National Results

National Results: D+

The findings of the 2014 Report Card indicate that, as a whole, the emergency care environment in the United States has worsened and patients continue to face significant challenges in accessing life-saving care. Overall, the national grade has declined to a D+, reflecting subpar grades in three of the five categories measured. The nation continues to perform worst in Access to Emergency Care, for which it earns a D-. This grade accounts for 30% of the national grade because it most directly impacts the emergency care environment, touching on issues related to the adequacy of the health care workforce, hospital capacity, and financial barriers to care. Particularly troubling, however, are the declining grades in several other categories, including Disaster Preparedness (C-) and the Quality and Patient Safety Environment (C). The nation held steady in Public Health and Injury Prevention (C) and Medical Liability Environment overall with a subpar C-.

Among the individual states, there were many changes in overall state rankings, with the District of Columbia placing first and surpassing Massachusetts, which held the top spot in the 2009 Report Card. Two states rose to the top 10 for the first time, Colorado (5th) and Ohio (7th), while at the other end of the spectrum, several states made their first appearance among the 10 bottom-ranked states: Montana (48th), Illinois (45th), Alabama (44th), Louisiana and Alaska (tied for 42nd).

In 2014, the highest grade received is a B- and the lowest grade is an F. Comparatively, 2009 grades ranged from a B to a D-, reflecting a declining trend in overall state grades and contributing to the overall worsening national grade. While four states received grades falling in the range of a B in both Report Cards, the number of states with a C grade has dropped dramatically.

That gap is accounted for by the increase in states receiving D’s and the addition for the first time of one state, Wyoming, receiving an F overall. It is also worth noting that within each of the letter grades in 2014, many states fall below the average, threatening to drop further if major and immediate improvements are not made.



Overall State Grade Map


National Trends and State Comparisons by Category 

Access to Emergency Care 

The national grade for Access to Emergency Care remains a D- as states continue to struggle with a plethora of issues, including health care workforce shortages, shortages of on-call specialists, limited hospital capacity to meet the needs of patients, long emergency department wait times, and increasing financial barriers to care. While the number of emergency physicians per capita, including board-certified emergency physicians, has increased slightly since the previous Report Card, the rates of many specialists have remained largely unchanged, with a national average of about 2 neurosurgeons per 100,000 people; 2.2 plastic surgeons; 3.5 ENTs; and 9.7 orthopedists and hand surgeons. While these rates reflect overall specialty areas, they do not indicate a specialist’s willingness to provide on-call services, and thus may overstate access to services.

Access to treatment centers has also shown mixed results since the 2009 Report Card, with no change in the per capita rate of Level I or II trauma centers (1.8 per 1 million people) but an improvement in the proportion of the population within 60 minutes of a trauma center (from 76.0 to 82.1%). Access to accredited chest pain centers has also improved (from 1.1 to 2.5 per 1 million people), however some states still lack any accredited chest pain centers. On the other hand, the per capita rate of pediatric specialty centers has decreased slightly (from 3.8 to 3.6 per 1 million people) and the proportion of adults with an unmet need for substance abuse treatment has increased (from 8.4 to 8.9%).

Financial barriers to care also persist, with increasing proportions of adults lacking health insurance (17.7%), and while more children are uninsured than was reported in 2009 (9.4%), this ranges from 2.5% in Massachusetts to 21.0% of children in Nevada. Additionally, data included in the current Report Card indicate that even those with insurance face financial barriers: 18.0% of children who have health insurance are underinsured, with health care costs reported as unreasonable by their parents. The rate of financial underinsurance among children ranges from a low of 11.8% of children in the District of Columbia to 23.2% in Minnesota.

Finally, hospitals’ capacity for providing effective and efficient emergency care has declined since the 2009 Report Card on nearly every measure. Per capita rates of staffed inpatient beds have fallen from 358.3 to 329.5 per 100,000 people, and psychiatric care beds have also declined from 29.9 to 26.1 per 100,000.

Contributing to these declines were an additional 19 hospital closures in 2011 alone. These factors contribute to emergency department crowding, reflected in the median emergency wait time of 272 minutes, or 4.5 hours, from emergency department arrival to departure for admitted patients. This ranges, however, from 176 minutes in South Dakota (2.9 hours) to 452 minutes in the District of Columbia (7.5 hours).

While the national grade in Access to Emergency Care has not changed, an overall shift in state-level grades tells a different story. Only 5 states in 2014 earn a B grade or better, compared with 11 states in 2009. The number of states receiving a C has also decreased, while the number earning a D did not change. The difference in grades from 2009 to 2014 is accounted for solely by the increase in the number of states receiving an F, which grew from 12 to 21 states, indicating that two-thirds of the states received a failing grade of a D or an F.



Access to Care State Map



Quality and Patient Safety Environment 

The nation continues to fare best in the Quality and Patient Safety Environment category, as many states have implemented systems and protocols to improve life-saving care and to facilitate effective and efficient systems of care. Despite improvements for a number of states in this category, the nation receives a C overall, representing a slight decline since 2009. Part of this decline is related to the addition of new indicators that allow better measurement of the true quality and patient safety environment.

For instance, while hospitals have greatly increased adoption of electronic medical records (92.0%) and computerized practitioner order entry (77.1%) since 2009, they lag in developing diversity strategies or plans (44.0%) and efforts to collect data on patients’ race and ethnicity and primary language (58.6%). The addition of these latter two indicators is particularly important as it will allow hospitals to investigate and address racial and ethnic disparities in the quality of care and types of treatment provided.

Another important addition to assessing the Quality and Patient Safety Environment is the time it takes to transfer a patient with chest pain to another facility. Nationally, this process takes 72 minutes on average; however this varies dramatically across the 48 contiguous states, from 28 minutes in Vermont to 178 minutes in Wyoming (the average transfer time in Hawaii was even higher, 219 minutes).

While these new indicators are important, it is also noteworthy that the nation overall failed to make progress on a number of measures. The number of states providing funding for quality improvement of the EMS system has declined, with five fewer states reporting doing so in 2014. No additional states reported (1) having a uniform system for providing pre-arrival instructions (2) funding for a state EMS medical director and (3) maintaining a statewide trauma registry in 2014 compared with 2009.

On the other hand, the nation has made some notable improvements, including a dramatic increase in the number of emergency medicine residents. On average, there are 18.3 residents per 1 million people, which represents a 42% increase over the 12.9 per 1 million reported in 2009. The number of states having or working on a STEMI system of care stands at 43, an increase from 29 in 2009. Finally, about half of states report having destination policies in place for stroke and STEMI patients that would allow EMS to bypass a local hospital for an appropriately designated specialty center, and 41 states have such a policy for trauma patients.

The slight decline in the national grade is affected by overall declines among the states. Many more states in 2014 earned C’s and F’s than in 2009, while there were eight fewer A’s and only three more B’s awarded. Maryland, Utah, Pennsylvania, and North Carolina all earned A’s in 2014, while the five bottom-ranking states were Wyoming, Montana, Louisiana, Nevada, and South Dakota.


Quality and Patient Safety State Map

Medical Liability Environment 

The Medical Liability Environment in the United States is still in crisis and threatens to further diminish the availability of on-call specialists and other providers in states where the risks of lawsuit or costs of liability insurance are prohibitive. The nation again receives a C- for its overall Medical Liability Environment—however, while this indicates that the nation has failed to make progress, it does not mean nothing has changed. Since the previous Report Card, a number of states have seen liability reforms declared unconstitutional, and there are constant challenges to rules already in place in many other states. While the overall grade may mask these serious problems, a few states, such as North Carolina, saw great success in improving its medical liability environment, which prevented the national grade from declining.

Since the 2009 Report Card, the states overall have seen slight positive changes in insurance premiums but detrimental changes in the legal atmosphere. While insurance premiums, on average, have declined for both primary care physicians and specialists, the average malpractice payment has increased 9% from $285,218 to $311,088. There is also great variation across the states in awards, which range from an average payment of $75,882 in Louisiana to $681,839 in Hawaii. While these numbers reflect the best available data on malpractice award payments, they likely underestimate the true cost of malpractice award payments, especially among states with patient compensation funds, due to limitations inherent in the data. Finally, the per capita rate of malpractice award payments (2.4 per 100,000 people) has not changed.

For tort reform, there have been virtually no changes overall, despite movement in both directions among the states. While two states passed legislation to place a cap on non-economic damages in medical liability cases (North Carolina, Tennessee), three states that had these rules prior to 2009 saw them struck down by the courts (Georgia, Illinois, Missouri). There were no changes in the number of states having abolished joint and several liability, either in full or partially, and providing for periodic payments of malpractice awards. The states have also seen declines in expert witness rules, with two fewer states providing for case certification (24 states total), one fewer requiring expert witnesses to be of the same specialty as the defendant (21) and licensed to practice medicine in the state (3).

On a positive note, however, two states passed additional liability protections for EMTALA-mandated care, bringing the total to eight states across the nation. This is particularly important since emergency care often requires that split-second, life-saving decisions be made with little or no knowledge of a patient’s medical history, including allergies, health conditions, medications, and prior treatment. States that provide additional protections to these providers, such as requiring clear and convincing evidence of negligence in liability cases, encourage physicians to provide coverage (including on-call coverage for high-risk specialties) for the emergency department and reduces the need to practice defensive medicine that may not be in a patient’s or payer’s best interest.

States that stand-out in this category include Colorado, Texas, Idaho, and Kansas—all of which received an A— while 10 states received an F: the District of Columbia, Illinois, New York, Kentucky, Rhode Island, Maryland, Pennsylvania, Missouri, New Jersey, and Washington.


Medical Liability State Map

Public Health and Injury Prevention

The Public Health and Injury Prevention category is unique in that the overall focus is on areas where state systems and initiatives can preemptively have a tremendous impact on improving health outcomes and ultimately reduce the overall need for emergency care. One example of this is immunizations for children and the elderly—reducing the number of people susceptible to contagious disease will ultimately save lives and prevent cases from reaching the emergency department, leaving the health care system available for other emergent needs. The grade for this category has not improved since 2009, and the nation earns a C overall. This grade reflects a mix of positive and negative changes over time, as well as the addition of important new indicators that have been incorporated into the 2014 Report Card.


Since the previous Report Card, there have been some dramatic declines in the proportion of children receiving the full schedule of immunizations, as well as in the proportion of older adults receiving influenza vaccinations, with rates varying widely across the states. Only about half of older adults in Alaska (51.8%) received an influenza vaccine in the previous 12 months, compared with 70.2% in Iowa and Louisiana. Health risk factors also continue to be a major concern with increasing rates of adult obesity, binge drinking, and smoking, as well as increasing rates of homicides and suicides, fall-related deaths, and poisoning-related deaths, which include drug overdoses.

At the same time, however, the nation has made some progress in certain areas. For instance, traffic safety has improved, with increased seat belt use and fewer traffic fatalities involving alcohol (from 42.0 to 36.3% of traffic fatalities). The overall infant mortality rate has also decreased slightly, although racial and ethnic health disparities vary widely across the states on this measure.

Figure 5 shows the grades earned in Public Health and Injury Prevention in 2009 and 2014. There has been a slight shift, with more states earning D’s and F’s in 2014, although a few more states also earned A’s. The states earning the top seven spots in this category were Massachusetts, Hawaii, Oregon, Utah, Washington, Minnesota, and Maine. The poorest performances, all earning an F, were from South Carolina, Mississippi, Texas, Arkansas, Wyoming, Missouri, Louisiana, Alaska, Alabama, and West Virginia.

Public Health and Injury Prevention State Map

Disaster Preparedness 

While the states overall have continued to improve and refine their disaster preparedness planning and practices, the national grade has fallen slightly to a C-. This is due, in large part, to wide variations across the states in hospital capacity and personnel preparedness. For instance, while nationally the number of health professionals registered in the Emergency System for Advance Registration of Volunteer Health Professionals (ESARVHP) has increased considerably, some states have yet to implement such a system for preparing its volunteer response: currently, there is an average of 61.0 physicians registered per 1 million people, but this ranges from 0 to 656.8 per 1 million across the states. Similarly, there are 279.6 nurses registered in ESAR-VHP per 1 million people overall, ranging from 0 in Mississippi to 1,069.1 per 1 million in the District of Columbia.

Federal funding for disaster preparedness has also declined since 2009, with states receiving an average of $9.52 per person, compared with $13.82 per person previously. There has been no change in the number of verified burn centers or burn unit beds per capita, and a slight decrease in availability of ICU beds. At the same time, however, the states have seen a large increase in bed surge capacity, (from 673.4 to 933.8 beds per 1 million people).

A considerable number of states have incorporated specific patient populations in their medical response plans to facilitate their ongoing care in the event of a natural disaster or mass casualty event. Many state medical response plans include special needs patients (44), mental health patients (35), patients dependent on dialysis (27), and patients dependent on medications for chronic conditions (25). Fewer states, however, include patients dependent on psychotropic medications (18) in their medical response plans.

Some Disaster Preparedness indicators used in the 2009 Report Card were achieved by all or virtually all states and were not included in this Report Card. New indicators were added to the category which revealed wide variations across the states and resulted in far fewer states receiving an A and far more receiving an F. The overall national grade for the category fell from a C+ to a C-. Only two states held on to A grades, the District of Columbia and North Dakota, while Louisiana, New York, and Nevada moved up in the rankings to fill out the top five places. The five bottom-ranking states were Ohio, Washington, Maine, Idaho, and Wyoming.

Disaster Preparedness State Map


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