Each year, the Commonwealth Fund uses data to rank the 50 states and Washington, D.C. on how well their health care systems are working. Missouri ranked near the bottom of that scorecard. KSMU talked with David Radley, a senior scientist with the Commonwealth Fund, to learn more about the scorecard and the Missouri health system's low ranking. This interview has been edited for length and clarity.
Q. As part of the Commonwealth Fund mission to improve health care in America and health care access for everyone living in America, your group publishes a state-by-state health system scorecard. Can you start by telling us the purpose of that scorecard when Commonwealth assigns a ranking to each state in terms of health system? What does that mean?
David Radley: That's a great question. Really what our goal with the scorecard is to give people some information that can help them set priorities, help them see attainable benchmarks that are being achieved in other states.
Q. What were some of your team's overall nationwide findings in this year's scorecard?
A. So this year's scorecard took a look at over 50 measures of performance. We saw that COVID really hit states quite differently. And we found the states that had historically strong health systems, states that have low uninsured rates, tended to get high marks for care quality. In states where people living in them tended to have better than average outcomes, those are the states that really proved to be the most resilient as the pandemic was unfolding and got the highest ranks.
On the flip side of that, we saw that states that tend to have a little bit lower-than-average performance — so maybe they have a higher uninsured rate, maybe the marks for care quality tended to be a little bit lower before the pandemic — those are the states that seemed to get hit particularly hard during the pandemic. And I think that's really where where Missouri falls.
This year, we saw Missouri ranked 47 overall when we consider all 50 measures in the scorecard. But on that smaller composite of the seven measures that were specific to COVID, Missouri ranks 40 out of 50 states plus D.C. So these numbers should be an indication that Missouri struggled a little bit. I want to be clear, I don't want to downplay this: The pandemic has hit all states very hard.
Q. Right. And so when we talk about Missouri ranking 47th, your study highlights some good areas, some improved indicators and top-ranked indicators, and some underperforming ones. In terms of less-positive areas — indicators that got worse in Missouri — preventable hospitalizations for adults of working age, 18 to 64, got worse. And in terms of bottom-ranked indicators, we have very little public health funding here in the Show-Me State. Any comment on those aspects?
A. It's really useful to think about these as the hospital admissions for things that you could really be treating or managing with really strong primary care.
For example, this might be a required a hospitalization for complications of diabetes. If you're really sick with diabetes, going to the hospital is probably the right thing.
But if you're managing your diabetes, you've got your care management plan with your primary care doc, you should be able to avoid most hospitalizations related to diabetes. And that's the kind of thing that's intuitive to measure. And so when we see high rates of avoidable hospitalizations, it's almost always an indication that maybe a little bit more investment in primary care is needed.
Missouri also didn't rank super-high on many measures of health care access. Of course, being able to access a primary care doc, it has a lot to do with whether or not you have health insurance, whether or not you have a usual provider, you know, somebody that you think of as being your usual doctor. These are important predictors of being able to manage chronic disease, if you have some sort of chronic illness.
And you know, Missouri has a 14 percent uninsured rate — that's 38th in the country, again, out of 51. So much higher than average. More Missourians are more likely to report avoiding needed health care because of its costs. Missouri ranks 43 on that indicator. So some of these other health care access indicators, I think, are actually playing into those high rates of hospitalization for these preventable causes.
Q. In terms of the states that did better than average, Hawaii and Massachusetts scored much higher than the other 50 states, including those better-than-average ones. Briefly, what are they doing right?
A. When we looked over the ways that the pandemic has played out across states, the states that had historically strong health systems tended to do best overall, and that sort of includes Massachusetts, Hawaii and a few others.
So these are states that have made big investments in health care access. Massachusetts had a law with a personal mandate for health insurance coverage long before the Affordable Care Act. The federal law was sort of modeled after that particular law. And so Massachusetts has also had a very long tradition of a huge amount of investment in both health care delivery and in public health. And those things are playing out.
In Hawaii's case, again, the state has a very low uninsured rate. Hawaii has got some particularly interesting laws that other states don't have around affordability — particularly among people who have employer-sponsored coverage. In terms of the health of Hawaiians, it makes sure that health care remains affordable. And of course, when health care is affordable, Hawaiians can access care more readily, and that helps with health outcomes, and it's sort of the trickle-down effect.
We really think about health care access as being the foundation that the rest of the system is built on.