Elder Care Index: All States Ranked

Which states provide the best overall environment for elder care? Our Elder Care Index scores every state across five pillars — affordability, nursing home quality, staffing levels, care access, and Medicaid support — to produce a single composite score and letter grade.

The rankings below reflect real data from CMS nursing home inspections, BLS employment statistics, Genworth cost surveys, and state Medicaid program analysis. Click any column header to re-sort, or click a state to see its full breakdown.

Explore individual pillar rankings: Affordability · Quality · Staffing · Access · Medicaid

Why North Dakota Ranks #1: Midwest Affordability Meets Care Infrastructure

North Dakota's top ranking isn't about excellence in any single area — it's about having no major weakness. Care costs run 26% below the national median, the state has more nursing home facilities per senior than almost anywhere else, and its Medicaid program covers assisted living through HCBS waivers. The one gap is staffing (0.59 RN hours/resident), but the state's small senior population of 115,000 means existing facilities aren't overwhelmed.

The Affordability-Staffing Tradeoff: Cheap Care Often Means Thin Staff

Six of the top 10 most affordable states — Missouri, Texas, Oklahoma, Louisiana, Georgia, and Illinois — rank in the bottom 15 for staffing. Missouri is the starkest example: #1 for affordability with assisted living at $3,000/month, but dead last (#51) for staffing at just 0.46 RN hours per resident per day. Families choosing care in low-cost states should scrutinize individual facility staffing reports, not just the price tag.

Florida's F Grade Isn't About Money — It's About Access

Florida ranks #49 overall despite above-average affordability (score: 80). The problem is access: with 4.8 million seniors and a score of just 4 out of 100 on care access, the state has far fewer facilities and providers per senior than almost anywhere else. Families in Florida face longer waitlists and fewer choices. If you're relocating a parent for retirement, the access data suggests looking beyond the Sun Belt.

#	State	Grade	Score	Afford.	Quality	Staffing	Access	Medicaid
1	North Dakota	A	61.2	88	48	34	66	70
2	District of Columbia	A	56.5	55	47	53	50	85
3	Kansas	A	56.3	87	45	24	54	70
4	Nebraska	A	55.9	85	46	26	49	70
5	Minnesota	A	55.7	70	46	32	50	85
6	Missouri	A	55.6	100	45	9	46	70
7	Arkansas	A	55.4	94	53	20	27	70
8	Iowa	A	54.9	84	47	20	52	70
9	South Dakota	A	54.2	90	45	22	52	55
10	Kentucky	A	53.7	89	49	24	26	70
11	Oklahoma	B	53.1	94	46	15	30	70
12	Utah	B	53.1	87	44	31	23	70
13	Louisiana	B	53.0	94	46	14	32	70
14	Wisconsin	B	52.5	78	45	30	34	70
15	Arizona	B	52.1	86	45	25	10	85
16	Indiana	B	51.9	84	46	17	38	70
17	Alabama	B	51.5	93	46	20	16	70
18	California	B	51.5	63	46	32	35	85
19	Ohio	B	51.2	82	45	16	38	70
20	Montana	B	50.8	83	46	26	19	70
21	New York	B	50.3	62	44	16	52	85
22	North Carolina	C	50.3	86	47	17	21	70
23	Illinois	C	50.2	85	44	13	32	70
24	Nevada	C	50.2	78	50	34	7	70
25	Pennsylvania	C	50.2	75	44	22	37	70
26	Maine	C	50.1	62	45	34	24	85
27	Idaho	C	49.9	82	43	26	19	70
28	Texas	C	49.5	96	45	8	31	55
29	Vermont	C	49.5	62	46	30	24	85
30	Colorado	C	49.3	76	44	19	20	85
31	New Mexico	C	49.3	80	42	13	22	85
32	Michigan	D	49.2	78	45	24	20	70
33	Mississippi	D	49.1	88	44	26	32	40
34	Washington	D	49.1	61	46	33	20	85
35	Georgia	D	48.7	89	45	12	16	70
36	Rhode Island	D	48.7	61	48	18	33	85
37	Oregon	D	48.5	56	46	41	14	85
38	South Carolina	D	48.3	88	48	19	14	55
39	Massachusetts	D	48.2	53	48	19	42	85
40	Virginia	D	48.0	79	45	19	18	70
41	West Virginia	D	48.0	75	46	17	27	70
42	Tennessee	F	47.4	85	46	19	17	55
43	Hawaii	F	47.2	55	49	49	6	70
44	Alaska	F	47.1	0	42	100	25	85
45	Delaware	F	46.8	59	42	37	24	70
46	Connecticut	F	46.5	58	43	20	31	85
47	Maryland	F	45.3	67	46	22	15	70
48	New Hampshire	F	44.9	63	45	21	21	70
49	Florida	F	44.6	80	46	20	4	55
50	New Jersey	F	44.3	59	44	20	26	70
51	Wyoming	F	42.3	82	47	22	22	15

How we calculate these scores → Our Methodology

Frequently Asked Questions

How is the Elder Care Index calculated?

Each state is scored across five pillars: Affordability (25%), Quality (25%), Staffing (20%), Access (15%), and Medicaid Support (15%). Scores are normalized and combined into a 0-100 composite, then assigned letter grades based on rank position (top 10 states = A, bottom 10 = F).

What data sources does the Elder Care Index use?

We use CMS Nursing Home Compare data for quality and staffing, Genworth Cost of Care Survey for pricing, BLS Occupational Employment data for workforce metrics, and state Medicaid program documentation for coverage analysis.

Why does my state have a low grade?

A low grade typically reflects weakness across multiple pillars. Click into your state's page to see exactly which areas pull the score down and which are relative strengths.

More Rankings

Overall Rankings By Affordability By Quality By Staffing By Access By Medicaid