It looks like Medicaid expansion will finally happen in Mississippi. On February 28, 2024, the Mississippi House of Representatives passed House Bill 1725, which would expand Mississippi’s Medicaid program; meanwhile, the Mississippi Senate has come out with its own plan, which has been referred to as “expansion light.” If the two chambers can reconcile the differences between these two proposals and get the governor’s signature (or override his veto), Mississippi will finally join the ranks of the vast majority of states that have expanded this critical program.

Currently, childless adults in Mississippi are ineligible for Medicaid at any amount of income—including $0 a year. Expanding Medicaid in the state would provide coverage for an estimated 123,000 adults in the state, including around 74,000 people who fall into the Medicaid “coverage gap.” Unfortunately the Mississippi House proposal is not perfect: the bill as passed includes a work reporting requirement, which has the potential to undermine people’s access to Medicaid coverage; the Senate plan also includes a similar requirement and would only expand Medicaid in the state to the poverty line.

Significant coverage gains like the ones Mississippi would see are possible in each of the ten states that have not yet expanded Medicaid, and these coverage gains can meaningfully promote health equity. This commentary begins by describing the Medicaid coverage gap and how it drives health inequities. It then highlights the negative impact of work reporting requirements on Medicaid enrollment and operations. It ends by discussing how expanding Medicaid in Mississippi and the other nine nonexpansion states would benefit these states and improve health equity.

The Medicaid Coverage Gap Drives Health Inequity

Under the Affordable Care Act (ACA), states can expand eligibility for their Medicaid programs up to 138 percent of the federal poverty limit (FPL): around $20,800 a year for an individual and around $35,600 a year for a family of three. Forty states and the District of Columbia have expanded their Medicaid programs in this way, shown in Map 1.

Map 1

Expanding Medicaid is a crucial step to achieving universal health coverage and closing the Medicaid coverage gap—a term that refers to people whose incomes are too low to qualify for subsidies to buy marketplace coverage, but too high for their state’s Medicaid program. This gap only exists because conservative efforts to undermine the ACA found success when the Supreme Court held in 2012 that states could not be required by the federal government to expand their Medicaid programs.

Nearly all of the Medicaid coverage gap population lives in the South: Texas, Florida, and Georgia alone make up 73 percent of the coverage gap population. As a result of this concentration in the South, people in the Medicaid coverage gap are disproportionately likely to be people of color—and even within these Southern states, people of color are disproportionately represented in the coverage gap. The Medicaid coverage gap also drives health inequities based on rural status. Rural communities are disproportionately likely to rely on Medicaid for health coverage, and more rural residents would likely be eligible for Medicaid under expansion due to the income divide between rural and urban communities. Figures 1 and 2 show these disparities.

Figure 1

Figure 2

One important aspect of the Medicaid coverage gap is its disparate, harmful impact on Black maternal health. In 2021, nearly 30 percent of reproductive-age women in the coverage gap were Black, and Medicaid pays for nearly two-thirds of all births to Black mothers. While federal law does require states to allow pregnant women with incomes up to 138 percent of the poverty line to enroll in Medicaid, this coverage is only available after they become pregnant, and it can take weeks before an application is processed. Denying Medicaid coverage until a person becomes pregnant worsens pregnancy outcomes and makes them more likely to be in worse health as they begin their pregnancies, and this burden disproportionately falls on Black birthing people.

Discussions of the Medicaid coverage gap must also acknowledge that many states are in the process of redetermining eligibility for their Medicaid programs for the first time in years. The pandemic-era ban on states removing individuals from their Medicaid programs expired in April 2023, and millions of people have been disenrolled as a result. By not expanding their Medicaid programs, nonexpansion states have ensured that more people will lose coverage, possibly without another affordable source of coverage ready.

Work Reporting Requirements Undermine the Goals of the Medicaid Program

One negative aspect of both of Mississippi’s Medicaid expansion proposals, however, is the inclusion of a work reporting requirement. Under the House bill, the expansion population would only be eligible for Medicaid if they can document working 20 hours per week, being enrolled full-time as a student, or being enrolled full-time in a workforce training program; the Senate plan significantly increases this amount, requiring recipients to report at least 120 of work hours per month. The reality, however, is that most Medicaid beneficiaries already work or would be eligible for an exemption.

A 2023 analysis of Census Bureau data by the Kaiser Family Foundation found that 61 percent of nonelderly adults enrolled in Medicaid work at least part time. Eleven percent were not working due illness or disability, and another 6 percent were not working due to school attendance; in all, nearly 80 percent of Medicaid beneficiaries are already achieving the goals of this work reporting requirement.

Figure 3

As a result, work reporting requirements largely constitute an attempt to create a barrier to enrolling in Medicaid. By requiring enrollees to report work to maintain eligibility, these policies predicate eligibility for Medicaid not just on working, but on regularly reporting that work, often through mechanisms that do not accommodate low-income households’ realities. For example, around one in four Medicaid enrollees lives in a home with no or limited Internet access, and enrollees of color are generally more likely to lack Internet access, making reporting difficult.

These policies have been shown to result in significant disenrollment. When Arkansas implemented a work reporting requirement in 2018, more than 18,000 people were removed from the program in the first year of its implementation. Research by the Kaiser Family Foundation found that much of this disenrollment was because people were unable or unaware of the need to report their compliance with the requirement, not because they were not working.

Expanding Medicaid Is A Good Deal For States

Every remaining state should expand their Medicaid programs. The federal government has taken many steps to ensure that states do not bear the full costs of expansion. First, the ACA as written, provides 90 percent of the costs of covering the expansion population, far more than the 50-60 percent range most states receive for their traditional Medicaid programs. States are only responsible for the remaining 10 percent, and in many states, hospitals advocate for creating a new tax on hospitals to pay for this remaining portion.

In addition to the already low percentage of new costs that states have to pay, the American Rescue Plan Act created an additional financial incentive for states to expand. Under the law, states that expand their Medicaid programs going forward receive a five-percentage-point boost to the percentage of traditional Medicaid costs that the federal government pays. Expansion spending tends to represent a very small percentage of overall Medicaid spending, and as a result, states would likely see a net increase in overall funding for their Medicaid programs, even after the required new spending for the expansion is taken into effect.

Mississippi would not receive these benefits under the state senate’s proposal, however: the Senate’s version of the bill would only expand Medicaid to those making below the poverty line. As a result, the state would only receive its standard federal contribution of 76.9 percent, rather than the full 90 percent, and it would not receive the additional federal funding for its traditional Medicaid costs.

Full Medicaid expansion would also help achieve true health equity. As discussed above, people in the coverage gap are disproportionately likely to be people of color and to be rural residents. Expanding Medicaid would eliminate a significant source of disparities in uninsured rates for these communities, bringing them closer to parity with their white and urban counterparts, respectively.

Expanding Medicaid would also help ensure that rural hospitals have a more sustainable revenue stream, preventing further hospital closures. Rural hospital closures since 2010 have been disproportionately concentrated in nonexpansion states and states that delayed expansion. Many of the rural hospitals that have closed are also those rural hospitals that are most likely to serve residents of color: for example, a 2021 analysis found that six of the nine hospitals that closed in Georgia since 2005 were in counties with more Black residents than the statewide average. Medicaid expansion is an opportunity to provide systemic relief to this intersectional barrier to care.

States Should Put Ideology Aside and Do What’s Right to Improve Health Outcomes

Expanding Medicaid increases access to health care, supports rural hospitals’ stability, and lowers spending by the state. Doing so addresses disparities in health coverage rates and provides a meaningful source of revenue for struggling rural hospitals. The remaining ten states that have not yet expanded their Medicaid programs should follow the lead of expansion states and expand their eligibility. It took seventeen years for every state to establish a Medicaid program—states should ensure it doesn’t take another seventeen years for every state to expand Medicaid.