Medicaid covers roughly 75 million Americans and represents one of the largest lines in both federal and state budgets. Within a shared federal framework, states control eligibility, program design, administration, delivery systems, and provider regulation, which produces 50 systems with distinct fiscal trajectories, administrative capacity, and policy environments.

This report scores each state across four dimensions of Medicaid governance: Program Design and Enrollment (36 points), Fiscal Sustainability and Budget Exposure (26 points), Program Integrity and Administrative Oversight (24 points), and Market Structure and Provider Environment (14 points). There are 16 metrics in total, which add up to a maximum of 100 points.

The scorecard rewards states that keep Medicaid closer to a targeted safety-net program, exercise fiscal discipline, minimize improper payments and fraud, run competent eligibility systems, and keep provider markets open. It is not a measure of health outcomes, beneficiary satisfaction, or overall system quality. The goal is narrower: to make differences in policy design, fiscal exposure, administrative performance, and provider-market conditions comparable across states.

Methodology

States are scored using binary, ordinal, or quintile methods depending on the metric, with continuous measures benchmarked against the national distribution rather than fixed targets. Data come from KFF, the Census Bureau, MACPAC, CMS, the HHS Office of Inspector General, and other national trackers of state health policy and provider regulation.

Overall Results

Scores range from 74 (Kansas, first) to 22 (California, last), with a state average of 45.5 and a median of 45. No state comes close to a perfect score—even the top performers carry real weaknesses.

Top 10: Kansas (74), Texas (67), Wyoming (64), Nebraska (62), South Dakota (61), Arkansas (60), Iowa (59), Mississippi (59), North Dakota (57), Utah (57).

Bottom 10: Kentucky, Oregon, Maryland, New Jersey, Idaho, New York, New Mexico, North Carolina, Rhode Island, and California.

The top 10 average 62 points; the bottom 10 average 29.8. The gap is not attributable to any single metric; high-ranked states tend to combine strength across design, fiscal management, and integrity, while low-ranked states tend to accumulate weaknesses across all four pillars at once.

Key Findings

The single biggest split in the data is expansion status. States that had not adopted the Affordable Care Act’s Medicaid expansion at the time of analysis average 57.7 points against 42.4 for expansion states, and every state within the bottom 10 has expanded. All 10 non-expansion states land in the top 18, a result that partly reflects the methodology’s treatment of expansion as a major driver of enrollment, spending, federal dependence, and departure from Medicaid’s traditional safety-net focus.

That said, Nebraska, South Dakota, Arkansas, Iowa, North Dakota, and Utah all expanded and still cracked the top 10, mostly on the strength of fiscal discipline, program-integrity performance, or eligibility administration. A few non-expansion states land outside the top 10 once fiscal exposure or improper payments catch up with them.

There is no single formula for a strong score, either. Kansas ranks first on a combination of tight program design, near-perfect integrity performance, and an open provider market. Texas gets to second almost entirely on design and integrity, despite substantial weaknesses in budget exposure and provider supply. Wyoming and Mississippi climb the rankings mostly through fiscal performance; South Dakota through integrity and provider-market strength; Arkansas through fiscal management and administrative oversight.

Fiscal sustainability does the most to separate the top and bottom tiers: the top 10 average 18 of 26 fiscal points, the bottom 10 average 7. Wyoming and Mississippi take the full 26; New York takes zero. States that combine fast spending growth, rising per-enrollee costs, and heavy Medicaid budget exposure tend to see those problems compound, often enough to erase advantages elsewhere in the scorecard.

Program integrity carries similar weight. Kansas earns all 24 points available; Arkansas, Missouri, South Dakota, Texas, Minnesota, Pennsylvania, and Washington all score well too. High improper payment rates and weak fraud enforcement substantially reduce scores in many other states.

Provider-market policy—certificate-of-need repeal, scope-of-practice expansion, interstate licensure, primary care supply—moves the needle, but not enough on its own. North Dakota takes all 14 points here. New Mexico and Colorado do well on this pillar specifically and still finish near the bottom overall, because provider-market strength cannot offset weak fiscal or program-integrity numbers.

Weak performance is almost always compounding rather than isolated. California is near the bottom on every pillar; design, spending growth, improper payments, provider supply, and provider flexibility all pull in the same direction. New York does better on administration and providers but scores zero on fiscal sustainability. Most of the other low-ranked states show the same pattern: some expansive program design, some fiscal pressure, some administrative gaps, some provider-market restriction, all stacking up at once.

Policy Implications

Some reforms can be pursued through relatively direct legislative or administrative action—repealing certificate-of-need laws, expanding NP/PA scope of practice, joining interstate licensure compacts, implementing an all-payer claims database, or moving early on work requirements. Others—improper payments, spending growth, provider supply, redetermination systems, overall budget exposure—take longer and require sustained institutional follow-through.

The throughline is that no state has solved Medicaid governance by getting one thing right. Program scope, fiscal exposure, eligibility administration, payment accuracy, fraud enforcement, provider capacity, and market regulation all move somewhat independently, and a state has to manage all of this simultaneously to score well. The point of this scorecard is to make those differences visible and comparable, and to give future editions a consistent baseline for tracking how state policy and administrative performance shift over time.