Scorecard on State Health System Performance

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

by David C. Radley, Sara R. Collins, and Jesse C. Baumgartner

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The COVID-19 pandemic has disrupted health care around the globe. In the United States, where it has claimed the lives of more than 185,000 people, health systems in every state have been stretched — in some cases severely.

The novel coronavirus has exposed and exacerbated existing weaknesses that have long been the focus of the Commonwealth Fund’s Scorecard on State Health System Performance. First, because most Americans get their health insurance through an employer, recent job losses have widened coverage gaps that existed prior to the crisis. The Urban Institute projects that 10 million people will lose their employer coverage by year’s end, leaving 3.5 million uninsured.1 The loss of job-based coverage has also brought into sharp relief the impact of states’ decisions not to expand Medicaid eligibility for low-income residents; 12 states have yet to expand their programs as allowed under the Affordable Care Act (ACA).2

Second, Black, Latino, and other communities of color, already more likely to be uninsured, have been disproportionally burdened by COVID-19 and the related economic fallout. Systemic racial and ethnic inequities in health care access and quality have contributed to higher hospitalization and mortality rates from COVID-19 among Black, Latino, American Indian, and Alaska Native individuals, among others.

Third, the pandemic has exposed the vulnerability of health providers reliant on the fee-for-service payment system. Many are facing steep revenue losses and the threat of closure as social-distancing restrictions, fear, and a nose-diving economy have driven down both the supply and demand for routine and elective care.3

Finally, the country faces many unanswered questions on the extent to which COVID-19 and the ongoing economic fallout will contribute to suicides, deaths from alcohol and substance use, and further erosion of Americans’ life expectancy.

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The 2020 Scorecard offers the latest available federal data on the state of the U.S. health system before it headed into the most severe public health crisis and economic collapse in modern times. It also highlights health system weaknesses that have left the U.S. far less prepared than other high-income countries to cope with public health threats like COVID-19. These weaknesses include:

  • a health care delivery system that is highly unequal in its care of people of color and those with low and moderate incomes.
  • an insurance system that still leaves millions without coverage.
  • exorbitant commercial insurance prices that fuel growth in health spending and expose people to high premiums and deductibles, even as many make wage concessions to keep their employer benefits.
  • an inadequate primary care system.
  • declining life expectancy.
  1. Jessica Banthin et al., Changes in Health Insurance Coverage Due to the COVID-19 Recession: Preliminary Estimates Using Microsimulation (Urban Institute, July 2020).
  2. Voters in Oklahoma and Missouri passed Medicaid expansion by ballot in June and August of 2020; the states are expected to implement expansion by the summer of 2021.
  3. Ateev Mehrotra et al., The Impact of the COVID-19 Pandemic on Outpatient Visits: Changing Patterns of Care in the Newest COVID-19 Hot Spots (Commonwealth Fund, Aug. 2020).