40.4 19 * 60.1 21 * * 57.7 26 * * 38.2 12 * 41.9 16 * 52.1 13 52.0 15 * 35.3 7 58.2 28 * 47.2 17 * 30.5 13 36.5 16 * 38.9 20 40.8 13 46.0 18 * 30.1 13 * 44.5 13 * 44.6 16 40.8 14 50.6 12 * * 48.9 23 28.0 9 48.4 12 * 8-39.5 18 38.5 15 50.9 19 * 46.0 20 * 23.3 10 34.8 15 41.0 15 * 28.5 12 59.5 16 * * 36.6 11 15-- 17 1.2 14 2.6 15 3.3 17 3.0 15 2.4 14 2.3 16 2.4 16 2.7 1815 3.9 16 2.9 14 2.8 14 2.5 16 3.2 16 3.1 16 2.7 17 2.9 18 3.0 16 3.0 16 2.1 17 2.6 16 2.8 16 3.4 16 3.1 17 2.9 16 3.5 15 3.3 16 3.0 15 3.6 17 2.3 16 3.2 15 2.9 17 5.5 16 2.6 15 2.7 16 3.4 16 3.2 14 2.7 17 3.1 15 3.4 1617 3.4 17 1.9 15 3.4 14 1.4 16 3.2 17 2.5 15 2.2 18 3.0 16 3.2 17 2.9 1711 00 rug costs andNotes: are adjusted * Denotes for regional a changewage of atdifferences; least 0.5 standard Medicare deviations. estimates Spending reflect estimates only the age exclude 65+ Medicare prescription fee-for-service drug costs and population. are adjusted — Indicates for regional that wage estimates differences; are not available. Medicare estimates r Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. Spending estimates exclude prescription drug costs and are adjusted for regional wage differences; Medicare estimates reflect only the age 65+ Medicare fee-for-service population. — Indicates that estimates are not available. commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance 49 AppendixE2. E2. Avoidable Hospital Use & Cost: Dimension Indicator Rates APPENDIX Avoidable Hospital Use & Cost: Dimension Ranking andRanking Indicatorand Rates (continued) facility ha ission 016 2012 19% 20 11 19 22 20 15 19 19 19 21 20 13 13 20 18 16 17 21 24 16 19 20 20 16 22 20 14 15 24 17 21 18 20 19 15 20 22 17 19 19 20 15 19 21 13 16 19 15 20 17 15 19 0 Nursing home residents with a hospital admission * * * * * * * * * * * * * * * * * * * Potentially avoidable Potentially avoidable emergency emergency Preventable Home Hospital health admissions patients department Adults withvisits Employer-sponsored department visits age Preventable hospitalizations age Hosp for pediatric asthma inappropriate ages 18–64 (rate per insurance 65 and older (rate per Medicare hospitalizations spendingages per 65 and older (rate per readmis with a hospital lowerspending (rate admission per 100,000) back 1,000) imaging per enrollee 1,000) 18–64 beneficiary (rate per 1,000) 1,000) 18–64 (r 2016 2013 2012 2015 2015 2016 2016 United 17% States 15% 16% 142.9 16% 87.2 * 71% 159.0 69% 142.2 Alabama 21 19 Alaska-13 Arizona9 7 Arkansas 26 23 California 20 19 Colorado 10 9 Connecticut 16 13 Delaware 19 16 District--of Columbia 19 Florida23 21 Georgia 19 16 Hawaii-5 Idaho11 11 Illinois22 17 Indiana 19 17 Iowa 15 14 Kansas 20 19 Kentucky 24 21 Louisiana 30 26 Maine12 12 Maryland 17 16 Massachusetts 14 13 Michigan 18 15 Minnesota 7 7 Mississippi 29 28 Missouri 20 17 Montana 12 13 Nebraska 16 16 Nevada 20 20 New Hampshire 14 13 New Jersey 21 18 New Mexico 13 13 New York 17 13 North18 Carolina 16 North15 Dakota 14 Ohio 15 12 Oklahoma 24 23 Oregon8 9 Pennsylvania 16 12 Rhode10Island 8 South20 Carolina 18 South15 Dakota 15 Tennessee 22 19 Texas23 20 Utah 11 10 Vermont 15 15 Virginia 20 15 Washington 13 12 West Virginia 19 16 Wisconsin 12 11 Wyoming 13 15 17 -61.9 14 124.7 15 80.6 17 95.8 15 129.1 14 136.3 16 16 -18 -143.1 15 96.6 16 68.6 14 14 -119.5 16 102.4 16 71.2 16 160.4 17 151.8 18 203.0 16 76.3 16 136.9 17 141.1 16 94.0 16 82.3 16 17 -161.2 16 76.6 15 82.1 16 112.3 15 17 -162.7 16 15 -231.5 17 113.3 16 15 -127.9 16 189.1 16 41.0 14 17 -149.0 15 133.0 16 76.2 17 72.9 17 114.3 15 93.4 14 27.6 16 100.0 17 83.6 15 98.1 18 86.0 16 122.7 17 17 -14 -84.4 15 * 69.0 17 86.8 14 * 100.4 15 * * 103.4 16 * 16 -15 --* 120.6 15 * 58.1 17 * * 50.1 15 * 14 -85.3 16 * 62.5 16 * 46.8 16 * 103.8 17 * 85.3 17 * * 16 -16 -93.3 15 * * 97.7 17 * * 94.2 16 53.2 16 * 17 -110.1 16 * 44.3 16 * * 42.0 16 * 109.7 16 * 18 --* 112.1 16 * 158.3 15 183.4 16 * * 77.7 16 * 44.4 15 102.3 16 * 109.1 15 * * 46.3 15 * 107.1 17 17 --* 16 -62.2 16 * 49.9 17 * 67.6 15 * 14 -21.7 16 56.0 16 * * 52.5 15 * 56.8 17 * * 62.1 15 * * 94.3 15 * * 171.5 59 166.0 75 175.7 68 157.1 68 130.0 75 147.4 74 162.9 67 150.6 72 -- -177.6 65 164.0 65 137.6 77 133.5 78 154.4 70 171.5 68 151.1 77 160.8 75 151.2 67 173.9 61 172.4 77 148.5 66 142.1 73 159.4 67 139.2 79 182.6 64 203.4 71 144.6 77 140.3 76 186.7 68 155.5 71 145.3 68 149.2 74 155.0 70 159.2 66 161.7 84 177.0 68 172.3 68 137.1 80 158.6 73 157.9 70 -- -143.3 82 168.3 64 175.6 65 131.9 74 163.5 77 168.4 66 137.5 78 181.7 65 163.8 73 165.8 73 157.4 58 149.8 69 * 148.8 67 144.0 65 * 117.7 74 133.1 70 * 142.8 68 141.2 69 * -- -163.8 66 149.9 64 122.3 71 * 137.9 69 * 142.4 68 151.7 66 134.6 76 145.0 72 * 136.4 67 150.3 61 150.2 73 * 131.7 67 125.6 71 141.9 68 127.6 73 * 155.0 64 186.8 65 * 136.4 69 * 131.7 75 184.9 62 * 131.7 68 * 125.6 68 143.5 73 122.4 70 142.5 65 133.1 72 * 158.3 67 157.4 66 124.8 76 * 140.3 70 * 135.9 67 * -- -125.9 74 * 152.5 63 159.9 64 115.9 70 * 137.4 75 * 150.9 66 125.8 77 159.5 66 142.4 72 144.5 69 * * * * * * * * * * * * * * * * * * Change States Improved 17 States Worsened 0 2017 2015 1128 90 2144 00 2013 2012 2016 2015 2013 2015 * $4,697 187.8 $4,882 196.9 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 3,706 191.7 7,186 204.7 4,453 177.9 3,117 185.0 4,915 166.9 4,625 172.7 5,067 189.3 4,509 159.0 3,548 247.9 4,748 178.9 4,951 200.6 3,460 130.8 4,906 162.1 4,575 192.0 4,955 199.9 3,784 183.6 4,079 172.9 4,393 218.7 4,404 236.3 4,661 232.5 3,683 192.9 4,659 208.9 3,903 214.2 4,483 180.5 3,982 230.9 4,266 196.7 4,553 158.5 4,507 152.6 4,022 165.4 5,245 192.2 4,771 170.3 4,407 169.9 5,279 172.6 4,497 197.4 4,306 187.2 4,464 218.7 4,312 211.1 4,300 161.9 4,185 186.7 4,018 187.7 176.4 -5,042 168.3 4,081 199.8 5,110 185.6 4,322 146.9 5,384 186.6 4,203 193.2 4,545 157.3 5,345 226.5 5,871 182.1 5,779 168.9 3,867 199.5 8,042 212.9 4,624 191.0 3,623 200.2 5,307 173.8 4,736 177.4 5,259 207.9 4,700 179.0 242.2 -5,044 199.0 4,786 197.1 3,299 138.3 5,282 172.9 4,904 199.3 5,510 209.7 3,851 186.2 4,391 188.7 4,134 236.3 4,330 238.3 4,998 219.3 3,819 193.6 4,603 207.9 3,848 222.9 4,814 185.7 3,255 246.2 4,563 209.4 4,847 163.3 5,215 157.5 4,227 164.3 5,725 183.1 5,063 179.6 4,995 193.5 6,053 178.8 4,764 217.1 4,786 168.2 4,696 230.2 4,634 236.5 4,754 166.7 4,246 193.5 4,242 212.2 188.8 -5,157 155.1 3,906 204.9 5,481 198.3 4,537 151.4 5,054 173.5 4,483 195.3 4,629 175.0 5,522 250.8 6,335 193.8 6,360 177.9 14 1216 2017 2016 $9,081 4.6 $9,534 5.3 * * ** * * * * * * * * ** * * * ** * * ** * * * * * * * * * * 9,479 6.0 5,792 4.4 8,197 4.6 8,798 5.3 8,564 3.6 7,628 3.5 9,255 3.9 8,792 5.2 8,981 -10,812 5.7 9,014 5.1 5,674 4.3 7,526 3.6 9,402 4.8 9,251 5.6 7,711 4.4 8,786 5.3 9,553 5.4 10,991 5.6 7,886 3.8 8,869 4.7 9,165 4.0 9,722 4.9 7,644 3.8 10,090 6.1 8,878 5.1 6,884 4.1 8,203 4.7 8,648 4.9 7,824 3.9 9,849 4.6 7,061 3.9 9,239 4.7 8,422 4.4 7,777 3.9 9,757 5.3 9,391 5.2 6,629 3.5 9,633 4.6 8,907 4.2 8,744 -7,380 4.2 9,331 5.7 10,381 5.3 8,116 4.0 7,030 4.1 8,294 4.6 7,359 3.3 8,792 5.5 7,888 4.3 6,856 5.0 10,463 7.9* 6,626 6.5* 8,751 6.4 9,799 7.3* 9,116 5.9 8,158 5.8 9,760 6.2 9,205 7.1 9,408 -10,953 7.8 9,484 7.2 6,195 6.5 8,020 6.4 9,850 7.0 9,640 7.2 8,335 6.5* 9,612 7.2* 9,900 7.6 11,257 6.9 8,604 6.4* 9,395 7.1 9,545 6.1 10,001 7.1 8,421 6.2* 10,819 7.4* 9,528 7.3* 7,552 6.2* 9,115 6.9* 9,203 7.1 8,352 6.3 10,208 6.3 7,729 6.6* 9,933 6.2* 9,003 6.5* 8,494 6.5* 9,862 7.3 10,498 7.3* 7,324 6.1* 9,753 6.7 9,141 6.6 9,002 -8,120 6.8* 9,762 7.3 10,848 7.2 8,654 6.3 7,626 6.3* 8,745 6.7 7,800 5.6 9,502 7.9* 8,229 6.7 7,613 6.9* 00 2149 2013 2017 2015 * 47.7 43.9 2.9 * * * * * * * * 55.8 -32.8 55.0 37.1 28.7 48.1 47.9 52.4 49.2 48.4 24.3 27.7 50.9 54.6 42.4 46.2 72.4 66.8 43.8 48.4 53.1 53.7 36.9 66.2 50.7 35.6 42.1 37.7 42.4 50.1 37.5 49.0 44.9 -58.4 53.5 30.8 52.6 47.1 42.6 43.0 55.8 50.6 26.9 39.5 44.8 31.5 67.0 39.9 -- 56.4 25.9 28.3 50.3 35.9 25.1 43.4 44.1 51.6 47.8 45.0 21.7 25.0 50.0 48.6 37.6 40.4 60.1 57.7 38.2 41.9 52.1 52.0 35.3 58.2 47.2 30.5 36.5 38.9 40.8 46.0 30.1 44.5 44.6 40.8 50.6 48.9 28.0 48.4 -39.5 38.5 50.9 46.0 23.3 34.8 41.0 28.5 59.5 36.6 -- 1.2 2.6 3.3 3.0 2.4 2.3 2.4 2.7 3.9 2.9 2.8 2.5 3.2 3.1 2.7 2.9 3.0 3.0 2.1 2.6 2.8 3.4 3.1 2.9 3.5 3.3 3.0 3.6 2.3 3.2 2.9 5.5 2.6 2.7 3.4 3.2 2.7 3.1 3.4 3.4 1.9 3.4 1.4 3.2 2.5 2.2 3.0 3.2 2.9 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 11 0 icates that estimates Notes: * Denotes are not available. a change of at least 0.5 standard deviations. Spending estimates exclude prescription drug costs and are adjusted for regional wage differences; Medicare estimates r Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. Spending estimates exclude prescription drug costs and are adjusted for regional wage differences; Medicare estimates reflect only the age 65+ Medicare fee-for-service population. — Indicates that estimates are not available. commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance 50 APPENDIX F1. Healthy Lives: Dimension and Indicator Ranking Top quartile Second quartile Third quartile Bottom quartile Data not available 1 2 3 4 5 5 7 8 9 10 11 12 12 14 14 16 17 18 19 20 20 22 23 23 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 Connecticut Minnesota Hawaii Massachusetts California Utah New York Washington New Hampshire Colorado Rhode Island Nebraska New Jersey Oregon Vermont North Dakota Idaho Wisconsin Virginia Arizona South Dakota Iowa Texas Wyoming Maryland Montana Kansas District of Columbia Illinois Maine Florida Michigan North Carolina Pennsylvania Delaware Alaska Georgia Missouri Nevada South Carolina Indiana New Mexico Ohio Tennessee Arkansas Alabama Louisiana Oklahoma Kentucky Mississippi West Virginia commonwealthfund.org M or t ca ali re ty am en Br ab ea le st to ca he nc al er th de Co a lo t h re s ct al ca nc Su er ic de id at ed hs ea th s Al co ho ld ea th s Dr ug po is on in gd In fa ea nt th m s or ta lit Ad y ul he t s w al h th o re po Ad rt ul fa ts ir wh or o po sm or Ad ok ul e ts wh o ar eo Ch be ild se o b re es n w e ho ar Ad eo ul ve m ts w rw or h ei et o gh ee ha to th ve r lo st si xo r Appendix F1. Healthy Lives: Dimension and Indicator Ranking Overall performance 1 1 2 1 2 1 2 1 1 1 1 1 2 1 1 2 1 2 3 2 2 2 3 2 3 2 3 4 3 1 3 3 3 3 3 2 4 4 4 4 3 3 3 4 4 4 4 4 4 4 4 2 1 1 2 2 3 1 2 1 2 1 2 3 2 1 2 4 1 4 2 1 1 3 1 4 1 2 4 3 2 2 2 4 3 4 1 4 3 3 3 3 3 4 3 3 3 4 4 4 4 4 1 1 1 1 1 1 2 2 2 1 1 2 2 2 3 1 2 1 3 2 3 3 3 1 3 1 3 2 4 2 2 3 2 3 3 4 3 3 4 3 4 2 4 4 4 4 4 4 4 4 4 1 2 2 1 1 4 1 3 3 4 1 2 1 3 3 4 4 2 1 3 4 2 1 4 1 4 3 1 1 3 2 2 2 2 1 4 2 3 4 3 3 4 2 3 4 3 2 3 3 2 4 2 3 1 2 3 2 1 4 3 4 2 3 1 4 3 4 3 3 1 4 4 3 1 4 1 4 3 2 1 3 3 2 2 1 2 4 1 1 4 3 2 4 2 3 1 1 1 4 2 1 3 4 1 2 4 1 3 2 2 4 2 4 1 4 1 3 1 2 2 2 3 1 1 1 1 4 1 1 4 3 4 3 3 3 4 4 2 2 3 3 2 3 3 4 3 2 2 3 2 4 1 4 1 2 2 1 1 2 1 1 1 1 2 3 1 1 1 3 2 3 2 2 1 2 2 1 3 2 2 4 3 2 3 3 4 3 4 2 4 3 2 3 4 3 4 4 4 4 4 4 3 4 4 1 1 1 1 2 1 2 2 1 1 2 1 3 2 1 1 1 2 1 4 1 1 4 1 1 1 2 1 3 2 3 3 3 3 3 3 3 3 4 3 4 4 3 4 4 4 4 4 4 4 4 1 1 1 1 1 1 1 1 2 2 2 2 1 2 2 3 1 2 2 2 3 2 2 3 1 2 2 1 2 2 2 3 2 3 2 4 2 4 3 3 4 3 4 4 4 4 4 4 4 4 4 1 1 1 1 1 1 1 1 1 1 2 3 1 2 1 3 2 3 2 2 3 4 3 2 2 1 3 1 2 2 2 3 3 2 2 4 3 3 1 4 4 2 4 4 4 4 4 4 4 4 4 1 1 3 1 3 1 3 1 1 2 3 2 4 1 3 1 1 1 2 1 1 3 3 2 4 2 3 4 4 2 4 3 3 2 2 1 3 1 2 3 1 4 3 4 2 3 2 4 4 4 4 1 1 1 1 1 1 2 1 2 1 1 1 2 2 2 1 1 2 2 1 2 1 1 3 1 3 2 1 1 4 3 3 3 3 3 2 4 4 3 4 3 2 4 4 4 4 4 4 4 4 4 June 2019 2019 Scorecard on State Health System Performance 51 APPENDIX Lives: Dimension Ranking and Indicator Rates AppendixF2. F2.Healthy Healthy Lives: Dimension Ranking and Indicator Rates Mortality amenable to health care (rate per 100,000) 2010-11 2014-15 Breast cancer deaths (rate per 100,000) Colorectal cancer deaths (rate per 100,000) Infant mortality (rate per 1,000) Adults who report fair or poor health Adults who sm 2013 2017 2013 2017 2012 2016 2013 2017 2013 20 United States 85.3 84.3 20.8 19.9 14.6 12.9 * 6.0 5.9 16% 17% 18% 1 Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 111.8 72.1 73.8 115.7 73.4 62.3 63.8 87.7 130.3 80.9 103.0 70.0 65.8 90.2 93.1 73.0 78.2 106.6 121.2 65.3 91.8 63.7 92.5 57.1 133.2 94.9 69.3 66.1 93.7 60.2 78.5 77.8 82.2 93.9 69.9 96.0 113.9 65.0 85.8 73.3 102.8 75.2 110.2 93.3 61.9 57.9 83.4 64.1 104.8 72.1 76.0 110.4 73.2 73.5 123.6 70.8 62.7 59.1 83.4 127.9 80.9 103.5 76.1 64.9 87.7 92.2 70.6 80.1 108.6 124.9 66.2 90.3 59.9 92.2 54.7 142.4 95.7 71.2 68.2 95.5 57.7 73.1 80.0 77.1 93.6 73.3 94.5 126.3 * 62.6 82.6 68.2 99.2 75.8 113.3 95.3 60.7 61.4 80.2 62.4 106.9 69.4 73.8 21.4 19.3 20.6 21.4 20.1 18.1 18.7 21.3 29.8 19.6 22.5 15.5 22.1 22.2 21.8 18.7 18.5 21.1 23.9 18.8 21.5 18.4 21.2 19.6 23.3 22.0 19.9 21.0 22.5 19.8 23.2 17.3 20.6 20.4 17.9 22.9 22.9 19.9 21.8 19.4 21.3 19.9 22.4 20.2 20.3 18.5 21.1 20.5 21.6 20.4 20.5 21.3 16.3 18.1 20.8 19.4 19.4 18.4 22.3 24.3 18.6 21.8 15.6 21.6 20.4 21.0 18.0 18.5 21.4 23.6 18.6 21.6 18.5 19.3 16.7 25.5 21.2 17.8 19.5 21.1 16.3 19.9 20.4 17.9 21.5 19.6 22.0 22.4 18.4 20.9 16.6 20.7 17.3 20.9 19.7 20.1 17.4 21.8 19.3 22.5 17.4 16.5 17.7 16.4 13.3 17.7 13.2 12.3 11.9 13.8 14.3 13.7 14.9 14.2 13.4 15.9 15.4 15.6 15.4 17.1 18.4 12.5 14.3 13.1 14.8 12.8 18.8 15.7 12.4 15.2 16.8 12.8 14.9 14.5 14.0 13.3 15.9 16.3 17.5 14.4 15.9 13.2 15.0 16.7 16.6 14.7 10.9 14.3 13.8 12.8 19.8 14.1 12.6 15.2 15.4 12.2 14.9 11.7 11.1 9.3 12.9 12.6 12.5 14.0 11.2 12.7 14.1 14.8 12.9 13.9 16.0 15.8 12.4 12.8 10.7 12.8 11.1 16.4 13.6 11.7 12.7 16.2 12.4 12.6 12.7 12.2 12.1 10.2 14.3 16.1 11.9 13.6 10.0 12.8 13.3 14.4 13.0 9.8 13.8 12.9 11.9 15.2 11.6 9.8 8.9 5.1 5.8 7.1 4.5 4.6 5.3 7.6 7.9 6.1 6.2 4.9 5.4 6.5 6.7 5.3 6.3 7.2 8.1 7.0 6.4 4.2 6.9 5.0 8.9 6.6 5.9 4.7 4.9 4.2 4.4 6.8 5.0 7.4 6.3 7.5 7.5 5.4 7.1 6.5 7.5 8.3 7.2 5.8 4.8 4.3 6.5 5.3 7.2 5.7 5.6 9.0 5.2 5.3 8.2 4.2 4.8 4.8 7.8 7.2 6.1 7.5 6.0 5.8 6.4 7.4 6.0 6.0 6.8 8.0 5.8 6.5 3.9 6.4 5.1 8.7 6.6 5.8 6.1 5.8 3.7 4.0 6.2 4.5 7.2 6.4 7.4 7.5 4.7 6.2 5.6 7.0 4.9 7.4 5.7 5.4 3.5 5.9 4.3 7.2 6.3 5.0 20 14 16 22 18 12 11 16 11 18 17 12 13 15 16 12 14 21 20 13 13 12 16 11 21 17 14 12 16 11 15 19 16 17 12 16 19 16 15 14 17 10 21 17 11 11 14 15 22 14 14 20 17 18 21 16 14 12 17 9 17 17 13 14 17 19 13 15 23 20 15 14 14 17 11 22 17 14 13 19 13 17 20 15 17 13 17 20 16 17 16 17 12 18 19 12 13 14 15 24 16 14 21 23 16 26 12 18 16 20 19 17 19 13 17 18 22 19 20 26 24 20 16 17 21 18 25 22 19 18 19 16 16 19 17 20 21 23 24 17 21 17 22 20 23 16 10 17 19 16 27 19 21 Change States Improved 0 States Worsened 1 Notes: * Denotes a change of at least 0.5 standard deviations. 20 5 * * * * * * * * * * * * * * * * * * * * * * * * * 39 0 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 8 8 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 3 18 Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance 52 APPENDIX Lives: Dimension Ranking and Indicator Rates (continued) AppendixF2. F2.Healthy Healthy Lives: Dimension Ranking and Indicator Rates y (rate ) 016 Adults who report fair or poor health 2013 2017 Mortality amenable to Colorectal cancer health care (rate per Breast cancer deaths Children deathswho (rateare per Adults100,000) who smoke Adults (rate who perare 100,000) obese overweight 100,000) or obese 2010-11 2013 2014-15 2017 5.9 United 16% States17% 18% 85.3 9.0 5.2 5.3 8.2 4.2 4.8 4.8 7.8 7.2 6.1 7.5 6.0 5.8 6.4 7.4 6.0 6.0 6.8 8.0 5.8 6.5 3.9 6.4 5.1 8.7 6.6 5.8 6.1 5.8 3.7 4.0 6.2 4.5 7.2 6.4 7.4 7.5 4.7 6.2 5.6 7.0 4.9 7.4 5.7 5.4 3.5 5.9 4.3 7.2 6.3 5.0 Alabama 20 20 Alaska 14 17 Arizona 16 18 Arkansas 22 21 California 18 16 Colorado 12 14 Connecticut 11 12 Delaware 16 17 District 11of Columbia9 Florida 18 17 Georgia 17 17 Hawaii 12 13 Idaho13 14 Illinois15 17 Indiana 16 19 Iowa 12 13 Kansas 14 15 Kentucky 21 23 Louisiana 20 20 Maine 13 15 Maryland 13 14 Massachusetts 12 14 Michigan 16 17 Minnesota 11 11 Mississippi 21 22 Missouri 17 17 Montana 14 14 Nebraska 12 13 Nevada 16 19 New Hampshire 11 13 New Jersey 15 17 New Mexico 19 20 New York 16 15 North17 Carolina 17 North12 Dakota 13 Ohio 16 17 Oklahoma 19 20 Oregon 16 16 Pennsylvania 15 17 Rhode14Island 16 South17 Carolina 17 South10 Dakota 12 Tennessee 21 18 Texas17 19 Utah 11 12 Vermont 11 13 Virginia 14 14 Washington 15 15 West22 Virginia 24 Wisconsin 14 16 Wyoming 14 14 111.8 21 23 72.1 16 73.8 115.7 26 12 73.4 18 62.3 16 63.8 20 87.7 130.3 19 17 80.9 103.0 19 13 70.0 17 65.8 18 90.2 22 93.1 19 73.0 20 78.2 106.6 26 121.2 24 20 65.3 16 91.8 17 63.7 21 92.5 18 57.1 133.2 25 22 94.9 19 69.3 18 66.1 19 93.7 16 60.2 16 78.5 19 77.8 17 82.2 20 93.9 21 69.9 23 96.0 113.9 24 17 65.0 21 85.8 17 73.3 102.8 22 20 75.2 110.2 23 16 93.3 10 61.9 17 57.9 19 83.4 16 64.1 104.8 27 19 72.1 21 76.0 8 8 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 16% 84.3* 110.4 21 21 73.2* 16 73.5 123.6 22 * 11 70.8 15 62.7* 13 59.1* 17 83.4* 127.9 14 * 16 80.9 103.5 17 * 13 76.1 14 64.9* 15 87.7* 22 92.2 17 70.6* 17 80.1* 108.6 25 124.9 23 17 66.2* 14 90.3* 14 59.9* 19 92.2* 14 54.7* 142.4 22 * 21 95.7 17 71.2* 15 68.2* 18 95.5 16 57.7 14 73.1* 18 80.0 14 77.1* 17 93.6* 18 73.3* 21 94.5* 126.3 20 * * 16 62.6 19 82.6* 15 68.2* 19 99.2* 19 75.8 113.3 23 16 95.3 60.7 9 16 61.4 16 80.2* 14 62.4* 106.9 26 16 69.4* 19 73.8* 2013 2013 2017 2017 2016 2013 29% 20.8 31% 19.9* 31% 14.6 33 21.4 28 19.3 28 20.6 37 21.4 25 20.1 22 18.1 25 18.7 31 21.3 23 29.8 27 19.6 31 22.5 23 15.5 30 22.1 30 22.2 32 21.8 32 18.7 31 18.5 34 21.1 33 23.9 29 18.8 29 21.5 24 18.4 32 21.2 26 19.6 37 23.3 31 22.0 25 19.9 30 21.0 27 22.5 27 19.8 27 23.2 28 17.3 25 20.6 30 20.4 31 17.9 31 22.9 34 22.9 27 19.9 30 21.8 27 19.4 33 21.3 30 19.9 35 22.4 32 20.2 24 20.3 25 18.5 27 21.1 27 20.5 37 21.6 29 20.4 29 20.5 38 21.3* 34 16.3* 31 18.1* 36 20.8 25 19.4 23 19.4 27 18.4* 31 22.3 23 24.3 30 18.6* 32 21.8 25 15.6* 30 21.6 31 20.4 34 21.0* 38 18.0* 33 18.5* 35 21.4 37 23.6* 30 18.6 31 21.6* 26 18.5* 32 19.3 28 16.7* 38 25.5 33 21.2* 26 17.8 33 19.5* 27 21.1 28 16.3 28 19.9 30 20.4* 25 17.9 33 21.5* 33 19.6* 35 22.0* 38 22.4* 29 18.4* 31 20.9 31 16.6* 36 20.7* 32 17.3* 34 20.9 33 19.7 25 20.1 28 17.4* 31 21.8* 28 19.3 40 22.5* 33 17.4* 29 16.5 35 17.7 26 16.4 27 13.3 34 17.7 31 13.2 27 12.3 30 11.9 31 13.8 34 14.3 37 13.7 32 14.9 25 14.2 26 13.4 27 15.9 34 15.4 30 15.6 31 15.4 34 17.1 34 18.4 28 12.5 34 14.3 27 13.1 32 14.8 28 12.8 37 18.8 29 15.7 23 12.4 29 15.2 30 16.8 24 12.8 32 14.9 25 14.5 32 14.0 31 13.3 37 15.9 33 16.3 34 17.5 20 14.4 32 15.9 36 13.2 33 15.0 31 16.7 38 16.6 33 14.7 19 10.9 22 14.3 27 13.8 25 12.8 35 19.8 30 14.1 27 12.6 Change States Improved 3 32 0 States Worsened18 0 1 Notes: * Denotes a change of at least 0.5 standard deviations. 020 28 5 * * * * * * * * * * * * * * * * * * * * * * * * * Adults Infantwho mortality have lost (rate six or per more 1,000) teeth 2017 2017 31% 12.9 * 33 15.2 24 15.4 24 12.2* 27 14.9* 30 11.7 28 11.1 219.3* 29 12.9 36 12.6 36 12.5 33 14.0 30 11.2* 23 12.7* 34 14.1* 26 14.8* 33 12.9* 32 13.9 40 16.0* 28 15.8* 29 12.4 36 12.8 26 10.7 33 12.8 25 11.1* 41 16.4* 26 13.6* 28 11.7* 29 12.7 28 16.2 25 12.4 35 12.6* 34 12.7* 31 12.2 30 12.1 22 10.2* 32 14.3 37 16.1* 24 11.9* 29 13.6* 31 10.0* 33 12.8 24 13.3* 38 14.4 31 13.0 269.8* 33 13.8* 28 12.9 25 11.9 35 15.2 26 11.6* 299.8 1339 12 0 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Adults who report fair or poor health Adults who sm 2012 2012 2016 2016 2013 2017 2013 20 10%6.0 10%5.9 16% 17% 18% 1 178.9 95.1 105.8 177.1 74.5 74.6 85.3 107.6 77.9 116.1 136.2 64.9 95.4 96.5 136.7 95.3 106.3 167.2 178.1 147.0 96.4 94.2 116.9 75.0 188.9 126.6 115.9 84.7 114.9 104.2 94.4 106.8 105.0 137.4 96.3 137.5 147.5 105.4 117.1 96.5 157.5 98.3 187.2 85.8 64.8 114.3 116.5 85.3 237.2 115.7 115.6 159.0* 105.2 85.3* 168.2 64.2 74.8 74.8 117.8 67.2 126.1 137.5 66.0 85.8 86.4 127.4 86.0 96.0 176.8 148.0* 145.8 76.5* 83.9 116.4 75.1 188.7 146.6* 115.8 76.1 115.8 103.7 94.0 106.2 94.5 127.2 86.4 147.4 147.5 104.7 116.2 85.6 137.0* 94.9 137.4* 75.7 65.4 103.5 95.9* 74.3 217.2* 106.3 125.0 20 14 16 22 18 12 11 16 11 18 17 12 13 15 16 12 14 21 20 13 13 12 16 11 21 17 14 12 16 11 15 19 16 17 12 16 19 16 15 14 17 10 21 17 11 11 14 15 22 14 14 20 17 18 21 16 14 12 17 9 17 17 13 14 17 19 13 15 23 20 15 14 14 17 11 22 17 14 13 19 13 17 20 15 17 13 17 20 16 17 16 17 12 18 19 12 13 14 15 24 16 14 21 23 16 26 12 18 16 20 19 17 19 13 17 18 22 19 20 26 24 20 16 17 21 18 25 22 19 18 19 16 16 19 17 20 21 23 24 17 21 17 22 20 23 16 10 17 19 16 27 19 21 8 8 1 8 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 3 18 Notes: * Denotes a change of at least 0.5 standard deviations. ** Denotes a change of 1.0 standard deviation or more. commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance 53 Appendix Deaths from Suicide, Alcohol, and Drugs, 2005-2017 APPENDIX F3.F3. Deaths from Suicide, Alcohol, and Drugs, 2005-2017 Suicide deaths (rate per 100,000) 2005 United States 10.9 2013 12.6 Alabama 11.5 14.4 Alaska 19.9 23.2 Arizona 16.4 17.5 Arkansas 14.3 17.3 California 9.1 10.2 Colorado 17.2 18.6 Connecticut 8.1 8.7 Delaware 9.7 12.5 District of Columbia 5.4 5.7 Florida 12.5 13.8 Georgia 10.6 12.0 Hawaii 8.2 11.8 Idaho 16.5 19.2 Illinois 8.6 9.9 Indiana 11.8 14.2 Iowa 11.2 14.4 Kansas 13.3 14.7 Kentucky 13.4 15.5 Louisiana 11.0 12.4 Maine 12.4 17.4 Maryland 8.4 9.2 Massachusetts 7.2 8.2 Michigan 11.0 12.9 Minnesota 10.5 12.1 Mississippi 12.7 13.0 Missouri 12.5 15.6 Montana 21.7 23.7 Nebraska 10.9 11.6 Nevada 19.8 18.6 New Hampshire 12.0 12.8 New Jersey 6.1 8.0 New Mexico 17.8 20.3 New York 6.0 8.1 North Carolina 11.5 12.6 North Dakota 13.7 17.3 Ohio 11.5 12.9 Oklahoma 14.8 17.2 Oregon 14.9 16.8 Pennsylvania 11.1 13.4 Rhode Island 6.3 12.2 South Carolina 11.8 14.0 South Dakota 15.4 18.0 Tennessee 14.0 15.4 Texas 10.9 11.7 Utah 15.4 21.4 Vermont 12.5 16.8 Virginia 11.2 12.5 Washington 12.8 14.0 West Virginia 13.2 16.4 Wisconsin 11.6 14.4 Wyoming 17.3 21.5 Notes: — Indicates that estimates are not available. 2017 Alcohol deaths (rate per 100,000) % Change 20052017 2005 2013 2017 Drug p (rate % Change 20052017 2005 14.0 28% 7.0 8.2 9.6 37% 10.1 13.8 16.6 27.0 18.2 20.8 10.5 20.3 10.5 11.6 6.6 14.0 13.6 15.2 23.2 11.2 16.3 15.0 19.1 16.9 15.2 18.9 9.8 9.5 14.1 13.8 15.0 18.5 28.9 14.7 20.3 18.9 8.3 23.3 8.1 14.3 20.1 14.8 19.1 19.0 15.0 11.8 16.3 22.5 16.8 13.4 22.7 18.3 13.4 16.9 21.1 15.4 26.9 44 36 11 45 15 18 30 20 22 12 28 85 41 30 38 34 44 26 38 52 17 32 28 31 18 48 33 35 3 58 36 31 35 24 47 29 29 28 35 87 38 46 20 23 47 46 20 32 60 33 55 5.2 19.5 11.3 4.9 11.2 10.5 4.8 6.2 14.5 8.0 5.7 3.5 9.5 4.4 4.9 6.1 6.3 5.6 4.6 8.2 4.7 5.5 6.8 6.5 5.5 5.5 12.1 6.4 8.9 7.5 5.2 16.2 5.2 6.7 10.9 6.1 9.3 13.4 3.5 4.9 8.3 11.0 6.9 5.8 6.7 7.5 4.4 9.4 5.3 7.9 11.6 4.7 16.7 16.0 5.9 11.2 13.8 6.8 6.0 9.9 8.8 6.2 4.5 11.9 5.8 7.3 9.0 6.8 6.6 5.8 8.5 4.8 6.2 7.8 8.7 5.3 6.5 16.8 9.1 11.8 10.3 5.4 22.7 6.7 7.6 13.5 6.8 11.4 15.5 5.2 10.1 7.4 13.7 8.3 6.5 8.4 12.7 5.2 13.3 7.3 8.9 16.3 6.8 20.2 16.2 7.9 11.6 16.5 8.2 9.2 9.3 9.9 7.3 5.8 11.6 7.7 9.6 11.5 9.8 9.6 6.6 11.3 5.5 8.4 9.1 10.0 6.3 7.9 20.7 11.8 14.8 10.3 6.3 30.6 7.0 8.4 14.0 8.9 14.1 17.4 6.0 9.6 10.5 20.2 10.2 7.9 9.3 11.8 7.1 13.4 11.6 11.2 20.3 31 4 43 61 4 57 71 48 -36 24 28 66 22 75 96 89 56 71 43 38 17 53 34 54 15 44 71 84 66 37 21 89 35 25 28 46 52 30 71 96 27 84 48 36 39 57 61 43 119 42 75 6.3 11.4 14.1 10.1 9.0 12.7 8.5 7.5 13.7 13.5 8.2 9.4 8.1 8.4 9.8 4.8 9.1 15.3 14.7 12.4 11.4 12.0 9.8 5.4 8.8 10.7 10.1 5.0 18.7 10.7 9.4 20.1 4.8 11.4 -10.9 13.8 10.4 13.2 14.3 9.9 5.5 14.5 8.5 19.3 8.5 7.5 13.0 10.5 9.3 4.9 12.7 14.4 18.7 11.1 11.1 15.5 16.0 18.7 15.0 12.6 10.8 11.0 13.4 12.1 16.6 9.3 12.0 23.7 17.8 13.2 14.6 16.0 15.9 9.6 10.8 17.5 14.5 6.5 21.1 15.1 14.5 22.6 11.3 12.9 2.8 20.8 20.6 11.3 19.4 22.4 13.0 6.9 18.1 9.3 22.1 15.1 10.2 13.4 32.2 15.0 17.2 Notes: — Indicates that estimates are not available. commonwealthfund.org 2013 June 2019 2019 Scorecard on State Health System Performance 54 2017 APPENDIX Appendix Deaths from Suicide, Alcohol, and Drugs, 2005-2017 F3.F3. Deaths from Suicide, Alcohol, and Drugs, 2005-2017 (continued) Alcohol deaths rate per 100,000) 13 8.2 4.7 16.7 16.0 5.9 11.2 13.8 6.8 6.0 9.9 8.8 6.2 4.5 11.9 5.8 7.3 9.0 6.8 6.6 5.8 8.5 4.8 6.2 7.8 8.7 5.3 6.5 16.8 9.1 11.8 10.3 5.4 22.7 6.7 7.6 13.5 6.8 11.4 15.5 5.2 10.1 7.4 13.7 8.3 6.5 8.4 12.7 5.2 13.3 7.3 8.9 16.3 2017 DrugSuicide poisoning deaths deaths (rateper per100,000) 100,000) (rate % Change 20052017 United 9.6 States 37% 2005 2005 10.1 10.9 2013 2013 2017 2017 13.8 12.6 Alabama 6.8 31 11.5 6.3 12.7 14.4 Alaska 20.2 4 11.4 19.9 14.4 23.2 Arizona 16.2 43 14.1 16.4 18.7 17.5 Arkansas 7.9 61 10.1 14.3 11.1 17.3 California 11.6 4 9.0 9.1 11.1 10.2 Colorado 16.5 57 12.7 17.2 15.5 18.6 Connecticut 8.2 71 8.5 8.1 16.0 8.7 Delaware 9.2 48 7.5 9.7 18.7 12.5 District 9.3 of Columbia-36 13.7 5.4 15.0 5.7 Florida 9.9 24 13.5 12.5 12.6 13.8 Georgia 7.3 28 10.6 8.2 10.8 12.0 Hawaii 5.8 66 9.4 8.2 11.0 11.8 Idaho 11.6 22 16.5 8.1 13.4 19.2 Illinois 7.7 75 8.4 8.6 12.1 9.9 Indiana 9.6 96 11.8 9.8 16.6 14.2 Iowa 11.5 89 11.2 4.8 14.4 9.3 Kansas 9.8 56 13.3 9.1 12.0 14.7 Kentucky 9.6 71 15.3 13.4 23.7 15.5 Louisiana 6.6 43 14.7 11.0 17.8 12.4 Maine 11.3 38 12.4 12.4 13.2 17.4 Maryland 5.5 17 11.4 8.4 14.6 9.2 Massachusetts 8.4 53 12.0 7.2 16.0 8.2 Michigan 9.1 34 11.0 9.8 15.9 12.9 Minnesota 10.0 54 10.5 5.4 12.1 9.6 Mississippi 6.3 15 12.7 8.8 10.8 13.0 Missouri 7.9 44 10.7 12.5 17.5 15.6 Montana 20.7 71 10.1 21.7 14.5 23.7 Nebraska 11.8 84 10.9 5.0 11.6 6.5 Nevada 14.8 66 18.7 19.8 21.1 18.6 New 10.3Hampshire 37 10.7 12.0 15.1 12.8 New 6.3Jersey 21 9.4 6.1 14.5 8.0 New 30.6Mexico 89 20.1 17.8 22.6 20.3 New 7.0York 35 4.8 6.0 11.3 8.1 North 8.4 Carolina 25 11.4 11.5 12.9 12.6 North 14.0 Dakota 28 13.7 -17.3 2.8 Ohio 8.9 46 10.9 11.5 20.8 12.9 Oklahoma 14.1 52 13.8 14.8 20.6 17.2 Oregon 17.4 30 10.4 14.9 11.3 16.8 Pennsylvania 6.0 71 13.2 11.1 19.4 13.4 Rhode 9.6 Island 96 14.3 6.3 22.4 12.2 South 10.5 Carolina 27 11.8 9.9 13.0 14.0 South 20.2 Dakota 84 15.4 5.5 18.0 6.9 Tennessee 10.2 48 14.5 14.0 18.1 15.4 Texas 7.9 36 10.9 8.5 11.7 9.3 Utah 9.3 39 19.3 15.4 22.1 21.4 Vermont 11.8 57 12.5 8.5 15.1 16.8 Virginia 7.1 61 11.2 7.5 10.2 12.5 Washington 13.4 43 13.0 12.8 13.4 14.0 West 11.6 Virginia 119 10.5 13.2 32.2 16.4 Wisconsin 11.2 42 11.6 9.3 15.0 14.4 Wyoming 20.3 75 17.3 4.9 17.2 21.5 Notes: — Indicates that estimates are not available. Alcohol deaths (rate per 100,000) %%Change Change200520052017 2017 2005 2013 2017 Drug p (rate % Change 20052017 2005 21.7 14.0 115% 28% 7.0 8.2 9.6 37% 10.1 13.8 18.0 16.6 20.2 27.0 22.2 18.2 15.5 20.8 11.7 10.5 17.6 20.3 30.9 10.5 37.0 11.6 44.0 6.6 25.1 14.0 14.7 13.6 13.8 15.2 14.4 23.2 21.6 11.2 29.4 16.3 11.5 15.0 11.8 19.1 37.2 16.9 24.5 15.2 34.4 18.9 36.3 9.8 31.8 9.5 27.8 14.1 13.3 13.8 12.2 15.0 23.4 18.5 11.7 28.9 14.7 8.1 21.6 20.3 37.0 18.9 30.0 8.3 24.8 23.3 19.4 8.1 24.1 14.3 20.1 9.2 46.3 14.8 20.1 19.1 12.4 19.0 44.3 15.0 31.0 11.8 20.5 16.3 22.5 8.5 26.6 16.8 10.5 13.4 22.3 22.7 23.2 18.3 17.9 13.4 15.2 16.9 57.8 21.1 21.2 15.4 12.2 26.9 186 44 77 36 57 11 53 45 30 15 39 18 264 30 393 20 221 22 86 12 79 28 47 85 78 41 157 30 200 38 140 34 30 44 143 26 67 38 177 52 218 17 165 32 184 28 146 31 39 18 119 48 16 33 62 35 163 246 58 219 36 23 31 304 35 111 24 47 -325 29 46 29 19 28 236 35 117 87 107 38 55 46 83 20 24 23 16 47 173 46 139 20 17 32 450 60 128 33 149 55 5.2 19.5 11.3 4.9 11.2 10.5 4.8 6.2 14.5 8.0 5.7 3.5 9.5 4.4 4.9 6.1 6.3 5.6 4.6 8.2 4.7 5.5 6.8 6.5 5.5 5.5 12.1 6.4 8.9 7.5 5.2 16.2 5.2 6.7 10.9 6.1 9.3 13.4 3.5 4.9 8.3 11.0 6.9 5.8 6.7 7.5 4.4 9.4 5.3 7.9 11.6 4.7 16.7 16.0 5.9 11.2 13.8 6.8 6.0 9.9 8.8 6.2 4.5 11.9 5.8 7.3 9.0 6.8 6.6 5.8 8.5 4.8 6.2 7.8 8.7 5.3 6.5 16.8 9.1 11.8 10.3 5.4 22.7 6.7 7.6 13.5 6.8 11.4 15.5 5.2 10.1 7.4 13.7 8.3 6.5 8.4 12.7 5.2 13.3 7.3 8.9 16.3 6.8 20.2 16.2 7.9 11.6 16.5 8.2 9.2 9.3 9.9 7.3 5.8 11.6 7.7 9.6 11.5 9.8 9.6 6.6 11.3 5.5 8.4 9.1 10.0 6.3 7.9 20.7 11.8 14.8 10.3 6.3 30.6 7.0 8.4 14.0 8.9 14.1 17.4 6.0 9.6 10.5 20.2 10.2 7.9 9.3 11.8 7.1 13.4 11.6 11.2 20.3 31 4 43 61 4 57 71 48 -36 24 28 66 22 75 96 89 56 71 43 38 17 53 34 54 15 44 71 84 66 37 21 89 35 25 28 46 52 30 71 96 27 84 48 36 39 57 61 43 119 42 75 6.3 11.4 14.1 10.1 9.0 12.7 8.5 7.5 13.7 13.5 8.2 9.4 8.1 8.4 9.8 4.8 9.1 15.3 14.7 12.4 11.4 12.0 9.8 5.4 8.8 10.7 10.1 5.0 18.7 10.7 9.4 20.1 4.8 11.4 -10.9 13.8 10.4 13.2 14.3 9.9 5.5 14.5 8.5 19.3 8.5 7.5 13.0 10.5 9.3 4.9 12.7 14.4 18.7 11.1 11.1 15.5 16.0 18.7 15.0 12.6 10.8 11.0 13.4 12.1 16.6 9.3 12.0 23.7 17.8 13.2 14.6 16.0 15.9 9.6 10.8 17.5 14.5 6.5 21.1 15.1 14.5 22.6 11.3 12.9 2.8 20.8 20.6 11.3 19.4 22.4 13.0 6.9 18.1 9.3 22.1 15.1 10.2 13.4 32.2 15.0 17.2 Notes: — Indicates that estimates are not available. commonwealthfund.org 2013 June 2019 2019 Scorecard on State Health System Performance 55 APPENDIX G1. Disparity: Dimension and Indicator Ranking 1 2 3 4 5 6 7 8 9 9 11 12 13 14 15 16 17 17 19 19 21 22 23 24 25 26 27 28 29 30 31 32 32 34 35 36 37 38 39 40 40 42 43 43 45 46 47 48 49 50 51 Hawaii New York New Mexico California Minnesota Washington Massachusetts Idaho Louisiana Pennsylvania Colorado Maine Rhode Island Alaska Utah Arizona Oregon Vermont Iowa North Dakota New Jersey Connecticut District of Columbia Nevada Montana Michigan Wisconsin Delaware Illinois West Virginia Nebraska Florida South Dakota Mississippi Maryland Alabama Wyoming New Hampshire Tennessee Kansas Kentucky Ohio Georgia Indiana Oklahoma North Carolina South Carolina Texas Virginia Arkansas Missouri commonwealthfund.org 1 1 2 2 2 2 1 3 2 1 2 3 1 2 3 3 2 1 1 3 3 2 1 3 2 1 2 1 3 1 4 4 4 4 2 3 4 2 3 4 1 2 4 3 4 4 4 4 4 2 3 0 1 0 1 2 1 1 0 1 3 2 0 0 4 4 4 2 0 2 0 2 1 0 4 0 2 2 0 2 0 0 3 0 0 2 1 0 0 1 4 2 2 4 4 2 3 3 4 3 2 4 ou ta us Ad ua ul t ls be s w ou ca h rc us o w eo eo e f f c nt w Hi os it gh ho t ut sp o u en t-o ca re d i f-p ng o ck et Ad m ul ed ts ic wi al th ou ta de Ad nt ul al ca t s w vi nc i t si t er ho sc u t re a en ll r Ad in ec ul gs o m t va s w m cc i t en i n ho de es u ta d ll Ch re ild co re m n m wi en th de ou d t Ch am ild ed d e re ic al nt n w ho al it p r ho m ev ut e e Ch nt a m ild iv e e c di re re ar ca co n w ev l a m it m ho i s nd it en u de t a Ho d ll sp va as ita cc th l a in es m dm a Ad ul ca t s w re i t h re d su in Un Un in su re d ch ad u ild lts Top quartile Second quartile Third quartile Bottom quartile Data not available re n Appendix G1. Disparity: Dimension and Indicator Ranking Overall performance 1 3 4 4 2 3 3 4 1 1 3 2 2 2 3 4 3 1 3 1 2 3 2 4 2 2 1 3 2 1 4 3 3 1 4 2 4 1 1 4 1 2 4 3 3 4 1 4 4 2 2 2 2 1 2 1 1 1 3 3 1 2 1 2 1 3 2 3 1 1 2 3 2 1 4 2 2 3 2 3 2 3 4 4 4 3 4 4 1 3 4 1 1 4 3 4 4 3 4 4 3 4 1 1 1 1 2 2 3 4 2 2 4 2 1 1 4 1 4 2 3 4 2 3 1 1 4 2 3 1 2 3 3 1 3 1 2 4 4 4 3 4 1 2 2 2 1 3 3 2 4 3 3 1 1 2 4 1 4 1 4 3 2 2 3 2 1 2 3 2 4 3 4 2 1 1 3 1 1 2 4 1 4 4 2 2 2 4 2 2 1 3 3 2 2 3 4 2 1 4 4 2 3 4 4 1 1 1 2 2 3 1 1 1 1 3 1 1 2 1 4 4 2 4 1 3 2 2 4 3 1 4 1 2 3 2 4 2 2 3 1 4 2 3 4 2 3 4 3 3 4 4 2 2 4 1 2 1 3 2 3 1 1 2 1 2 3 1 3 4 3 4 1 2 2 1 3 4 1 2 3 2 1 3 2 3 2 3 3 3 3 2 2 3 3 4 1 2 3 2 1 4 2 4 4 3 1 3 3 2 4 1 2 4 1 2 2 1 4 2 1 4 3 3 4 1 0 2 2 4 2 2 4 3 2 1 2 3 1 3 3 4 2 1 1 1 3 3 4 2 2 1 1 4 3 4 4 3 1 4 2 4 2 2 2 1 2 1 1 1 1 1 3 2 3 1 3 2 1 1 2 3 1 4 3 4 4 3 1 3 1 2 1 2 3 4 3 3 4 2 4 4 4 3 4 4 3 4 2 2 3 2 3 2 2 1 1 1 1 1 4 4 2 1 2 3 2 3 4 3 3 3 1 4 1 1 2 4 3 3 3 3 3 3 4 3 4 3 1 4 1 2 1 3 2 2 2 4 4 June 2019 0 4 1 2 2 1 4 0 0 4 1 0 0 0 0 2 1 0 1 0 4 0 0 2 0 3 4 0 3 0 2 3 0 0 4 0 0 0 1 2 3 4 1 3 3 2 0 2 3 0 3 2019 Scorecard on State Health System Performance 56 APPENDIX G1. Disparity: Dimension and Indicator Ranking (continued) 1 1 2 4 1 4 1 4 3 2 2 3 2 1 2 3 2 4 3 4 2 1 1 3 1 1 2 4 1 4 4 2 2 2 4 2 2 1 3 3 2 2 3 4 2 1 4 4 2 3 4 Top quartile Second quartile Third quartile Bottom quartile Data not available ta de Ad nt ul al ca t s w vi nc i t si h t er sc o u t re a en ll r Ad in ec ul gs o m va ts w m cc i t en i n ho de es u ta d ll Ch re ild co re m n m wi en th de ou d t CUh a ni m lnd ed d e srue ic al nt nrewd ho al iat p r dhuo m ev lutt e s en a CUh ni m t i lnd ve ed re srue ca i c co rnew re al m d ict vi an m hio si d en ldu t d e trea HAdo nll d uspl v ac acsa tistaw ci trhe liat ne m hd om s a uits sai uo sn PAod usa tue flo db e lntstiw srop pca alhl uerd y o u r ciea o l tsme awv tor d e eo eon fic nf tc idt r PHr ovis awbitl ieg s tit ehoe vh sa m 6s5p eonut u ge tecra ean at-bo 65 green d i lfe-p onlg hoo an cy d e csk d r peit HAdo aml uspl iez t dati ag istaw cioa e 6 li3t nl s 5 a h0-od ag nd uaty e o l ared Ad d e aedn ul m r tai hcae ts w lsvs iso nalc hit int teh oh r s oreu ra te cr pto a ee rltl Ad ni rfae ul ng icro s omr va ts w m po cc iht eon in ohos rd es um ed toa k lle ACdh r e uilld co trs m ewn m hwo en itah de roe d uot bae ACdh sme uilld ed tdee trsew ic ent nhw al tha oi ho l p thh m a o re vue e v t l e Ch nt oa sm ild iv t es e c dixi re re ar coar co n w ev lm m it a m ho is nodr it e en u de t a Ho d ll sp va i as ta cc th l a in es m dm a Ad u lts wi th ou tm ed i ca l Appendix G1. Disparity: Dimension and Indicator Ranking Overall performance 41 12 13 14 25 26 37 18 19 19 11 1 12 3 13 1 14 1 15 2 16 1 17 4 17 4 19 2 19 4 21 1 22 3 23 2 24 2 25 4 26 3 27 1 28 4 29 1 30 2 31 3 32 2 32 4 34 2 35 2 36 3 37 1 38 4 39 2 40 3 40 4 42 2 43 3 43 4 45 3 46 3 47 4 48 4 49 2 50 2 51 4 Hawaii1 1 2 New York 3 1New Mexico 3 3 California 2 2 Minnesota 4 Washington 1 3 Massachusetts 1 2 Idaho 4 1 2 Louisiana 1 Pennsylvania 1 2 2 Colorado 2 Maine 1 3 Rhode Island 4 1 Alaska 2 3 Utah 1 4 Arizona 4 3 Oregon 3 4 1 Vermont 3 Iowa 4 2 North Dakota 1 2 1New Jersey 0 Connecticut 3 2 District 4of Columbia 2 Nevada 4 1 2 Montana 2 3 Michigan 2 2 Wisconsin 4 1 Delaware 3 Illinois 2 3 West Virginia 1 2 3 Nebraska 2 Florida 3 2 South Dakota 1 3 3 Mississippi 3 3 Maryland 3 3 Alabama 4 2 Wyoming 2 New2Hampshire 1 3Tennessee 1 Kansas 1 3 4 Kentucky 3 Ohio 3 1 2 Georgia 4 Indiana 2 3 2 Oklahoma 2 North 1 Carolina 1 South 4 Carolina 1 Texas 4 2 Virginia 3 4 4 Arkansas 4 3 Missouri 4 commonwealthfund.org 1 3 1 2 4 2 2 4 2 1 2 3 2 2 1 1 2 2 1 3 1 1 2 1 3 1 3 2 1 3 1 3 3 2 2 1 1 3 2 2 3 1 2 4 1 3 3 4 1 4 4 3 4 1 4 3 4 1 2 3 1 4 2 2 3 3 4 4 3 1 3 2 4 4 2 3 4 4 4 4 3 4 4 2 3 3 4 0 2 1 2 0 3 1 2 2 3 1 2 1 2 0 1 1 3 1 2 1 0 1 0 4 4 4 2 4 1 2 0 3 2 0 3 2 4 1 3 0 3 4 3 0 1 2 4 2 1 0 1 2 0 4 0 3 3 0 3 0 3 2 3 1 3 0 4 0 3 1 4 4 3 2 1 2 4 4 1 4 2 2 1 3 3 2 4 2 3 2 2 4 4 1 0 3 4 4 1 4 2 2 3 1 3 4 4 0 1 0 1 4 3 1 2 0 2 0 2 0 3 0 4 2 3 1 1 0 3 1 1 0 2 4 3 0 2 0 4 2 2 0 2 3 1 4 3 0 2 3 1 0 4 2 3 3 0 1 0 4 2 0 4 0 1 0 1 4 2 1 3 2 4 4 1 3 3 4 2 1 0 4 2 4 3 2 0 2 3 2 1 2 1 1 2 2 1 1 1 2 1 3 1 3 4 1 2 1 2 2 4 1 4 3 1 2 4 3 1 1 2 1 2 2 3 3 1 2 3 1 4 4 1 2 4 2 3 2 2 3 3 2 4 3 2 4 3 4 1 4 3 2 4 3 4 2 1 3 3 4 4 2 1 3 1 3 4 3 3 4 4 3 4 4 2 4 3 4 3 1 1 1 1 2 1 2 1 3 2 4 1 2 3 2 4 1 2 3 1 3 1 2 4 1 1 4 1 2 3 2 4 1 2 3 2 1 4 1 2 4 2 2 3 3 2 1 4 2 4 3 4 3 1 4 3 2 1 4 2 4 3 4 3 4 3 4 4 2 1 4 2 4 2 3 2 3 1 4 3 3 2 3 4 3 4 3 1 1 2 2 1 4 3 1 4 1 1 2 4 1 3 2 2 2 1 3 2 2 1 2 3 2 2 1 4 1 3 2 4 1 2 4 1 3 1 3 3 1 1 3 2 4 1 4 4 3 4 2 2 4 2 1 2 4 4 3 2 3 2 3 1 2 3 4 3 2 2 4 2 4 3 4 2 3 1 4 4 4 3 2 4 3 4 4 3 4 1 1 2 1 1 2 1 2 3 4 1 1 4 1 2 1 3 3 2 1 4 1 3 2 1 1 2 4 1 4 2 2 4 1 1 3 3 2 1 2 3 4 1 3 4 1 3 4 2 1 3 2 3 4 2 1 4 2 2 1 2 3 3 1 3 4 2 3 3 4 2 3 3 4 2 3 4 3 4 4 3 4 1 2 3 2 4 4 2 1 2 1 1 2 3 1 2 3 1 1 2 1 2 3 1 3 2 3 3 1 2 3 4 4 1 3 1 4 1 1 3 2 3 2 1 3 1 4 1 2 4 3 2 1 2 3 1 2 4 3 2 1 3 4 3 3 2 3 4 2 2 4 3 4 3 4 1 3 2 3 4 2 3 1 3 4 2 2 1 4 2 4 3 4 1 3 2 3 1 2 3 4 2 1 3 2 1 4 1 1 2 3 2 3 1 4 1 2 1 1 4 3 3 2 3 4 4 1 2 0 3 2 3 2 4 4 1 2 1 2 4 3 3 1 2 3 1 2 3 1 4 3 3 1 4 2 2 3 1 4 1 2 1 3 3 3 2 4 3 2 2 3 1 4 1 2 4 1 3 4 4 4 2 3 1 1 4 1 2 1 4 2 2 2 2 1 3 2 3 1 2 1 4 1 1 4 1 3 1 2 3 3 4 1 2 3 2 1 1 2 1 2 3 4 1 4 4 3 3 2 4 1 4 3 1 1 3 3 2 1 3 2 1 3 2 3 4 4 3 2 3 4 4 2 3 4 3 4 4 2 3 4 1 4 3 3 4 2 2 3 2 3 2 2 1 1 1 1 1 4 4 2 1 2 3 2 3 4 3 3 3 1 4 1 1 2 4 3 3 3 3 3 3 4 3 4 3 1 4 1 2 1 3 2 2 2 4 4 June 2019 0 4 1 2 2 1 4 0 0 4 1 0 0 0 0 2 1 0 1 0 4 0 0 2 0 3 4 0 3 0 2 3 0 0 4 0 0 0 1 2 3 4 1 3 3 2 0 2 3 0 3 2019 Scorecard on State Health System Performance 57 APPENDIX G2. Disparity: Indicator Rates for Low-Income Population and Difference from Higher-Income Population Appendix G2. Disparity: Indicator Rates for Low-Income Population and Difference From Higher-Income Population Uninsured adults 2017 United States Adults without a Uninsured children usual source of care 2017 2017 Adults age 18 and older who went without care because of cost in past year 2017 High out-of-pocket medical spending 2016-17 Adults without a dental visit 2016 Adults without all recommended cancer screenings Adults witho recommen vaccines 2016 2017 Rate Disparity Rate Disparity Rate Disparity Rate Disparity Rate Disparity Rate Disparity Rate Disparity Rate 23% -19 7% -5 28% -12 23% -16 25% -23 24% -13 35% -10 65% -22 -15 -17 -13 -14 -14 -13 -11 -6 -24 -29 -9 -20 -16 -17 -10 -23 -9 -14 -19 -15 -5 -10 -12 -26 -22 -13 -23 -18 -15 -21 -14 -9 -26 -18 -12 -27 -12 -11 -10 -25 -25 -20 -35 -20 -2 -23 -13 -8 -12 -26 4 12 11 6 4 6 4 --9 10 3 4 4 9 4 8 5 3 5 6 2 4 5 5 8 10 11 10 -6 5 4 7 13 5 8 5 7 -7 10 5 13 11 -7 3 2 6 17 -2 -7 -7 -4 -2 -4 -2 ---5 -7 ---3 -7 -3 -6 -4 -1 --4 -1 -3 -4 --6 ---6 --4 --2 -5 --3 -3 -3 -5 --5 --2 -8 -8 --5 -1 --4 -- 24 31 34 21 34 30 20 24 26 30 33 17 34 21 25 26 29 16 22 14 27 20 18 27 26 26 31 27 44 13 23 32 21 32 24 19 28 29 13 15 23 30 20 45 36 12 33 30 22 20 39 -8 -6 -13 -7 -16 -10 -12 -11 -6 -11 -14 -5 -13 -9 -10 -12 -14 -1 -5 -6 -17 -12 -7 -6 -5 -9 -6 -14 -16 -5 -9 -13 -11 -17 -1 -6 -12 -12 -3 -8 -4 -11 -4 -22 -12 -3 -17 -12 -5 -5 -14 27 14 19 25 20 21 18 21 12 26 29 15 24 20 23 14 26 17 25 14 22 14 17 15 29 25 20 24 31 16 23 18 18 31 16 17 28 22 14 18 25 26 20 37 24 11 27 17 20 21 32 -20 -4 -11 -17 -13 -13 -12 -12 -7 -19 -21 -11 -17 -14 -16 -9 -20 -10 -17 -7 -18 -8 -11 -9 -20 -19 -12 -18 -22 -10 -17 -10 -11 -23 -13 -10 -21 -15 -7 -11 -18 -20 -14 -28 -15 -6 -20 -9 -12 -14 -24 29 24 24 28 20 31 28 23 20 24 25 21 32 26 27 28 29 24 25 26 26 27 26 26 23 29 35 29 24 32 24 19 20 30 33 25 25 31 26 21 28 30 29 25 34 27 30 25 27 28 33 -28 -20 -21 -26 -18 -28 -26 -21 -19 -22 -24 -19 -29 -24 -24 -26 -28 -22 -23 -25 -25 -26 -24 -25 -21 -27 -33 -26 -21 -30 -23 -17 -19 -27 -31 -23 -22 -29 -25 -20 -26 -27 -27 -23 -31 -25 -28 -23 -26 -26 -29 25 14 26 23 25 24 17 24 14 26 25 18 25 21 25 22 23 24 29 21 26 17 19 18 24 29 20 24 25 15 20 24 20 19 25 22 26 21 22 17 27 20 27 31 22 22 21 26 25 17 22 -13 -5 -14 -14 -15 -13 -10 -16 -4 -12 -14 -8 -15 -8 -15 -14 -14 -13 -14 -14 -16 -9 -10 -10 -11 -16 -6 -16 -14 -9 -11 -13 -9 -7 -15 -13 -13 -11 -11 -11 -17 -11 -14 -19 -12 -16 -12 -15 -15 -11 -12 37 34 34 38 29 34 31 35 28 36 36 36 39 33 42 33 38 38 33 35 33 33 35 33 34 43 47 39 36 38 32 39 33 33 43 36 41 42 33 26 38 38 35 44 36 42 33 35 36 29 40 -13 1 -6 -10 -6 -7 -11 -16 -8 -8 -12 -18 -5 -6 -14 -8 -11 -14 -7 -13 -8 -11 -12 -9 -10 -19 -15 -12 -8 -16 -5 -6 -7 -11 -15 -10 -11 -18 -6 -5 -15 -15 -10 -19 -10 -18 -9 -8 -10 -7 -6 67 71 70 65 67 57 61 58 69 69 69 58 67 69 71 60 68 66 71 61 60 59 68 58 69 61 66 60 69 60 60 65 64 58 63 62 59 69 60 56 67 58 67 67 70 59 65 62 60 67 68 Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 27 26 23 18 18 18 16 14 8 32 35 12 27 19 21 12 26 12 20 23 18 7 13 14 31 26 19 27 25 18 25 19 13 31 21 15 35 16 14 13 30 28 25 43 25 7 27 17 12 14 33 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Di * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Notes: Rates are for the states' low income population, generally those whose household income is under 200% FPL. Disparity is the difference between the states' low-income and higher-income (400%+ FPL) populations. (*) Notes: Rates are for the states’ low income population, generally those whose household income is under 200% FPL. Disparity is the difference between the states’ low-income and higher-income (400%+ FPL) populations. (*) denotes meaningful improvement or worsening from the baseline period. Baseline data not shown, refer to state profiles at datacenter.commonwealthfund.org for baseline data. commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance 58 APPENDIX G2. Disparity: Indicator Rates for Low-Income Population and Difference from Higher-Income Population (continued) her-Income Appendix Population G2. Disparity: Indicator Rates for Low-Income Population and Difference From Higher-Income Population Adults without all recommended cancer screenings s without a ntal visit 2016 e 5 4 6 3 5 4 7 4 4 6 5 8 5 1 5 2 3 4 9 1 6 7 9 8 4 9 0 4 5 5 0 4 0 9 5 2 6 1 2 7 7 0 7 1 2 2 1 6 5 7 2 2016 Disparity % * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Adults without all recommended Uninsured vaccines adults Rate 2017 Disparity Rate Rate -13United35% States -10 65% 23% -13Alabama 37 * -5Alaska 34 * -14Arizona 34 * -14Arkansas 38 * -15California 29 * -13Colorado 34 * -10Connecticut 31 * -16Delaware35 * -4District of 28 Columbia * -12Florida 36 * -14Georgia 36 -8Hawaii 36 * -15Idaho 39 * -8Illinois 33 * -15Indiana 42 * -14Iowa 33 * -14Kansas 38 -13Kentucky 38 -14Louisiana 33 * -14Maine 35 * -16Maryland33 -9Massachusetts 33 * -10Michigan 35 -10Minnesota33 * -11Mississippi 34 * -16Missouri 43 * -6Montana 47 * -16Nebraska 39 * -14Nevada 36 * -9New Hampshire 38 * -11New Jersey 32 * -13New Mexico 39 -9New York 33 * -7North Carolina 33 * -15North Dakota 43 -13Ohio 36 -13Oklahoma41 * -11Oregon 42 * -11Pennsylvania 33 * -11Rhode Island 26 * -17South Carolina 38 * -11South Dakota 38 -14Tennessee35 * -19Texas 44 * -12Utah 36 * -16Vermont 42 * -12Virginia 33 * -15Washington 35 * -15West Virginia 36 * -11Wisconsin29 * -12Wyoming40 * -13 1 -6 -10 -6 -7 -11 -16 -8 -8 -12 -18 -5 -6 -14 -8 -11 -14 -7 -13 -8 -11 -12 -9 -10 -19 -15 -12 -8 -16 -5 -6 -7 -11 -15 -10 -11 -18 -6 -5 -15 -15 -10 -19 -10 -18 -9 -8 -10 -7 -6 67 27 71 26 70 23 65 18 67 18 57 18 61 16 58 14 698 69 32 69 35 58 12 67 27 69 19 71 21 60 12 68 26 66 12 71 20 61 23 60 18 597 68 13 58 14 69 31 61 26 66 19 60 27 69 25 60 18 60 25 65 19 64 13 58 31 63 21 62 15 59 35 69 16 60 14 56 13 67 30 58 28 67 25 67 43 70 25 597 65 27 62 17 60 12 67 14 68 33 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Adults age 18 and older who went Children without a Children without without care all Hospital admissions Children without a medical Adults without a because of cost in High out-of-pocket and dental recommended for pediatric asthma Uninsured medical children home preventive usual sourcecare of care visit past vaccines year medical (rate perspending 100,000) 2017 Disparity Rate -19 -8 63% 7% -22 -8 -15 -8 -17 -9 -11 -13 -14 -8 -14 -6 -10 -13 -11 -5 -13 -6 -24 -7 -29 -7 -4 -9 -20 -2 -16 -9 -10 -17 -10 -6 -10 -23 -12 -9 -14 -6 -19 -9 -10 -15 -3 -5 -10 -12 -6 -26 -8 -22 -8 -13 -7 -10 -23 -18 -1 -15 -6 -21 -3 -14 -5 -6 -9 -26 -5 -18 -7 -12 -3 -27 -6 -11 -12 -11 -2 -10 -2 -11 -25 -10 -25 -20 -9 -35 -6 -11 -20 -3 -2 -16 -23 -10 -13 -6 -8 -12 -7 -26 -7 664 59 12 66 11 706 644 586 574 66 -56 -689 70 10 513 634 594 609 624 568 595 593 475 616 542 634 665 615 618 62 10 51 11 72 10 53 ---6 685 624 497 57 13 565 658 595 697 68 -587 60 10 545 68 13 58 11 57 -557 523 552 736 65 17 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 2017 2017 Disparity Rate -25 -5 28% 39% -29 -2 -22 -7 -32 -7 -32 -4 -20 -2 -20 -4 -21 -2 -27 --23 --25 -5 -31 -7 -14 --35 --20 -3 -23 -7 -33 -3 -19 -6 -28 -4 -13 -1 -17 --26 -4 -23 -1 -20 -3 -29 -4 -24 --29 -6 -23 --20 --33 -6 -15 --4 --28 --26 -2 -5 -9 -16 --28 -3 -20 -3 -24 -3 -22 -5 -34 --18 -5 -16 --17 -2 -34 -8 -19 -8 -25 --24 -5 -16 -1 -11 --39 -4 -23 -- 24 34 31 38 34 39 21 42 34 39 30 21 20 21 24 34 26 25 30 35 33 34 17 36 34 21 58 25 40 26 27 29 38 16 35 22 28 14 23 27 32 20 30 18 33 27 45 26 34 26 62 31 39 27 42 44 49 13 33 23 31 32 42 21 32 32 46 24 47 19 50 28 50 29 35 13 30 15 26 23 37 30 43 20 36 45 47 36 39 12 35 33 37 30 33 22 32 20 43 39 43 ** ** ** * ** * ** ** * ** ** * * ** ** ** ** * * * * ** ** ** * * ** * ** ** ** * ** ** ** ** ** ** * * * * * ** ** * ** ** 2017 2016 Disparity Disparity Rate Rate -12 -16 23% 33 -81 -6 -5 -13 -14 -17 -7 -16 -12 -10 -3 -12 -7 -11 -14 -6 -3 -11 -4 -14 -11 -16 -5 -13 -10 -39 -9 -10 -21 -12 -6 -14 -17 -16 -1 -5 -3 -6 -2 -17 -12 -12 -13 -7 -6 -21 -6 -5 -7 -40 -9 -18 -6 -14 -16 -16 -13 -15 -5 -10 -9 -13 -19 -11 -7 -17 -22 -15 -1 -33 -6 -12 -19 -12 -13 -13 -3 -8 -1 -15 -4 -11 -18 -20 -4 -22 -23 -12 -7 -14 -3 -17 -21 -12 -9 -19 -5 -29 -5 -14 -13 27 27 14 42 19 27 25 36 20 38 21 23 18 30 21 22 12 35 26 41 29 25 15 28 24 24 20 32 23 30 14 32 26 33 17 23 25 32 14 30 22 33 14 19 17 38 15 34 29 32 25 41 20 40 24 26 31 33 16 31 23 39 18 35 18 32 31 25 16 40 17 43 28 33 22 41 14 28 18 32 25 34 26 36 20 41 37 31 24 31 11 29 27 37 17 28 20 43 21 21 32 48 * * ** ** ** ** ** ** ** * * ** ** * ** ** * ** ** * ** * ** * * * * * * ** ** ** ** * ** ** ** ** ** ** * ** ** ** * ** * * ** ** 2016-17 2015 2016 2014 Disparity Disparity Rate Rate Disparity Disparity -16 -10 25%-- -23-- -20 -14 -23 -4 -119 -17 -16 -13 -10 -13 -3 -12 -13 -12 -3 -11 -7 -19 -15 -21 -3 -11 -10 -17 -3 -14 -10 -16 -6 -10 -9 -20 -14 -104 -178 -7 -3 -18 -14 -8 -7 -11 -19 -13 -9 -20 -11 -19 -28 -12 -5 -18 -12 -22 -13 -10 -15 -17 -20 -10 -14 -11 -8 -23 -13 -13 -15 -10 -28 -21 -1 -15 -8 -7 -2 -11 -19 -18 -9 -20 -15 -14 -28 -28 -6 -15 -10 -15 -6 -20 -6 -10 -9 -12 -24 -141 -24 -20 29-24-105 24 28 80 126 20 130 31 28-23-20-169 24 25 72 21-32-153 26 122 27 28 64 156 29 107 24 25-26-364 26 206 27 160 26 112 26 23-163 29 35-29 69 147 24 32-277 24 153 19 436 20 30 91 33-199 25 150 25 31 59 278 26 21-28-30-29 60 25 87 34-27-119 30 25 47 27 59 174 28 33-- -28--20--21 -57 -26--18 -68 -28 -44 -26--21--19--110 -22 -24 -37 -19--29--24 -93 -24 -97 -26 -20 -28 -78 -22 -83 -23--25--309 -25 -154 -26 -107 -24 -25 -68 -21--27 -83 -33--26 -48 -21 -69 -30--207 -23 -17 -46 -337 -19 -27 -55 -31--158 -23 -112 -22 -29 -15 -229 -25 -20--26--27--27 -37 -23 -47 -31--25--28 -86 -237 -26--135 -26 -29-- * * * * * * * * * * * * * * * * * * * * * * * * Potentially avoidable emergency department visits Adults a age 65without and older (rate dental pervisit 1,000) Preventable Hospita Adults hospitalizations without allage 65 Adults readmis witho recommended and older (rate per recommen age 65 a cancer screenings 1,000) vaccines (rate pe 2016 2015 201720 Rate Rate Disparity Disparity Rate Rate Disparity Disparity RateRateDi 24% 366 35% 99 396 25 ** 453 14 * 413 26 ** 385 23 ** 301 25 ** 339 24 ** 379 17 ** 385 24 ** 430 14 ** 370 26 * 396 25 * 232 18 * 294 25 ** 400 21 ** 408 25 ** 353 22 ** 349 23 ** 427 24 ** 441 29 * 355 21 ** 358 26 ** 343 17 ** 399 19 ** 332 18 ** 466 24 ** 411 29 ** 384 20 ** 320 24 ** 305 25 * 390 15 ** 320 20 ** 348 24 ** 283 20 * 445 19 ** 358 25 ** 436 22 ** 458 26 ** 309 21 ** 330 22 * 437 17 ** 440 27 ** 289 20 * 411 27 * 361 31 ** 276 22 * 321 22 ** 423 21 ** 317 26 * 444 25 ** 369 17 ** 341 22 * -192 -13 -13 -226 -281 -5 -14 -236 -14 -214 -15 -156 -13 -177 -10 -209 -16 -228 -259 -4 -12 -193 -14 -228 -101 -8 -15 -135 -216 -8 -15 -222 -14 -183 -14 -176 -13 -225 -14 -248 -14 -177 -16 -184 -154 -9 -10 -191 -10 -156 -11 -278 -16 -219 -239 -6 -16 -175 -14 -157 -218 -9 -11 -157 -13 -181 -122 -9 -265 -7 -15 -200 -13 -227 -13 -247 -11 -158 -11 -150 -11 -255 -17 -274 -11 -147 -14 -232 -19 -183 -12 -131 -16 -172 -12 -246 -15 -161 -15 -230 -11 -191 -12 -177 37 34 34 38 29 34 31 35 28 36 36 36 39 33 42 33 38 38 33 35 33 33 35 33 34 43 47 39 36 38 32 39 33 33 43 36 41 42 33 26 38 38 35 44 36 42 33 35 36 29 40 *118 * 77 * 64 *120 * 68 * 61 * 94 *109 *109 *122 101 * 52 * 61 *119 *112 * 88 92 146 *115 * 93 99 * 97 110 * 68 *128 *109 * 76 * 98 * 85 *117 *103 63 * 88 *108 83 121 *126 * 62 *101 *111 *101 89 *122 *100 * 53 * 75 *112 * 70 *132 * 89 *101 -10 -56 65% 63 * -13 1 * -6 -10 * -6 -7 -11 * -16 * -8 * -8 * -12 * -18 -5 * -6 -14 * -8 * -11 * -14 -7 * -13 * -8 * -11 * -12 * -9 -10 -19 -15 * -12 -8 * -16 * -5 -6 * -7 * -11 * -15 -10 -11 * -18 * -6 * -5 -15 -15 -10 * -19 * -10 -18 -9 * -8 -10 * -7 * -6 -66 -51 -36 -75 -40 -37 -51 -67 -72 -76 -59 -29 -37 -71 -65 -49 -50 -88 -63 -55 -54 -44 -56 -28 -81 -62 -44 -59 -54 -70 -53 -34 -41 -67 -42 -68 -79 -33 -50 -62 -62 -52 -76 -56 -29 -42 -71 -40 -73 -50 -66 67 71 70 65 67 57 61 58 69 69 69 58 67 69 71 60 68 66 71 61 60 59 68 58 69 61 66 60 69 60 60 65 64 58 63 62 59 69 60 56 67 58 67 67 70 59 65 62 60 67 68 69 *34 *46 70 *51 *36 *66 *70 61 *91 *63 *29 *28 *74 *69 *44 53 *80 *61 *42 67 63 77 *43 72 *70 29 *46 *58 *50 *77 *40 *59 *66 32 *74 *69 *32 *64 *61 *69 39 *73 *59 *38 *30 *76 *40 *68 *45 48 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ow-income andNotes: higher-income Rates are(400%+ for theFPL) states' populations. low income(*)population, denotes meaningful generally those improvement whose household or worsening income fromisthe under baseline 200% period. FPL. Disparity Baseline is the datadifference not shown, between refer tothe state states' profiles low-income at datacenter.commonwealthfund.org and higher-income (400%+ FPL) forpopulations. baseline data. (*) Notes: Rates are for the states’ low-income population, generally those whose household income is under 200% FPL. Disparity is the difference between the states’ low-income and higher-income (400%+ FPL) populations. * Denotes meaningful improvement or worsening from the baseline period. Baseline data not shown; refer to state profiles at datacenter.commonwealthfund.org for baseline data. Trend data not available for children without all components of a medical home, and children without a medical and dental preventive care visit. — Indicates that estimates are not available. commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance 59 APPENDIX G2. Disparity: Indicator Rates for Low-Income Population and Difference from Higher-Income Population (continued) Appendix G2. Disparity: Indicator Rates for Low-Income Population and Difference From Higher-Income Population al admissions iatric asthma er 100,000) 2015 e Potentially avoidable emergency department visits age 65 and older (rate per 1,000) Adults age 18 and Preventable Hospital 30-day older who went without care Adults without all hospitalizations age 65 readmission rate Adults without who report a because of cost in High out-of-pocket Adults Adults without who have a lostrecommended and older (rate per age 65 and older Adults Uninsured 1,000) adults Uninsured (rate per children 1,000) usual fairsource or poor ofhealth care Adults past year who smoke medical Adults who spending are obese dental six or visit more teethcancer screenings 2014 Disparity Rate 2017 2015 Disparity 28% 30% -12-22 23% 24% -16-13 25% 39% -2-36 -7-18 -7-22 -4-41 -2-28 -4-18 -2-33 ---43 ---36 -5-56 -7-35 ---14 ---13 -3-38 -7-39 -3-21 -6-28 -4-44 -1-28 ---20 -4-30 -1-24 -3-36 -4-16 ---42 -6-36 ---14 ---23 -6-34 ---24 -4-39 ---18 -2-21 -5-39 ---13 -3-39 -3-38 -3-14 -5-28 ---23 -5-42 ---19 -2-41 -8-30 -8-21 ---12 -5-46 -1-20 ---30 -4-20 ---28 24 33 * 31 33 * 34 30 * 21 39 * 34 27 * 30 30 20 28 * 24 29 * 26 20 30 26 * 33 31 * 17 19 * 34 24 * 21 31 * 25 31 * 26 26 * 29 30 * 16 40 * 22 33 * 14 28 27 32 * 20 31 * 18 32 * 27 21 * 26 27 26 29 31 24 27 31 * 44 35 13 38 * 23 31 * 32 25 * 21 29 * 32 36 24 24 19 33 * 28 36 * 29 28 * 13 31 * 15 32 * 23 30 * 30 26 20 30 * 45 29 36 24 12 26 * 33 30 * 30 29 * 22 34 * 20 32 * 39 31 * -8-23 -6-23 -13-22 -7-31 -16-19 -10-24 -12-23 -11-21 -6-16 -11-18 -14-23 -5-11 -13-17 -9-25 -10-21 -12-20 -14-23 -1-28 -5-26 -6-21 -17-25 -12-27 -7-26 -6-16 -5-17 -9-22 -6-19 -14-27 -16-25 -5-32 -9-24 -13-17 -11-21 -17-30 -1-17 -6-25 -12-28 -12-19 -3-22 -8-27 -4-24 -11-20 -4-23 -22-19 -12-19 -3-21 -17-23 -12-21 -5-22 -5-24 -14-24 27 33 * 14 39 * 19 21 * 25 35 * 20 13 * 21 26 * 18 17 * 21 26 * 12 30 * 26 22 * 29 25 * 15 15 * 24 22 * 20 22 * 23 34 * 14 29 * 26 30 * 17 40 * 25 33 * 14 29 22 23 * 14 22 * 17 31 * 15 22 * 29 30 * 25 37 * 20 35 * 24 27 * 31 22 * 16 30 * 23 16 * 18 23 * 18 17 * 31 26 * 16 29 17 32 * 28 30 * 22 19 * 14 30 * 18 24 * 25 27 * 26 35 * 20 33 * 37 20 * 24 15 * 11 27 * 27 26 * 17 22 * 20 37 * 21 26 * 32 25 * -20-20 -4-26 -11-11 -17-24 -13 -3 -13-16 -12 -9 -12-14 -7-25 -19-12 -21-13 -11 -4 -17-12 -14-11 -16-20 -9-18 -20-19 -10-23 -17-18 -7-18 -18-14 -8-13 -11-19 -9-13 -20-16 -19-23 -12-26 -18-16 -22 -8 -10-20 -17 -6 -10-13 -11 -8 -23-16 -13-15 -10-19 -21-17 -15 -9 -7-16 -11-15 -18-15 -20-21 -14-22 -28 -9 -15-10 -6-18 -20-15 -9-12 -12-23 -14-15 -24-13 29 44 24 39 24 39 28 52 20 34 31 34 28 38 23 36 20 45 24 39 25 44 21 33 32 35 26 41 27 39 28 51 29 45 24 45 25 44 26 32 26 38 27 31 26 39 26 37 23 45 29 41 35 33 29 41 24 31 32 42 24 36 19 34 20 32 30 48 33 41 25 45 25 47 31 38 26 40 21 39 28 45 30 45 29 43 25 39 34 30 27 42 30 44 25 39 27 43 28 42 33 38 --Alabama396 * --Alaska 453 -57Arizona 413 * --Arkansas385 * -68California301 * -44Colorado339 * --Connecticut 379 * --Delaware385 * --District of430 Columbia * -110Florida 370 * -37Georgia 396 * --Hawaii 232 * --Idaho 294 * -93Illinois 400 * -97Indiana 408 * -20Iowa 353 * -78Kansas 349 * -83Kentucky427 * --Louisiana441 --Maine 355 * -309Maryland 358 * -154Massachusetts 343 * -107Michigan399 * -68Minnesota 332 * --Mississippi 466 * -83Missouri411 * --Montana384 * -48Nebraska320 * -69Nevada 305 --New Hampshire 390 * -207New Jersey 320 * -46New Mexico 348 * -337New York283 -55North Carolina 445 * --North Dakota 358 * -158Ohio 436 * -112Oklahoma 458 * -15Oregon 309 * -229Pennsylvania 330 * --Rhode Island 437 * --South Carolina 440 * --South Dakota 289 * -37Tennessee 411 * -47Texas 361 * --Utah 276 --Vermont321 * -86Virginia 423 * 7Washington 317 * --West Virginia 444 * -135Wisconsin 369 * --Wyoming 341 * -226 -281 -236 -214 -156 -177 -209 -228 -259 -193 -228 -101 -135 -216 -222 -183 -176 -225 -248 -177 -184 -154 -191 -156 -278 -219 -239 -175 -157 -218 -157 -181 -122 -265 -200 -227 -247 -158 -150 -255 -274 -147 -232 -183 -131 -172 -246 -161 -230 -191 -177 27 118 * 26 *77 23 *64 18 120 * 18 *68 18 *61 16 *94 14 109 * 8 109 * 32 122 * 35 101 * 12 *52 27 *61 19 119 * 21 112 * 12 *88 26 *92 12 146 * 20 115 * 23 *93 18 *99 7 *97 13 110 * 14 *68 31 128 * 26 109 * 19 *76 27 *98 25 *85 18 117 * 25 103 * 19 *63 13 *88 31 108 * 21 *83 15 121 * 35 126 * 16 *62 14 101 * 13 111 * 30 101 * 28 *89 25 122 * 43 100 * 25 *53 7 *75 27 112 * 17 *70 12 132 * 14 *89 33 101 * * * * * * * * * * * * * * 2016 -5-33 5 0 6 0 9 2 3 2 4 6 7 4 6 0 2 3 9 7 7 3 6 1 9 0 9 8 0 7 9 7 9 4 - * 20162016 Rate Rate Disparity Disparity RateRate Disparity Disparity Rate 23% 99 * * * * * 2016-17 2017 Rate Rate Disparity Disparity -192 * * 2017 2017 Rate Rate Disparity Disparity --United366 States * * 2017 2017 RateRateDisparity Disparity Rate Rate Disparity Disparity -- * 2017 2015 -19 -56 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * -22 -15 -17 -13 -14 -14 -13 -11 -6 -24 -29 -9 -20 -16 -17 -10 -23 -9 -14 -19 -15 -5 -10 -12 -26 -22 -13 -23 -18 -15 -21 -14 -9 -26 -18 -12 -27 -12 -11 -10 -25 -25 -20 -35 -20 -2 -23 -13 -8 -12 -26 -66 -51 -36 -75 -40 -37 -51 -67 -72 -76 -59 -29 -37 -71 -65 -49 -50 -88 -63 -55 -54 -44 -56 -28 -81 -62 -44 -59 -54 -70 -53 -34 -41 -67 -42 -68 -79 -33 -50 -62 -62 -52 -76 -56 -29 -42 -71 -40 -73 -50 -66 7%63 4 69 * 12 34 * 11 46 * 6 70 4 51 * 6 36 * 4 66 -- 70 -- 61 9 91 * 10 63 * 3 29 4 28 4 74 * 9 69 * 4 44 8 53 * 5 80 * 3 61 * 5 42 6 67 2 63 4 77 * 5 43 * 5 72 8 70 * 10 29 11 46 10 58 * -- 50 6 77 * 5 40 4 59 * 7 66 * 13 32 5 74 * 8 69 * 5 32 * 7 64 * -- 61 7 69 * 10 39 5 73 * 13 59 * 11 38 * -- 30 7 76 * 3 40 * 2 68 6 45 * 17 48 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * -23 -10 24% 17% * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * -28 -20 -21 -26 -18 -28 -26 -21 -19 -22 -24 -19 -29 -24 -24 -26 -28 -22 -23 -25 -25 -26 -24 -25 -21 -27 -33 -26 -21 -30 -23 -17 -19 -27 -31 -23 -22 -29 -25 -20 -26 -27 -27 -23 -31 -25 -28 -23 -26 -26 -29 -8 -7 -11 -17 -13 -12 -13 -7 -27 -13 -11 -7 -5 -13 -8 -17 -13 -11 -6 -3 -5 -7 -8 -9 -11 -10 -7 -10 -5 -16 -11 -6 -8 -16 -9 -10 -11 -10 -11 -7 -10 -17 -9 -6 -6 -16 -14 -13 -6 -12 -11 25 14 26 23 25 24 17 24 14 26 25 18 25 21 25 22 23 24 29 21 26 17 19 18 24 29 20 24 25 15 20 24 20 19 25 22 26 21 22 17 27 20 27 31 22 22 21 26 25 17 22 * 22 * 23 * 12 * 23 * 9 * 14 * 13 * 18 * 12 21 22 12 * 14 * 12 * 21 * 16 * 16 * 33 * 22 * 25 * 14 * 16 * 23 * 16 * 26 * 28 * 24 * 12 * 16 * 23 * 15 * 11 * 13 * 19 * 18 * 26 * 26 * 19 21 * 12 * 21 17 24 * 10 * 9 * 24 * 20 14 * 33 * 19 19 -13 -12 35% * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Adults witho recommen vaccines -13 -5 -14 -14 -15 -13 -10 -16 -4 -12 -14 -8 -15 -8 -15 -14 -14 -13 -14 -14 -16 -9 -10 -10 -11 -16 -6 -16 -14 -9 -11 -13 -9 -7 -15 -13 -13 -11 -11 -11 -17 -11 -14 -19 -12 -16 -12 -15 -15 -11 -12 -15 -18 -8 -17 -6 -11 -10 -12 -9 -16 -15 -9 -12 -7 -15 -12 -12 -25 -14 -19 -10 -12 -19 -13 -17 -22 -20 -8 -11 -19 -9 -7 -8 -13 -14 -21 -20 -16 -15 -9 -17 -11 -18 -6 -6 -19 -16 -11 -24 -15 -12 37 34 34 38 29 34 31 35 28 36 36 36 39 33 42 33 38 38 33 35 33 33 35 33 34 43 47 39 36 38 32 39 33 33 43 36 41 42 33 26 38 38 35 44 36 42 33 35 36 29 40 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 2017 Disparity Rate -10 65% -13 1 -6 -10 -6 -7 -11 -16 -8 -8 -12 -18 -5 -6 -14 -8 -11 -14 -7 -13 -8 -11 -12 -9 -10 -19 -15 -12 -8 -16 -5 -6 -7 -11 -15 -10 -11 -18 -6 -5 -15 -15 -10 -19 -10 -18 -9 -8 -10 -7 -6 67 71 70 65 67 57 61 58 69 69 69 58 67 69 71 60 68 66 71 61 60 59 68 58 69 61 66 60 69 60 60 65 64 58 63 62 59 69 60 56 67 58 67 67 70 59 65 62 60 67 68 Di * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * own, refer to state Notes: profiles Ratesatare datacenter.commonwealthfund.org for the states' low income population, for baseline generally data. those whose household income is under 200% FPL. Disparity is the difference between the states' low-income and higher-income (400%+ FPL) populations. (*) Notes: Rates are for the states’ low-income population, generally those whose household income is under 200% FPL. Disparity is the difference between the states’ low-income and higher-income (400%+ FPL) populations. * Denotes meaningful improvement or worsening from the baseline period. Baseline data not shown; refer to state profiles at datacenter.commonwealthfund.org for baseline data. commonwealthfund.org June 2019 2019 Scorecard on State Health System Performance 60 APPENDIX H. State Scorecard Indicator Descriptions and Source Notes ABBREVIATIONS ACS PUMS = American Community Survey, Public Use Micro Sample MEPS IC = Medical Expenditure Panel Survey, Insurance Component AHRQ = Agency for Healthcare Research and Quality NCCDPHP = National Center for Chronic Disease Prevention and Health Promotion BRFSS = Behavioral Risk Factor Surveillance System CAHMI = Child and Adolescent Health Measurement Initiative NCHS = National Center for Health Statistics CCW = Chronic Conditions Warehouse NCIRD = National Center for Immunization and Respiratory Diseases CDC = Centers for Disease Control and Prevention NIS PUF = National Immunization Survey, Public Use Data File CMS = Centers for Medicare and Medicaid Services NSCH = National Survey of Children’s Health CPS ASEC = Current Population Survey, Annual Social and Economic Supplement NSDUH = National Survey of Drug Use and Health HCAHPS = Hospital Consumer Assessment of Healthcare Providers and Systems Survey NVSS-I = National Vital Statistics System–Linked Birth and Infant Death Data NVSS-M = National Vital Statistics System–Mortality Data HCUP NIS = Healthcare Cost and Utilization Project, Nationwide Inpatient Sample OASIS = Outcome and Assessment Information Set HCUP SID = Healthcare Cost and Utilization Project, State Inpatient Databases SAMHSA = Substance Abuse and Mental Health Services Administration MDS = Minimum Data Set WONDER = Wide-ranging Online Data for Epidemiologic Research MedPAR = Medicare Provider and Analytic Review SAF = Standard Analytic Files DEFINITIONS FOR INDICATORS 1. Adults ages 19–64 uninsured: Percent of adults ages 19–64 without health insurance coverage. Authors’ analysis of 2013 and 2017 1-year ACS PUMS (U.S. Census Bureau). 2. Children ages 0–18 uninsured: Percent of children ages 0–18 without health insurance coverage. Authors’ analysis of 2013 and 2017 1-year ACS PUMS (U.S. Census Bureau). 3. Adults without a usual source of care: Percent of adults age 18 and older who did not have one (or more) person they think of as their personal health care provider. Authors’ analysis of 2013 and 2017 BRFSS (CDC, NCCDPHP). 4. Adults who went without care because of cost in the past year: Percent of adults age 18 and older who reported a time in the past 12 months when they needed to see a doctor but could not because of cost. Authors’ analysis of 2013 and 2017 BRFSS (CDC, NCCDPHP). 5. Individuals with high out-of-pocket medical spending: Percent of individuals residing in households where all residents are commonwealthfund.org under age 65 with out-of-pocket medical spending that equaled 10 percent or more of income, or 5 percent or more of income if low-income (under 200% of federal poverty level), not including over-the-counter drug costs or health insurance premiums if insured. This measure includes both insured and uninsured individuals. Two years of data are combined to ensure adequate sample size for state-level estimation. Ougni Chakraborty, Robert F. Wagner School of Public Service, New York University, analysis of 2014, 2015, 2017, and 2018 CPS ASEC (U.S. Census Bureau). 6. Employee health insurance contributions as a share of median income: We compared employees’ average contributions to their employer-sponsored health insurance premiums as a percent of state median household incomes for the under-65 population in each state. Premium contribution data are originally reported separately for single-person and family plans; we therefore used a weighted average of single and family premium contributions compared with single and family median household incomes. Authors’ analysis of 2013 and 2017 MEPS-IC (AHRQ) and 2014 and 2018 CPS ASEC (U.S. Census Bureau). June 2019 2019 Scorecard on State Health System Performance 61 APPENDIX H. State Scorecard Indicator Descriptions and Source Notes (continued) 7. Adults without a dental visit in past year: Percent of adults age 18 and older who did not visit a dentist, or dental clinic within the past year. Authors’ analysis of 2012 and 2016 BRFSS (CDC, NCCDPHP). 8. Adults without all age- and gender-appropriate cancer screenings: Percent of adults ages 50–74 who did not receive sigmoidoscopy or colonoscopy in the last ten years or a fecal occult blood test in the last two years; a mammogram in the last two years (women ages 50–74 only); and a pap smear in the last three years (women ages 25–64 only). Authors’ analysis of 2012 and 2016 BRFSS (CDC, NCCDPHP). 9. Adults without all age-appropriate vaccines: Percent of adults age 18 and older who did not receive a flu shot in the past year and a pneumonia vaccine ever if age 65 and older. Authors’ analysis of 2013 and 2017 BRFSS (CDC, NCCDPHP). 10. Diabetic adults ages 18–64 without a hemoglobin A1c test: The share of adult diabetic patients ages 18–64 who did not have at least one hemoglobin A1c test during the year (expressed as a rate per 100 employer-insured enrollees). Michael E. Chernew and Andrew Hicks, Harvard Medical School Department of Health Care Policy, analysis of the 2015 and 2016 Truven Marketscan Database. 11. Medicare beneficiaries received a high-risk drug: Percent of fee-for-service Medicare beneficiaries ages 65 and older who received at least one drug from a list of 13 classes of high-risk prescriptions that should be avoided by the elderly. J. Zheng, Harvard University, analysis of 2015 Medicare Part D claims. 12. Children without all components of a medical home: Percent of children ages 0–17 who did not have all of the following, according to parents’ reports: a personal doctor or nurse, a usual source for sick and well care, family-centered care, any problems getting needed referrals, and effective care coordination when needed. For more information, see www.childhealthdata.org. Authors’ analysis of 2016 and 2017 NSCH (CAHMI). 13. Children without a medical and dental preventive care visit in the past year: Percent of children ages 0–17 who did not have a preventive medical visit and, if ages 1–17, a preventive dental visit in the past year, according to parents’ reports. For more information, see www.childhealthdata.org. Authors’ analysis of 2016 and 2017 NSCH (CAHMI). 14. Children who did not receive needed mental health treatment: Percent of children ages 3–17 who had any kind of emotional, developmental, or behavioral problem that required treatment or counseling and who did not receive treatment from a mental health professional (as defined) during the past 12 months, according to parents’ reports. For more information, see commonwealthfund.org www.childhealthdata.org. Authors’ analysis of 2016 and 2017 NSCH (CAHMI). 15. Children ages 19–35 months who did not receive all recommended vaccines: Percent of children ages 19–35 months who did not receive at least 4 doses of diphtheria, tetanus, and accellular pertussis (DTaP/DT/DTP) vaccine; at least 3 doses of poliovirus vaccine; at least 1 dose of measles-containing vaccine (including mumps-rubella (MMR) vaccine); the full series of Haemophilus influenza type b (Hib) vaccine (3 or 4 doses depending on product type); at least 3 doses of hepatitis B vaccine (HepB); at least 1 dose of varicella vaccine, and at least 4 doses of pneumococcal conjugate vaccine (PCV). Data from the 2013 and 2017, NIS-PUF (CDC, NCIRD). 16. Hospital 30-day mortality: Risk-standardized, all-cause 30-day mortality rates for fee-for-service Medicare patients age 65 and older hospitalized with a principal diagnosis of heart attack, heart failure, pneumonia or stroke between July 2010 and June 2013, and July 2013 and June 2016. All-cause mortality is defined as death from any cause within 30 days after the index admission, regardless of whether the patient dies while still in the hospital or after discharge. Authors’ analysis of Medicare enrollment and claims data retrieved from 4th Quarter 2018 and 4th Quarter 2014 Hospital Compare (CMS). 17. Central line-associated bloodstream infections (CLABSI), Standardized Infection Ratio (SIR): All CLABSIs reported to the National Healthcare Safety Network from all applicable hospital locations, including intensive care units, neonatal intensive care units, and wards. The standardized infection ratio compares the observed number of CLABSIs reported by hospitals within the state to the predicted number of infections based on the referent period, adjusting for key risk factors. Data are from the CDC’s 2015 and 2016 National and State Healthcare-Associated Infections Progress Reports. 18. Hospital patients discharged without instructions for home recovery: Percent of hospitals in the state with of hospitals in a state with HCAHPS patient experience summary scores lower than the national median. Authors’ analysis of 2017 HCAHPS as administered to adults discharged from acute care hospitals. Retrieved from 4th Quarter 2018 Hospital Compare (CMS). 19. Home health patients who did not get better at walking or moving around: Percent of all home health episodes in which a person did not improve at walking or moving around compared to a prior assessment. Episodes for which the patient, at start or resumption of care, was able to ambulate independently are excluded. Authors’ analysis of 2013 and 2017 OASIS. Data retrieved from 3rd quarter 2018 and 2nd quarter 2014 Home Health Compare (CMS). June 2019 2019 Scorecard on State Health System Performance 62 APPENDIX H. State Scorecard Indicator Descriptions and Source Notes (continued) 20. Nursing home residents with an antipsychotic medication: Percent of long-stay nursing home residents who received an antipsychotic medication, excluding residents with Schizophrenia, Tourette’s syndrome, and Huntington’s disease. Authors’ analysis of 2013–2017 MDS. Data retrieved from June 2018 and June 2014 Nursing Home Compare (CMS). 21. Adults with any mental illness (AMI) reporting unmet need: Percent of adults ages 18 or older with AMI (defined below) who reported a perceived need for mental health treatment or counseling in the past 12 months that was not received. This measure could include adults who reported that they received some type of mental health service in the past 12 months; an unmet need for services after adults had received some services would indicate a perceived need for additional services that they did not receive. Data are from the 2009–2011 and 2014–2016 NSDUH (SAMHSA), as reported in Mental Health America’s 2019 State of Mental Health in America (http://www. mentalhealthamerica.net). 22. Adults with any mental illness (AMI) who did not receive treatment: Percent of adults ages 18 or older with AMI (defined below) who reported they did not receive mental health treatment in the past 12 months. Mental health treatment is defined as receiving treatment or counseling for any problem with emotions, nerves, or mental health in the 12 months prior to the interview in any inpatient or outpatient setting, or the use of prescription medication for treatment of any mental or emotional condition that was not caused by the use of alcohol or drugs. Data are from the 2009–2011 and 2014–2016 NSDUH (SAMHSA), as reported in Mental Health America’s 2019 State of Mental Health in America (http://www.mentalhealthamerica.net). Note: Adults with any mental illness (AMI) is defined as adults ages 18 or older who currently or at any time in the past year have had a diagnosable mental, behavioral, or emotional disorder (other than a developmental or substance use disorder) of sufficient duration to meet diagnostic criteria specified within the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, regardless of the level of impairment in carrying out major life activities. AMI was estimated based on a statistical model of a clinical diagnosis and responses to questions on distress, impairment, past year major depressive episode, past year suicidal thoughts, and age. For more information, see: SAMHSA, NSDUH, Methodological Summary and Definitions, https://www.samhsa.gov/data/ sites/default/files/NSDUH-MethodSummDefsHTML-2015/ NSDUH-MethodSummDefsHTML-2015/NSDUHMethodSummDefs-2015.htm. 23. Hospital admissions for pediatric asthma, per 100,000 children: Excludes patients with cystic fibrosis or anomalies of commonwealthfund.org the respiratory system, and transfers from other institutions. Authors’ analysis of 2012 and 2015 HCUP SID (AHRQ); not all states participate in HCUP. Estimates for total U.S. are from the HCUP NIS (AHRQ). 24 & 25. Potentially avoidable emergency department (ED) visits: Potentially avoidable ED visits were those that, based on diagnoses recorded during the visit and the health care service the patient received, were considered to be either nonemergent (care was not needed within 12 hours), or emergent (care needed within 12 hours) but that could have been treated safely and effectively in a primary care setting. This definition excludes any ED visit that resulted in an admission, as well as ED visits where the level of care provided in the ED was clinically indicated. This approach uses the New York University Center for Health and Public Service Research emergency department algorithm developed by John Billings, Nina Parikh, and Tod Mijanovich (see: Emergency Room Use — The New York Story, The Commonwealth Fund, Nov. 2000, http://www.commonwealthfund.org/ publications/issue-briefs/2000/nov/emergency-room-use--thenew-york-story). Ages 18–64, per 1,000 employer-insured enrollees: Michael E. Chernew and Andrew Hicks, Harvard Medical School Department of Health Care Policy, analysis of the 2015 and 2016 Truven Marketscan Database. Ages 65 and older, per 1,000 Medicare beneficiaries: Jie Zheng, Harvard University, analysis of 2012 and 2015 Medicare Enrollment and SAF Claims Data 20% sample of fee-for-service Medicare beneficences ages 65 and older (CMS, CCW). 26 & 27. Admissions for ambulatory care–sensitive conditions: Hospital admissions for one of the following eight ambulatory care–sensitive (ACS) conditions: long-term diabetes complications, lower extremity amputation among patients with diabetes, asthma or chronic obstructive pulmonary disease, hypertension, congestive heart failure, dehydration, bacterial pneumonia, and urinary tract infection. Ages 18–64, per 1,000 employer-insured enrollees: Michael E. Chernew and Andrew Hicks, Harvard Medical School Department of Health Care Policy, analysis of the 2015 and 2016 Truven Marketscan Database. Ages 65–74 and older, per 1,000 Medicare beneficiaries: Admissions of fee-for-service Medicare beneficiaries ages 65-74 or ages 75 and older (measure reported separately for each age group but combined into a population-weighted average). Authors’ analysis of 2013 and 2017 CCW data, retrieved from the February 2019 CMS Geographic Variation Public Use File (CMS, Office of Information Products and Analytics). June 2019 2019 Scorecard on State Health System Performance 63 APPENDIX H. State Scorecard Indicator Descriptions and Source Notes (continued) 28 & 29. 30-day hospital readmissions: All hospital admissions among patients who were readmitted within 30 days of an acute hospital stay for any cause. A correction was made to account for likely transfers between hospitals. Ages 18–64, per 1,000 employer-insured enrollees: Michael E. Chernew and Andrew Hicks, Harvard Medical School Department of Health Care Policy, analysis of the 2015 and 2016 Truven Marketscan Database. Age 65 and older, per 1,000 Medicare beneficiaries: Readmissions among fee-for-service Medicare beneficiaries ages 65 and older. Authors’ analysis of 2013 and 2017 CCW data, retrieved from the February 2019 CMS Geographic Variation Public Use File (CMS, Office of Information Products and Analytics). 30. Short-stay nursing home residents with a 30-day readmission to the hospital: Percent of newly admitted nursing home residents who are rehospitalized within 30 days of being discharged from a hospital to the nursing home. Vincent Mor, Brown University, analysis of 2012 and 2016 Medicare enrollment data, MDS, and MedPAR File (CMS). 31. Long-stay nursing home residents with a hospital admission: Percent of long-stay residents (residing in a nursing home for at least 90 consecutive days) who were hospitalized within six months of baseline assessment. Vincent Mor, Brown University, analysis of 2012 and 2016 Medicare enrollment data, MDS, and MedPAR File (CMS). 32. Home health patients with a hospital admission: Percent of home health episodes among fee-for-service Medicare beneficiaries during which the patient was admitted to an acutecare hospital. Authors’ analysis data from CMS Medicare claims data. Data retrieved from 4th quarter 2018 and 3rd quarter 2014 Home Health Compare (CMS), representing patient experiences in 2017 and 2013. 33. Adults ages 18–50 with low back pain who had an imaging study at diagnosis: The share of employer-insured adults ages 18–50 who had a new primary diagnosis of low back pain with an imaging study (plain X-ray, MRI, or CT scan) within 28 days of the diagnosis (expressed as a rate per 100 enrollees). Enrollees who have a diagnosis for which an imaging study may be clinically appropriate (cancer, recent trauma, IV drug abuse, or neurologic impairment) are excluded. Michael E. Chernew and Andrew Hicks, Harvard Medical School Department of Health Care Policy, analysis of the 2015 and 2016 Truven Marketscan Database. 34. Total employer-sponsored insurance spending per enrollee: Total spending per enrollee in employer-sponsored insurance commonwealthfund.org plans estimated from a regression model of reimbursed costs for health care services from all sources of payment including the health plan, enrollee, and any third party payers incurred in 2013 and in 2015. Outpatient prescription drug charges are excluded. Enrollees with capitated plans and their associated claims are also excluded. Estimates for each state were adjusted for enrollees’ age and sex, the interaction of age and sex, partial year enrollment and regional wage differences. Michael E. Chernew and Andrew Hicks, Harvard Medical School Department of Health Care Policy, analysis of the 2015 and 2016 Truven Marketscan Database. 35. Total Medicare (Parts A and B) reimbursements per enrollee: Total Medicare fee-for-service reimbursements include payments for both Part A and Part B but exclude Part D (prescription drug costs) and extra CMS payments for graduate medical education and for treating low-income patients. Reimbursements reflect only the age 65 and older Medicare fee-for-service population. Authors’ analysis of 2013 and 2017 CCW data, retrieved from the February 2019 CMS Geographic Variation Public Use File (CMS, Office of Information Products and Analytics). 36. Mortality amenable to health care, deaths per 100,000 population: Number of deaths before age 75 per 100,000 population that resulted from causes considered at least partially treatable or preventable with timely and appropriate medical care (see list), as described in E. Nolte and M. McKee, “Measuring the Health of Nations: Analysis of Mortality Amenable to Health Care,” British Medical Journal, Nov. 15, 2003, 327 (7424): 1129–32. Authors’ analysis of mortality data from CDC restricted-use Multiple Cause-of-Death file (NCHS) and U.S. Census Bureau population data, 2003–2015. Causes of death Ages Intestinal infections 0–14 Tuberculosis 0–74 Other infections (diphtheria, tetanus, septicaemia, poliomyelitis) 0–74 Whooping cough 0–14 Measles 1–14 Malignant neoplasm of colon and rectum 0–74 Malignant neoplasm of skin 0–74 Malignant neoplasm of breast 0–74 Malignant neoplasm of cervix uteri 0–74 Malignant neoplasm of cervix uteri and body of uterus 0–44 Malignant neoplasm of testis 0–74 Hodgkin’s disease 0–74 Leukemia 0–44 Diseases of the thyroid 0–74 Diabetes mellitus 0–49 Epilepsy 0–74 Chronic rheumatic heart disease 0–74 Hypertensive disease 0–74 June 2019 2019 Scorecard on State Health System Performance 64 APPENDIX H. State Scorecard Indicator Descriptions and Source Notes (continued) Cerebrovascular disease 0–74 All respiratory diseases (excluding pneumonia and influenza) 1–14 Influenza 0–74 Pneumonia 0–74 Peptic ulcer 0–74 Appendicitis 0–74 Abdominal hernia 0–74 Cholelithiasis and cholecystitis 0–74 Nephritis and nephrosis 0–74 Benign prostatic hyperplasia 0–74 Maternal death Congenital cardiovascular anomalies Perinatal deaths, all causes, excluding stillbirths Misadventures to patients during surgical and medical care Ischaemic heart disease: 50% of mortality rates included All 0–74 All 46. 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 2017 NSCH (CAHMI). 47. Adults who have lost six or more teeth: Percent of adults ages 18–64 who have lost six or more teeth because of tooth decay, infection, or gum disease. Authors’ analysis of 2012 and 2016 BRFSS (CDC, NCCDPHP). All 0–74 37. Breast cancer deaths per 100,000 female population: Authors’ analysis of NVSS–M, 2013 and 2016 (NCHS), retrieved using CDC WONDER. 38. Colorectal cancer deaths per 100,000 population: Authors’ analysis of NVSS–M, 2013 and 2016 (NCHS), retrieved using CDC WONDER. 39. Suicide deaths per 100,000 population: Authors’ analysis of NVSS-M, 2013 and 2016 (NCHS), retrieved using CDC WONDER. 40. Alcohol-related deaths per 100,000 population: Authors’ analysis of NVSS-M, 2013 and 2017 (NCHS), retrieved using CDC WONDER. 41. Drug poisoning deaths per 100,000 population: Authors’ analysis of NVSS-M, 2013 and 2017 (NCHS), retrieved using CDC WONDER. 42. Infant mortality, deaths per 1,000 live births: Authors’ analysis of NVSS-I, 2012 and 2016 (NCHS), retrieved using CDC WONDER. 43. Adults who report fair/poor health: Percent of adults age 18 and older who reported being in fair or poor health. Authors’ analysis of 2013 and 2017 BRFSS (CDC, NCCDPHP). 44. Adults who smoke: Percent of adults age 18 and older who ever smoked 100 or more cigarettes (five packs) and currently smoke every day or some days. Authors’ analysis of 2013 and 2017 BRFSS (CDC, NCCDPHP). 45. 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 2013 and 2017 BRFSS (CDC, NCCDPHP). commonwealthfund.org June 2019 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.