This report evaluates state Medicaid programs using a 50-state scorecard designed to measure the extent to which each state’s program reflects principles of program integrity, administrative competence, fiscal restraint, and a competitive health care environment affecting Medicaid access. The scorecard does not attempt to measure every dimension of Medicaid performance, nor does it claim to capture all normative goals that may be brought to bear in debates over public insurance. Rather, it provides a clear, comparable framework for assessing how state Medicaid programs differ in structure, trajectory, and governance.

The scorecard assigns each state a total score out of 100 points across 16 metrics grouped into four major pillars: Program Design and Enrollment, Fiscal Sustainability and Budget Exposure, Program Integrity and Administrative Oversight, and Market Structure and Provider Environment. These pillars were selected to reflect core policy concerns relevant to Medicaid’s long-term performance: whether the program is tightly targeted, whether it is fiscally sustainable, whether it is administered with appropriate discipline and oversight, and whether the broader health policy environment supports access, competition, and efficient care delivery.

 

Conceptual Approach

The central premise of this report is that Medicaid should function as a targeted safety-net program while remaining fiscally sustainable, administratively effective, and compatible with a functional and accessible health care market. States that maintain tighter eligibility structures, exercise greater cost discipline, enforce stronger integrity safeguards, and remove unnecessary barriers to provider participation and market competition score more favorably under this framework. Conversely, states that have expanded the size and fiscal footprint of Medicaid, tolerated higher levels of waste or administrative dysfunction, or maintained more restrictive provider-market rules score less favorably.

The scorecard evaluates state Medicaid programs primarily through the lenses of fiscal sustainability, program integrity, administrative competence, and broader health care market structure. Reasonable policymakers may disagree about the ideal size and scope of Medicaid or the appropriate balance between public and private coverage. The report does not attempt to resolve every normative debate surrounding public insurance. Instead, it seeks to provide a transparent and comparable framework for evaluating how states differ across a set of measurable fiscal, administrative, and structural indicators relevant to long-term program performance and governance. Every effort was made to ensure that individual metrics are transparent, grounded in publicly available data, and applied consistently across states.

 

Metric Selection, Data Sources, and Scoring Framework

The 16 metrics included in this report were chosen for four reasons. First, each metric was intended to reflect a meaningful aspect of Medicaid policy, administration, fiscal exposure, or the health care market in which Medicaid operates. Second, the metric needed to vary across states in a way that would produce informative comparisons. Third, the underlying data had to be publicly available and sufficiently comparable across states. Fourth, the metric needed to be simple enough to explain clearly in a scorecard format.

The final set of metrics includes both direct Medicaid-policy variables and a limited number of adjacent structural indicators. Some metrics measure explicit policy choices, such as Medicaid expansion status, early work requirement activity, managed care organization presence, and all-payer claims database status. Others measure fiscal or administrative outcomes, such as improper payment rates, Medicaid spending growth, per-enrollee cost growth, budget exposure, and procedural disenrollment during redeterminations. Still others measure features of the surrounding provider and regulatory environment that affect whether Medicaid beneficiaries can access care, including certificate-of-need laws, provider supply, scope-of-practice rules, and Interstate Medical Licensure Compact participation.

Not every potentially relevant variable was included. Some candidate measures were excluded because the data were too inconsistent, too burdensome to collect, too difficult to defend methodologically, or too duplicative of stronger indicators already in the model. In general, the report favors measures that are directionally strong and readily explainable over highly elaborate indices that may create a false sense of precision.

The scorecard relies on publicly available state-level data drawn from national datasets, policy trackers, and official federal or state-oriented sources. Major sources include KFF (formerly the Kaiser Family Foundation) Medicaid trackers; the U.S. Census Bureau’s American Community Survey (ACS); Medicaid and CHIP Payment and Access Commission (MACPAC) MACStats files; Centers for Medicare & Medicaid Services (CMS) improper payment reporting; Department of Health and Human Services (HHS) Office of Inspector General (OIG) Medicaid Fraud Control Unit (MFCU) data; the All-Payer Claims Database (APCD) Council; the Cicero Institute certificate-of-need dataset; America’s Health Rankings; the American Association of Nurse Practitioners (AANP); the American Academy of Physician Associates (AAPA); and the Interstate Medical Licensure Compact (IMLC) Commission.

Where possible, the scorecard uses a single consistent national source per metric rather than mixing multiple sources for the same measure. This approach improves comparability and reduces the risk that differences in underlying methodology, update cycles, or definitions will distort the rankings. In several cases, raw source values required additional construction before scoring. For example, the private-to-Medicaid coverage metric was constructed from American Community Survey coverage categories, the spending-growth metrics were calculated from MACPAC time-series data, and the Medicaid Fraud Control Unit metric was normalized relative to Medicaid enrollment.

 

The scorecard awards a maximum of 100 points. Metric weights were determined based on substantive importance rather than statistical equalization. Some measures, such as Medicaid expansion status and improper payment rate, were weighted more heavily because they reflect especially consequential program choices or outcomes. Others, such as APCD status or IMLC participation, were given more modest weights because they are best understood as supporting indicators rather than core drivers of performance.

The four pillars and their associated weights are:

• Program Design and Enrollment: 36 points
• Fiscal Sustainability and Budget Exposure: 26 points
• Program Integrity and Administrative Oversight: 24 points
• Market Structure and Provider Environment: 14 points

 

Within those pillars, individual metrics were scored using one of three methods: binary scoring, ordinal scoring, or quintile-based scoring.

Binary scoring was used where the relevant policy condition is best understood as present or absent. Under this method, a state either receives the full number of points assigned to the metric or receives zero. Examples include Medicaid expansion status, early work requirement activity, MCO presence, and certificate-of-need status.

Ordinal scoring was used where policy differences are real but are better represented by a small number of categories than by a continuous variable. Under this method, states are grouped into discrete tiers and assigned points accordingly. APCD status, nurse practitioner scope of practice, physician assistant scope of practice, and IMLC participation are scored using this approach.

Quintile scoring was used for continuous variables. States were ranked from best to worst based on the substantive direction of the variable. For some measures, higher values are better; for others, lower values are better. Because the scorecard evaluates 50 states, quintiles were generally constructed by grouping states into sequential performance bands based on their rank within the national distribution.

Quintiles were chosen for several reasons. First, they preserve broad relative performance groupings across states without creating the appearance of excessive precision. Second, they provide a consistent and easily interpretable framework for comparing states across multiple continuous variables. Third, they simplify presentation for nontechnical readers by translating raw numeric distributions into standardized performance bands.

The score allocations within quintile-based metrics are not always linear. This was done to preserve the relative weight of stronger and weaker performance while avoiding fractional scores. For example, some six-point metrics use a 6-4-3-1-0 distribution, while some ten-point metrics use a 10-8-6-2-0 distribution. These distributions reflect a judgment that stronger and weaker relative performance categories should receive greater differentiation than middle-tier categories.

For each quintile-based metric, performance is evaluated relative to other states rather than against an absolute benchmark. A state’s score therefore reflects its position within the national distribution, not whether it meets a predefined target level. This approach is intended to facilitate consistent cross-state comparison within a uniform relative ranking framework.

In cases where multiple states shared identical values at a quintile boundary, quintile group sizes may vary slightly in order to avoid assigning tied observations to different scoring categories.

The complete dataset, including all underlying values, quintile assignments, and scoring calculations, is provided in Appendix A. The accompanying Excel file allows for full replication and review of the scorecard.

 

Pillar I: Program Design and Enrollment

Program Design and Enrollment is worth 36 points. This pillar evaluates whether a state’s Medicaid program remains relatively targeted, whether the state has taken steps to connect Medicaid eligibility to work or economic participation, whether it administers eligibility redeterminations competently, whether it uses managed care, and whether private coverage remains strong relative to Medicaid coverage.

 

Medicaid Expansion Status

Medicaid expansion status is worth 12 points and is scored as a binary variable. States that have not adopted Medicaid expansion receive 12 points. States that have adopted expansion receive 0 points.

This metric receives the largest single weight in the scorecard because expansion is treated as the most consequential structural driver of Medicaid program size and long-term fiscal exposure. Medicaid expansion fundamentally changes the program from a targeted safety net for low-income children, pregnant women, people with disabilities, and other vulnerable populations into a broader coverage program for able-bodied adults. Although expansion may increase insurance coverage, it also increases enrollment, spending, and federal dependence while expanding the program beyond its original safety-net focus.

The source for this metric is the KFF Medicaid Expansion Tracker.[1] Current expansion status was extracted directly for each state.

 

Work Requirements

Work requirement activity is worth 8 points and is scored as a binary variable. States receive 8 points if they had any early work requirement activity identified by KFF in connection with the new federal guidelines established by the 2025 federal reconciliation bill.[2]^,[3] States with no early activity receive 0 points.

For purposes of this scorecard, “early work requirement activity” includes states classified by KFF as adopting early through a state plan amendment, having an approved waiver, having a pending waiver, or having a waiver at the state level. These categories represent different stages of policy development, but all receive equal credit because the metric is intended to capture early policy movement rather than implementation outcomes.

This metric is included because work requirements reinforce the link between public benefits and economic participation, helping limit dependency and better target scarce Medicaid resources. The report recognizes that this is a transition period. As states implement federal changes, the proper way to evaluate work requirement policy may change in future scorecard editions. For example, once baseline compliance becomes mandatory nationwide, future updates may need to assess whether states go beyond federal minimum requirements, how strictly they implement exemptions, or whether their systems are designed to promote employment rather than simply satisfy federal compliance.

 

Redetermination Performance

Redetermination performance is worth 6 points and is scored by quintile, with lower procedural disenrollment rates scoring better. States in the best quintile receive 6 points, followed by 4, 3, 1, and 0 points for progressively worse quintiles.

This metric reflects state performance during the Medicaid unwinding period following the COVID-19 public health emergency, when states were required to resume eligibility redeterminations after a period of continuous coverage. The data come from KFF Medicaid unwinding reports and use the cumulative value from the most recent complete reporting period.[4]

The metric specifically measures the share of disenrollments classified as “terminated for procedural reasons.” It is important to distinguish procedural terminations from individuals who were formally “determined ineligible.” Ineligibility determinations reflect substantive eligibility enforcement, while procedural disenrollment generally reflects terminations tied to administrative or renewal-process failures, including incomplete paperwork, unsuccessful contact attempts, verification problems, or unresolved documentation requirements.

This scorecard focuses on procedural disenrollment because it is intended to measure the efficiency and accuracy of a state’s renewal system rather than the aggressiveness of eligibility enforcement alone. States with lower procedural disenrollment rates are treated as demonstrating stronger administrative performance, more effective renewal infrastructure, and a greater ability to distinguish between truly ineligible beneficiaries and individuals terminated for non-substantive procedural reasons. High procedural disenrollment rates may indicate administrative friction, weak renewal systems, communication failures, or excessive reliance on procedural termination mechanisms rather than accurate eligibility determination.

At the same time, this metric should not be interpreted as discouraging eligibility enforcement. States are expected to remove individuals who no longer qualify for Medicaid coverage. A state can aggressively enforce eligibility rules while still minimizing unnecessary procedural churn through effective verification systems, automated renewals, and clear beneficiary communication. Because this metric focuses specifically on procedural terminations rather than overall disenrollment levels or formal ineligibility determinations, it is best understood as an administrative-performance measure rather than a direct measure of enrollment reduction.

The scorecard addresses broader eligibility enforcement and program-integrity concerns through other metrics, particularly improper payment rates, work requirement activity, fiscal-growth measures, and MFCU enforcement strength. Collectively, those measures evaluate whether states maintain appropriate controls over program size, spending growth, and improper enrollment while still administering renewals competently and consistently.

 

Managed Care Organization Presence

Managed care organization presence is worth 4 points and is scored as a binary variable. States receive 4 points if they have at least one comprehensive Medicaid managed care organization (MCO) in place. States without a comprehensive MCO receive 0 points.

The source for this metric is KFF’s Medicaid MCO data, which are based on KFF analysis of CMS managed care enrollment information.[5] This report uses KFF rather than relying directly on the CMS dataset because KFF identified and adjusted for apparent classification discrepancies in the underlying CMS data. The metric includes comprehensive MCOs, not limited-benefit plans, prepaid ambulatory health plans, prepaid inpatient health plans, Programs of All-Inclusive Care for the Elderly, or public managed care arrangements that do not function as comprehensive private MCOs. Oregon’s Coordinated Care Organizations are counted as MCOs. Idaho is not credited as an MCO state because, although Idaho’s plans for dual-eligible individuals are categorized by CMS as MCOs, KFF does not treat Idaho as an MCO state in its broader Medicaid managed care work because those plans are secondary to Medicare.

This metric is a modest indicator and should not be overstated. MCO presence alone is not a direct measure of competition, quality, or cost control. The report considered using the number of MCOs in each state but rejected that approach because a larger number of MCOs does not necessarily indicate greater competition. In some states, multiple MCOs reflect regional contracting structures rather than meaningful beneficiary choice. Still, the presence of comprehensive MCOs indicates that a state has introduced some degree of private-sector administration, capitated payment, and risk-bearing into its Medicaid program rather than relying exclusively on a fully state-administered fee-for-service model.

 

Private-to-Medicaid Coverage Ratio

The private-to-Medicaid coverage ratio is worth 6 points and is scored by quintile, with higher values scoring better. States in the highest quintile receive 6 points, followed by 4, 3, 1, and 0 points for progressively lower quintiles.

This metric is constructed from 2024 American Community Survey state-level data for adults ages 19 to 64.[6] The calculation uses two mutually exclusive coverage categories: individuals with employer-sponsored insurance only and individuals with Medicaid or means-tested public coverage only. The final measure is constructed as the share of combined employer-sponsored and Medicaid coverage accounted for by employer-sponsored insurance.

This metric is intended to capture the relative balance between private coverage and Medicaid dependence. A higher value suggests that, among the relevant coverage categories, a larger share of adults are covered through employer-sponsored insurance rather than Medicaid. This may reflect stronger labor-market attachment, less crowd-out of private coverage, and a more sustainable balance between private insurance and public coverage.

The metric does not assume that all variation is driven exclusively by Medicaid policy itself. Broader economic conditions, labor-market structure, demographic composition, and employer coverage patterns also affect the ratio. Nevertheless, the measure provides a useful directional indicator of the role Medicaid occupies relative to employer-based coverage within a state’s broader health coverage system. States with higher private-to-Medicaid coverage ratios are treated as maintaining a more targeted safety-net structure and a less expansive reliance on public coverage among the nonelderly adult population.

 

Pillar II: Fiscal Sustainability and Budget Exposure

Fiscal Sustainability and Budget Exposure is worth 26 points. This pillar evaluates the growth trajectory of Medicaid spending, the growth in per-enrollee costs, and Medicaid’s share of state-funded budgets. Together, these metrics assess both the pace at which Medicaid spending is rising and the degree to which Medicaid consumes state fiscal capacity.

 

Five-Year Medicaid Spending Growth

Five-year Medicaid spending growth is worth 10 points and is scored by quintile, with lower growth scoring better. States in the lowest-growth quintile receive 10 points, followed by 8, 6, 2, and 0 points for progressively higher-growth quintiles.

The source for this metric is MACPAC MACStats, using total Medicaid spending data from Exhibit 16 for 2019 through 2023.[7] The metric uses a compound annual growth rate calculated from the beginning and ending values over the five-year period. In Excel, this was calculated using the RRI function, based on the number of periods, starting value, and ending value. Spending values are reported in millions.

This metric reflects the broader long-term trajectory of each state’s Medicaid program. States with lower spending growth are treated as more fiscally sustainable because they are less likely to crowd out other state priorities or require future tax increases, benefit reductions, or provider-payment constraints. The metric does not by itself explain why spending grew. Spending growth may reflect enrollment changes, benefit design, provider rates, health care inflation, demographic shifts, or policy choices. For that reason, this measure is paired with per-enrollee cost growth and Medicaid budget share to provide a broader picture of fiscal exposure.

 

Per-Enrollee Cost Growth

Per-enrollee cost growth is worth 8 points and is scored by quintile, with lower growth scoring better. States in the lowest-growth quintile receive 8 points, followed by 6, 4, 2, and 0 points for progressively higher-growth quintiles.

The source for this metric is MACPAC MACStats, using spending per full-year-equivalent enrollee from Exhibit 23 for 2019 through 2023.[8] Like the total spending growth metric, per-enrollee cost growth was calculated as a compound annual growth rate using the RRI function in Excel.

This metric measures cost growth independent of enrollment growth. A state may experience rising total Medicaid spending because more people enroll, because the average cost per enrollee rises, or both. Per-enrollee cost growth isolates the second factor. Lower per-enrollee cost growth suggests stronger cost discipline, better pricing dynamics, or a more sustainable program structure. Higher growth suggests that Medicaid is becoming more expensive even after accounting for changes in enrollment.

 

Medicaid Share of State Budget

Medicaid share of state budget is worth 8 points and is scored by quintile, with lower shares scoring better. States in the lowest-share quintile receive 8 points, followed by 6, 4, 2, and 0 points for progressively higher-share quintiles.

The source for this metric is MACPAC MACStats, using Exhibit 5.[9] The extracted value is state-funded Medicaid spending as a share of the state-funded budget. This reflects state budget shares from fiscal year 2023, the most recent year from which data were available.

This metric captures Medicaid’s burden on state fiscal capacity. Even if a state’s Medicaid spending growth is moderate, Medicaid may still consume a large share of the state budget. A larger budget share reduces fiscal flexibility and can crowd out other priorities, including education, transportation, public safety, tax relief, and other state responsibilities. For that reason, this metric complements the spending-growth measures by capturing Medicaid’s current budgetary footprint rather than only its trajectory.

 

Pillar III: Program Integrity and Administrative Oversight

Program Integrity and Administrative Oversight is worth 24 points. This pillar evaluates whether states administer Medicaid with appropriate discipline, minimize improper payments, enforce fraud and abuse laws, and maintain data infrastructure that can support better oversight.

 

Improper Payment Rate

Improper payment rate is worth 12 points and is scored by quintile, with lower rates scoring better. States in the lowest-rate quintile receive 12 points, followed by 9, 6, 3, and 0 points for progressively higher-rate quintiles.

The source for this metric is the CMS Payment Error Rate Measurement (PERM) program.[10] Because PERM reviews state Medicaid programs on a rolling three-year cycle, not every state has a new improper payment rate in the same year. This report uses the most recent available improper payment rate for each state, drawn from the 2023–2025 PERM reporting cycle. The values for states reported in 2023, 2024, and 2025 were combined into a single cross-sectional dataset for scoring purposes.

Improper payments do not necessarily indicate fraud in every case. They may include documentation errors, eligibility mistakes, coding issues, or payments made without sufficient verification. Nevertheless, improper payment rates are among the clearest available indicators of waste, error, and weak administrative controls in Medicaid. Because Medicaid is a large public program involving substantial federal and state spending, a high improper payment rate is a serious program-integrity concern even when it does not prove intentional misconduct.

This metric receives one of the highest weights in the scorecard because it directly reflects whether taxpayer dollars are being spent in accordance with program rules. Lower improper payment rates indicate stronger administrative oversight and better payment discipline.

 

MFCU Enforcement Strength

MFCU enforcement strength is worth 8 points and is scored by quintile, with higher enforcement strength scoring better. States in the strongest quintile receive 8 points, followed by 6, 4, 2, and 0 points for progressively weaker quintiles.

The source for this metric is the HHS OIG’s Annual MFCU report for fiscal year 2024,[11] supplemented by Medicaid enrollment data from data.medicaid.gov.[12] The enforcement measure uses fraud convictions reported in the OIG statistical chart and normalizes those convictions relative to total Medicaid enrollment—per 100,000 enrollees—during the same fiscal-year period. Enrollment data correspond to FY 2024, defined as October 2023 through September 2024.

This normalization is important. Raw conviction totals would systematically favor larger states simply because they have more Medicaid enrollees and more providers. By measuring convictions relative to Medicaid enrollment, the scorecard evaluates enforcement intensity rather than sheer volume. The metric is intended to capture how actively states investigate and prosecute Medicaid fraud and abuse while reducing distortion from state size.

The report uses convictions rather than recoveries as the preferred enforcement indicator because recoveries can be distorted by unusually large one-time settlements or cases. Convictions provide a simpler and more stable indicator of active enforcement. This measure complements the improper payment metric. Improper payment rates capture weakness or error in payment systems, while MFCU enforcement strength captures the relative intensity with which states investigate and prosecute Medicaid fraud and abuse after potential misconduct is identified.

 

APCD Status

APCD status is worth 4 points and is scored as an ordinal variable. States with an existing APCD receive 4 points. States with voluntary APCD activity or strong interest receive 2 points. States with no APCD activity receive 0 points.

The source for this metric is the APCD Council. APCD status was extracted from the Council’s state map and converted into ordinal scoring categories.[13]

This metric is included as a modest indicator of transparency and analytic capacity. An APCD does not, by itself, guarantee better Medicaid performance or stronger program integrity. However, claims databases can support better oversight, price transparency, policy analysis, and data-driven decision-making. They can also help policymakers and researchers better understand cost trends, utilization patterns, and market dynamics. Because the effect is indirect, APCD status receives a limited weight compared with core integrity measures such as improper payment rates and MFCU enforcement.

 

Pillar IV: Market Structure and Provider Environment

Market Structure and Provider Environment is worth 14 points. This pillar evaluates whether the broader health policy environment in each state is likely to support provider availability, competition, and care access. These measures are not Medicaid-specific in the narrowest sense, but they affect the environment in which Medicaid beneficiaries actually seek care. A state can provide Medicaid coverage on paper while maintaining regulatory barriers that restrict supply, reduce provider flexibility, or limit access to care.

 

Certificate-of-Need Laws

Certificate-of-need (CON) laws are worth 4 points and are scored as a binary variable. States without CON laws receive 4 points. States with CON laws in place receive 0 points.

The source for this metric is the Cicero Institute’s certificate-of-need dataset.[14] The scorecard uses the dataset’s state classifications and legislative history to construct a binary measure of whether certificate-of-need requirements remain in effect within a state.

CON laws restrict the ability of health care providers to build or expand facilities, add services, or invest in certain equipment without government approval. These restrictions are often justified as tools for cost control or planning, but they can also limit supply, protect incumbent providers, and reduce competition. States without CON restrictions score more favorably because a less restrictive market is generally more conducive to provider availability, innovation, and patient access.

The report recognizes that CON regimes vary substantially in scope and intensity across states. Some states maintain broader and more restrictive systems than others. However, the scorecard uses a binary approach in order to preserve transparency, comparability, and methodological simplicity across all 50 states.

 

Primary Care Provider Supply

Primary care provider supply is worth 4 points and is scored by quintile, with higher supply scoring better. States in the highest-supply quintile receive 4 points, followed by 3, 2, 1, and 0 points for progressively lower-supply quintiles.

The source for this metric is America’s Health Rankings.[15] The extracted value is primary care providers per 100,000 population.

Provider supply is a core determinant of access. Medicaid coverage is less meaningful if beneficiaries cannot find providers who are available, geographically accessible, or able to accept new patients. Although provider supply is affected by many factors beyond Medicaid policy alone, it remains an important feature of the health care environment in which Medicaid operates. Higher provider supply suggests a stronger access environment and greater system capacity.

The scorecard uses overall primary care provider supply rather than attempting to measure only providers who accept Medicaid patients. While Medicaid participation rates are important, comparable 50-state data on active Medicaid acceptance are less standardized and may not consistently reflect actual provider availability or appointment access. Overall provider supply was selected as a more stable and comparable proxy for whether a state’s health care system has sufficient baseline capacity to support patient access, including for Medicaid beneficiaries.

 

Nurse Practitioner Scope of Practice

Nurse practitioner scope of practice is worth 2 points and is scored as an ordinal variable. States with independent practice receive 2 points. States with reduced independent practice receive 1 point. States requiring supervision receive 0 points.

Classifications are based on AANP practice-environment categories, with terminology slightly adapted for clarity.[16] Broader scope-of-practice authority allows nurse practitioners to practice more fully according to their training and can increase provider availability, particularly in primary care and other general access settings, especially in rural or underserved areas.

This metric receives a modest weight because scope-of-practice reform is not a Medicaid policy in the narrow sense. However, it affects the provider environment in which Medicaid beneficiaries seek care. States that allow nurse practitioners to practice with fewer unnecessary restrictions may improve access, expand system capacity, and reduce bottlenecks in primary care and routine outpatient services.

 

Physician Assistant Scope of Practice

Physician assistant scope of practice is worth 2 points and is scored as an ordinal variable. States classified as optimal receive 2 points. States classified as advanced or moderate receive 1 point. States classified as reduced receive 0 points.

The source for this metric is the AAPA Scope of Practice Map.[17] The state classifications were converted into ordinal scoring categories.

As with nurse practitioner scope of practice, physician assistant practice authority affects provider flexibility and system capacity, particularly in primary care and other general access settings. Broader PA authority allows clinicians to operate more fully at the top of their training and can improve access in underserved or provider-shortage areas.

This metric receives a limited weight because it is an indirect Medicaid access measure rather than a direct measure of Medicaid program performance. Nevertheless, it remains relevant to whether a state’s broader health care labor market supports timely and efficient access to care.

 

IMLC Participation

IMLC participation is worth 2 points and is scored as an ordinal variable. States that are IMLC members receive 2 points. States with compact legislation introduced or passed but not yet fully active receive 1 point. States with no activity receive 0 points.

The source for this metric is the Interstate Medical Licensure Compact Commission’s official participating-state list.[18] State status was converted into ordinal scoring categories.

IMLC participation facilitates cross-state physician licensure and can support telehealth expansion, provider mobility, and access to specialized care. Its direct Medicaid impact is limited, which is why the metric receives only 2 points. Still, compact participation reflects whether a state has removed one barrier to physician availability and cross-state care delivery.