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Achieving Racial and Ethnic Equity in U.S. Health Care: A Scorecard of State Performance

November 17, 2021

In this report, we evaluate health equity across race and ethnicity, both within and between states, to illuminate how state health systems perform for Black, white, Latinx/Hispanic, AIAN, and Asian American, Native Hawaiian, and Pacific Islander (AANHPI) populations. Our hope is that policymakers and health system leaders will use this tool to investigate the impact of past policies on health across racial and ethnic groups, and that they will begin to take steps to ensure an equitable, antiracist health care system for the future.

Racial and Ethnic Inequities in Health Care Coverage and Access, 2013–2019

June 9, 2021

In this brief, we update our 2020 report on coverage and access inequities using 2013–2019 data from the American Community Survey Public Use Microdata Sample (ACS PUMS) and the Behavioral Risk Factor Surveillance System (BRFSS). We examine trends in Black and Latinx/Hispanic disparities across the following measures, with a particular focus on the effects of Medicaid expansion on equity at the state level:adults ages 19 to 64 who are uninsuredadults ages 18 to 64 who went without care in the past 12 months because of costadults ages 18 to 64 who report having a usual health care provider.

Inequities in Health and Health Care in Black and Latinx/Hispanic Communities: 23 Charts

June 3, 2021

COVID-19 has devastated Black and Latinx/Hispanic communities in the United States during the past year, erasing recent life expectancy gains and reinforcing racism as a potent, structural driver of health and human inequity.The health disparities contributing to this burden are long-standing. They reach well beyond the pandemic and have left many communities of color with historically worse outcomes. This chartbook details inequities between white, Black, and Latinx/Hispanic communities across a range of health indicators in four main areas:insurance coverage and access to carereceipt of health serviceshealth statusmortality.

2018 Scorecard on State Health System Performance

May 3, 2018

Hawaii, Massachusetts, Minnesota, Vermont, and Utah are the top-ranked states according to the Commonwealth Fund's 2018 Scorecard on State Health System Performance, which assesses all 50 states and the District of Columbia on more than 40 measures of access to health care, quality of care, efficiency in care delivery, health outcomes, and income-based health care disparities.The 2018 Scorecard reveals that states are losing ground on key measures related to life expectancy. On most other measures, performance continues to vary widely across states; even within individual states, large disparities are common.Still, on balance, the Scorecard finds more improvement than decline between 2013 and 2016 in the functioning of state health care systems. This represents a reversal of sorts from the first decade of the century, when stagnating or worsening performance was the norm.

Reducing Racial and Ethnic Disparities in Access to Care: Has the Affordable Care Act Made a Difference?

August 24, 2017

Issue: Prior to the Affordable Care Act (ACA), blacks and Hispanics were more likely than whites to face barriers in access to health care.Goal: Assess the effect of the ACA's major coverage expansions on disparities in access to care among adults.Methods: Analysis of nationally representative data from the American Community Survey and the Behavioral Risk Factor Surveillance System.Findings and Conclusions: Between 2013 and 2015, disparities with whites narrowed for blacks and Hispanics on three key access indicators: the percentage of uninsured working-age adults, the percentage who skipped care because of costs, and the percentage who lacked a usual care provider. Disparities were narrower, and the average rate on each of the three indicators for whites, blacks, and Hispanics was lower in both 2013 and 2015 in states that expanded Medicaid under the ACA than in states that did not expand. Among Hispanics, disparities tended to narrow more between 2013 and 2015 in expansion states than nonexpansion states. The ACA's coverage expansions were associated with increased access to care and reduced racial and ethnic disparities in access to care, with generally greater improvements in Medicaid expansion states.

Aiming Higher: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition

March 16, 2017

Issue: States are a locus of policy and leadership for health system performance.Goal: To compare and evaluate trends in health care access, quality, avoidable hospital use and costs, health outcomes, and health system equity across all 50 states and the District of Columbia.Methods: States are ranked on 44 performance measures using recently available data. Key findings: Nearly all states improved more than they worsened between 2013 and 2015. The biggest gains were in health insurance coverage and the ability to access care when needed, with states that had expanded their Medicaid programs under the Affordable Care Act experiencing the most improvement. There were also widespread state improvements on key indicators of treatment quality and patient safety; hospital patient readmissions also fell in many states. However, premature deaths crept up in almost two-thirds of states, reversing a long period of decline. Wide variations in performance across states persisted, as did disparities experienced by vulnerable populations within states.Conclusion: If every state achieved the performance of top-ranked states, their residents and the country as a whole would realize dramatic gains in health care access, quality, efficiency, and health outcomes.

A Long Way in a Short Time: States' Progress on Health Care Coverage and Access, 2013-2015

December 19, 2016

Issue: The Affordable Care Actís policy reforms sought to expand health insurance coverage and make health care more affordable. As the nation prepares for policy changes under a new administration, we assess recent gains and challenges.Goal: To compare access to affordable health care across the U.S. between 2013 and 2015. Methods: Analysis of most recent publicly available data from the U.S. Census Bureau and the Behavioral Risk Factor Surveillance System.Key findings and conclusions: Between 2013 and 2015, uninsured rates for adults ages 19 to 64 declined in all states and by at least 3 percentage points in 48 states and the District of Columbia. For children, uninsured rates declined by at least 2 percentage points in 28 states. The share of adults age 18 and older who reported forgoing a visit to the doctor when needed because of costs dropped by at least 2 percentage points in 38 states and D.C. In contrast, there was little progress in expanding access to dental care for adults, which is not a required benefit under the ACA. These findings illustrate the impact that policy can have on access to care and offer a focal point for assessing future policy changes.

The Slowdown in Employer Insurance Cost Growth: Why Many Workers Still Feel the Pinch

October 26, 2016

Although predictions that the Affordable Care Act (ACA) would lead to reductions in employer-sponsored health coverage have not been realized, some of the law's critics maintain the ACA is nevertheless driving higher premium and deductible costs for businesses and their workers.Goal: To compare cost growth in employer-sponsored health insurance before and after 2010, when the ACA was enacted, and to compare changes in these costs relative to changes in workers' incomes.Methods: The authors analyzed federal Medical Expenditure Panel Survey data to compare cost trends over the 10-year period from 2006 to 2015.Key findings and conclusions: Compared to the five years leading up to the ACA, premium growth for single health insurance policies offered by employers slowed both in the nation overall and in 33 states and the District of Columbia. There has been a similar slowdown in growth in the amounts employees contribute to health plan costs. Yet many families feel pinched by their health care costs: despite a recent surge, income growth has not kept pace in many areas of the U.S. Employee contributions to premiums and deductibles amounted to 10.1 percent of U.S. median income in 2015, compared to 6.5 percent in 2006. These costs are higher relative to income in many southeastern and southern states, where incomes are below the national average.

Health System Performance for the High-Need Patient: A Look at Access to Care and Patient Care Experiences

August 1, 2016

Achieving a high-performing health system will require improving outcomes and reducing costs for high-need, high-cost patients—those who use the most health care services and account for a disproportionately large share of health care spending. Goal: To compare the health care experiences of adults with high needs—those with three or more chronic diseases and a functional limitation in the ability to care for themselves or perform routine daily tasks—to all adults and to those with multiple chronic diseases but no functional limitations. Methods: Analysis of data from the 2009–2011 Medical Expenditure Panel Survey. Key findings: High-need adults were more likely to report having an unmet medical need and less likely to report having good patient–provider communication. High-need adults reported roughly similar ease of obtaining specialist referrals as other adults and greater likelihood of having a medical home. While adults with private health insurance reported the fewest unmet needs overall, privately insured highneed adults reported the greatest difficulties having their needs met. Conclusion: The health care system needs to work better for the highest-need, most-complex patients. This study's findings highlight the importance of tailoring interventions to address their needs

The Changing Landscape of Health Care Coverage and Access: Comparing States' Progress in the ACA's First Year

December 9, 2015

This analysis compares access to affordable health care across U.S. states after the first year of the Affordable Care Act's major coverage expansions. It finds that in 2014, uninsured rates for working-age adults declined in nearly every state compared with 2013. There was at least a three-percentage-point decline in 39 states. For children, uninsured rates declined by at least two percentage points in 16 states. The share of adults who said they went without care because of costs decreased by at least two points in 21 states, while the share of at-risk adults who had not had a recent checkup declined by that same amount in 11 states. Yet there was little progress in expanding access to dental care for adults, which is not a required insurance benefit under the ACA. Wide variation in insurance coverage and access to care persists, highlighting many opportunities for states to improve.

Aiming Higher: Results from a Scorecard on State Health System Performance, 2015 Edition

December 9, 2015

The fourth Commonwealth Fund Scorecard on State Health System Performance tells a story that is both familiar and new. Echoing the past three State Scorecards, the 2015 edition finds extensive variation among states in people's ability to access care when they need it, the quality of care they receive, and their likelihood of living a long and healthy life. However, this Scorecard—the first to measure the effects of the Affordable Care Act's 2014 coverage expansions—also finds broad-based improvements. On most of the 42 indicators, more states improved than worsened. By tracking performance measures across states, this Scorecard can help policymakers, health system leaders, and the public identify opportunities and set goals for improvement. The 50 states and the District of Columbia are measured and ranked on 42 indicators grouped into five domains: access and affordability, prevention and treatment, avoidable hospital use and cost, healthy lives, and equity. Individual indicators measure things like rates of children or adults who are uninsured, hospital patients who get information about how to handle their recovery at home, hospital admissions for children with asthma, and breast and colorectal cancer deaths, among many others.

Closing the Gap: Past Performance of Health Insurance in Reducing Racial and Ethnic Disparities in Access to Care Could Be an Indication of Future Results

March 5, 2015

This historical analysis shows that in the years just prior to the Affordable Care Act's expansion of health insurance coverage, black and Hispanic working-age adults were far more likely than whites to be uninsured, to lack a usual care provider, and to go without needed care because of cost. Among insured adults across all racial and ethnic groups, however, rates of access to a usual provider were much higher, and the proportion of adults going without needed care because of cost was much lower. Disparities between groups were narrower among the insured than the uninsured, even after adjusting for income, age, sex, and health status. With surveys pointing to a decline in uninsured rates among black and Hispanic adults in the past year, particularly in states extending Medicaid eligibility, the ACA's coverage expansions have the potential to reduce, though not eliminate, racial and ethnic disparities in access to care.