Vermont, Hawaii Top Health Care Scorecard

"You betcha, I feel good about the reforms we put in place," Douglas told ABCNews.com. "It's centered on quality and containing costs. Care shouldn't start in the emergency room."

All Vermonters are encouraged to have yearly exams and adults are notified when they are due for check-ups.

Douglas talks to children about "getting off the couch" and set an example just this week by joining elementary students on a walk to school.

With the second oldest population in the nation, Vermont subsizes care for seniors and the disabled to defray the costs of home care. Nursing home beds were reduced by 200 last year.

In one pilot program, electronic medical records can avert expensive tests like MRIs and x-rays. One emergency room doctor seeing a woman with stomach pains discovered in her online medication history that she had not filled her prescription for ulcer medicine.

"It takes time and so a lot of the fruits come from years of work and planning and cooperation," said Douglas.

Health Care Affects a State's Economy

But Mississippi, with the highest infant mortality and low birth rates in the nation, makes access to these Medicaid programs more difficult, according to Roy Mitchell, director of the Mississippi Health Advocacy Program (MHAP).

"I am not at all surprised we were 51st on the list," he told ABCNews.com. "We are last on several health indicators. Our policy makers work hard at being last."

Despite one of the highest matches of federal to state dollars in Medicaid funding, the state mandates "face-to-face" eligibility, requiring all new applicants and those reapplying for benefits to come in for an interview.

"As a direct result, 65,000 children have fallen off the rolls," Mitchell said.

"Mississippi does virtually no outreach at all. They don't publish where these face to face stations are and what times," he said. "It's a bureaucratic maze even to find out where to go. And when they get there they don't have a certain document."

Of those, about 77 percent would be eligible, he said. "It's touted as fraud prevention."

These disparities between the highest and lowest ranked states could be alleviated with national reform, according to Commonwealth.

The report emphasizes the need for insurance reform that rewards good outcomes, payment reform with an emphasis on prevention and advanced information systems that travel with the patient from physician to physician, saving time, money and preventing errors.

"What the scorecard is showing is that we have a system under stress, no matter where we live," said co-author Schoen. "The costs are rising more than people's incomes. We need to act."

Schoen said she has hope for reform. "There is real leadership and people are taking reform seriously."

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