New Heartland Institute study evaluates every state across 16 measures of Medicaid policy, spending, program integrity, and provider-market conditions
Kansas, Texas, and Wyoming lead the nation; California, Rhode Island, and North Carolina are at the bottom
Non-expansion states substantially outperform expansion states under report’s Medicaid governance framework
SCHAUMBURG, IL (September 9, 2026) – A new 50-state study from The Heartland Institute finds substantial differences in how states design, finance, administer, and regulate their Medicaid programs, with Kansas earning the highest overall score and California the lowest.
The Medicaid Report Card: A 50-State Analysis of Medicaid Policy, Spending, and Governance, authored by Heartland Senior Policy Analyst and Research Fellow Jack McPherrin, evaluates every state using 16 metrics across four areas of Medicaid governance: Program Design and Enrollment; Fiscal Sustainability and Budget Exposure; Program Integrity and Administrative Oversight; and Market Structure and Provider Environment.
Visit MedicaidReportCard.com for an interactive map of the state-by-state results, the executive summary, and the full report (PDF).
Medicaid provides health coverage to roughly 75 million Americans and is one of the largest expenditures in federal and state budgets. Although the program operates under a common federal framework, states retain significant control over eligibility, administration, delivery systems, and provider regulation. The result is effectively 50 distinct Medicaid systems with markedly different fiscal trajectories, administrative capabilities, and policy environments.
The scorecard awards up to 100 points based on whether states maintain Medicaid as a relatively targeted safety-net program, control spending and budget exposure, limit improper payments and fraud, administer eligibility systems effectively, and maintain health care markets conducive to provider access and competition.
Kansas ranks first with 74 points, followed by Texas at 67 and Wyoming at 64. Nebraska and South Dakota round out the top five.
The Top 10 states are:
- Kansas, 74
- Texas, 67
- Wyoming, 64
- Nebraska, 62
- South Dakota, 61
- Arkansas, 60
- Iowa, 59
- Mississippi, 59
- North Dakota, 57
- Utah, 57
At the other end of the rankings, California was last with 22 points. The bottom 10, in descending order, are Kentucky, Oregon, Maryland, New Jersey, Idaho, New York, New Mexico, North Carolina, Rhode Island, and California.
Overall scores average 45.5 nationally, with a median of 45. The top 10 states average 62 points compared with just 29.8 among the bottom 10.
The report finds that the divide between higher- and lower-ranked states extends well beyond any one policy choice.
Among its major findings:
- Medicaid expansion status represents the clearest overall dividing line. States that had not adopted the Affordable Care Act’s Medicaid expansion at the time of the analysis average 57.7 points, compared with 42.4 among expansion states. Every non-expansion state is in the top 18, while every state in the bottom 10 has expanded Medicaid. Expansion is also a heavily weighted component of the scorecard, reflecting the report’s view that expansion increases enrollment, spending, federal dependence, and Medicaid’s departure from its traditional safety-net focus.
- Medicaid expansion does not determine the rankings by itself. Six expansion states—Nebraska, South Dakota, Arkansas, Iowa, North Dakota, and Utah—still rank among the top 10 because of stronger performance in areas such as fiscal discipline, program integrity, eligibility administration, and provider-market policy.
- Fiscal sustainability produces one of the largest gaps between strong and weak states. The top 10 average 18 of 26 available points for fiscal sustainability, compared with just seven points among the bottom 10. Wyoming and Mississippi receive all 26 available fiscal points, while New York receives none. The report finds that states facing rapid total spending growth, rising per-enrollee costs, and heavy Medicaid budget exposure often see those pressures compound.
- Program integrity is another major separator. Kansas receives all 24 available points for program integrity and administrative oversight, while Arkansas, Missouri, South Dakota, Texas, Minnesota, Pennsylvania, and Washington also perform strongly. Elevated improper-payment rates and weak Medicaid fraud enforcement significantly reduce scores in many lower-performing states.
- Provider-market reform helps but cannot compensate for weaknesses elsewhere. The report evaluates certificate-of-need laws, primary care provider supply, nurse practitioner and physician assistant practice authority, and interstate physician licensure. North Dakota earns all 14 available points in this category. However, states such as New Mexico and Colorado demonstrate that relatively open provider markets alone cannot overcome weak fiscal or program-integrity performance.
The study also illustrates that there is no single model for strong Medicaid governance. Kansas reaches first place through a combination of targeted program design, exceptionally strong program-integrity performance, and a comparatively open provider market. Texas is second primarily through program design and integrity despite weaknesses in fiscal exposure and provider supply. Wyoming and Mississippi rely heavily on strong fiscal performance, while South Dakota benefits from strong integrity and provider-market scores.
Likewise, poor performance tends to reflect several problems occurring simultaneously. California scores near the bottom across program design, spending growth, improper payments, provider supply, and provider flexibility. New York performs better in some administrative and provider categories but receives no points for fiscal sustainability. Similar combinations of expansive program design, fiscal pressure, administrative weaknesses, and provider-market restrictions appear throughout much of the bottom tier.
The report is not intended to measure health outcomes, beneficiary satisfaction, or every aspect of health care quality. Instead, it provides a standardized framework for comparing the governance and long-term trajectory of state Medicaid systems, using publicly available data from KFF, the U.S. Census Bureau, the Medicaid and CHIP Payment and Access Commission, the Centers for Medicare & Medicaid Services, the U.S. Department of Health and Human Services Office of Inspector General, and other national health-policy datasets.
The report identifies several reforms states can pursue, including repealing or narrowing certificate-of-need restrictions, expanding nurse practitioner and physician assistant practice authority, joining interstate licensure compacts, developing all-payer claims databases, and pursuing work or community-engagement policies where appropriate. Other challenges—including improper payments, spending growth, provider shortages, eligibility administration, and Medicaid’s overall share of state budgets—require longer-term administrative and institutional reform.
The central conclusion is that strong Medicaid governance requires states to manage several problems at the same time. Program scope, fiscal discipline, eligibility administration, payment accuracy, fraud enforcement, provider capacity, and market regulation operate somewhat independently of one another. No state earns a near-perfect score, and even the highest-ranked states have significant weaknesses.
Read the full Medicaid Report Card here.
The following statement from Jack McPherrin, author of the Medicaid Report Card and Senior Policy Analyst and Research Fellow at The Heartland Institute, may be used for attribution. For interview requests or additional comment, please contact Director of Communications Jim Lakely at [email protected]. You can also call/text Jim at 312-731-9364.
“The most important finding is that there is no single trick to governing Medicaid well. States can keep enrollment relatively targeted and still lose control of spending. They can manage costs well and still tolerate high improper-payment rates. They can open their provider markets while struggling with basic program administration.
“The states that rise to the top generally do several things well at once, while the states at the bottom tend to accumulate problems across several areas. That is ultimately what this report is designed to make visible, while also providing state policymakers a clearer sense of where their own state is succeeding and where there is room for reform.”
Jack McPherrin
Senior Policy Analyst and Research Fellow
The Heartland Institute
The Heartland Institute is a national nonprofit organization founded in 1984 that focuses on free-market solutions to social and economic problems. For more information, visit Heartland.org or call 312-377-4000.
Jack McPherrin is a Senior Policy Analyst and Research Fellow for The Heartland Institute.
