The COVID-19 pandemic pushed the U.S. health care system to its limit and amplified persistent gaps among states as they grappled with the coronavirus and its emerging variants, according to the Commonwealth Fund’s 2022 Scorecard on State Health System Performance.

For the first time, the scorecard, which ranks states’ health care systems based on how well they work to provide high-quality, accessible, and equitable health care, also looked specifically at how well states have managed COVID-19.

Overall, states that entered the pandemic with stronger health care systems fared better. Hawaii, Maine, Vermont, Washington, and Oregon achieved the top rankings across the COVID-19-specific measures, while Alabama, Oklahoma, Kentucky, Mississippi, and Georgia ranked at the bottom.

The scorecard added seven COVID-19-specific measures including state vaccination rates, hospital and intensive care unit (ICU) capacity, and what is known as “excess mortality” (death rates that exceed historical norms), from the beginning of the pandemic through the end of March 2022.

A few other highlights from the COVID-19-related findings include:

• The death toll from COVID-19 extends far beyond deaths directly attributed to the virus. Since the pandemic began in February 2020, all states have reported more deaths than typical, from COVID-19 as well as other causes. The number of excess deaths varied fivefold across states, from 110 per 100,000 people in Hawaii to 596 per 100,000 in Mississippi.

Historically stronger health systems like Massachusetts, Hawaii, and Minnesota had the best overall health outcomes during 2020, including lower rates of preventable mortality and overall healthier populations. West Virginia, Mississippi, and Kentucky, among the states hit hardest by COVID-19, had some of the highest levels of preventable mortality.

Premature deaths from treatable causes grew at unprecedented rates in 2020. With people postponing routine health services because of COVID-19, deaths from treatable chronic conditions like heart disease and diabetes rose. These deaths were particularly high in the South and parts of the Midwest. Moreover, Black, Latinx/Hispanic, and Indigenous people, among the groups most affected by COVID-19, experienced some of the most significant mortality increases.

Deaths from preventable causes such as drug overdoses and alcohol rose across the country. Drug overdose deaths increased to record highs in almost every state during 2020 and 2021, as people struggled with the pandemic’s impacts and more potent synthetic opioids became more prevalent. The toll was particularly devastating in West Virginia and the Southeast.

• COVID-19 has pushed hospitals toward a breaking point — with many operating close to capacity while understaffed.

ICUs full for extended periods of time: Between August 2020 and March 2022, 16 states and the District of Columbia operated at high intensive care unit (ICU) capacity for at least 150 days. Texas and Alabama stand out, with 566 and 517 days at or above 80 percent ICU capacity, respectively. Rhode Island, Georgia, Mississippi, New Mexico, and Oklahoma also exceeded 300 days.

Hospital staffing shortages: Since August 2020, 18 states have experienced at least 100 days when a significant share (25%) of their hospitals reported critical staffing shortages. Alabama had 516 days of staffing shortages; South Carolina, New Mexico, and Rhode Island each experienced more than 400 days of staffing shortages.

In addition to the COVID-19-specific measures and rankings, the scorecard uses the most current data available to assess all 50 states and the District of Columbia on 49 health care measures covering access, quality, service use and costs of care, and health outcomes. On these overall health system rankings, Hawaii, Massachusetts, and Connecticut were top-ranked states, while Mississippi, Oklahoma, and West Virginia were ranked at the bottom.

The scorecard can be found here and will allow users to explore key findings, access data available for individual states and topics, and view data at a glance through custom tables, graphs, and maps.


The study authors suggest policy strategies to improve health system performance in the years ahead, among them:

• Strengthening the ability of state health systems to respond to future crises through a national pandemic preparedness strategy, drawing on recent lessons learned, that delineates federal and state responsibilities and authorities.
• Reducing the number of deaths from preventable causes by lowering insurance and administrative barriers for addiction treatment, as well as boosting investment in good primary care — the foundation for a highperforming health care system — and fully integrating behavioral health with primary care services.
• Continuing to make coverage more affordable and care more accessible. This includes making the American Rescue Plan Act’s marketplace premium subsidy enhancements permanent. Additionally, filling the Medicaid coverage gap by providing a federal insurance option for people with low incomes who live in states that have yet to expand eligibility for Medicaid.


The Commonwealth Fund’s 2022 Scorecard on State Health System Performance evaluates 56 health care indicators as well as income- and race and ethnicitybased differences in performance within states. Findings are based on the authors’ analysis of the most recent publicly available data from federal agencies including the U.S. Census Bureau, Centers for Disease Control and Prevention, and the Centers for Medicare and Medicaid Services, as well as other data sources. For more detail, see “Scorecard Methods” in the report.

The full report is available here.