Group Points to Disparities as Reform Argument : There is a fivefold difference in performance between the highest- and lowest-ranked states.

A continued wide disparity in access to and quality of care across the United States argues strongly for a national health reform plan, according to executives at the Commonwealth Fund, who released a state-by-state survey of 38 health indicators.

According to the Commonwealth Fund survey, there is a fivefold difference in performance on the indicators between the highest-ranked states and the lowest. "The differences we see among the states translate to real lives and real dollars," Karen Davis, president of the Commonwealth Fund, said at a press conference. "In the richest country in the world, there is no justification for any state to be far below the best state for quality and access to health care."

Health reform legislation under consideration in Congress would go a long way toward improving access and coverage, and that would increase quality overall, Ms. Davis said.

This is the second time the nonprofit group has taken a microscopic look at issues of cost, quality, and access in each state and the District of Columbia. Since the first report card in 2007, the number of uninsured adults has risen—and this survey was done on the eve of the recession, so the "worst is yet to come," according to Cathy Schoen, senior vice president of the Commonwealth Fund.

Coverage for children, however, has remained steady or improved, thanks to the federally supported Children's Health Insurance Program (CHIP), Ms. Schoen said.

States in the top quartile have been top performers in previous scorecards and have higher rates of insured adults and children, better access to primary care, and lower mortality from preventable diseases, among other indicators. The top quartile comprises Connecticut, Hawaii, Iowa, Maine, Massachusetts, Minnesota, Nebraska, New Hampshire, North Dakota, Rhode Island, South Dakota, Vermont, and Wisconsin.

Ten of the 13 states in the lowest quartile—Alabama, Arkansas, Florida, Kentucky, Louisiana, Mississippi, Nevada, Oklahoma, Tennessee, and Texas—also ranked at the bottom on the previous 2007 report. Illinois, New Mexico, and North Carolina dropped into the lowest quartile since the last survey, while California, Georgia, and West Virginia moved up out of the last quartile in this most recent report. The lower-performing states had rates of uninsured adults and children that were double those in the top quartile.

The uninsured and those with low incomes tended to have poorer access to care and to receive a lower quality of care, Ms. Schoen said.

The report also reflected some bright spots: The quality of hospital care for heart attack, heart failure, pneumonia, and the prevention of surgical complications improved dramatically for all states, as did the quality of nursing home care. The Commonwealth Fund attributed the improvements to the increasing national efforts to measure and benchmark performance, including Medicare's Hospital Compare and Nursing Home Compare Web sites.

Conversely, data on ambulatory care quality is sorely lacking, Ms. Schoen said. From what can be gleaned, states' performance on preventive care stayed the same or declined. And poor coordination of care is resulting in continued high—and increasing—rates of hospital readmissions, according to the scorecard.

Ms. Davis touted the patient-centered medical home as a way to improve performance in preventive care, ambulatory care, and hospital readmissions. She said that 31 states are sponsoring medical home projects, and that the Commonwealth Fund is supporting efforts in Colorado, Idaho, Massachusetts, Oregon, and Pennsylvania to help safety net clinics become medical homes.

According to Ms. Davis and her colleagues, if the lower-performing states were helped to reach the levels of the higher-performing states, 29 million more people would be insured; 78,000 fewer adults and children would die prematurely each year from preventable conditions; 9 million more adults aged 50 years and older would receive recommended preventive care; and almost 800,000 more children would receive key vaccinations.

The organization also said that the nation could realize $5 billion in savings a year by avoiding preventable admissions and readmissions.