State-by-State Scorecard of Racial and Ethnic Disparities Finds All States’ Health Systems Are Failing People of Color

A new health-equity scorecard released Nov. 18 by the Commonwealth Fund finds deep-seated racial and ethnic health inequities in all 50 states and the District of Columbia — disparities that have been exacerbated by the COVID-19 pandemic.

Achieving Racial and Ethnic Equity in U.S. Health Care: A Scorecard of State Performance is a comprehensive examination of how healthcare systems are functioning for people of color in every state. Part of the Commonwealth Fund’s
ongoing series examining individual state health system performance, the report uses 24 measures to evaluate each state on healthcare access, quality and service use, and health outcomes for Black, white, Latinx/Hispanic, American
Indian/Alaska Native (AIAN), and Asian American, Native Hawaiian, and Pacific Islander (AANHPI) populations.

The health-equity scorecard reveals that even among high-performing states, racial and ethnic health disparities can be dramatic. For example, Minnesota’s healthcare system, which has historically performed well in Commonwealth Fund state scorecard rankings, has some of the largest health disparities between white and nonwhite communities. Maryland, Massachusetts, and Connecticut are other traditionally high-scoring states where white residents receive some of the best care in the country but where quality of care is far worse for many populations of color. Similarly, in states like Mississippi and Oklahoma whose healthcare systems have historically performed poorly for both white and Black populations, white patients still received markedly better care.

In addition to showing how people of different races and ethnicities fare within each state, the Fund’s scorecard ranks how well each state’s health system is working for each racial and ethnic group. For instance, the healthcare system in
California works better for Latinx/Hispanic people than the Texas healthcare system. In both Texas and California, however, the health system benefits white people more. Among states with large American Indian populations, South
Dakota, North Dakota, Montana, and Wyoming have the worst-performing health systems for these communities, while California’s system ranks at the top — though there are still wide disparities with other populations in the state.

POLICY IMPLICATIONS

Structural racism and generations of disinvestment in communities of color are chief among many factors contributing to pervasive U.S. health inequities, the authors note. As the COVID-19 pandemic has shown, people in many communities of color are more likely than members of white communities to live in poverty, to work in low-paying, high-contact industries, and to reside in high-risk living environments. Many Black, Latinx/Hispanic, and AIAN
populations then face an unequal health system when they need to access care. They are less likely to have health insurance, more likely to face cost-related barriers to care and medical debt, and more likely to receive suboptimal care.

Health inequities are perpetuated and reinforced by each of these contributing factors — all of which have their roots in both past and current policies at the federal, state, and local levels. The authors suggest pursuing four broad policy
goals to create an equitable, antiracist health system:

1. Ensuring affordable, comprehensive, and equitable health insurance coverage for all
2. Strengthening primary care
3. Lowering administrative burden for patients
4. Investing in social services.

Since health inequities vary across states, there are also opportunities for state programs to tailor interventions that address the unique needs of their communities.

HOW WE CONDUCTED THIS STUDY

State health system performance was evaluated for each of five racial and ethnic groups — Black (non-Latinx/Hispanic), white (non-Latinx/Hispanic), AIAN (non-Latinx/Hispanic), AANHPI (non-Latinx/Hispanic), and Latinx/Hispanic
(any race) — among 24 indicators of health system performance. Indicators were grouped into three performance domains: health outcomes, healthcare access, and quality and use of healthcare services.

For each of the 24 indicators, the researchers calculated a standardized score for each state/population group with sufficient data (e.g., Latinx/Hispanic individuals in Texas). Within each performance domain, they combined indicator values to create a summary score. The domain summary scores in each state were then combined to create a composite state health system performance score for each racial and ethnic group.

Based on the overall composite scores, each racial/ethnic group within each state received a percentile score providing both national and state-level context on the performance of a state health system for that population. The percentile scoring, from 1 (worst) to 100 (best), reflects the observed distribution of health system performance for all groups measured in this report and enables comparisons within and across states. For example, California’s health system score of 50 for Latinx/Hispanic individuals indicates that it is performing better for those residents than Florida’s health system does for Latinx/Hispanic people, with a score of 38. However, both groups fare worse than white residents in California, where the health system performs at a score of 89 for them.

Online viewers can use the interactive exhibits to see which states perform best and worst and to focus on specific racial and ethnic groups. State and group-specific profiles are available for download.

Read the full report