A new report from The Commonwealth Fund delivers a clear message: the U.S. health system is backsliding. After a brief period of improvement in access to care and fewer racial and ethnic health disparities in every state, the environment under current state and federal health policies is likely to make those disparities worse, the report showed.
“The most important thing to think about when we are discussing disparities, when we’re discussing equity, is that it affects everyone,” said Laurie Zephyrin, M.D., senior vice president of the Commonwealth Fund and a clinical assistant professor of Obstetrics and Gynecology at NYU Langone School of Medicine. Wide-ranging disparities and inequity are in every state, she said during an April 28 press conference one day before the report’s release.
Disproportionate access to health care affects more than the most marginalized. . Instead, disproportionate access means the health system has failed, and that failure affects everyone, Zephyrin explained.
“That’s what we’re seeing now, and that’s what this report actually shows,” she said. “In every state, we’re seeing these inequities. We’re seeing these disparities, and these disparities are wide-ranging. The most important thing to think about when we’re discussing disparities and when we’re discussing equity, is that [they affect] everyone.”
A significant reversal of progress
For journalists, the report shows the most important shift is a reversal of progress. After the pandemic, rates of people skipping needed care because of cost fell to record lows during 2021 and 2022, and then began climbing again as state and federal coverage expansions were eroded, the authors reported. Those trends are especially pronounced among Hispanic, American Indian and Alaska Native communities.
You could also ask why policy protections are not closing the gaps they were designed to address. For example, although Native Americans are exempt from Medicaid work requirements, the report noted that exemptions on paper do not necessarily translate into equitable access in practice.
Also, you will note that the report shows the effects of the policies journalists have been reporting, meaning the story is shifting from prediction to proof — and to the need for more accountability reporting that ties policy decisions to measurable health outcomes.
Accountability in this context doesn’t mean confronting politicians with abstract questions about equity. It means reporting that clearly links decisions on Medicaid eligibility changes, benefit design or funding levels, to what the report documents: rising cost-related care avoidance, persistent mortality gaps and uneven access to follow-up care.
Higher mortality shows a systemic failure
The report also shows that disparities in mortality remain one of the clearest indicators of systemic failure. Black, American Indian and Alaska Native populations continue to die from preventable and treatable conditions at higher rates than among other groups in every state, even as overall U.S. life expectancy has improved.
By itself, access to care does not resolve inequity. Black women in most states, for example, receive mammograms at relatively high rates but still experience the highest levels of breast-cancer mortality. That problem leads to delays in follow-up care, later-stage diagnoses and gaps in insurance coverage for diagnostic services, all of which contribute to worse outcomes.
Even states that rank highly overall are not exceptions. Places often held up as national leaders — including Massachusetts and other Northeastern states — still show significant disparities across racial and ethnic groups. The report makes clear that strong systems do not automatically produce equitable outcomes. Targeted policy and health system decisions are what determine whether gaps narrow, persist or widen.
