Disclaimer: General educational research only — not legal or medical advice. Advance-directive and POLST rules vary by state. Talk with your doctor and an estate planning attorney about your situation.
Estate Planning Data & Research → End-of-Life Wishes by State
Whether someone dies at home with hospice or in an ICU often depends on two things: what they wrote down ahead of time, and whether the people around them knew it. Medicare data shows how differently end-of-life care plays out from state to state, and two states changed their rules this year.
We analyzed Medicare’s 2024 Geographic Variation data on hospice use in every state, and CMS’s state-level hospice quality measures. We also checked this year’s advance-directive and POLST (portable medical order) legislation against official state sources.
Health care documents cover the end of life. A will or trust covers what comes after. See whether you need a will, a living trust or both.
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Key findings
- 844,306 people in Original Medicare used hospice in 2024, 3.04% of enrollees, up from 2.89% in 2019. The share rose in 42 states.
- Alabama has the highest hospice use (4.38%), followed by Utah (4.19%), Oklahoma (4.09%), Mississippi (3.87%) and Louisiana (3.84%). Alaska (1.30%) and New York (1.59%) have the lowest.
- Medicare paid $12.9 billion for hospice in Original Medicare in 2024, an average of $15,292 per hospice user. Per-user spending ranges from $21,657 in California to $10,196 in Kentucky.
- These numbers leave out more than half of Medicare. 54.8% of beneficiaries with both Part A and Part B were in Medicare Advantage or other health plans in 2024, and they aren’t counted here. That share ranges from 65.7% in Rhode Island to 2.7% in Alaska.
- Hospices nearly always ask. In every state, 99.4% or more of hospice patients had their treatment preferences documented at admission (Oct. 2024–Sept. 2025).
- Visits at the very end vary widely. The share of hospice patients who got in-person visits from a nurse or social worker on at least two of their last three days of life ranges from 76.5% in Wisconsin to 20.4% in California (2023–2024). The state median is 62.5%.
- Two states moved POLST laws this year. California’s SB 1088 (Chapter 677, Statutes of 2026) renames the form “Portable Orders Listing Scope of Treatment,” allows electronic signatures and honors out-of-state forms. Pennsylvania’s SB 730, which would write the state’s POLST into law, passed the Senate 49–0 and cleared the House Health Committee on Oct. 7, 2026.
Hospice use by state
| State | Original Medicare enrollees using hospice, 2024 | 2019 | Hospice users, 2024 | Medicare hospice spending per user | Share of Medicare in Medicare Advantage (not counted) | Hospice patients visited on 2 of last 3 days of life (2023–24) |
|---|---|---|---|---|---|---|
| United States | 3.04% | 2.89% | 844,306 | $15,292 | 54.8% | — |
| Alabama | 4.38% | 3.77% | 16,221 | $16,255 | 64.1% | 69.4% |
| Alaska | 1.30% | 1.12% | 1,330 | $13,753 | 2.7% | 50.4% |
| Arizona | 3.00% | 2.90% | 18,693 | $15,830 | 54.7% | 55.7% |
| Arkansas | 3.54% | 3.14% | 11,570 | $14,463 | 47.6% | 64.6% |
| California | 2.89% | 2.58% | 77,503 | $21,657 | 56.4% | 20.4% |
| Colorado | 2.71% | 2.51% | 11,001 | $15,456 | 56.8% | 62.3% |
| Connecticut | 3.14% | 3.04% | 8,010 | $12,427 | 61.9% | 61.8% |
| Delaware | 2.96% | 3.06% | 4,425 | $14,700 | 34.0% | 63.9% |
| District of Columbia | 2.04% | 2.05% | 970 | $17,706 | 38.5% | 36.7% |
| Florida | 3.73% | 3.54% | 71,523 | $15,607 | 59.7% | 60.9% |
| Georgia | 3.65% | 3.31% | 26,106 | $16,798 | 59.6% | 58.7% |
| Hawaii | 2.59% | 2.36% | 2,618 | $19,530 | 61.8% | 56.9% |
| Idaho | 2.90% | 2.89% | 5,147 | $14,079 | 51.9% | 61.8% |
| Illinois | 2.91% | 2.83% | 33,483 | $12,787 | 46.8% | 57.7% |
| Indiana | 3.24% | 3.14% | 19,647 | $13,919 | 52.6% | 66.4% |
| Iowa | 3.22% | 3.21% | 12,621 | $11,433 | 39.2% | 73.1% |
| Kansas | 3.28% | 3.16% | 11,561 | $13,241 | 35.5% | 64.5% |
| Kentucky | 2.77% | 2.54% | 10,693 | $10,196 | 57.3% | 63.4% |
| Louisiana | 3.84% | 3.36% | 13,305 | $15,270 | 59.7% | 55.8% |
| Maine | 3.56% | 3.20% | 4,798 | $13,981 | 61.6% | 76.3% |
| Maryland | 2.57% | 2.60% | 18,339 | $12,101 | 27.1% | 59.5% |
| Massachusetts | 2.87% | 2.68% | 22,633 | $15,459 | 38.8% | 67.5% |
| Michigan | 3.37% | 3.14% | 24,418 | $14,420 | 65.5% | 63.3% |
| Minnesota | 3.13% | 2.88% | 12,035 | $14,259 | 64.0% | 67.0% |
| Mississippi | 3.87% | 3.28% | 12,676 | $15,734 | 44.8% | 62.5% |
| Missouri | 3.37% | 3.16% | 17,982 | $13,584 | 56.9% | 61.2% |
| Montana | 2.03% | 2.34% | 3,396 | $11,301 | 31.3% | 59.9% |
| Nebraska | 2.83% | 2.75% | 6,394 | $11,689 | 36.1% | 69.5% |
| Nevada | 3.03% | 2.53% | 7,147 | $16,866 | 56.3% | 49.8% |
| New Hampshire | 2.86% | 2.63% | 5,461 | $14,059 | 38.3% | 72.1% |
| New Jersey | 2.68% | 2.72% | 22,764 | $14,333 | 44.9% | 54.9% |
| New Mexico | 2.83% | 2.63% | 5,424 | $15,349 | 54.3% | 63.9% |
| New York | 1.59% | 1.64% | 23,946 | $14,098 | 57.0% | 50.8% |
| North Carolina | 3.19% | 2.92% | 27,329 | $14,251 | 59.0% | 64.4% |
| North Dakota | 2.10% | 1.87% | 1,809 | $11,061 | 36.9% | 66.5% |
| Ohio | 3.30% | 3.41% | 31,178 | $14,529 | 59.7% | 62.2% |
| Oklahoma | 4.09% | 3.50% | 16,888 | $16,101 | 43.6% | 54.9% |
| Oregon | 2.59% | 2.53% | 9,311 | $14,551 | 59.0% | 51.5% |
| Pennsylvania | 2.64% | 2.74% | 30,193 | $12,231 | 57.6% | 59.9% |
| Rhode Island | 3.44% | 3.11% | 2,541 | $13,462 | 65.7% | 76.4% |
| South Carolina | 3.30% | 3.01% | 19,665 | $15,818 | 48.1% | 65.3% |
| South Dakota | 2.22% | 2.18% | 2,501 | $10,548 | 38.6% | 71.2% |
| Tennessee | 3.19% | 2.86% | 19,127 | $13,153 | 56.2% | 66.5% |
| Texas | 3.70% | 3.41% | 66,216 | $17,804 | 58.4% | 51.0% |
| Utah | 4.19% | 3.79% | 7,556 | $15,686 | 57.0% | 71.4% |
| Vermont | 2.35% | 2.24% | 2,342 | $12,641 | 34.7% | 66.0% |
| Virginia | 2.84% | 2.69% | 24,944 | $13,768 | 41.8% | 59.2% |
| Washington | 2.39% | 2.39% | 15,392 | $13,664 | 53.2% | 57.0% |
| West Virginia | 2.83% | 2.57% | 5,146 | $12,052 | 57.1% | 65.7% |
| Wisconsin | 3.18% | 3.09% | 15,657 | $15,723 | 60.5% | 76.5% |
| Wyoming | 1.99% | 1.58% | 1,912 | $11,483 | 18.5% | 67.6% |
Sources: CMS Medicare Geographic Variation Public Use File (Original Medicare enrollees, 2019 and 2024); CMS Hospice – State Data (Hospice Quality Reporting Program), HVLDL measure, 2023–2024. Hospice use = Original Medicare enrollees with a hospice claim in the year, divided by all Original Medicare enrollees (not by deaths).
Why the numbers differ
Hospice use is measured against all enrollees, not deaths. The rate isn’t adjusted for age or death rates, which differ by state.
Medicare Advantage takes a big bite out of the denominator. The Geographic Variation file covers only Original Medicare enrollees. In states where most beneficiaries are in Medicare Advantage, the data describes a minority of older residents. Alaska is the exception. 97.3% of its beneficiaries with Parts A and B are in Original Medicare, so its low hospice use isn’t a coverage artifact.
Counts fall while rates rise. Original Medicare hospice users peaked at 981,048 in 2020 and fell to 844,306 in 2024, as Original Medicare enrollment shrank from 32.4 million to 27.7 million. The share of enrollees using hospice still went up.
Quality measures use different periods. The treatment-preferences measure covers October 2024 to September 2025. The last-days visits measure is claims-based and covers calendar years 2023 and 2024. CMS doesn’t publish a national figure in the state file.
The laws that changed in 2026
California SB 1088 (signed Sept. 27, 2026; Chapter 677, Statutes of 2026):
- Renames the POLST form “Portable Orders Listing Scope of Treatment.”
- Lets a physician, nurse practitioner or physician assistant sign. An individual with capacity, or their health care agent, conservator or surrogate, also signs.
- Makes electronic signatures sufficient.
- Treats a POLST or similar form validly executed in another state as valid and enforceable in California.
- Says POLST and DNR forms are voluntary. Care or facility admission can’t be conditioned on completing or refusing one.
Pennsylvania SB 730 would codify Pennsylvania Orders for Life-Sustaining Treatment in Title 20 (Decedents, Estates and Fiduciaries). It passed the Senate 49–0 on June 23, 2026. The House Health Committee reported it on Oct. 7, 2026, and it was laid on and removed from the table the same day. It has not passed the House.
Elsewhere, 26 advance-directive and end-of-life bills in 13 jurisdictions matched our LegiScan scan of current sessions. They include medical aid-in-dying bills in Ohio (HB 835, referred to committee in May 2026) and Massachusetts (H2505, reporting date extended to July 31, 2026). We list them without taking a position.
What this means for your family
Write your wishes down, and name someone to speak for you. A living will (or advance directive) records the treatment you want or don’t want. A health care power of attorney, also called a health care proxy, names the person who decides when you can’t. Both are usually signed while you’re healthy.
A POLST is different, and it’s for later. A POLST is a medical order signed with your clinician, usually when you’re seriously ill or frail. California’s new law tells clinicians to explain the difference between an advance directive and a POLST when completing one.
Hospice is a choice you make. To elect Medicare hospice, a doctor certifies a life expectancy of six months or less. You accept comfort care instead of care to cure the illness and sign an election statement. The person you name as your health care agent may be the one making that call.
Put these documents with your will. Your executor, your health care agent and your family should know where to find them. See our essential estate documents and the family conversation.
Related: The incapacity gap · Older adults living alone, by state · Estate planning law tracker
Methodology
Hospice use. CMS Medicare Geographic Variation – by National, State & County (2014–2024 public use file), state and national rows, all ages. Fields: BENES_OM_CNT (Original Medicare enrollees), BENES_HOSPC_CNT and BENES_HOSPC_PCT (enrollees with hospice use), HOSPC_MDCR_PYMT_AMT and HOSPC_MDCR_PYMT_PER_USER (Medicare hospice payments), HOSPC_CVRD_DAYS_PER_1000_BENES and MA_PRTCPTN_RATE. Pulled Oct. 8, 2026.
Hospice quality. CMS Provider Data Catalog, Hospice – State Data (dataset eda0-92f0). H_001 Treatment Preferences (Oct. 1, 2024–Sept. 30, 2025). H_011 Hospice Visits in the Last Days of Life (HVLDL): the share of patients with in-person RN or medical social worker visits on at least two of the final three days of life (Jan. 1, 2023–Dec. 31, 2024). Hospice Care Index indicators are in the CSV download.
Laws. California SB 1088 text from leginfo.legislature.ca.gov. Pennsylvania SB 730 history from palegis.us. Other bill statuses come from LegiScan (scan of Oct. 8, 2026, 137 unique bills scanned, 26 title-relevant).
What this doesn’t measure. No federal source counts how many people have an advance directive or POLST, by state. Hospice data covers Original Medicare only. Medicare Advantage enrollees, people under 65 without Medicare, and deaths without hospice aren’t described.
Related research: turning 65 in 2026, state by state counts the people reaching Medicare age this year and lists the documents to prepare.
Frequently asked questions
Which state uses hospice the most?
Among Original Medicare enrollees in 2024, Alabama (4.38%), Utah (4.19%) and Oklahoma (4.09%) had the highest hospice use. Alaska (1.30%) and New York (1.59%) had the lowest.
What’s the difference between a living will and a POLST?
A living will (advance directive) is your own written statement of wishes, usually made in advance. A POLST is a medical order signed with your clinician, typically when you’re seriously ill, that tells emergency and other providers what to do.
What did California’s SB 1088 change?
It renamed the POLST “Portable Orders Listing Scope of Treatment.” It also allowed nurse practitioners and physician assistants to sign, made electronic signatures valid, and made out-of-state POLST forms enforceable in California. Care can’t be conditioned on completing or refusing one.
Who qualifies for Medicare hospice?
People with Part A whose doctor certifies a life expectancy of six months or less and who choose comfort care instead of curative treatment for that illness.
Does this data include Medicare Advantage?
No. The Geographic Variation file covers Original Medicare enrollees only, about 45% of beneficiaries with both Part A and Part B in 2024.
Sources
All data is public-domain U.S. government data. Pulled Oct. 8, 2026.
- CMS, Medicare Geographic Variation – by National, State & County (2014–2024 PUF). data-api dataset 6219697b-8f6c-4164-bed4-cd9317c58ebc. https://data.cms.gov/summary-statistics-on-use-and-payments/medicare-geographic-comparisons/medicare-geographic-variation-by-national-state-county
- CMS Provider Data Catalog, Hospice – State Data, dataset eda0-92f0. https://data.cms.gov/provider-data/dataset/eda0-92f0 (
- CMS, Hospice Quality Reporting Program, current measures (HVLDL definition). https://www.cms.gov/medicare/quality/hospice/current-measures
- Medicare.gov, Hospice care coverage (eligibility). https://www.medicare.gov/coverage/hospice-care
- California SB 1088 (Chapter 677, Statutes of 2026; approved Sept. 27, 2026). https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=202520260SB1088
- Pennsylvania SB 730 (2025–2026), bill history. https://www.palegis.us/legislation/bills/2025/sb730
- LegiScan scan, Oct. 8, 2026 (advance_directive topic: 137 unique bills, 26 title-relevant, 13 jurisdictions), in OH HB835 and MA H2505 statuses from that scan.
Cite this data
Family Estate Guide, “End-of-Life Wishes by State: Hospice Use, Hospice Care and the Laws Changing in 2026,” October 2026. https://familyestateguide.com/estate-planning-data/end-of-life-wishes-by-state/
You’re welcome to reuse the table or map with a link back to this page. CMS data is public domain.
Published October 8, 2026 by Family Estate Guide. Data vintage: CMS Geographic Variation 2024; CMS Hospice State Data (latest release, pulled Oct. 8, 2026). Laws checked Oct. 8, 2026. Editorial standards.