In this March 3, 2021, file photo, senior citizens leave a COVID-19 vaccination site operated by Maine Health in the site of a former department store in Sanford. Credit: Robert F. Bukaty

The health systems in Hawaii and Maine have performed best of all the states during the COVID-19 pandemic, according to new rankings that weighed such factors as vaccination rates, capacity in hospital and intensive care units, and death rates.

Alabama ranked at the bottom in the scorecard, followed by Oklahoma, Kentucky, Mississippi and Georgia.

The rankings, released Thursday, were compiled by the Commonwealth Fund, a private foundation that promotes health equity and higher health care quality, efficiency and access. Every year, Commonwealth uses dozens of measures to produce a ranking of state health care systems. This year, it added categories specific to how state health care systems performed during COVID-19 from February 2020 to the end of March 2022. Vermont, Washington and Oregon rounded out the top five.

Generally, the states judged to have overall stronger health systems also ranked well in their COVID-19 performance. The reverse was true of those scoring poorly in their overall health care rankings.

How quickly states got shots into arms after vaccines first became available at the end of 2020 was one of the measures that Commonwealth used in assessing the state COVID-19 response.

Vermont moved the fastest, followed by Massachusetts, Connecticut and Maine. They were able to fully vaccinate (meaning, typically, two doses) 70 percent of the population ages 12 and older within 200 days from when the vaccines became available.

By contrast, 21 states still had not reached 70 percent by the end of March 2022. Alabama, Mississippi and Wyoming had failed to reach even 60 percent.

Although the U.S. Centers for Disease Control and Prevention recommended boosters, fewer than 40 percent of adults in the United States had gotten one by the end of March, with the rates varying considerably across the states.

More than half of adults got boosters in Maine, Rhode Island and Vermont. By contrast, not even a quarter of adults in Alabama, Mississippi and North Carolina had received a booster shot.

Another measure Commonwealth analysts looked at was how stressed hospital systems became during the pandemic. The report noted that between August 2020 and March 2022, the nation experienced 4.6 million COVID-19-related hospitalizations. To determine how pressed health systems were, analysts measured the number of days during that time in which at least 80 percent of intensive care unit beds in each state were occupied.

They found that 16 states and the District of Columbia operated ICUs at or above 80 percent capacity for at least 150 days. Texas and Alabama were at or above that percentage for 566 and 517 days, respectively. Georgia, Mississippi, New Mexico, Oklahoma and Rhode Island each exceeded 300 days at or above 80 percent.

One other measure that Commonwealth used in its rankings was the number of “excess” deaths each state experienced during the pandemic. Excess deaths, the analysis explains, means deaths above the norm, some as a result of COVID-19, but others the consequence of disruptions in access to health care caused by the pandemic.

Generally, the states with stronger overall health systems had fewer excess deaths than states with weaker systems.

The number of excess deaths ranged from a low of 110 per 100,000 people in Hawaii to a high of 596 per 100,000 in Mississippi.

Nationwide, the analysis found, premature deaths from treatable conditions such as heart disease and diabetes rose between 2019 and 2020 from 83.8 to 89.8 deaths per 100,000 residents. The most pronounced increases were in the Midwest and the South.

The good news in the report was that the rate of people with health care insurance remained fairly stable across the states during the pandemic, although it did dip a bit in 2021.

The reasons: Fewer people lost their employer-sponsored health insurance than expected, safety net provisions in the Affordable Care Act helped those who lost their insurance, congressional action early in the pandemic kept people enrolled in Medicaid, and increased subsidies became available during the pandemic to help people pay for private health insurance plans.

Some of those provisions will expire when the national public health emergency is eventually lifted, which could cause a steep decline in numbers of people with health insurance.

Story by Michale Ollove, Stateline-Pew