Hawaii once again ranked among the best states overall when it comes to its health care system, just behind Massachusetts, in an extensive analysis of 58 metrics that assess access to care, health outcomes, quality, costs, reproductive care and women’s health.

The assessment is done annually by the Commonwealth Fund, a private foundation that conducts research on health care issues with the goal of creating a better and more equitable health care system. Among the bottom-­ranked states in the 2023 report were Mississippi and West Virginia.

Hawaii has consistently topped the Commonwealth Fund’s scorecard in recent years, often coming in first overall. The state has scored high when it comes to health outcomes and healthy behaviors, health insurance coverage and access to care, despite longstanding concerns about a shortage of providers, particularly in rural areas and the neighbor islands.

Some of Hawaii’s success can be attributed to the state’s Prepaid Health Care Act, which requires private employers to provide health insurance for employees who work at least 20 hours a week. The 1974 law has helped ensure the majority of residents have health insurance.

In 2021 only 5.2% of Hawaii adults ages 19 to 64 were uninsured, according to the Commonwealth Fund’s latest data. By comparison, Texas had the worst rate at 24.3% of adults in the same age group uninsured. The national average in 2021 was 12%.

The high rate of insured residents has helped keep medical debt relatively low in Hawaii. About 5% of isle residents have medical debt, according to the report, while in southern states as much as a quarter of the population carries debt, which the fund attributes to coverage gaps and inadequate insurance.

Overall, this year’s report found that states across the country experienced a surge in preventable or avoidable deaths and unmet health care needs, particularly among children. Most of the avoidable deaths between 2019 and 2021 were due to the COVID-19 pandemic and resulting delays in accessing care, according to the report.

In Arizona, which had the largest increase, avoidable deaths rose by 45%. Hawaii saw only a small increase in preventable deaths.

However, when it comes to mental health care, Hawaii ranked among the worst states in access to care. Some 75% of children ages 12 to 17 who had a major depressive episode did not receive mental health services between 2019 and 2020, according to the report, compared with the national average of 60%.

The rate of adults needing but going without mental health services in Hawaii also was high, with 69% not receiving treatment for mental illness during that period.

For the first time, the Commonwealth Fund this year evaluated how the states performed when it comes to reproductive care and women’s health. In this area, Hawaii’s scores were mixed. The state has low mortality rates for women ages 15 to 44 and scores among the top 10 states for women in up-to-date breast and cervical cancer screenings.

But Hawaii, along with Texas, Florida, Arkansas and New Mexico, is among the worst states in terms of women receiving early prenatal care. About 28% of women in Hawaii did not initiate prenatal care within the first trimester of their pregnancy. Prenatal care is considered critical to identifying early pregnancy risks and helping to improve health outcomes for mothers and their babies.

The high rate of women forgoing early pregnancy checkups has alarmed Hawaii’s Department of Health, particularly with syphilis cases in the state increasing more than tenfold over the past decade. Catching and treating syphilis early in a pregnancy can prevent it from being passed on to the fetus. Left untreated, as many as 40% of babies die from the infection.

Syphilis-infected babies also can be born with physical deformities, anemia, blindness, deafness and meningitis.