Healthcare Access on the Rise in the U.S., but Infant Mortality and Regional Disparities Raise Alarms

The Commonwealth Fund's 2025 State Health System Performance Scorecard presents a paradoxical view of American healthcare, documenting substantial progress in insurance coverage while revealing troubling declines in childhood vaccination rates and persistent regional health disparities. The comprehensive analysis evaluates all 50 states and the District of Columbia across 50 healthcare indicators using data collected through 2023.

Health insurance coverage has achieved remarkable improvements over the past decade, with adult uninsured rates falling to a historic low of 11 percent by 2023. Every state has experienced coverage gains since 2013, primarily through expanded Medicaid eligibility and enhanced Affordable Care Act tax credits that have made healthcare more accessible across diverse populations.

Commonwealth Fund President Joseph Betancourt emphasized the report's significance for policymakers, stating that "falling rates of early childhood vaccination in nearly every state, rising infant mortality and enduring racial and regional health gaps—this scorecard a powerful tool for policymakers." He added that "policies that make healthcare more affordable and accessible work—and make a difference for people everywhere, every day."

However, these coverage achievements face serious threats from proposed federal policy changes. Sara Collins, senior scholar and vice president at The Commonwealth Fund, warned that if ACA subsidies expire or Medicaid faces cuts, "we would expect to see the effects on the marketplaces very quickly." Congressional Budget Office projections suggest that 16 million additional people could become uninsured by 2034, potentially bringing the national total to over 40 million Americans without coverage.

The report identified childhood vaccination rates as an area of urgent concern, with fewer young children receiving the complete series of seven recommended vaccines between 2019 and 2023. Five states experienced vaccination rate drops exceeding 10 percent during this period. The decline appears connected to vaccine misinformation and political polarization affecting public health messaging.

"There has been increasing concern given, certainly, what's been said by federal authorities and concerns around vaccine safety; we saw a lot of this information during the COVID vaccination period as well," Betancourt said. "While we haven't researched this ourselves directly, I'd certainly say that no doubt that in my clinical practice, and as we speak to other caregivers, some of the messages that we're seeing on the national landscape, some of the questions that are emerging, create skepticism among people now. We certainly espouse vaccine safety; there's no doubt that vaccines are one of the safest and one of the most effective public health interventions that our nation's ever seen."

Regional disparities remain pronounced, particularly in Southern states where many have not expanded Medicaid, resulting in higher uninsured rates despite ACA marketplace enrollment gains. "Most states in the South continue to lag in insurance coverage, but we've seen enormous gains in marketplace enrollment since the enhanced premium tax credits in 2021," Collins explained. "In states like Alabama that didn't expand Medicaid, those more affordable tax credits have helped drive down uninsured rates."

The connection between policy decisions and health outcomes is evident in infant mortality data. Commonwealth researcher Kristen Kolb noted that "states that have expanded Medicaid eligibility have lower infant mortality rates," highlighting the importance of comprehensive coverage policies.

One positive development emerged from the analysis: drug overdose deaths declined in 37 states and the District of Columbia between 2022 and 2023. However, this progress remains vulnerable to policy changes. "While there are good signs of progress, including further declines in overdose deaths in provisional data for 2024, the number of annual deaths remains elevated above pre-pandemic levels," Kolb said. "More than 70% of adults who needed substance use treatment did not receive it in 2022."

The Commonwealth Fund experts emphasized that sustained federal action remains critical for continued progress. "States have shown they can make lasting gains in the health of their residents, but they can't go at it alone. Improvement requires federal leadership, commitment to science, and stable financial support," Collins concluded.

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