Kansas earned the highest score and California the lowest in a new 50-state evaluation of Medicaid governance released September 9 by The Heartland Institute. The Medicaid Report Card, authored by senior policy analyst Jack McPherrin, assessed every state using 16 metrics covering program design, fiscal sustainability, program integrity, and provider markets. The analysis found substantial differences in how states manage Medicaid, which provides coverage to roughly 75 million Americans and represents one of the largest budget items for federal and state governments.
Kansas led the rankings with 74 points out of 100, followed by Texas at 67 and Wyoming at 64. Nebraska scored 62 points and South Dakota earned 61 to round out the top five. Arkansas, Iowa, and Mississippi each secured 59 points, while North Dakota and Utah tied at 57 points to complete the top 10. California finished last with just 22 points, preceded by Rhode Island, North Carolina, New Mexico, New York, Idaho, New Jersey, Maryland, Oregon, and Kentucky in the bottom 10. Nationally, overall scores averaged 45.5 with a median of 45, while the top 10 states averaged 62 points compared with just 29.8 among the bottom 10. States that hadn't adopted the Affordable Care Act's Medicaid expansion averaged 57.7 points, compared with 42.4 among expansion states—every non-expansion state landed in the top 18, while every state in the bottom 10 had expanded Medicaid.
The report identifies fiscal sustainability as one of the sharpest dividing lines between high and low performers. The top 10 states averaged 18 of 26 available fiscal points, while the bottom 10 averaged just seven. Wyoming and Mississippi received all 26 fiscal points, whereas New York received none. Program integrity created another major gap: Kansas earned all 24 available points for program integrity and administrative oversight, while the analysis found that elevated improper-payment rates and weak fraud enforcement significantly reduced scores in many lower-performing states. According to McPherrin, "the most important finding is that there is no single trick to governing Medicaid well," and states can "keep enrollment relatively targeted and still lose control of spending" or "manage costs well and still tolerate high improper-payment rates."
The report explains that Medicaid expansion status represents the clearest overall dividing line because expansion increases enrollment, spending, federal dependence, and moves Medicaid away from its traditional safety-net focus—though six expansion states still ranked in the top 10 through stronger performance in fiscal discipline, program integrity, and provider-market policy. States facing rapid spending growth, rising per-enrollee costs, and heavy budget exposure often see those pressures compound, the analysis notes. Poor performance typically reflects several problems happening simultaneously: California scored near the bottom across program design, spending growth, improper payments, provider supply, and provider flexibility, while similar combinations of expansive programs, fiscal pressure, administrative weaknesses, and provider restrictions appear throughout much of the bottom tier. Even relatively open provider markets can't compensate for weak fiscal or program-integrity performance, the report finds.
The report recommends states pursue reforms including repealing or narrowing certificate-of-need restrictions, expanding nurse practitioner and physician assistant practice authority, joining interstate licensure compacts, and developing all-payer claims databases. Longer-term challenges such as improper payments, spending growth, provider shortages, and Medicaid's overall share of state budgets require sustained administrative and institutional reform. The central conclusion is that strong Medicaid governance requires states to manage several problems simultaneously—program scope, fiscal discipline, eligibility administration, payment accuracy, fraud enforcement, provider capacity, and market regulation all operate somewhat independently, and even the highest-ranked states have significant weaknesses.