The Commonwealth Fund Blog

Two Americas

August 14, 2013

Tags: access to care Affordable Care Act Medicaid

David BlumenthalBy David Blumenthal, M.D.

Economists at Harvard University recently reported that geography is a particularly powerful predictor of economic mobility in the United States. For those of us who work in health care, this should not be surprising: we already have abundant evidence that where you live matters a lot when it comes to health and the quality of care you receive. Increasingly, the U.S. is not one country, but two―divided geographically by persistent, troubling differences in people’s access to affordable, high-quality health care.

This is a clear message of The Commonwealth Fund’s state and local scorecards on health system performance, which have documented these divisions over much of the past decade. And the message will be reinforced in our newest health system scorecard, which focuses on low-income populations in the U.S. (look for it next month). Certain regions of the country―the Northeast and Northwest, parts of the Midwest, the North-Central states―regularly perform well. Other regions―generally the South, Southeast, and Southwest―perform poorly. The former have health outcomes that are among the best in the industrialized world. Results in the latter look more like those of developing countries in South Asia, South America, and Latin America.

Troubling as these findings are, geography is not destiny. Particular areas within the worst-performing states do relatively well. Austin, Texas, scored in the top half of regions in The Commonwealth Fund’s local scorecard―an outlier in a state that ranked 46th in our last state scorecard. Similarly, the Greensboro and Hickory areas of North Carolina ranked among the top half of regions of the U.S., much better than the state as a whole, which placed in the bottom fifth of states. But these oases of high performance in otherwise poor-performing regions are not sufficient to change the overall patterns. Two Americas

And while we can take some comfort in positive outliers, the sheer variation in cost, quality, and overall health system performance across the country is reason for significant concern. Our recent local scorecard documented consistent 10-to-20-percentage-point differences between high- and low-performing regions on a host of measures related to health care access, quality, and costs. Gaps between the best- and lowest-performing areas are staggering. For example, the proportion of adults with health insurance in the leading regions is more than 50 percent higher than in the lagging areas, while the rate of potentially preventable mortality in the best region is one-third of that in the worst.

The reasons for regional disparities in health and health care are not yet fully understood, and we must understand them before we can address them. Poor-performing regions tend to have much higher proportions of uninsured citizens. This could get somewhat better because of the Affordable Care Act (though not if states in those areas don’t take advantage of the law). Other explanations undoubtedly lie outside the realm of health care, in education, poverty levels, diet, and lifestyle.

Unfortunately, many of the states that lag in health care performance are choosing not to expand eligibility for Medicaid under the Affordable Care Act. We know that insurance coverage, including Medicaid, improves access to care and results in improved health for previously uninsured people. States skipping expansion will also miss an opportunity to lower the costs of uncompensated care for their hospitals and forgo an infusion of federal dollars for traditionally underserved and rural areas. Uneven implementation of the ACA, therefore, could increase preexisting disparities in the health and health care available in high- and low-performing areas of the U.S.

Persistent differences in health care across the country matter for all of us. In the end, we are one nation and one people. When some of our citizens suffer, we all suffer. If some regions lag economically because of health care deficits, we will all feel the downward tug on employment, tax revenues, GDP, and our international competitiveness. We are stronger as a country when all of us are strong.

The U.S. health care divide deserves much more attention than it has received. The Commonwealth Fund remains committed to tracking the two “health care Americas,” an undertaking that will continue next month with the release of our new scorecard on health system performance for low-income populations. Bringing the troubling variation in health outcomes within our country to light is a crucial step toward closing the chasm between these two Americas and ensuring that everyone has the opportunity to live a long, healthy, and productive life.

Post Comment Read or Post Comments

Rohit Khanna of In Vivo says:
August 17, 2013


This is a fascinating article and one wonders how many "Two health care" systems there are in other jurisdictions (i.e. Canada, U.K., etc.) given the U.S. data that you have shared. Although the issue is clearly multi-factorial and not restricted to one single driver, I can't help but wonder what role and impact the adoption of new(er) technology and the quality of the health care provider him/herself has to do with this. In other words, are southern/southwestern/southeastern states lagging because they make new(er) drugs and devices less accessible to their constituents? Similarly, is there data that shows that 'the best and brightest' in medicine are gravitating towards northeastern and northwestern states by virtue of better working conditions, access to better research funding, higher salaries and/or different compensation models? As mentioned, the insurance gap is clearly a 'driver' in these overall differences but surely the availability of technology and the quality of those delivering the care must contribute to this issue.

Ralph Freidin, MD of Mt Auburn Hospital - emeritus says:
August 16, 2013

“How much is my life worth?”

Four years ago, in Atlanta at a free medical clinic for those without health insurance I was asked to see a panicked 34 y/o woman. She had two jobs. Neither provided health insurance. Her salaries were insufficient to buy her own policy. For months she had pelvic pain. Finally using all of her savings, she saw doctor. An ultrasound showed a suspicious ovarian mass. A CT scan was recommended. The cost $2000. Not having the money, she asked “Am I going to die because I cannot afford the test?” She arrived at the free clinic, she implored, “Is my life not worth it?” After listening to her account, I arranged for evaluation and treatment at an Atlanta teaching hospital

A year later, I heard a story of a young woman from Massachusetts facing a life threatening illness. She, too, had no insurance. But she lived in Massachusetts where by law everyone must have health insurance. When she developed multiple bruises, she applied for Mass Health, the state program for residents unable to afford state mandated health insurance. With insurance, she was able to see a doctor who diagnosed acute leukemia. With insurance, she received the most advanced chemotherapy, multiple transfusions, and a bone marrow transplant. Four years later, after more than a million dollars of public funds had been spent, she is well without a sign of recurrent disease.

Grateful for health reform in Massachusetts saving her life, she asked if the Commonwealth had misspent its money to save her life. ‘’What is the value of my life?’ she asked. An economist replied that the Commonwealth had invested wisely on a person who has a lifetime to contribute to society.

Among the millions of Americans without health insurance who live in states willing to forgo the dollars available from ACA I have no doubt there are many more who will be asking the similar questions as they watch the tale of two Americas develop.

Ralph B Freidin, MD

Paul Nelson of Family Health Care, P.C. says:
August 15, 2013

Our nation's healthcare industry suffers from a colossal paradigm paralysis that prevents any reform from originating within the healthcare industry itself. This paradigm paralysis has occurred because the payors of each citizen's healthcare also determine what qualifies for reimbursement. In effect, the payors determine both the ECONOMIC MANDATE as well as the SOCIAL MANDATE for our nation's healthcare. This inherent conflict of interest has been resolved by preferentially paying for Complex Healthcare Needs rather than Basic Healthcare Needs. The result is Primary Health Care that is neither equitably available, culturally accessible, justly efficient nor reliably effective for each citizen. The payor problem is aggravated by the lack of connection between the training centers and the front lines of Primary Health Care, as has existed for our nation's agriculural industry through the Cooperative Extension Service established by Congress in 1914 (the Smith-Lever Act). Remember that among the developed countries of the world, our nation's agriculture is the most efficient and our nation's healthcare is the least efficient.

I propose that true rather than incremental reform will require a semi-autonomous, nationally sanctioned and widely supported institution having the sole responsibility to promote true healthcare reform. Most importantly this reform would establish the resources necessary to support the development of enhanced Primary Health Care for each citizen, community by community. In effect, the local process would be nationally sanctioned but not nationally controlled. Established by Congress, this national institution would function according to the attributes for managing a common resource as described by Elinor Ostrom, a 2009 Nobel Prize winner in economics: decentralized governance. In addition to promoting high quality Primary Health Care, the institution should have a GOAL to reduce the cost of our nation's healthcare to 13% of the gross domestic product and reduce our nation's maternal mortality ratio by 80%. The result would represent a 25% reduction in the cost of our nation's healthcare ( viz., a $650 billion decrease in 2010 alone) and a maternal mortality rate among the best 10 developed nation's of the world (instead of the current level among the worst 10 of these nations).

John Hatch of John D. Hatch, P.C. says:
August 14, 2013

Sounds like you have a solution in search of a problem. How are you defining "health system performance?" Average life expectancy? Average length and cost of hospital stay? Morbidity? Number of doctors per 1,000? Overall health outcomes should be the measure, not how many have insurance or government benefits.