The Elder Care Index is a composite score that ranks all 50 states and Washington, D.C. across five dimensions of elder care. This page explains exactly how we calculate each score, where the data comes from, and the decisions we made along the way — including the limitations.
Each state receives a score from 0 to 100, calculated as a weighted average of five pillar scores:
| Pillar | Weight | What It Measures |
|---|---|---|
| Affordability | 25% | How much care costs relative to the national median |
| Quality | 25% | CMS nursing home health inspection ratings |
| Staffing | 20% | RN and total nurse hours per resident per day |
| Access | 15% | Care facilities and workers per senior population |
| Medicaid | 15% | Coverage breadth, eligibility, and program scope |
The composite score determines each state's rank. Letter grades are assigned by rank position: the top 10 states receive an A, the next 11 receive a B, the next 10 a C, the next 10 a D, and the bottom 10 an F.
We use four primary datasets, all publicly available:
For each state, we calculate how much each of seven care types costs compared to the national median, expressed as a percentage difference. These percentage differences are combined into a single weighted average, where higher-cost care types (like nursing homes at ~$132K/year) carry more weight than lower-cost types (like adult day care at ~$21K/year). This reflects the reality that nursing home costs have a much larger financial impact on families.
The weighted average is then normalized across all states using min-max scaling, where the most affordable state scores 100 and the most expensive scores 0.
Quality is measured using CMS average health inspection ratings by state, on a 1-to-5 scale.
An important note about this pillar: Average health inspection ratings are remarkably similar across all states, ranging from approximately 2.69 to 3.13. This 0.44-point range means the difference between the "best" and "worst" state averages is small. To handle this honestly, we normalize Quality scores against the full theoretical CMS range of 1 to 5, rather than stretching the narrow observed range across 0 to 100. This means all states score between roughly 42 and 53 on this pillar — accurately reflecting that state-level quality averages don't vary much.
Individual facility quality varies far more than state averages. We strongly recommend checking specific facility ratings on Medicare Care Compare rather than relying on state-level averages alone.
Staffing is measured using CMS-reported nursing hours per resident per day. Two components are combined:
Each component is normalized using min-max scaling across all states, then combined at the weights above.
Access measures how many care options exist relative to each state's 65+ population (using Census ACS 2023 estimates). Three metrics are combined:
Each metric is normalized using min-max scaling, then combined at the weights above. States with large, fast-growing retiree populations (like Florida) tend to score lower because demand outpaces infrastructure.
Medicaid is the largest payer for long-term senior care in the U.S. This pillar evaluates four aspects of each state's Medicaid program:
Most pillar components use min-max normalization: the state with the best raw value scores 100, the worst scores 0, and all others are scaled proportionally between them. This is a standard approach for creating comparable scores across metrics with different units and ranges.
The exception is the Quality pillar, which uses theoretical range normalization (1-5 CMS scale) instead of observed min-max, as explained above.
Letter grades are assigned by rank position, not score thresholds:
| Grade | Rank Range | Count |
|---|---|---|
| A | #1 – #10 | 10 states |
| B | #11 – #21 | 11 states |
| C | #22 – #31 | 10 states |
| D | #32 – #41 | 10 states |
| F | #42 – #51 | 10 states |
This means grades reflect relative standing, not absolute quality. A "C" grade means a state is in the middle of the pack — not that its elder care system is "average" in any absolute sense.
No composite index is perfect. Here are the key limitations of ours:
We plan to update the Elder Care Index as new data becomes available from CMS, BLS, and Genworth. The current version uses 2024 data published in early 2025.
Questions about our methodology? We welcome feedback at our About page. See the full rankings or explore state-by-state data.