Hawaii leads and Oklahoma lags on a new state scorecard about health system performance.

The scorecard is the first of its kind from the Commonwealth Fund, a private foundation focused on health care.

The Commonwealth Fund rated states based on 32 indicators, including access, quality, cost, insurance, preventive care, potentially avoidable hospital visits, and premature death (death before age 75).

The top five states in order are Hawaii, Iowa, New Hampshire, Vermont, and Maine.

The bottom five states are Nevada, Arkansas, Texas, Mississippi, and Oklahoma.

Wide Range

The top-rated states scored two to three times higher than the lowest-ranked states.

"Where you live really matters in terms of your experience with the American health care system," Commonwealth Fund President Karen Davis told reporters at a news conference.

"The wide variation and gaps between leading and lagging states add up to substantial human and economic cost for the nation," says Cathy Schoen, the Commonwealth Fund's senior vice president for research and evaluation.

Schoen says that if all states equaled the top-rated states, there would be 90,000 fewer premature deaths before age 75 from conditions such as diabetes, infection, respiratory disease, and treatable cancers. In addition, 22 million more adults and children would be insured, cutting U.S. uninsured rates in half.

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Room for Improvement

Every state has room for improvement -- even those leading the scorecard -- notes Schoen, who worked on the scorecard with other experts.

"Each of the top states has some indicators in the bottom half of the state distribution," Schoen says. In other words, though those states may rank highly overall, they're not acing every category in the scorecard.

Insurance tracked with the states' ratings.

"In general, states that did well in the overall rankings had the lowest rates of uninsured in the nation, and states that did poorly had the highest rates of uninsured in the nation," Schoen says.

But high ratings didn't always mean high costs.

"Indeed, some states have high quality and lower cost," Schoen says. She adds that "high costs tend to track higher rates of potentially preventable hospital use and 30-day re-admission rates, indicating a need for a focus on prevention and primary care and care coordination."

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State Rankings

Here is the list of how the states and Washington, D.C., ranked overall. States with the same ranking are listed together.

1. Hawaii


3. New Hampshire, Vermont

4. Maine

5. Rhode Island

6. Connecticut

7. Massachusetts

8. Wisconsin

9. South Dakota

10. Minnesota

11. Nebraska

12. North Dakota

13. Delaware

14. Pennsylvania

15. Michigan

16. Montana, Washington

17. Maryland

18. Kansas

19. Wyoming

20. Colorado, New York

21. Ohio, Utah

22. Alaska, Arizona, New Jersey

23. Virginia Idaho, North Carolina

25. Washington, D.C.

26, South Carolina

27. Oregon

28. New Mexico

29. Illinois

30. Missouri

31. Indiana

32. California

33. Tennessee

34. Alabama

35. Georgia

36. Florida

37. West Virginia

38. Kentucky

39. Louisiana, Nevada

40. Arkansas

41. Texas

42. Mississippi, Oklahoma

This article was reviewed by Louise Chang, MD.

SOURCES: The Commonwealth Fund Commission on a High-Performance Health System: "Aiming Higher: Results from a State Scorecard on Health System Performance," June 2007. Karen Davis, president, The Commonwealth Fund. Cathy Schoen, senior vice president for research and evaluation, The Commonwealth Fund.