Based on recent reports, Mississippi is frequently cited as the hardest state to get Medicaid, largely because it has not expanded Medicaid under the Affordable Care Act and has very restrictive eligibility requirements for adults. Other states with exceptionally difficult, low-income eligibility criteria include Texas, Alabama, and Wyoming.
There isn't one single "worst" state, as it depends on the metric, but Mississippi, Louisiana, Kentucky, West Virginia, Texas, and South Dakota frequently rank low for access, quality, and affordability, facing challenges like lack of providers, transportation, and lower reimbursement rates, especially in the Southeast. States with low Medicaid expansion enrollment and higher potential impacts from federal cuts, like South Dakota, Wyoming, and Utah, also appear on "worst" lists.
In comparison, the 10 worst states for healthcare were:
States Most Severely Affected
U.S. states with the highest Medicaid expenditure 2022
Total Medicaid spending surpassed 804 billion U.S. dollars in 2022. The state of California had the highest expenditure throughout the year, followed by New York and Texas.
Vermont, Utah and Minnesota topped the Commonwealth Fund's Medicare performance scorecard in 2025, whereas Kentucky, Mississippi and Louisiana struggled the most.
As of early 2026, ten states have not expanded Medicaid under the Affordable Care Act (ACA), creating a "coverage gap" for low-income adults: Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming, with most of these states concentrated in the South. These states have resisted expansion due to partisan opposition to the ACA, differing views on government's role in healthcare, and concerns about costs, though the federal government funds most of the expansion.
The state with the highest Medicaid income limit is Alaska, where households of eight people must have a maximum income of less than $77,526. Alaska Medicaid income limits also include the highest limit for households of one person, $22,597. Read on to find out all the Medicaid income limits by state.
New Mexico had the highest percentage of residents enrolled in Medicaid in 2022, while Utah had the lowest, according to new data released by the Census Bureau Sept. 14 as part of its American Community Survey.
The 10 worst programs—ranked in order from 50 to 41—are Mississippi, Texas, Idaho, Oklahoma, South Dakota, Indiana, South Carolina, Colorado, Alabama, and Missouri, the report concluded.
Medicaid alternatives often involve the Affordable Care Act (ACA) Marketplace for subsidies and low-cost plans, CHIP for children and pregnant individuals, employer-sponsored plans, or specialized options like Direct Primary Care (DPC) or Basic Health Programs, providing coverage for those above Medicaid income thresholds or seeking different care models. The key is finding coverage through programs like the ACA Marketplace if you lose Medicaid, getting CHIP for kids, or exploring employer/DPC options.
Medicaid is facing significant changes due to the 2025 budget reconciliation bill (H.R. 1/OBBBA), introducing federal work/community engagement requirements for some enrollees, potential funding cuts, restrictions for certain immigrants, and increased out-of-pocket costs for some expansion adults, leading states to already cut spending and providers to leave, risking access issues for millions, especially people with disabilities, older adults in long-term care, and low-income families.
As of 2025, the following states had not accepted federal funding to expand Medicaid:
One likely reason fewer doctors accept Medicaid patients is that those claims are paid at a lower rate than other insurance. More providers would be interested in Medicaid if the program's reimbursements were similar to Medicare payments, according to the report.