When State Rankings Fall Short

States are often ranked on measures such as education, maternal mortality, income potential, etc. Indicators are provided to explain how these rankings were determined – indicators such as access, outcomes, or cost, among myriad others.  

Faced with a table of indicators for a state, along with a summary ranking, it’s easy to be lulled into believing that those few indicators are the only thing that matter in determining rankings. But such a view ignores the larger context in which health outcomes exist, a context that includes the effects of both present-day choices and historical systems of power.  

Articles such as this one published by WalletHub suggest that South Carolina and North Carolina are among the five worst states for healthcare. But their analysis and subsequent reporting miss key contextual factors. The first and most pervasive is systemic racism, of course. Without including historic, institutional, or systemic racism as a variable, we don't do these rankings any (racial) justice. For instance, stating that certain states have higher rates of maternal mortality or STDs without acknowledging medical providers’ implicit bias leaves us with a massively incomplete picture.  

The other, and more top of mind (potentially correlating) variable obscured by “outcome” measures, is whether a state has expanded Medicaid – especially in states with a high rural population. In North Carolina, about 40% of the state’s residents live in 80 rural counties. Rural areas consistently have fewer providers of all types, but they also have “higher rates of drug and alcohol use, suicide, years of productive life lost, injury, teen births, uninsured patients and preventable hospitalizations.”  

But even for the rest of the state that lives in more urban areas, living near a medical provider does not mean a person has access to medicine.  

Without Medicaid expansion, people who are not “low-income enough” to gain access to Medicaid but are “too high-income" to benefit from the subsidized Affordable Care Act (ACA) plan fall into the coverage gap. In the United States, that means that they just don’t have coverage. They can rely on safety net programs, but those programs are not designed to buoy the millions in need of a full spectrum of medical care. In North Carolina and South Carolina the coverage gap amounts to 400,000 people. In North Carolina alone, nearly half a million people are going without insurance who would benefit from Medicaid Expansion and the closure of the coverage gap.  

States that expanded Medicaid have higher rankings than those that didn’t. The top 5 states for healthcare on this list all expanded. In fact, the top 10 states all expanded. It isn’t until you reach number 14 on the list that you find a state that has yet to expand Medicaid. Whether or not a state expanded Medicaid is related so strongly to health outcomes, expansion could very well be used as a proxy measure for where a state ranks on healthcare. 

According to the National Bureau of Economic Research, North Carolina has the nation’s third highest total of excessive deaths from failure to expand Medicaid. This is clearly unacceptable, but we have an opportunity to right this wrong. Expansion is not currently up for debate in South Carolina, but it is in North Carolina. After unseating a veto-proof majority in the State legislature in 2018, North Carolina democrats have promised to sustain Governor Cooper’s veto of the latest budget, which excludes expansion. North Carolina’s GOP is holding the healthcare of half a million North Carolinian’s hostage by refusing to negotiate, creating a budget stalemate that has yet to come close to a conclusion.  

The time is now to expand Medicaid. Our lawmakers might not be able to tackle systemic racism in one legislative session and with one year’s budget, but they can vastly improve the lives of 500,000 people in North Carolina. Planned Parenthood South Atlantic believes that all people should be afforded the dignity of having access to healthcare, being able to choose their providers, and making decisions about their bodies without fearing bankruptcy.  

What can you do? 

• Improving access to healthcare can only improve our “rank.” The Trump Administration recently forced Planned Parenthood out of the Title X program, the nation’s only federal funding source for sexual and reproductive health services. Most of the people who benefit from Title X are lower income and people of color. Take action to #ProtectX and let your elected officials know that you want more healthcare, not less.  

• Until the budget contains an expansion of Medicaid, it’s a budget that we cannot accept. Tell your representatives in the General Assembly to sustain Governor Cooper’s veto of the budget. Demand that our elected officials represent the health needs of all, and not just some, of their constituency.  

• In an unprecedented move, the South Carolina Legislature is holding a hearing outside of session to discuss a HB 3020, a 6-week ban on abortion. Invite your family and friends to attend the hearing and let your lawmakers know that restrictions on abortion are dangerous, that you don’t want politicians in the exam room, and that you oppose this bill.