American health care is getting worse. That conclusion comes from a comprehensive state-by-state analysis conducted by Governing magazine and the University of Richmond and funded by the Pew Charitable Trusts in Philadelphia. The study found dramatic improvements in the efficacy of treatment but declining access to treatment. The information is consistent with the trends in several key indicators, including growing prevalence of diabetes and obesity. Matthew M. Zack and his colleagues at the Centers for Disease Control and Prevention found that those most affected are the middle-aged and those with only a high school education. The Zack group used the CDC's Behavioral Risk Factor Surveillance surveys to develop trend data by state for the period 1993 to 2001 on the number of unhealthy days, both mental and physical. These data, shown on the maps, record a significant decline in health between 1993¿1995 and 1999¿2001.

The states, which bear the major responsibility for administering public health programs, have had to divert some of their resources to fight bioterrorism. But the heart of the problem is Medicaid, which targets the disadvantaged. The federal government customarily pays 59 percent of Medicaid costs, with the states paying the balance, which in fiscal year 2004 amounted to an estimated $120 billion. Twenty years ago Medicaid accounted for 8 percent of state expenditures, but it is likely to go over 25 percent in the next year or so.

This article was originally published with the title Getting Sicker.

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