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.
Overview
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.
Data Sources
We use four primary datasets, all publicly available:
- CMS Nursing Home Compare — Health inspection ratings, overall ratings, staffing hours per resident, and facility counts. Published by the Centers for Medicare & Medicaid Services. This is the same data behind Medicare's Care Compare tool.
- Genworth Cost of Care Survey (2024) — Median costs for seven care types in every state: adult day care, home health aides, independent living, assisted living, memory care, nursing home (semi-private), and nursing home (private room).
- Bureau of Labor Statistics (BLS) — Occupational employment data for home health aides, registered nurses, and certified nursing assistants by state.
- State Medicaid Program Documentation — Eligibility limits, expansion status, assisted living coverage, and HCBS waiver scope, compiled from Medicaid.gov, KFF, and individual state Medicaid agencies.
Pillar 1: Affordability (25%)
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.
Pillar 2: Quality (25%)
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.
Pillar 3: Staffing (20%)
Staffing is measured using CMS-reported nursing hours per resident per day. Two components are combined:
- RN hours per resident per day (60% weight) — Registered nurses provide the highest level of clinical care. Higher RN hours are strongly correlated with better patient outcomes in published research.
- LPN/aide hours per resident per day (40% weight) — Licensed practical nurses and aides provide the majority of direct hands-on care.
Each component is normalized using min-max scaling across all states, then combined at the weights above.
Pillar 4: Access (15%)
Access measures how many care options exist relative to each state's 65+ population (using Census ACS 2023 estimates). Three metrics are combined:
- Nursing home facilities per 10,000 seniors (35% weight) — From CMS facility counts.
- Home health aide employment per 10,000 seniors (40% weight) — From BLS occupational data. This captures availability of home-based care, which is increasingly preferred over institutional care.
- RN + CNA employment per 10,000 seniors (25% weight) — From BLS. Captures the broader healthcare workforce available to serve seniors.
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.
Pillar 5: Medicaid Support (15%)
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:
- Income eligibility limit (30% weight) — The monthly income threshold for Medicaid nursing home coverage. Higher limits mean more seniors qualify. Normalized via min-max scaling.
- HCBS waiver scope (30% weight) — Rated as comprehensive (100), limited (50), or minimal (0) based on the breadth of Home and Community-Based Services waivers available. States with comprehensive HCBS programs offer robust alternatives to institutional care.
- Assisted living coverage (25% weight) — Whether the state's Medicaid program covers assisted living services through HCBS waivers. Binary: 100 if yes, 0 if no.
- Medicaid expansion status (15% weight) — Whether the state has expanded Medicaid under the ACA. Expansion strengthens the overall Medicaid infrastructure and provider networks. Binary: 100 if expanded, 0 if not.
Normalization
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.
Grading
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.
Limitations
No composite index is perfect. Here are the key limitations of ours:
- State averages mask local variation. A state with a low overall score may still have excellent individual facilities, and vice versa. Always research specific providers.
- Nursing home data dominates. CMS data primarily covers nursing homes. Assisted living, memory care, and home care are less consistently reported at the state level, so our quality and staffing pillars rely on nursing home metrics.
- Quality scores cluster tightly. As noted above, the CMS health inspection rating range across states is only 0.44 points. Quality contributes less differentiation to the composite than other pillars.
- Medicaid data is categorical. HCBS scope is rated as comprehensive/limited/minimal based on our assessment of available documentation. Reasonable people could categorize some states differently.
- Cost data is a snapshot. The Genworth survey represents median costs at a point in time. Costs change, and individual facilities vary widely within each state.
- Pillar weights are editorial. The 25/25/20/15/15 split reflects our judgment about what matters most to families. Different weights would produce different rankings.
Per-State Medicaid Eligibility Data
In addition to the composite index above, every state Medicaid page (e.g. Wisconsin, California) presents granular eligibility data — income limits, asset limits, Community Spouse Resource Allowance (CSRA), home equity caps, HCBS waiver programs, spend-down rules, and estate recovery practices. Because the underlying programs differ meaningfully state-by-state, this data is compiled from the following primary sources:
- Medicaid.gov — Federal program rules, waiver approvals, and CMS guidance documents.
- KFF State Medicaid Profiles — State-by-state eligibility thresholds, expansion status, and waiver scope.
- HHS ASPE — Federal Poverty Level guidelines, published annually each January.
- Individual state Medicaid agency publications — Each state's Department of Health Services or equivalent (e.g. Wisconsin DHS, California DHCS, Texas HHSC) publishes the authoritative income/asset thresholds, Miller Trust rules, and program documentation we cite per state.
- Federal SSI Federal Benefit Rate (FBR) — Most states' institutional Medicaid income cap is set at 300% of the SSI FBR, which the Social Security Administration publishes annually.
State-Specific Exception Handling
Several states deviate from the standard rules in ways that materially affect eligibility. We document these exceptions explicitly on the relevant state pages:
- Wisconsin — Despite not formally expanding Medicaid under the ACA, Wisconsin covers childless adults up to 100% FPL through a long-standing Section 1115 waiver (BadgerCare Plus). For long-term care, Family Care, Family Care Partnership, and IRIS are entitlement programs without HCBS waitlists.
- California — Medi-Cal eliminated the asset limit for non-MAGI Medicaid beneficiaries in 2024. Income limits for aged/disabled adults follow modified rules (100% FPL based) rather than the 300% SSI FBR cap used elsewhere.
- Alaska and Hawaii — Use adjusted Federal Poverty Level thresholds (1.25× and 1.15× the contiguous-48 baseline) for any FPL-indexed eligibility category. Institutional Medicaid income caps remain federal (not state-adjusted).
- Income-cap states (e.g. Florida, Texas, Wisconsin) — Applicants whose monthly income exceeds the cap must establish a Qualified Income Trust (Miller Trust) to qualify for long-term care Medicaid. We flag this requirement on each affected state's page.
- Medically Needy ("spend-down") states — Some states allow applicants to "spend down" excess income on medical expenses to qualify; others do not. This is documented per state.
Refresh Cadence & Known Limitations
- FPL guidelines — Refreshed each January when HHS publishes new poverty guidelines.
- State Medicaid eligibility — Refreshed when states change income/asset thresholds, approve new waivers, or modify expansion status. There may be a delay between a state policy change and our update.
- Cost data (Genworth) — Updated annually when the Cost of Care Survey is released.
- Program enrollment figures — Sourced from CMS reporting and individual state agencies; reporting periods vary by state and may lag the current month.
- Authoritative source. Eligibility determinations are made by your state Medicaid agency; this methodology page documents how we compile, update, and cite their data. See our disclaimer for the long-form scope statement.
Updates
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.
If you find an error in our data, please contact us with the page URL, the specific data point, and a source link. We take accuracy seriously and will verify and correct issues promptly. See also our Disclaimer.
Questions about our methodology? We welcome feedback at our About page. See the full rankings or explore state-by-state data.