Which US Counties Achieved the Best Health Care Performance?

A county-level analysis of the US health care system from 2014 to 2019 identified wide variation in progress toward improving the patient experience, enhancing health outcomes, and reducing spending.1 Counties in Rhode Island, Iowa, Idaho, Virginia, and Hawaii ranked among the top performers, whereas regions such as the District of Columbia, Alaska, and Mississippi lagged behind.

Published in The Lancet Public Health, this study also identified key policies linked to higher performance, including Medicaid expansion, competitive insurance markets, and stronger managed care systems.

New research highlights which US counties lead in patient experience, health outcomes, and cost efficiency—and the policies that drive success. | Image credit: Rawf8 - stock.adobe.com

“Our assessment of applying the Triple Aim framework to evaluate health system performance at the US county level identified high variation in county performance across the USA,” wrote the researchers of the study. “The populations of counties with high unadjusted performance scores were substantially wealthier and more educated and had lower prevalences of obesity and tobacco use than lower-performing counties.”

The Institute for Healthcare Improvement Triple Aim framework is a guiding model for transforming health care to better serve individuals and communities.2 It emphasizes 3 interconnected goals of enhancing the patient experience of care by focusing on quality and satisfaction, improving population health through prevention and better outcomes, and reducing per capita health care costs. By addressing these aims simultaneously, the framework provides a foundation for building more efficient, equitable, and patient-centered health systems.

In this study, the researchers evaluated progress toward the Triple Aim at the US county level between 2014 and 2019 by combining data on patient experience, health outcomes, and health care spending.1 Patient experience was measured using a composite indicator, health outcomes were assessed through life expectancy, and spending was evaluated using purchasing power–adjusted per capita health care expenditures.

For each county, overall performance scores were first calculated without adjustment, then adjusted scores were generated to account for underlying county characteristics beyond the direct control of health systems. Linear regression models were used to identify policy-related factors associated with higher performance, offering insights into which strategies may drive success in achieving the Triple Aim.

The study revealed substantial variation across US counties in achieving the Triple Aim. Counties with higher unadjusted performance scores generally had populations that were wealthier, more educated, more urban, and had lower rates of obesity and smoking.

For patient experience, scores in 2019 ranged from 0.15 to 1.00, with Rhode Island, Massachusetts, and the District of Columbia leading. For health outcomes, county life expectancy at birth varied widely, from 65 to 92 years, with the highest averages in New York, Hawaii, and California, and the lowest in Mississippi, West Virginia, and Kentucky.

Within states, the median gap between the counties with the shortest and longest life expectancies was 9 years (interquartile range [IQR], 7–11). For spending, age-standardized per capita costs ranged from $2797 to $12,361. Hawaii, Washington, and Utah had the lowest spending, whereas the District of Columbia, West Virginia, and Alaska had the highest, with a median within-state gap of $4,186 (IQR, $2698–$5575).

Importantly, progress toward the Triple Aim was strongly linked to specific policy factors, including the prioritization of managed care, broader Medicaid expansion, and greater competition among hospitals and insurance providers, highlighting how policy choices can directly influence health system performance. A 13% increase in Medicare managed care enrollment was linked to a 0.007 (95% UI, 0.005-0.008) performance boost, whereas a 34% increase in Medicaid managed care added 0.004 (95% UI, 0.002-0.006). Medicaid expansion raised scores by 0.004 (95% UI, 0.003-0.006), and expanding children’s Medicaid eligibility by 55% increased scores by 0.01 (95% CI, 0.008-0.011).

In contrast, reduced competition hurt performance: higher insurance market concentration cut scores by 0.009 (95% UI, 0.008-0.011), and greater hospital concentration lowered them by 0.003 (95% UI, 0.001-0.005).

However, the researchers noted some limitations, including variability in measuring Triple Aim components, reliance on modeled and imputed data, and applying the framework at the county level rather than individual health systems. Additionally, the 2014–2019 time frame did not capture recent trends like COVID-19, and county-level policy associations may not have reflected individual-level effects.

Despite these limitations, the researchers believe the study identifies counties and states with strong health system performance, disparities, and policies associated with health care performance.

“These results can help policymakers develop strategies that reduce health care spending, increase access to and quality of care, and ultimately improve health outcomes across the USA in the future,” wrote the researchers.

References

1. Lescinsky H, Beauchamp M, Bisignano C, et al. Evaluating US county health-care system performance and key associated factors (2014–19): a Triple Aim framework analysis. Lancet Public Health. 2025;10(9):E741-E750. doi:10.1016/s2468-2667(25)00173-2

2. Triple Aim. Institute for Healthcare Improvement. Accessed August 28, 2025. https://www.ihi.org/library/topics/triple-aim