Commonwealth Fund gives healthcare in southeastern states failing grades across the board

The southeastern region of the U.S. scored worst across the board in the Commonwealth Fund’s annual scorecard ranking states' healthcare system performance.

Declining overall health, shrinking access to reproductive care and discrepancies in healthcare between state lines stood out among 58 measures, including healthcare access, quality, cost and health outcomes. Preventable deaths due to pregnancy, drug overdoses, firearms and certain treatable chronic conditions rose dramatically during the first two years of the COVID-19 pandemic, the report found. Insurance coverage during the pandemic rose to record levels, report authors said, but as COVID-era policies wane, experts are ringing alarm bells.

“The scorecard really gives us a detailed view of how we've come out of the pandemic, and it sounds alarms of clear and present dangers in a couple of different areas,” Joseph Betancourt, M.D., president of The Commonwealth Fund, said in a press conference. “We've gone backward on life expectancy. Avoidable deaths, women's health, mental health, substance abuse disorder, are all critical issues that require urgent attention. You can see through our evidence that federal and state policies do matter. The variations that we see in this data don't happen coincidentally or by happenstance.”

Massachusetts received the best overall score across seven dimensions of health system performance evaluated. Hawaii, New Hampshire, Rhode Island and Vermont also made it to the top five. The lowest states overall were Arkansas, Texas, Oklahoma, West Virginia and Mississippi.

Deaths due to COVID-19 helped increase the number of preventable deaths across the country, lowering the country’s overall life expectancy. Black Americans suffered the most pronounced disintegration in life expectancy.

The report argues that preventable deaths before age 75 can largely be avoided through effective public health measures and primary care. Underlying health and socioeconomic characteristics, state pandemic responses and share of the population vaccinated were all factors that played a role in untimely deaths. Firearms-related mortalities were also highlighted as rising at an alarming rate—up 23% since 2019.

While all states saw large increases in avoidable deaths, the report pointed out that Arizona, Louisiana, Mississippi, New Mexico and Texas stand apart for experiencing a 35% increase. Black and Native American people experience the highest rates of deaths due to preventable and treatable causes, according to The Commonwealth Fund report.

Maternal deaths in American Indian and Alaskan Native populations increased from around 50 deaths per 100,000 live births in 2020 to nearly 120 in 2021. Deaths of Black mothers increased by more than 25 deaths per 100,000.

“We see wide state variations in reproductive care and women's health outcomes,” said Laurie Zephyrin, Ph.D., Commonwealth Fund vice president of advancing health equity, during the press conference. “Ultimately, we see states with the worst outcomes are also implementing and considering further restrictions on reproductive care. This really raises concerns about inequity in access and inequity in health outcomes.

“As we think about how to protect women's ability to access reproductive health care, we have to promote policies and innovative payment models and digital tools that can really support the continuum of reproductive and women's healthcare," she said.

This year’s scorecard added 12 new measures evaluating maternal and pregnancy-related outcomes along with access to reproductive services. Representatives from The Commonwealth Fund reiterated a sentiment stated multiple times in the report—the data presented was from before the 2022 Supreme Court Dobbs decision.

Outcomes were shown to vary greatly between states with 9.6 deaths per 100,000 live births in California and over 40 in Arkansas, Alabama, Louisiana, Tennessee and Mississippi. “It’s important to note that California has made concerted efforts to address racial equity in maternal health over the past decade,” the report authors said.

The Commonwealth Fund researchers suggested that Medicaid coverage be extended in the postpartum period to 12 months. The American Rescue Plan Act, a COVID-era stimulus package, gave states the option to extend coverage, an opportunity 36 states have taken advantage of and six are planning on while three states have opted for limited extensions. The report suggested that Congress make the option permanent.

Diverse, comprehensive, community-based maternal health workforces can be invested in as can care that addresses social determinants of health, especially race, the report authors said.

Models supporting mothers with maternal mental health conditions and substance use disorders must be invested in, according to the report. Irrespective of parental status, many patients in the U.S. were also shown to not have access to behavioral healthcare.

In 2021, for the first time, combined deaths from drug overdoses, alcohol and suicide caused over 200,000 deaths, 50,000 more than the pre-pandemic high in 2019. An average of 60% of youth between the ages of 12 to 17 with a major depressive episode did not receive mental health services, the report showed. That percentage hit a nadir in Washington D.C. at 33% and a zenith at 77% in South Carolina.

When it comes to overall healthcare access, The Commonwealth Fund pointed to looming cuts to Medicaid as cause for alarm. Of the 18 states with the highest uninsured rates, the report showed that 13 were Medicaid non-expansion states.

“Expanding Medicaid programs in the southeastern region would be the first step towards improving their health system performance,” said Sara Collins, Ph.D., Commonwealth Fund senior scholar and vice president of health care coverage and access and tracking health system performance, during the press conference. “I'll give the example of Mississippi where 30% of people with incomes under 200% of poverty, which is about $55,000 for a family of four, are uninsured. That is extremely high.

“That also means that there are wide disparities between lower-income people and higher-income people in nearly all these states on measures of access both uninsured but also measures of not getting healthcare because of cost," she said.

When it comes to avoidable mortality and increasing behavioral care, the report suggests expanding primary care access, integrating behavioral health into primary care and increasing community-based healthcare workforces.

A steady drumbeat throughout the report and comments made during the corresponding press conference called for increased access through expanded insurance coverage and decreased cost of care. Researchers recommended auto-enrollment mechanisms, expanded Medicaid and lower out-of-pocket costs as paths to a more equitable healthcare system.

“The 10 remaining Medicaid non-expansion states can move forward on expansion, or Congress can help Medicaid-eligible people in those states get covered immediately through a federal fallback action,” Collins said. “Policymakers can protect consumers from being financially ruined by medical debt. Policymakers and stakeholders will need to address the root cause of the nation's medical debt and affordability crisis by reining in the high healthcare prices charged by many healthcare providers that are relentlessly driving up U.S. healthcare costs.”