U.S. Healthcare Access Improved in 2023, but Infant Mortality, Vaccination Declines and Regional Gaps Raise Concern

Although there have been gains in health insurance access in the last couple of years, new problems are emerging across the U.S. health system, particularly in children’s health, infant mortality and avoidable deaths, according to the 2025 State Health System Performance Scorecard released by The Commonwealth Fund.

The new report ranks all 50 states and the District of Columbia across 50 indicators covering access, quality, outcomes and equity from data collected by Commonwealth up to 2023.

During a June 17 briefing on the report, Commonwealth Fund President Joseph Betancourt, M.D., highlighted the importance of the scorecard for policymakers.

Over the past decade, it was found that health insurance coverage has steadily improved nationwide, with the adult uninsured rate falling to a record low of 11% by 2023 and every state seeing gains since 2013.

“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.”

Over the past decade, it was found that health insurance coverage has steadily improved nationwide, with the adult uninsured rate falling to a record low of 11% by 2023 and every state seeing gains since 2013.

However, Commonwealth Fund leaders warned that these advancements—driven by expanded Medicaid eligibility and enhanced ACA tax credits—are at risk of being undone by proposed federal policy changes.

Sara Collins, Ph.D., senior scholar and vice president at The Commonwealth Fund, noted that if ACA subsidies expire or Medicaid is cut, “we would expect to see the effects on the marketplaces very quickly.”

Collins cited new projections from the Congressional Budget Office showing that 16 million more people could become uninsured by 2034, bringing the national total to over 40 million.

“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,” she said.

Another area of urgent concern is the sharp decline in early childhood vaccination rates in much of the country.

Between 2019 and 2023, fewer young children received the full series of seven recommended vaccines, with rates dropping by more than 10% in five states.

During the briefing, the speakers suggested that vaccine misinformation and political polarization are playing a major role.

“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.”

Recent changes to how the federal government determines vaccine recommendations may make the situation worse by reducing insurance coverage for vaccines, he suggested.

Betancourt added that Commonwealth leaders want folks to have access to accurate information so they can make informed choices; however, the leadership team is “concerned” about where the national dialogue is heading.

At the same time, the South continues to lag behind the rest of the country on many measures, despite some notable gains in ACA marketplace enrollment.

Many Southern states still have not expanded Medicaid, contributing to persistently higher uninsured rates and weaker access to care.

“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 said. “In states like Alabama that didn’t expand Medicaid, those more affordable tax credits have helped drive down uninsured rates.”

These coverage gains, however, don’t solve deeper challenges. Many people in the South still face persistent health system inequities and barriers to getting the care they need.

“States that have expanded Medicaid eligibility have lower infant mortality rates,” added researcher at Commonwealth, Kristen Kolb.

She mentioned that investments in doula services, prenatal education and postpartum mental health support are effective strategies that some states are beginning to adopt.

Amid these challenges, the report offered at least one hopeful development: a decline in drug overdose deaths in 37 states and the District of Columbia between 2022 and 2023.

However, panelists warned that this progress is fragile.

“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.”

She added that restructuring of the Substance Abuse and Mental Health Services Administration alongside cuts to federal funding for state and local treatment programs “threatens to reverse the progress that has been made.”

Ultimately, the Commonwealth Fund experts expressed that while states have demonstrated they can drive improvements in public health, sustained and coordinated federal action is critical.