A new report offers a bleached picture of the state of the country’s health care system as a result of the COVID-19 pandemic, with premature deaths on the rise across states while disparities in access to reproductive care for women have widened.
Deaths directly attributable to COVID-19 brought about a stark rise in preventable mortality for each state between 2019 and 2021, according to the findings of a new analysis released Thursday by the Commonwealth Fund. The report also found a large increase after 2019 in “avoidable” deaths, which were defined as those that occurred from otherwise treatable chronic health conditions such as diabetes and heart disease. The researchers’ report suggests the rise in deaths from those conditions that likely resulted in them being left unmanaged because patients were delayed getting preventive care due to service disruptions caused by the pandemic.
“The scorecard really gives a detailed view of how we’ve come out of the pandemic, and it sounds alarms,” said Commonwealth Fund President Dr. Joseph Betancourt during a call with reporters held Wednesday. “We have gone backward on life expectancy, backward on avoidable deaths – women’s health, mental health, substance use disorders are all critical issues that require urgent attention.”
Other notable contributors to the rise in premature deaths from 2019 to 2021 include a 51% increase in deaths from drug overdose, which in 2021 reached a record high of more than 106,000. Deaths from alcohol rose 39% over that period, and firearm-related mortality increased by 23% in 2021 compared to 2019. Deaths from drug overdose, alcohol and suicide combined accounted for approximately 200,000 in 2021 for the first time, according to the report, an increase of around 50,000 compared to 2019.
“Efforts to lower drug overdose deaths would likely have the biggest impact on avoidable mortality in the short term,” said report co-author David Radley, senior scientist for tracking health system performance at the Commonwealth Fund in response to questions from US News. “Policy makers could take action to increase access to additional care, implement and expand harm reduction policies for the quickest impact. In the medium to longer term, working to integrate behavioral health with primary care and strengthening the primary care workforce will be important.”
Arizona, Louisiana, Mississippi, New Mexico and Texas had the largest increase in the rate of avoidable death from 2019 to 2021, with each of those states experiencing a more than 35% rise over that period. Arizona had the biggest increase of all states, rising 45% from 249.3 deaths per 100,000 population in 2019 to 362.6 per 100,000 in 2021.
Altogether, such deaths have contributed to a drop in US life expectancy for two consecutive years.
The report ranks the health system performance of states and the District of Columbia by using 58 performance indicators grouped into seven dimensions, including health care access and affordability; prevention and treatment; avoidable hospital use and costs; healthy lives, which involves risky health behaviors; income disparity; racial and ethnic equity; and reproductive care and women’s health. The analysis used publicly available data from government agencies, including the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services and the US Census Bureau.
For the first time, the report includes rankings for states’ performances on providing reproductive care and women’s health outcomes. The issue of reproductive care has gained more attention in recent years due to both the disproportionate impact the COVID-19 has had on maternal health, as well as concerns that the US Supreme Court’s 2022 decision to roll back abortion rights may lead to limited access to maternal health care services and poorer health outcomes.
Report co-author Dr. Laurie Zephyrin, senior vice president for advancing health equity for the Commonwealth Fund, said some of the worst reproductive care and women’s health outcomes are occurring in states that are passing and considering further restrictions on reproductive care, which she contends will only make it more difficult for women to access such services.
“Right now, we see wide state variations in reproductive care and women’s health outcomes,” Zephyrin said. “This really raises concerns about inequities in access, and inequities in health outcomes.”
Nationally, maternal mortality jumped nearly 64% from a rate of 20.1 deaths per 100,000 live births in 2019 to 32.9 per 100,000 in 2021, according to the report. Between 2019 and 2021, state maternal mortality rates ranged from a low of 9.6 per 100,000 in California to a high of 50.3 per 100,000 in Mississippi.
The Commonwealth Fund report found the mortality rate from all causes among women of reproductive age (15 to 44 years) increased 40% from 89.4 deaths per 100,000 women in 2019 to 124.2 per 100,000 in 2021, with a range of 78.9 per 100,000 in Hawaii to 238.6 per 100,000 in West Virginia.
Among the report’s recommendations to states to improve reproductive care and women’s health include extending Medicaid coverage for postpartum care services from 60 days to 12 months. The enactment of the American Rescue Plan Act in 2021 granted states the option to extend postpartum Medicaid coverage to 12 months for five years, which thus far, 36 have done. Other recommendations include providing funding for community-based organizations focused on maternal health outcomes and expanding and diversifying the maternal and reproductive health care workforce.
The report found states varied widely in providing women access to early prenatal care. While only 11% of women in Vermont went without access to prenatal care during their first trimester of pregnancy, states like Texas and Florida had the largest share of women without access, at nearly 30%. “Prenatal care is critical to identifying early risks and supporting people throughout their pregnancy, and it can improve outcomes for mothers and their babies,” the report stated.
Overall, the report ranked Massachusetts as having the best performing health system in the US, with the state coming first in most categories, including health care access and affordability; prevention and treatment; racial and ethnic health equity; and reproductive care and women’s health. Other top states include Hawaii, New Hampshire, Rhode Island and Vermont.
Mississippi ranked last for health system performance, coming in near the bottom of nearly every category, including 50th for reproductive care and women’s health, and 50th in healthy lives, while ranking 49th for racial and ethnic health equity. Along with Mississippi, other states that received poor marks included West Virginia and Oklahoma, which were tied for the 49th, followed by Texas and Arkansas.
Many of the issues outlined in the report highlight a need to expand health care access, which report authors warned could be further complicated by the end of temporary federal policies put in place during the public health emergency to expand health insurance coverage, which resulted in the US reached a record low uninsured rate of 8% last year.
Most notable is the potential loss of health care coverage for as many as 15 million enrollees of Medicaid and the Children’s Health Insurance Program as states undergo the process of “unwinding” their continuous enrollment policies. During the public health emergency, states received federal funding to maintain Medicaid coverage to enrollees without eligibility renewals and redeterminations. As potentially millions more Americans become newly uninsured in the coming months, the report authors recommend policymakers take actions to fill those coverage gaps by addressing some of the administrative hurdles to eligibility and enrollment that can disrupt coverage for Medicaid enrollees.
“Federal and state policies do matter,” Betancourt said. “The variations that we see in this data don’t happen coincidentally or by happenstance – we really hope that this report along with the moral courage of leaders in all 50 states can drive us toward addressing these challenges both now and into the future.”