About the scorecard

For the scorecard, the Commonwealth Fund rated states and Washington, D.C. on 31 measures across four key domains:

• Access to care (5 indicators), including measures of access to a usual source of care, routine checkups, dental care among older adults, share of Medicare Advantage plans in a state requiring prior authorization, and Medicare beneficiaries referred for home healthcare who received timely services.
• Quality of care (13 indicators), including measures of receipt of preventive care, falls with injury and prescriptions for medications that should be avoided among older adults, indicators of hospital and ED use that might be reduced with timely and effective care and follow-up care, and measures of quality in hospital, post-acute, and long-term care settings.
• Costs and affordability (5 indicators), including estimates of Medicare beneficiary spending per person, share of Medicare spending directed towards primary care, beneficiaries' out-of-pocket spending on medications, and rates at which older adults went without care because of cost.
• Population health (8 indicators), including measures of fair or poor health status, poor physical health, poor mental health, functional limitations, food insecurity, and loneliness among older adults, as well as life expectancy at age 65 and diagnoses of three or more chronic conditions.

The data used for the scorecard generally covered 2023 through 2025 and was drawn from publicly available sources, including CMS, selected federal surveys, and vital statistics datasets.

The best (and worst) states for Medicare beneficiaries

Overall, the Commonwealth Fund found that Vermont, Utah, and Minnesota were the top three ranked states for Medicare beneficiaries, while Louisiana, Mississippi, and Kentucky were the bottom three.

The Commonwealth Fund found that access to needed care varied significantly depending on a Medicare beneficiary's place of residence. For example, fewer than 10% of Medicare Advantage plans in South Dakota require prior authorization for specialist physicians or preventive care services compared to over 70% of plans in Washington. Generally, traditional Medicare doesn't require prior authorization for coverage of services.

Quality of care also varied significantly depending on where a Medicare beneficiary lived. The Commonwealth Fund found that the number of hospital admissions that could have been avoided with high-quality outpatient care ranged from a low of around 14 per 1,000 beneficiaries in Idaho to a high of almost 35 per 1,000 in West Virginia.

Commentary

Gretchen Jacobson, VP of Medicare at the Commonwealth Fund, said that Medicare "is a lifeline for millions of Americans," noting that the scorecard "shows how people's experiences with the program vary widely depending on where they live."

"In some states, beneficiaries can see doctors quickly and afford their prescriptions; in others, they face higher costs, delays, or red tape," she said. "By learning from states where Medicare works best, policymakers and health leaders can strengthen the program for everyone."

During a webinar, David Radley, a senior scientist for the Commonwealth Fund, explained that "when we look at the top-performing states, including Vermont, Colorado, Utah, and Minnesota, one of the things that they have in common is that ... they do really well on the population health metrics."

"These are states where they have better … life expectancy at age 65, fewer people reporting poor mental health days, and people giving themselves high self-reported health," Radley added.

Radley also noted that Minnesota and Vermont have very low uninsured rates. "For that younger-adult working-age population, that means that [if] people … are sick, if they do have a chronic illness, they're much more likely to be having that chronic illness managed and keeping that disease in check as they age into Medicare," he said.

As for the states lower on the rankings, Radley pointed to "deep, deep poverty" and said that social determinants of health can also create barriers to care.

Despite the consistency among core benefits, "there are stark differences among states in beneficiaries' ability to afford care, access doctors, and avoid unnecessary hospitalizations," the Commonwealth Fund said in a press release. "Although Medicare is a federal program, access to care and health outcomes are shaped by a mix of state and local factors — such as the strength of a state's health system, the affordability of supplemental coverage, and the structure of private Medicare Advantage and drug plans — all of which vary across the country."