The Sorry States of Health Care

A state-by-state study shows who has the best and worst grades on 32 health indicators, and even the best are none too good

If you live in Hawaii, you're not just tanned and relaxed, chances are you are also better placed, health-wise, than the rest of the country, and certainly than the residents of Mississippi and Oklahoma.

That's the determination of a new survey by the nonprofit Commonwealth Fund that ranks the health-system performance of all 50 states plus Washington, D.C. Hawaii comes out No. 1 in the rankings, while Mississippi and Oklahoma tie for last place. The researchers conclude that if all the states could reach the low levels of mortality achieved by Hawaii, some 90,000 fewer deaths before the age of 75 would occur annually.

The U.S. health-care system is, just like the nation, a federalist entity, made up of 51 distinct health-care systems—the states and Washington, D.C (see, 6/12/07, "Universal Health Care: Say Yes"). The states have tremendous authority on how medical care is delivered, monitored, and paid for within their borders.

They regulate both hospitals and insurers, deliver public health services such as vaccinations, and determine which residents are covered under Medicaid and the State Children's Health Insurance Program (SCHIP). Some states are also far ahead of the federal government on health-care reform. Maine and Massachusetts, for example, both have universal health-care laws in place, while California and several other states are considering similar legislation. (See our interactive table featuring the Commonwealth Fund data for each state.)

Dismal Percentages

New York-based Commonwealth Fund, a nonpartisan group that does health-care research, decided to issue a report card on how each state is doing on health care as a tool to identify areas of success and failure. Its researchers measured each state on 32 indicators, such as the percentage of people insured, the number of adults who receive screening and preventive care, hospital admissions for people with chronic illnesses, infant mortality, deaths from treatable cancers, and equity-of-care gaps by income and insurance status.

One stark finding: Even in the best states, performance fell far short of optimal standards. The percentage of adults age 50 or older receiving all recommended preventive care ranged from a high of 50% in Minnesota to a low of 33% in Idaho, while the percentage of diabetics receiving proper care ranged from 65% in Hawaii to 29% in Mississippi.

The problems with state health-care systems go far beyond the level of uninsured residents, says Commonwealth President Karen Davis, an economist. "The states have started moving into a leadership position on access to care by making health insurance affordable and mandated, but they can't figure out what to do about the cost and quality problems." Davis says she was particularly surprised by the wide variations among states on many of the measures—sometimes a 20- to 30-point difference between the best and worst states.

Focus on Hospital Admissions

The study highlights some of the reasons behind the high cost of health care in the U.S. by measuring avoidable uses of hospitals and medical care. Rates of potentially preventable hospital admissions ranged from more than 10,000 per 100,000 Medicare enrollees in the worst performing states to 5,000 per 100,000 enrollees in the five best. There was also a twofold variation in rates of readmission within 30 days of leaving the hospital (from 24% in Louisiana and Nevada to 13% in Vermont and Wyoming). Such rapid readmissions to hospitals is often a sign that care was not delivered optimally the first time.

The researchers estimated that if all states could reach low levels of preventable hospital admissions and readmissions for Medicare recipients, hospitalization rates for senior citizens alone could be reduced by 30% to 47% and save Medicare $2 to $5 billion a year.

Hawaii, incidentally, does not come out on top simply because it is paradise. It was the first state to expand access to health insurance, back in 1974 when it passed a law requiring all employers to provide health insurance to full-time workers. "Though we also think it's the healthy living," says Davis. All of the data compiled for the state scorecards can be found at

See BusinessWeek's slide show of the best and worst states for health care, and join a debate about nationalized health insurance.

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