Wisconsin Ranks 16th in the Nation for Medicaid Governance

Sunday, October 25th, 2026 -- 9:00 AM

A new 50-state study from The Heartland Institute ranks Wisconsin 16th in the nation for Medicaid governance with a score of 52 out of 100, placing it second among its four neighboring states behind Iowa (7th) and ahead of Minnesota (29th), Illinois (31st), and Michigan (38th).

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 (36 points);
• Fiscal Sustainability and Budget Exposure (26);
• Program Integrity and Administrative Oversight (24);
• And Market Structure and Provider Environment (14).

Overall scores average 45.5 nationally, with a median of 45. Wisconsin outscored Iowa in two of the four scoring categories, earning 24 of 36 for program design against Iowa’s 19, and 18 of 26 for fiscal sustainability against Iowa’s 16.

It still finished nine places behind Iowa nationally, because of a single category: program integrity, where Wisconsin earned 4 of 24 points. That score ties Wisconsin with Rhode Island for the lowest program integrity mark in the country.

Wisconsin is the only state among the five that has not adopted Medicaid expansion, worth 12 points under the scorecard and the largest single metric in the framework.

The good news for Wisconsin:

• The only non-expansion state in the region. Wisconsin earned the full 12 points available for not adopting Medicaid expansion. Iowa, Minnesota, Illinois, and Michigan all forfeited them.
• Strongest program design score in the region. Wisconsin earned 24 of 36 points, ahead of Iowa (19), Illinois (11), Minnesota (8), and Michigan (4).
• Best redetermination performance in the region. Wisconsin’s 62.8 percent redetermination rate leads the group, compared with 72.1 percent in Iowa, 79.0 percent in Minnesota, and 80.8 percent in Michigan.
• Solid fiscal numbers and the region’s strongest private coverage. Per-enrollee Medicaid costs fell 0.1 percent and five-year spending growth was 3.4 percent, worth 18 of 26 fiscal points. Wisconsin’s 86.8 percent private-to-Medicaid coverage ratio is the highest of the five states.

The bad news for Wisconsin:

• Lowest program integrity score in the country. Wisconsin’s 4 of 24 ties Rhode Island for last nationally and is the single largest drag on its overall ranking.
• Third-highest improper payment rate in the nation. At 9.1 percent, Wisconsin’s rate earned zero of the 12 points available and towers over Illinois (1.2 percent), Iowa (1.9 percent), Minnesota (2.2 percent), and Michigan (3.3 percent).
• Weak fraud enforcement. Wisconsin earned 2 of 8 points for Medicaid Fraud Control Unit enforcement, tied with Michigan for the weakest in the region and far behind Minnesota, which earned full marks.
• No early work requirement activity. Wisconsin forfeited the 8 points available. Iowa is the only state in the region that earned them.
• Restrictive provider environment. Reduced nurse practitioner practice authority left Wisconsin with 6 of 14 points, behind Minnesota (9) and Iowa (7). All five states in the region maintain active certificate-of-need laws.

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. Nationally, Kansas ranks first with 74 points and California last with 22.

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. 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.

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