Preventive care, health equity falter despite access gains

Childhood vaccination rates go down

Despite gains in healthcare access and affordability, the report outlined lapses in preventive care access, including childhood vaccinations. In most states, fewer than 75% of children had received all doses of the recommended early childhood vaccines by 2023.

In 7 states (Vermont, New Hampshire, Massachusetts, Rhode Island, Connecticut, Maryland and North Carolina), childhood vaccination rates are at or above 75%. In 10 states (New Jersey, Kentucky, Tennessee, Alabama, Nebraska, Montana, Nevada, California, Alaska and Georgia) childhood vaccination rates are at or below 65%.

What's more, the researchers found that the number of kids receiving all recommended early childhood vaccines decreased in most states. In 15 states, the number of kids getting the full scope of childhood vaccines increased between 2019 and 2023, while in the remaining states included in the study, the vaccination rate went down.

These findings might reveal disparities in public health efforts nationwide, the report authors indicated, but they can also be indicative of other issues. For example, a child might start the vaccine schedule but not finish it due to access issues, high healthcare costs and lack of insurance coverage.

Still, many of the states performing well in childhood vaccinations also perform well on overall preventive care quality. Massachusetts, Maryland and Connecticut all have high childhood vaccination rates and good scores for prevention and treatment.

Infant mortality rates indicative of reproductive health policies

Between 2018 and 2022, the infant mortality rate declined in 20 states, the analysis showed, but racial and regional disparities remain.

The infant mortality rate for babies born to Black women in 2022 was 10.9, while the rate was 4.5 for babies born to White women.

There were also steep disparities by state. Massachusetts had the lowest infant mortality rate at 3.3 infant deaths per 1,000 live births. In Mississippi, which had the highest rate, there were 9.1 infant deaths per 1,000 live births.

Some of the regional disparities could be driven by healthcare access problems.

Indeed, the report authors noted that timely access to care, access to patient education materials and community-based care can help reduce infant mortality. But in rural states, which tended to see higher infant mortality rates, workforce shortages, maternity ward closures and general geographic barriers can limit access to resources.

That said, policies that restrict reproductive and maternal healthcare might also be at play, the researchers added. This is especially salient as data shows worsening maternal mortality between 2018 and 2022.

"Threatened access to reproductive and maternal health care may further worsen infant mortality and sharpen current disparities between states," the report authors explained.

"Following the overturning of Roe v. Wade, which eliminated the constitutional right to abortion as of June 2022, there is evidence that ob/gyns and medical trainees are avoiding or leaving states with restrictive abortion policies in place, making it harder for women in those states to get the reproductive health care they need."

Racial health disparities in premature, avoidable death remain

Finally, the researchers found both geographic and racial disparities in premature and avoidable deaths.

Avoidable death refers to a death before age 75 from certain infections, injuries and illnesses that could have been avoided with stronger primary and preventive care. The Commonwealth Fund researchers said high avoidable death rates can indicate health system deficiencies.

In 2023, there were 278 premature avoidable deaths per 100,000 people under age 75 nationwide. That rate varied significantly by state, with the lowest being in Massachusetts (201 per 100,000) and the highest in West Virginia (445 per 100,000).

But the issue goes deeper than geographic health disparities. There are also racial disparities in premature avoidable deaths.

In every state, the avoidable death rate was higher for Black people than it was for other racial and ethnic groups. Although in a handful of states these disparities were modest, that wasn't the case in most.

In 42 states plus the District of Columbia, avoidable death rates were about twice those of other races and ethnicities. In about a third of states and the District of Columbia, Black people were around three times more likely to die an avoidable death compared to other races and ethnicities.

"These deeply rooted racial disparities are linked to health-related social challenges, lower rates of insurance coverage, and a history of racially discriminatory state and federal policies," the research team explained.

Moving forward

Curtailing problems with preventive care, childhood vaccination, maternal and infant health and racial health disparities will require a concerted effort, the report authors said.

Policies to fortify health insurance coverage, build stronger primary and preventive healthcare systems and increase better access to specialty care, such as reproductive health, will be essential.

"When it comes to enacting large-scale reform, history shows that states cannot be expected to go it alone," the report authors concluded. "They require federal leadership, commitment, and financial support. In the absence of a strong federal role, health outcomes and quality of care will worsen and disparities will grow, leaving Americans in states with fewer resources even further behind."

Sara Heath has covered news related to patient engagement and health equity since 2015.