"Deaths of despair" become an epidemic
The most alarming message of the report was the continued rise in what the authors called "Deaths of Despair"—suicides and deaths due to substance abuse. The report notes regional differences in the numbers--some states are seeing more deaths from drug overdoses due in large part to opioid abuse (the New England region), while states in the upper Midwest and West had higher rates of death from suicide and alcohol, rather than drugs. "Opioid use disorder, as well as the emergence of highly lethal synthetic opioids (e.g., fentanyl and carfentanil) in the illicit drug supply, have fueled a rise in drug overdose deaths that have affected families across the country," the report said. "Together, rising death rates from suicide, alcohol, and drug overdose contribute to the recent decline in average life expectancy at birth in the United States."
Insurance coverage improved—then stalled
The report says one major finding is how insurance gains have stalled in states, after seeing improvement after the adoption of the ACA. "In most states, progress stalled after 2015," the report said. "From 2016 to 2017, more than half of states simply held on to earlier gains; 16 states, including those that did and did not expand Medicaid, experienced upticks of 1 percentage point in their adult uninsured rate." The report added that much of the improvement in insurance rates before the numbers stalled has been due to states' adopting the Medicaid expansion provisions of the ACA. The expansion has been available to states, but not all states enacted the expansion when the ACA was put in place; with some states adopting the expansion in the past few years. "States' decisions about whether to expand their Medicaid programs have had stark implications for their uninsured rates," the report said. "Among the 17 states that have yet to expand Medicaid, five had the highest uninsured rates, ranging from 18 percent to 24 percent."
Paths to future improvement
The report has several recommendations on how states can improve rankings. This includes a wider adoption of Medicaid expansion in states that have rejected or restricted it. Reinsurance, an ACA provision that expired in 2017, is also recommended, as some states have reinstated reinsurance plans in their markets with good results. Other efforts by states to control costs or experiment with public option insurance plans also were praised by the report. However, the authors also note that it will take a combination of state and federal steps to truly improve health care nationwide. "The gains made in people's coverage and access to health care following enactment of the ACA have stalled and even eroded in some states," said Sara Collins, the study's coauthor and Commonwealth Fund vice president for health care. "There are a number of steps — including expanding Medicaid eligibility, enhancing subsidies, and changing the way providers are paid in private plans — that states and the federal government can take to improve access to care and lower costs." Read more:
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