A state-by-state assessment of health care finds that suicide remains a national crisis in the U.S., and the growth in the numbers of insured Americans has stalled after improving for several years after the implementation of the Affordable Care Act (ACA). The Commonwealth Fund's yearly scorecard on health looks at all 50 states and grades them on 47 health care measurements covering access; quality; service use and costs of care; health outcomes; and income-based health care disparities. Related: In ranking of healthiest countries, U.S. comes in at 35 "What we're seeing is a regional epidemic when it comes to premature deaths from suicide, alcohol, and drugs," said David Blumenthal, M.D., Commonwealth Fund president. "It's going to take solutions that meet local need, and greater cooperation across all sectors — at both the federal and state level — to end the crisis that is shortening life expectancy in the United States." This year, top honors again went to Hawaii, despite performing worse overall than previous years. Mississippi held onto its less-desirable last-place ranking, and Delaware plunged 17 places. Several states showed significant improvement in health measurements, including Rhode Island, Missouri, Washington, West Virginia and Arkansas.

"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."