Vermont has beaten out Hawai'i for the best health care scorecard in the nation in a new analysis of health systems by the Commonwealth Fund.

The analysis looked at 38 indicators of health care access, quality, costs and health outcomes, finding Hawai'i continues to have one of the better systems in the country, though it slipped slightly in several areas.

The scorecard is the second done by the Commonwealth Fund, a private foundation that seeks to improve health care system performance. In its inaugural ranking in 2007, the New York-based foundation ranked Hawai'i the best in the nation. This report found that in general states that did well two years ago continued to lead and widened the gap with lower-performing states.

"Where you live in the U.S. matters in terms of your health care, and it shouldn't," Cathy Schoen, Commonwealth Fund senior vice president, said in a prepared statement.

Vermont pulled ahead of Hawai'i three years after it passed reforms to cover the uninsured and looked at ways to prevent and control chronic disease.

Hawai'i improved in many areas, but fell in terms of measures of access and healthy lives.

It remained among the top states in insuring children and adults and for low Medicare reimbursements per enrollee.

It had a notable slip in infant mortality, falling to 36th place from first, and to 37th place from 18th when it came to percentage of people at least 50 who did not receive recommended screening and health care.

It also continued to rank poorly when it came to percent of hospitalized patients receiving recommended care for heart problems and pneumonia (50th), percent of surgical patients receiving appropriate care to prevent complications (51st) and percent of heart failure patients given written instructions at discharge (48th).

The report concluded by saying the study underscores the need for comprehensive national reforms that expand coverage, improve quality of care and control costs.

In this respect, it said Hawai'i could have 25,600 more adults covered by health insurance if it improved to the best performing state's rate.

Along the same lines, it could reduce hospital admissions and re-admissions and have 182 fewer premature deaths from causes that are potentially treatable with timely care.

It also said 45,809 more adults ages 50 or older would receive recommended preventive care.