Background

The Affordable Care Act (ACA), passed in 2010, allows states to expand Medicaid eligibility to non-Medicare-eligible individuals under age 65 with income up to 138% of the federal poverty level (FPL). Though expansion was originally intended, under the ACA, to be mandatory for all states, in 2012, the US Supreme Court ruled that the policy is a state option. Since 2014, 40 states and the District of Columbia have expanded Medicaid. The 2021 American Rescue Plan Act incentivized expansion by offering states that had not yet expanded a two-year, five-percentage-point increase to their Federal Medical Assistance Percentage for their base (i.e., non-expansion) Medicaid population. This means that, in Mississippi for example, the federal government would pay 81.9% of the Medicaid costs for two years for the approximately 643,000 current enrollees in the state, instead of the 76.9% that is currently paid.

In the 10 states that have not expanded Medicaid to date, expansion is possible either through state ballot initiatives or legislation. In Mississippi, expansion must be approved by the state legislature. The Mississippi House passed legislation in February that would allow the state to expand Medicaid with a work requirement. To include a requirement that individuals who enroll meet and report work requirements, or meet and report eligibility for an exemption, the state would need approval from the Center for Medicare and Medicaid Services for a Section 1115 waiver.

Designed as a way for states to test changes to their Medicaid program, 1115 waivers have, under recent administrations, reflected that administration’s policy priorities. The Biden administration has historically rejected waivers that include work requirements; the Mississippi House legislation stated that if CMS rejected the state’s work requirements waiver request, the state would submit a state plan amendment allowing for expansion without the work requirement. In March, the state Senate passed an amended version of the House bill that would expand Medicaid to only 100% FPL and would require an approved work requirement waiver. The Mississippi House and Senate ultimately did not come to a compromise, and the legislation did not make it out of conference committee. Lawmakers may bring the bill back up in 2025.

Estimated Impact of Medicaid Expansion

Avalere conducted an analysis to estimate the number of uninsured individuals who could be potentially eligible for Medicaid if Mississippi expanded Medicaid eligibility in 2025 up to 138% FPL. The analysis divided the potential eligible population by age group (19–64 and 50–64), as well as by county and state legislative district. The interactive map below includes details for each of these subgroups. Based on the data analyzed, Avalere estimates that a total of around 125,000 uninsured individuals in Mississippi could be eligible for Medicaid through expansion in 2025, or slightly above 7% of the total 19–64 population in the state. Just over 28,000 of the 125,000 are between the ages of 50 and 64, or around 5% of the total 50–64 population in the state.

Of the uninsured, potentially eligible population that is between the ages of 50 and 64, 58% (16,300 individuals) reside in rural counties. This statistic is also reflective of the entire uninsured 19–64 population. Rural areas tend to be lower income, have lower access to care, and skew older in their populations compared to urban areas. Urban counties account for 42% of the uninsured 50–64 population (11,800 individuals) that could gain coverage under expansion, and over half reside in five counties: Hinds, Harrison, Jackson, DeSoto, and Rankin. These are also the most populous counties for the entire 19–64 potentially eligible population.

Methodology

To estimate the uninsured individuals who could gain Medicaid coverage in Mississippi under expansion of up to 138% FPL, Avalere used 2022 American Community Survey data on health insurance coverage by current insurance status (uninsured, employer-sponsored insurance, and direct purchase), income (0–138% FPL), age (19–64), and county and legislative districts. To designate rural-urban classifications, we used US Department of Agriculture data. We then focused on the uninsured number and derived 2025 estimates from 2022 data applying a net growth factor of approximately 10% to the 2022 identified population. To calculate the growth factor, we analyzed Medicaid growth in Mississippi prior to the COVID-19 maintenance of effort requirements as well as the enrollment impacts of the redetermination efforts in the state that have been ongoing since March 2023.

Funding for this research was provided by the AARP Public Policy Institute. Avalere retained full editorial control.