The scorecard reveals substantial variation in how states structure, finance, and administer their Medicaid programs. Scores range from a high of 74 out of 100 in Kansas to a low of 22 in California. The average state score is 45.5, and the median score is 45. This distribution suggests that the scorecard is capturing meaningful differences across states rather than producing a narrow cluster of similar results. At the same time, no state comes close to receiving a perfect score. Even the highest-ranked states have identifiable weaknesses, and many lower-ranked states perform well in at least some areas.
The distribution reinforces that this scorecard is best understood as a comparative framework rather than a declaration that any state has fully solved—or entirely failed—Medicaid governance. The absence of both exceptionally high and exceptionally low scores suggests that Medicaid governance involves tradeoffs rather than simple policy maximization.
Key findings include:
Overall Results
Kansas ranks first overall with 74 points, followed by Texas with 67, Wyoming with 64, Nebraska with 62, South Dakota with 61, and Arkansas with 60. Iowa and Mississippi are tied at 59, followed by North Dakota and Utah, which are tied at 57. At the bottom of the rankings, California scores 22, followed by New Mexico, North Carolina, and Rhode Island, each with 28; New York with 29; Idaho with 31; and Maryland and New Jersey, each with 32.
Top 10 States by Overall Score
|
Rank |
State |
Score |
|
1 |
Kansas |
74 |
|
2 |
Texas |
67 |
|
3 |
Wyoming |
64 |
|
4 |
Nebraska |
62 |
|
5 |
South Dakota |
61 |
|
6 |
Arkansas |
60 |
|
7 |
Iowa |
59 |
|
8 |
Mississippi |
59 |
|
9 |
North Dakota |
57 |
|
10 |
Utah |
57 |
Bottom 10 States by Overall Score
|
Rank |
State |
Score |
|
41 |
Kentucky |
34 |
|
42 |
Oregon |
34 |
|
43 |
Maryland |
32 |
|
44 |
New Jersey |
32 |
|
45 |
Idaho |
31 |
|
46 |
New York |
29 |
|
47 |
New Mexico |
28 |
|
48 |
North Carolina |
28 |
|
49 |
Rhode Island |
28 |
|
50 |
California |
22 |
While the top and bottom performers attract the most attention, much of the distribution is concentrated in the middle, where many states are separated by only a few points.
Several states received identical overall scores and should be considered substantively tied under the framework. For clarity, tied states are presented in sequential rank order throughout the report, but small differences in rank should not be interpreted as large differences in real-world performance where total scores are identical or very close.
The spread between the top and bottom states is nevertheless meaningful. The top 10 states average 62 points overall, while the bottom 10 states average 29.8. That gap reflects differences across multiple pillars, not simply a single policy variable. The results therefore reinforce the central premise of the scorecard: Medicaid governance is multidimensional, and state performance must be evaluated across program design, fiscal sustainability, administrative oversight, and provider-market structure rather than through any one metric alone.
Program Design Remains a Major Differentiator
One clear pattern is that Medicaid expansion status remains an important dividing line under this scoring framework. All 10 non-expansion states rank in the top 18. Non-expansion states average 57.7 points, compared with 42.4 points among expansion states. The bottom 10 states are all expansion states. This finding is not surprising given the structure of the scorecard: Medicaid expansion status is worth 12 points, the largest single metric weight, because the methodology treats expansion as a major structural driver of program size, fiscal exposure, and the degree to which Medicaid remains targeted to its traditional safety-net populations.
Expansion status does not fully explain the rankings, however. Several expansion states score near the top. Nebraska ranks fourth, South Dakota fifth, Arkansas sixth, Iowa seventh, North Dakota ninth, and Utah 10th despite having adopted Medicaid expansion. This indicates that expansion states can still score well if they offset expansion-related weaknesses with stronger performance in other areas, such as redetermination performance, work requirement activity, fiscal sustainability, program integrity, or provider-market flexibility.
Conversely, non-expansion status alone does not guarantee a top ranking. Florida, Tennessee, Wisconsin, Alabama, Georgia, and South Carolina all benefit from non-expansion status but are held back by weaknesses in areas such as fiscal exposure, improper payments, program integrity, certificate-of-need laws, provider scope of practice, or redetermination performance. As such, the scorecard does not simply sort states by expansion status. Expansion is a major variable under the framework, but state performance ultimately depends on how each state performs across all 16 metrics.
High Performance Takes Multiple Forms
One of the central lessons of the scorecard is that state Medicaid performance is multidimensional. The highest-ranked states are not identical, and they do not succeed by following a single model. Some perform well because they maintain tighter program design. Others are carried by unusually strong fiscal performance, program integrity, or provider-market openness. The top states therefore illustrate different pathways to relatively strong Medicaid governance.
Kansas ranks first because it combines strong performance across several major categories: no Medicaid expansion, strong redetermination performance, MCO presence, a strong private-to-Medicaid coverage ratio, low improper payments, strong MFCU enforcement, existing APCD infrastructure, no active CON laws, independent NP practice, and IMLC participation. Kansas does not perform perfectly across the board, however. It receives no points for early work requirement activity, scores poorly on per-enrollee cost growth, and loses points for reduced PA scope of practice. Its first-place ranking therefore reflects breadth of strength rather than perfection.
Texas, ranked second, follows a somewhat different path. Its score is driven largely by program design and program integrity. Texas has not expanded Medicaid, maintains MCO presence, performs well on the private-to-Medicaid coverage ratio, receives strong improper payment and MFCU scores, has existing APCD infrastructure, and has no active CON law. Yet Texas also has weaknesses, including no early work requirement activity, high Medicaid budget exposure, low primary care provider supply, and limited provider flexibility.
Wyoming, ranked third, shows another path to a high score: fiscal restraint. Wyoming receives the full 26 points available in the fiscal sustainability pillar, reflecting strong performance on Medicaid spending growth, per-enrollee cost growth, and Medicaid share of the state budget. Mississippi also receives the full 26 fiscal points, which helps place it in the top 10 despite weaker program-integrity and provider-environment scores. Hawaii also earns the full 26 fiscal points, although its overall ranking is lower because of Medicaid expansion, weak redetermination performance, and limited provider-market scores. While these examples show that fiscal sustainability can significantly improve a state’s standing, it does not by itself determine overall performance.
The top-performing expansion states are also instructive. Nebraska ranks fourth despite Medicaid expansion because it scores well on early work requirement activity, redetermination performance, MCO presence, private coverage relative to Medicaid, improper payments, and provider flexibility. South Dakota ranks fifth because it combines strong redetermination performance, a strong private-to-Medicaid coverage ratio, solid fiscal scores, very strong program-integrity performance, and a strong provider environment. Arkansas ranks sixth because it performs particularly well on fiscal sustainability and program integrity, receiving 22 of 26 fiscal points and 22 of 24 integrity points.
Ultimately, these examples demonstrate that there is no single model of high-performing Medicaid governance. Non-expansion status provides a significant advantage under this framework, but states can also perform well through fiscal discipline, stronger integrity systems, better eligibility administration, provider-market reform, and stronger private coverage relative to Medicaid enrollment.
Pillar-Level Patterns
The pillar results reinforce the broader pattern. The top 10 states average 62 points overall. They average 19.7 out of 36 in Program Design and Enrollment, 18.0 out of 26 in Fiscal Sustainability and Budget Exposure, 16.0 out of 24 in Program Integrity and Administrative Oversight, and 8.3 out of 14 in Market Structure and Provider Environment.
By contrast, the bottom 10 states average 29.8 points overall. They average only 7.3 in Program Design, 7.0 in Fiscal Sustainability, 9.0 in Program Integrity, and 6.5 in Provider Environment. The largest differences between high- and low-scoring states therefore appear in program design, fiscal sustainability, and program integrity. Provider-market policies can make a difference, but they generally do not dominate the overall rankings because the pillar is intentionally weighted more modestly.
This also explains why some states with strong provider-environment scores still rank relatively low. New Mexico, for example, receives 10 of 14 points in the provider environment pillar because it has no active CON law, independent NP practice, advanced PA practice authority, and IMLC progress. Yet it ranks 47th overall because it performs poorly on program design and fiscal sustainability. Colorado receives 11 of 14 provider-environment points but ranks 39th because of Medicaid expansion, no early work requirement activity, high Medicaid budget exposure, weak MFCU enforcement, and elevated improper payments. North Dakota, by contrast, receives a perfect 14 of 14 in provider environment and ranks ninth overall, but it also benefits from strong fiscal sustainability and a strong private-to-Medicaid coverage ratio.
The lesson is not that provider-market reform is unimportant. Rather, provider-market openness generally cannot compensate for broad weaknesses in program design, fiscal exposure, or administrative oversight. Provider supply, scope-of-practice rules, CON laws, and interstate licensure all affect the environment in which Medicaid beneficiaries seek care. But within the overall scorecard, they are one part of a larger governance picture.
Additional patterns emerge from several of the scorecard’s lower-weighted metrics. MCO presence, APCD status, and IMLC participation provide useful information about program structure, transparency infrastructure, and provider-market flexibility, but they do not by themselves determine overall performance. MCO presence is common, with 41 states receiving credit. IMLC participation is also widespread. APCD status varies more, but existing APCD infrastructure appears in both high- and low-ranked states.
These measures are included because they matter, but their modest weights appropriately reflect their indirect relationship to overall Medicaid governance. A state with MCO presence, APCD infrastructure, or IMLC participation may have stronger administrative or market capacity than a state without those features. However, these indicators generally cannot overcome weak fiscal performance, poor integrity scores, expansive program design, or major provider-market restrictions on their own.
Weak Performance Is Usually Multidimensional
The lower-ranked states tend to be weak across multiple dimensions rather than failing because of a single metric. California ranks last with 22 points because it scores poorly in nearly every major category: 5 out of 36 in Program Design, 6 out of 26 in Fiscal Sustainability, 6 out of 24 in Program Integrity, and 5 out of 14 in Provider Environment. Its few strengths, including MCO presence, existing APCD infrastructure, and the absence of CON laws, are not enough to offset Medicaid expansion, no early work requirement activity, high spending growth, high per-enrollee cost growth, weak provider flexibility, low provider supply, and high improper payments.
New York illustrates a different form of weak overall performance. It receives 13 of 24 points in Program Integrity, including a strong improper payment score and existing APCD infrastructure, and it performs fairly well on redeterminations and primary care provider supply. However, it receives zero out of 26 points in Fiscal Sustainability, reflecting weak performance on all three fiscal metrics. Its overall score of 29 is therefore driven less by a total absence of strengths than by very large weaknesses in fiscal trajectory and budget exposure.
North Carolina, New Mexico, Rhode Island, Idaho, Maryland, and New Jersey similarly have identifiable strengths but are held back by combinations of Medicaid expansion, no early work requirement activity, weak redetermination or private-coverage performance, fiscal pressure, weak MFCU enforcement, CON laws, or restrictive provider-market rules. This pattern is important because it shows that low scores are generally not the result of one isolated weakness; they tend to reflect overlapping problems across program design, fiscal sustainability, integrity, and market structure.
Opportunities for Improvement
A forward-looking interpretation of the scorecard is that no state’s position is fixed. Some policy choices could raise a state’s score relatively quickly, while others would require longer-term administrative or fiscal improvement before affecting the underlying data. Binary and ordinal measures, such as early work requirement activity, APCD status, CON laws, NP and PA scope of practice, and IMLC participation, are more directly tied to identifiable policy choices. By contrast, quintile-based outcomes such as improper payment rates, spending growth, per-enrollee cost growth, budget share, redetermination performance, and provider supply may take more time to improve because they depend on implementation quality, fiscal trends, administrative systems, workforce conditions, and/or broader market dynamics.
Even the highest-ranked states have clear opportunities for improvement. Kansas could increase its score by taking early work requirement action, improving per-enrollee cost growth, and broadening PA scope of practice. Texas could improve through early work requirement activity, reducing Medicaid’s share of the state budget, increasing provider supply, and broadening NP and PA practice authority. Wyoming, despite ranking third and receiving a perfect fiscal sustainability score, could improve by adopting comprehensive MCO arrangements, increasing MFCU enforcement strength, developing APCD infrastructure, repealing CON restrictions, and strengthening provider supply.
Middle-ranked states also have obvious pathways. Florida ranks 18th and benefits from non-expansion status, MCO presence, a strong private-to-Medicaid coverage ratio, existing APCD infrastructure, and relatively strong MFCU enforcement. Its score would improve if it took early work requirement action, reduced Medicaid budget exposure, lowered improper payments, repealed CON restrictions, and broadened provider scope-of-practice rules. Illinois, ranked 31st, performs well on improper payments but is held back by Medicaid expansion, no early work requirement activity, rapid spending and per-enrollee cost growth, no APCD activity, and restrictive provider-market rules. Colorado, despite strong provider-environment scores and existing APCD infrastructure, would need stronger fiscal and program-integrity performance to move substantially higher.
Lower-ranked states likewise have room to improve. California could raise its score through several discrete policy changes, including early work requirement activity, broader provider scope-of-practice authority, IMLC participation, and continued attention to improper payment reduction. Larger fiscal improvements, such as reducing spending growth or per-enrollee cost growth, would likely take longer but would matter substantially under the framework. New York’s clearest path is fiscal: it receives zero points in the fiscal sustainability pillar, so improving spending growth, per-enrollee cost growth, and budget exposure would have a major effect. New York could also improve through stronger MFCU enforcement, CON reform, and IMLC participation. New Mexico, North Carolina, and Rhode Island all illustrate that while even low-ranked states often have some strengths, sustained improvement requires addressing multiple categories at once rather than relying on one isolated reform.
Conclusion
The broader conclusion is that Medicaid governance cannot be reduced to any single policy choice or outcome measure. Expansion status matters under this framework, but so do fiscal trajectory, administrative integrity, redetermination performance, private coverage patterns, enforcement activity, provider supply, and regulatory barriers. Some states score well because they maintain tighter program design. Others score well because they have strong fiscal performance or strong program-integrity systems. Some states with expansive Medicaid programs still perform comparatively well because they offset expansion-related weaknesses elsewhere. Conversely, low-scoring states generally exhibit multiple overlapping weaknesses rather than one isolated flaw.
This scorecard should therefore be understood as a comparative governance tool, not as a complete measure of health system quality or beneficiary experience. It does not answer every question one might ask about Medicaid, nor does it attempt to measure every goal that policymakers may value. Its purpose is narrower but important: to make interstate differences systematic and open to scrutiny. By comparing states across program design, fiscal sustainability, administrative oversight, and provider-market structure, the scorecard stresses the choices and tradeoffs that shape Medicaid’s long-term trajectory. As new data become available and states continue to modify their programs, future editions can track how those choices affect performance over time. Thus, the value of this framework lies not only in ranking states at a single point in time, but in identifying where states are strong, where they are weak, and where improvement remains possible.
