Expansion, spending pushes Illinois Medicaid to 31st among states
[September 18, 2026]
By Sean Reed | The Center Square
(The Center Square) – New analysis of Medicaid programs in each state in
the U.S. ranked Illinois a few spots below the middle, based on criteria
like how the state has expanded the program’s scope and spending growth.
The Heartland Institute, a self-described nonprofit think tank focused
on “free-market solutions to social and economic problems,” produced an
evaluation of each state’s Medicaid program, ranking Illinois’ program
implementation 31st.
Jack McPherrin, a senior policy analyst and research fellow with the
institute, co-authored the report, which he said focuses on the
structure, integrity and fiscal sustainability of state-implemented
Medicaid programs.
“The purpose of the scorecard isn't necessarily to say that, for
instance, Kansas has the best health care system in America or that
California has the worst,” McPherrin said. “The scorecard itself is a
much narrower assessment.”
McPherrin said the middling score is due to a combination of aspects
ranging from implementation and program expansion to fiscal
sustainability.
“Illinois has decided to expand Medicaid, along with 39 other states. It
has no meaningful early work requirement activity in accordance with the
federal statute passed last year. It has rapid Medicaid spending and per
annually cost growth. It has no all payer claims database and its
provider market is generally fairly restricted,” McPherrin said.
The category Illinois performed worst in was fiscal sustainability,
which the researcher attributed to increased spending.
“In terms of fiscal sustainability, of course, that's more of a
long-term measure.It's not something that can be fixed immediately, but
the more that's being spent on Medicaid, the less that can go towards
other policy areas and other things that might be important to
consumers,” McPherrin said.
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The state spent about $43.17 billion during the 2026 fiscal year
that ended July 31. Spending was up $6.11 billion from FY 2024,
according to state comptroller data.
For every dollar spent by the state on Medicaid, the federal
government reimburses about 51.82%.
Illinois tied Indiana in overall score, while Iowa ranked well
ahead.
“[Iowa] has very strong performance on program design,
administrative oversight, provider market indicators. It has early
work requirement activity, which is one of the things that really
distinguishes it from Illinois,” McPherrin said.
He said the key takeaways from the research for Illinois, at least
legislatively, is that the program in Illinois could improve
fiscally by rolling back expansion beyond the initially created
program, though he acknowledged that would be politically difficult.
“I understand that that's politically – might be a little bit
difficult, especially in a state like Illinois, but there are a lot
of downstream effects of that that create the problems that that
Illinois is facing here,” McPherrin said.
He pointed to low-ranking Kentucky, which has a conservative
legislature, to note that the program’s size and sustainability
aren’t strictly tied to politics.
He said that the rankings are focused on "rigorous" methodology to
assess the program in each state, and the study is made to be
replicable and transparent.
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