If all states did as well as some states on leading health indicators, the nation would be a healthier place, according to a state scorecard on health system performance released in June by the Commonwealth Fund.

"The rich geographical diversity of the United States is part of its appeal. The diverse performance of the health care system across the U.S., however, is not," the Commonwealth Fund said.

The June report ranks states on five dimensions of health system performance—access to health care, quality of care, costs of care, potentially avoidable use of hospitals, and the ability to lead healthy lives. Taken together, those categories cover 32 separate indicators of performance, ranging from infant mortality to the percentages of adults and children who have health insurance.

"Currently, where you live in the United States matters for quality and care experiences," the report points out. "There is wide variation among states, Leading states consistently outperform lagging states. All states have substantial room to improve."

Many of the highest-ranking states healthwise are in the upper Midwest—Iowa, Minnesota, Nebraska, North Dakota, South Dakota, and Wisconsin--and in the Northeast—Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont. Performing in the next rank down on the Commonwealth Fund's five indicators are Colorado, Idaho, Montana, Utah, Washington, and Wyoming in the Northwest and Kansas is the Midwest, plus Maryland, Michigan, New York, Ohio, and Pennsylvania.

Ten widely separated states--Arizona, Idaho, Illinois, Indiana, New Jersey, New Mexico, North Carolina, Oregon, South Carolina, and Virginia—fall into the next quartile, with a large number of states—Alabama, Arkansas, California, Florida, Georgia, Kentucky, Louisiana, Mississippi, Nevada, Oklahoma, Tennessee, Texas, and West Virginia—ending up at the bottom of the rankings.

What Is Being Measured

• Access. The nation would insure 22 million more adults and children if all states moved to the level of coverage provided in the top-performing states. The percent of adults under age 65 who were uninsured ranges from a low of 11 percent in Minnesota to a high of 30 percent in Texas. The percent of uninsured children varies fourfold, from 5 percent in Vermont to 20 percent in Texas.
• Quality. Even in the best states, performance falls far short of optimal standards. Childhood immunization rates range from 94 percent in Massachusetts to less than 75 percent in the bottom five states. The percent of children with a medical home that helps coordinate care ranges from a high of 61 percent in New Hampshire to less than 40 percent in the bottom 10 states.
• Avoidable use of hospitals and costs of care. State rates of hospital admission for childhood asthma range from a low of 55 per 100,000 children in Vermont to more than 300 per 100,000 in South Carolina. For Medicare, if all states reached the low levels of hospital admissions found in the highest ranked states, Medicare could save billions of dollars annually.
• Equity. Equity gaps by income and insurance coverage exist in most states but the gaps are widest in states that perform poorly overall on quality and access indicators.
• Healthy Lives. If death rates for all states improved to levels achieved by the best state (Minnesota, with 70.2 deaths per thousand), about 90,000 fewer premature deaths would occur annually. The report points out, however, that health system performance is only one of many forces that shape health status and longevity, including family history, immigration status, risk factors such as smoking and obesity, and workplace and environmental regulations.

The implications of its state scoreboard, the Commonwealth Fund said, are that "we have much to gain as a nation by aiming higher with a coherent set of national and state policies. Benchmarks set by leading states show that there are broad opportunities to improve and achieve more and better health care. All states can do better, and all should continually ask, 'Why not the best?'"

Information about the report, "Aiming Higher: Results from a State Scoreboard on Health System Performance," which shows the performance of individual states on 32 indicators of health system performance, is available at www.commonwealthfund.org.