States made progress in areas that were the target of efforts to improve


reduction since 2011 in the share of adults who smoke

There have been widespread gains in health care access

During the first three years of the Affordable Care Act’s major insurance coverage expansions, the adult uninsured rate declined by at least five percentage points in 47 states.

And in nearly three-quarters of states, substantially fewer adults skipped needed care because of costs. States that expanded their Medicaid programs have made the largest gains.26

Cost barriers to receiving care fell as uninsured rates fell following ACA coverage expansions

  • Select a year to see changes over time.
  • Uninsured adults


    Adults who went without care because of costs

  • Less than 10%
  • 10%-14%
  • 15% or more
Data: Uninsured (ages 19–64): U.S. Census Bureau, 2011–2016 One-Year American Community Surveys. Public Use Micro Sample (ACS PUMS). Cost barriers (age 18 and older): 2011–2016 Behavioral Risk Factor Surveillance System (BRFSS).

Nursing home care has improved, and home health patients have gained physical mobility

The percentage of home health patients who got better at walking or moving around — a key measure of quality of care — rose substantially in every state. In nursing homes, the potentially harmful use of antipsychotic drugs as “chemical restraints” has fallen in nearly all states. This change likely reflects the goals of the National Partnership to Improve Dementia Care in Nursing Homes, which supports state-based coalitions in efforts to reduce inappropriate antipsychotic drug use and improve care for residents with dementia.27

Notes: Chemical restraints means use of antipsychotic medication.

Data: OASIS (via CMS Home Health Compare); MDS (via CMS Nursing Home Compare).

Tobacco use continues to wane

Adult smoking rates fell by at least three percentage points in all but four states between 2011 and 2016.

States with some of the highest rates, such as Nevada and Oklahoma, saw the largest declines.28 States like California with long-standing comprehensive tobacco control policies have seen substantial reductions in health care spending because of lower smoking rates.29 Limiting tobacco use continues to represent a major opportunity for states to improve public health.30

Tobacco use continues to decline: Nevada and Oklahoma had among the largest reductions in adult smoking between 2011 and 2016

Data: 2011, 2013, and 2016 Behavioral Risk Factor Surveillance System (BRFSS).

Avoidable hospital use has declined

Hospital readmission rates for elderly Medicare beneficiaries continued to fall in nearly half the states (particularly those with the highest rates) during the 2012–15 period.

This reduction was the goal of federal financial penalties, as well as initiatives that brought hospitals and postacute care providers together to improve patients’ transitions in care.31 There was also a continuing reduction in potentially preventable hospital admissions in several states, possibly because of better ambulatory care management.

What Is Being Done?

States’ gains likely reflect the influence of government policies, regulatory actions, and collaborative improvement efforts, all of which may be reinforced by the public reporting of performance data by the federal government, states, and other groups.

With federal assistance, many states also are working with health plans, care providers, and other stakeholders to promote quality measurement and improvement in Medicaid and to spread payment and delivery system transformation more broadly.32

At the same time, recognition that performance incentives can sometimes be gamed, or can unfairly penalize providers treating a large share of vulnerable or high-need patients, is prompting discussions of how to improve these incentives.33

A Closer Look:

New York Moves to Improve

  1. Susan L. Hayes et al., What’s at Stake: States’ Progress on Health Coverage and Access to Care, 2013–2016 (The Commonwealth Fund, Dec. 2017),
  2. Centers for Medicare and Medicaid Services, National Partnership to Improve Dementia Care in Nursing Homes (CMS, n.d.), The Partnership built on the Advancing Excellence in America’s Nursing Homes Campaign, launched in 2007 with support from the Commonwealth Fund; see: National Nursing Home Quality Improvement Campaign, Campaign History (NNHQIC, n.d.),
  3. Rebekah R. Rhoades and Laura A. Beebe, “Tobacco Control and Prevention in Oklahoma: Best Practices in a Preemptive State,” American Journal of Preventive Medicine 48, no. 1, Suppl. 1 (Jan. 2015): S6–S12,
  4. James Lightwood and Stanton A. Glantz, “The Effect of the California Tobacco Control Program on Smoking Prevalence, Cigarette Consumption and Healthcare Costs: 1989–2008,” PLoS ONE 8, no. 2 (Feb. 2013),
  5. National Center for Chronic Disease Prevention and Health Promotion, Best Practices for Comprehensive Tobacco Control Programs — 2014 (Centers for Disease Control and Prevention, 2014),; and National Governors Association, Health Investments That Pay Off: Taking a Comprehensive Approach to Tobacco Control (NGA Center for Best Practices, Aug. 16, 2016),
  6. Robert Fornango et al., Project Evaluation Activity in Support of Partnership for Patients Interim Evaluation Report, Final September 2015 (Centers for Medicare and Medicaid Services, revised Dec. 29, 2015),; and David Ruiz et al., Evaluation of the Community- Based Care Transitions Program: Final Evaluation Report (Centers for Medicare and Medicaid Services, Nov. 2017),
  7. Lauren S. Hughes, Alon Peltz, and Patrick H. Conway, “State Innovation Model Initiative: A State-Led Approach to Accelerating Health Care System Transformation,” JAMA 313, no. 13 (Apr. 7, 2015): 1317–18,; Julia C. Martinez, Martha P. King, and Richard Cauchi, Improving the Health Care System: Seven State Strategies (National Conference of State Legislatures, July 2016),; Martha Hostetter, Sarah Klein, and Douglas McCarthy, Hennepin Health: A Care Delivery Paradigm for New Medicaid Beneficiaries (The Commonwealth Fund, Oct. 2016),; and Sara Rosenbaum et al., Medicaid Payment and Delivery System Reform: Early Insights from 10 Medicaid Expansion States (The Commonwealth Fund, Oct. 2017),
  8. Qian Gu et al., “The Medicare Hospital Readmissions Reduction Program: Potential Unintended Consequences for Hospitals Serving Vulnerable Populations,” Health Services Research 49, no. 3 (June 2014): 818–37,; Andrew M. Ibrahim et al., “Association of Coded Severity with Readmission Reduction After the Hospital Readmissions Reduction Program,” JAMA Internal Medicine 178, no. 2 (Feb. 1, 2018): 290–92,; and Ashish K. Jha, “To Fix the Hospital Readmissions Program, Prioritize What Matters,” JAMA 319, no. 5 (Feb. 6, 2018): 431–33,