Kansas Tops National Medicaid Report Card While California Finishes Last, Study Finds
A nationwide evaluation of state Medicaid systems released Sunday ranks Kansas first in the country for overall program governance and places California in last place.
The 50-state study, titled “The Medicaid Report Card: A 50-State Analysis of Medicaid Policy, Spending, and Governance,” was published by the Heartland Institute, a free-market think tank based in suburban Chicago. Jack McPherrin, a senior policy analyst and research fellow at the organization, authored the analysis.
Researchers examined how each state runs its version of the joint federal-state program, which covers about 75 million people across the country. Using public records from the U.S. Census Bureau, the Centers for Medicare & Medicaid Services, and the Medicaid and CHIP Payment and Access Commission, the report graded states across 16 benchmarks grouped into four main buckets: program design, budget exposure, administrative oversight, and local healthcare market rules.
States could earn up to 100 points based on their ability to focus enrollment on traditional safety-net populations, curb improper billings, maintain fiscal discipline, and preserve open access for doctors and clinics.
Kansas led all states with 74 points, driven by perfect scores in administrative integrity and an open local provider market. Texas followed in second place with 67 points, and Wyoming took third with 64. Rounding out the top 10 were Nebraska (62), South Dakota (61), Arkansas (60), Iowa (59), Mississippi (59), North Dakota (57), and Utah (57).
Hospital Hallway. Source: Unsplash
California ranked 50th with 22 points, penalized for rapid cost increases, higher estimated improper payments, and tighter rules on medical providers. The rest of the bottom 10 included Kentucky, Oregon, Maryland, New Jersey, Idaho, New York, New Mexico, North Carolina, and Rhode Island.
The study found a wide gap between top- and bottom-performing states, with the overall national average landing at 45.5 points.
The sharpest divide centered on whether states expanded Medicaid under the Affordable Care Act. Non-expansion states averaged 57.7 points, and all of them placed within the top 18 spots. In contrast, expansion states averaged 42.4 points, and every state in the bottom 10 had expanded its rolls. The study heavily weighted program size, arguing that expansion pushes up state spending and broadens enrollment past the core safety net.
Even so, expansion alone did not dictate outcomes. Six states that expanded their programs—Nebraska, South Dakota, Arkansas, Iowa, North Dakota, and Utah—still reached the top 10 by scoring well in budget controls, eligibility checks, and provider rules.
Spending control and program integrity also drove big point swings. In the fiscal sustainability category, which carries 26 possible points, top-10 states averaged 18 points, while bottom-10 states averaged seven. Wyoming and Mississippi picked up all 26 fiscal points, while New York received zero. On oversight, Kansas earned a maximum 24 points, while elevated rates of improper payments dragged down lower-ranked states.
The study noted that it does not measure patient health outcomes or beneficiary satisfaction. Instead, it focuses on financial trajectories and regulatory frameworks, pointing to policy options like trimming certificate-of-need rules and letting nurse practitioners practice more independently.
“The most important finding is that there is no single trick to governing Medicaid well,” McPherrin said in a statement accompanying the report. “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.”
McPherrin added that the highest-ranking states manage several challenges at once, while lower-ranked states see weaknesses multiply across multiple categories.
“That is ultimately what this report is designed to make visible,” McPherrin said, “while also providing state policymakers a clearer sense of where their own state is succeeding and where there is room for reform.”