Women in the United States face a growing number of threats to their health and well-being, a new report says, and there are vast disparities from state to state.
In their inaugural state-by-state analysis on women’s health, researchers at the Commonwealth Fund, a private foundation focused on health issues, collected data on health care quality, outcomes and access for women in the US. The data came from several sources, including the US Centers for Disease Control and Prevention, and the researchers evaluated states on 32 specific metrics, scoring them relative to each other.
The report, released Thursday, reveals that states in the Northeast scored highest. Massachusetts came out on top as “the best-performing health system for women overall,” with Vermont, Rhode Island, Connecticut and New Hampshire rounding out the top five.
The poorest performers were spread across the southern half of the country. Mississippi had the lowest score overall, followed by Texas, Nevada, Oklahoma and Arkansas.
“This is the very first time we at the Fund have created a scorecard exclusively focused on states’ performance in reproductive care and women’s health,” said Dr. Joseph Betancourt, president of the Commonwealth Fund.
“While some states undoubtedly are championing women’s continued access to vital health and reproductive services, many others are failing to ensure that women can get and afford the health care they need. This failure is having a disproportionate impact on women of color and women with low incomes,” he said. “My hope is that policymakers can use these findings to identify and address gaps in care, guaranteeing that all women across the United States can live healthy lives with access to quality, affordable care – no matter where they live or what their background is.”
‘Health of women … is in a perilous place’
The new report reveals that life expectancy for US women is the lowest it’s been in nearly two decades – since 2006.
“The health of women in the United States is in a perilous place,” the authors wrote, highlighting nationwide increases in deaths from preventable causes, as well as significant state-by-state differences in how many women are dying in reproductive age.
In 2022, the mortality rate ranged from about 204 deaths for every 100,000 women of reproductive age in West Virginia to around 71 deaths per 100,000 in Hawaii, the report says.
“We looked at deaths from all causes among women and girls ages 15 to 44, a common way to identify women of reproductive age, and we found a threefold difference across states, with the highest rates of death concentrated in the Southeastern states,” said David Radley, a senior scientist for the Commonwealth Fund’s Tracking Health System Performance initiative.
Causes of death included those related to pregnancy – with mental health conditions as the most frequently reported cause of preventable pregnancy-related deaths – as well as other preventable causes such as substance use, Covid-19 and treatable chronic health conditions. The report also noted that the maternal death rate nearly doubled between 2018 and 2022, with rates for Black and American Indian and Alaska Native women increasing the most.
Deaths from breast and cervical cancer also are considered in the new report as preventable and treatable with timely screening and health care. Breast and cervical cancer deaths were found to be highest in Southern states.
“We also saw big differences across states in women’s ability to access care,” Radley said. “The state of health care for women in this country is in a vulnerable place.”
A fractured landscape of health policies – including Medicaid coverage and access to abortion and reproductive care – contributes to significant state-level inequalities for women across the country, according to the new report.
“We found big differences across states in a woman’s ability to access reproductive health care services, the quality of care she’s likely to receive and the outcomes she’s likely to experience,” Radley said. “We looked at insurance coverage and found that uninsured rates among women ranged from 2.5% to over 20% uninsured, with the highest uninsured rates in states that have not expanded their Medicaid programs.”
Expanding Medicaid coverage to cover more people with household incomes below a certain level is linked with lower rates of maternal mortality, smaller racial and ethnic disparities in maternal mortality and infant health outcomes, and broader use of reproductive health care services, according to the report. The three states with the lowest maternal mortality rates – Vermont, California and Connecticut – have all expanded Medicaid.
Ten states have not expanded Medicaid – Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin and Wyoming – leaving about 800,000 women uninsured. Each of those states, except for Wisconsin, ranked below the average on women’s health.
Women in states that had not expanded Medicaid eligibility were among those most at risk of lacking insurance coverage, the researchers found. Among women ages 15 to 44, those in Texas, Georgia and Oklahoma had the highest rates of being uninsured. Those in Massachusetts, the District of Columbia and Vermont had the lowest uninsured rates.
“But access isn’t just about having coverage, it’s also about being able to get to a service provider when care is needed. It’s estimated that over 5 million women already live in a county that’s considered a maternity care desert, meaning there’s no hospital or birth center offering obstetric care and there are no obstetric providers,” Radley said.
“We looked at the adequacy of the maternity care workforce in each state and found that states with the most restrictive abortion policies also tended to have the fewest maternity care providers,” he said. “There’s concern among experts that abortion bans and restrictions may reduce the number of maternity care providers even further.”
‘Are those divides … going to continue?’
States with abortion restrictions tend to have the fewest maternity care providers, higher rates of maternal mortality and broad disparities in health systems, according to the new report.
Fourteen states – Alabama, Arkansas, Idaho, Indiana, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Oklahoma, South Dakota, Tennessee, Texas and West Virginia – have enacted near-total bans on abortion since the US Supreme Court’s Dobbs decision revoked the federal right to abortion two years ago. All but one of those states ranked below average in the new ranking of women’s health from the Commonwealth Fund, and seven were among the poorest-performing states.
The policy choices that state lawmakers put forth, including fully expanding Medicaid and imposing abortion restrictions, have “clearly had implications for people in their states,” said Sara Collins, senior scholar and vice president for health care coverage and access and tracking health system performance at the Commonwealth Fund.
“Those are clear policy choices that states are making that are linked to the politics in their state and that are having an impact on women’s access to health care,” Collins said.
“Are those divides that we’re seeing going to continue into the future?” she asked. “Are there going to be more women who are living in states that don’t have full access to reproductive health care? Or are those trends going to reverse? And a lot of that is tied to the politics, both in states but also at the federal level.”
