Health care varies widely based on where you live. Report ranks best, worst states.

A new report sheds light on glaring disparities and preventable deaths in the U.S., finding surges in deaths from treatable causes, gaps in maternal health care and inequities in health care access.

The Commonwealth Fund’s 2023 Scorecard on State Health System Performance ranked states based on health care access and affordability, reproductive health care access and outcomes, premature death rates, medical debt and other factors between 2019 and 2021, amid the COVID-19 pandemic.

The top five states with the highest overall health system scores include Massachusetts, Hawaii, New Hampshire, Rhode Island and Vermont.

The states scoring the lowest were Mississippi, West Virginia, Oklahoma, Texas and Arkansas.

Six of the 10 lowest ranking states did not expand Medicaid eligibility programs. Rates of uninsured adults were also highest in states that didn’t adopt Medicaid expansion.

“Expanding their Medicaid programs would be the first step toward improving their health system performance,” Sara Collins, vice president of health care coverage and access at the Commonwealth Fund, said in a media briefing.

“There are wide disparities between lower incomes people and higher income people in nearly all these states," she added.

Here are the key findings.

Racial disparities

People of color experienced higher death rates amid COVID-19, and Black, American Indian and Alaska Native people had the highest rates of preventable deaths from treatable causes.

Along with Hispanic people, Black and Indigenous people saw the largest drops in life expectancy, driven by structural inequities and systemic racism.

South Dakota had the highest rate of preventable deaths for Indigenous people; Washington, D.C., saw the highest rate for Black people and New Mexico, for Hispanic people.

Laurie Zephyrin, senior vice president of advancing health equity at the Commonwealth Fund, said public and health policy changes must prioritize equity.

“As we think about any intervention, we truly have to center equity. When we design a health care system that focuses on people that are most marginalized, that improves health care delivery and outcomes for all,” she said.

Maternal mortality

Maternal deaths surged for all women during the pandemic, but disproportionately among women of color as communities across the nation lose maternal health care.

Maternal death rates for American Indian and Alaska Native women more than doubled from 2020 to 2021, rising from about 48 to 118 deaths per 100,000.

Similarly, Black women’s deaths rose from 55 to about 70 deaths per 100,000.

Hispanic women’s rates also surged from 18 to 28 deaths per 100,000; white women’s rates went from 18 to 26.6, and Asian American, Native Hawaiian and Pacific Islanders’ rates went from 13.6 to 18.8 per 100,000.

The nation must “invest in the maternal health care workforce,” including OBGYN practitioners, midwifery and doula care, said Zephyrin.

Access to reproductive health care

The report also breaks down state rankings for access to reproductive care as more than a dozen states enacted abortion bans.

The five states ranking lowest for reproductive care and women’s health were New Mexico, Mississippi, Texas, Alaska and Oklahoma, while the highest were Massachusetts, Rhode Island, New Hampshire, Maine and Connecticut.

Nearly 30% of women in Texas and Florida didn’t receive early prenatal care, in contrast with 11% in Vermont.

New Jersey, Alaska, Missouri and Arizona had the highest rates of women who reported lacking a postpartum checkup visit, though the report was missing data for eight states, four in the South.

Nationwide, overall death rates among women surged between 2019 and 2021, due to rising maternal mortality as well as COVID-19 and substance use deaths.

Mental health

Mental health-related deaths saw an alarming surge during the pandemic: Combined deaths from drug overdoses, alcohol and suicide caused more than 200,000 deaths in 2021 – roughly 50,000 more than 2019 before the pandemic.

Teenagers and adults with mental health needs lacked access to care: Nearly 60% of adolescents ages 12 to 17 who experienced a major depressive episode were not linked to needed treatment, the report notes according to a 2020 federal survey.

Hawaii had the highest rate of adults 18 and older with any mental illness who did not receive treatment at 69%.

Other highlights from the report:

• The Scorecard measures deaths from preventable causes and causes that are treatable with timely health care interventions. Preventable deaths rose during the pandemic across all states, with Mississippi bearing the highest number of deaths before age 75 – about 518 deaths per 100,000, followed by West Virginia, Oklahoma, Arkansas, Tennessee and Louisiana.

• The South had the highest rates of medical debt.

• Firearm-related deaths rose 23% since 2019, with mass shootings and suicides in part driving the surge.

This article originally appeared on USA TODAY: Health rankings report: Which states are best, worst for access?