North Dakota performs well on private coverage retention, Medicaid spending growth, per-enrollee cost growth, Medicaid budget exposure, provider environment indicators, and IMLC participation. The state also benefits from MCO presence, no active CON law, independent NP practice, optimal PA scope of practice, and strong primary care provider supply. Even so, North Dakota’s overall score is held down by Medicaid expansion, no early work requirement activity, weak MFCU enforcement activity, and no APCD activity.