Despite significant improvements in the number of insured adults and children, Nevada ranked 48th in the nation for overall health care in a 2019 scorecard released by the Commonwealth Fund on Wednesday.

The report scored the Silver State at 50th for access and affordability, 51st for prevention and treatment, 38th for avoidable hospital use and cost and 39th for the healthiness of its residents' lifestyles. The only category in which the state outperformed the national average was in health care disparities — the gap between the level of care received between lower- and higher-income residents — at 24th.

The report is the seventh edition of the state health system performance scorecard released by the Commonwealth Fund, a private foundation focused on health care and health policy. The report primarily looked at data from 2017, which is the most recently available public dataset, and included the District of Columbia in its analysis.

The scorecard divided the states it analyzed into regional subgroups, pairing Nevada with five other Western states — California, Oregon, Washington, Hawaii, and Alaska. Nevada ranked 6th out of six in all categories that the report analyzed among the Western subgroup. The only states that fared worse than Nevada nationally were Texas, Oklahoma and Mississippi.

The state’s most improved areas were in the categories of uninsured children and uninsured adults, owing in large part to the state’s decision to expand Medicaid and fill in historical eligibility gaps in 2014. Still, the state ranked 44th and 40th in the categories, respectively.

Sara Collins, a vice president at the Commonwealth Fund, attributed the difference between Nevada, which has the highest uninsured rate of any other Medicaid expansion state other than Alaska, and Massachusetts, which has the lowest uninsured rates in the nation, in part to the Silver State’s significant undocumented immigrant population.

“Nevada is a case of a state that has expanded their Medicaid program, but they still are struggling with some higher uninsured rates in the state, and it's largely stemming from a very large undocumented immigrant population in the state,” Collins said. “Nevada has an issue that's regional, that is specific to the state, that's really different from Massachusetts.”

Though Nevada’s uninsured rate showed some improvement, the report found that wasn’t true for all states.

“We find that coverage and access gains made following the Affordable Care Act insurance expansions have stalled in many states and even begun to erode in some with uninsured rates creeping upward,” said David Radley, a senior scientist with the Commonwealth Fund.

The report noted that cost barriers to accessing health care are also on the rise, with an increasing share of adults nationally skipping needed health care because of its price.

The scorecard also looked at the way that states are affected regionally by deaths from suicide, alcohol and drug overdoses. Generally, states in the Rust Belt and the Northeast experienced the highest rates of drug poisoning deaths — Nevada fell somewhere in the middle, with 21.6 drug poisoning deaths per 100,000 residents — while states in the West experienced more suicide- and alcohol-related deaths. Nevada reported 20.3 suicides and 14.8 alcohol deaths per 100,000 residents in 2017.

“Drug overdose mortality is disproportionately impacting states in the eastern part of the country and suicide and alcohol related deaths are occurring at higher rates in the West,” Radley said.

The report additionally found that Nevada is one of 11 states in which average employee health insurance contributions were eight percent or more of the median income or more in 2017. (Nevada came in at 8.2 percent.)

Among the 47 measures the report looked at, Nevada overperformed in potentially avoidable emergency department visits for those 65 and older (6th) and obese adults (2nd). Other categories where Nevada fared better than other states include adults who smoke (4th) and non-elderly adults with high out-of-pocket medical costs compared to their annual household income (8th).

But Nevada ranked last (51st) in the nation in three categories — adults without all recommended vaccines, adults without a usual source of care, and children without a primary care doctor and effective care coordination — and near last (50th) in several others, including adults with an untreated mental illness, skilled nursing facility patients with a hospital readmission and colorectal cancer deaths.

The state ranked 49th in a number of other categories including hospitals with lower-than-average patient experience ratings, adults with mental illness who did not receive treatment and children without age-appropriate medical and dental preventive care in the last year. The state came in at 48th for adults without a dental visit in the last year, avoidable emergency department visits for adults and adults who went without care because of the cost in the last year.