Medicaid expansion in Mississippi
- No Medicaid expansion, but Mississippi is seeking federal approval for a work requirement
- CMS received 320 comments on the proposed Medicaid work requirement. 319 were in opposition
Mississippi has not expanded Medicaid under the Affordable Care Act (ACA), although the state medical association came out in support of expansion in August 2016, hoping to push lawmakers towards expanding coverage. Non-disabled adults without children are not eligible for Medicaid regardless of how low their income is, and parents with dependent children are only eligible with incomes that don’t exceed 27 percent of the poverty level. This is one of the lowest eligibility caps in the country — only four states have lower limits.
If Mississippi did expand Medicaid, FamiliesUSA estimates that 200,000 people would be newly eligible for coverage (some estimates put the number even higher, at 220,000). Unfortunately, in the poorest, sickest state in the US, the Governor and the Legislature have opted to reject federal funds that would provide health insurance for the state’s poorest residents.
Because subsidies are only available in the exchange for people whose household incomes are at least 100 percent of poverty, there are 99,000 people in Mississippi who are in the coverage gap and have no realistic access to health insurance (some analyses indicate that there are more like 130,000 people in the coverage gap in Mississippi). They aren’t eligible for Medicaid, and they also aren’t eligible for subsidies. According to the Kaiser Family Foundation, this is 30 percent of Mississippi’s total uninsured population — the highest percentage of any of the states where Medicaid has not yet been expanded.
Rhonda White is among them. Her job pays just $8.25/hour, and she can only get about 15 hours a week. She lives with her disabled husband and mother, along with her daughter and three grandchildren – all in a two-bedroom house in rural Mississippi. And while several of them have health conditions, they can’t access medical care because Mississippi hasn’t accepted federal funding to expand Medicaid.
Mississippi seeks federal approval to implement a Medicaid work requirement that’s expected to strip 5,000 very low-income parents of their Medicaid coverage each year.
Despite the fact that Mississippi hasn’t expanded Medicaid and has some of the most stringent eligibility guidelines in the country, the state is seeking federal approval to make it even harder for people to get Medicaid coverage in Mississippi.
In October 2017, Mississippi submitted a proposed 1115 waiver to CMS, detailing the work requirement that the state wants to implement. The waiver is still pending approval as of September 2018, but if approved, it would allow Mississippi to require some Medicaid enrollees to work, volunteer, attend school, participate in substance abuse treatment, or otherwise fulfill the work requirement for at least 20 hours per week.
People would be exempt if they are disabled, physically or mentally unable to work, a primary caregiver for someone in need of care, elderly, under the age of 19, pregnant, Native American, or included in various other exempt populations. Since Mississippi has not expanded Medicaid under the ACA, the vast majority of the state’s Medicaid enrollees would already be exempt from the work requirement. The work requirement would really only apply to certain low-income parents and people receiving transitional medical assistance (a program that extends Medicaid coverage for up to 12 months for people who start earning too much money to continue to qualify for Medicaid).
Mississippi Medicaid covers about 755,000 people, but only about 56,000 of them are in the low-income parent Medicaid eligibility category. And of those, most would have exemptions. About 15,000 to 20,000 people would end up having to work as a result of the work requirement, and many are already working.
Ultimately, about 5,000 people are expected to lose coverage in Mississippi each year if the work requirement is implemented. And according to the Clarion-Ledger, 91 percent of the people who would lose access to Medicaid under the proposed work requirement in Mississippi are low-income mothers. And more than two-thirds are African American.
These low-income parents are in a catch-22 situation: If they earn more than 27 percent of the poverty level (that works out to about $467/month for a household of three), they’ll no longer be eligible for Medicaid. And if they don’t work, they’ll also lose access to Medicaid as a result of the work requirement. So in order to have health insurance, they would either have to maintain a job that provides health insurance coverage, or earn at least 100 percent of the poverty level so that they could obtain premium subsidies in the exchange and purchase an affordable individual health plan. 100 percent of the poverty level is about $1,731/month for a household of three, so it’s a big jump from the Medicaid eligibility cutoff to the start of eligibility for premium subsidies.
To address these concerns, the state proposed an additional 12 months of transitional Medicaid coverage for people who remain in compliance with the work requirement for the full 24 months. Georgetown University’s Joan Alker describes this as a “wholly inadequate solution.” It’s temporary, doesn’t provide any sort of solution after the 24 months of transitional Medicaid coverage ends, and hinges on the unrealistic expectation that low-income, working parents will not experience even one month of unemployment during their 24 months of transitional Medicaid.
CMS had initially opened a comment period in January-February 2018 for Mississippi’s waiver proposal. But after the state revised the proposal to add an additional 12 months of transitional Medicaid coverage, the comment period was re-opened, through August 18. During the re-opened comment period, 320 comments were submitted, and 319 of them were in opposition to the state’s proposed Medicaid work requirement. The revised proposal is under review by CMS, and the state is requesting an implementation date of July 2019.
Who is eligible?
- Adults without dependent children are not eligible at all (this is generally the case in states that have not expanded Medicaid) unless they’re disabled.
- Adults with dependent children are only eligible if their household income doesn’t exceed 27 percent of poverty level. This is about $4,419 a year for a family of three, one of the most strict thresholds in the country.
- Infants under one are eligible for Medicaid if their household income is up to 199 percent of poverty.
- Children 1 – 5 are eligible if their household income is up to 148 percent of poverty.
- Children 6 – 18 are eligible if their household income is up to 138percent of poverty.
- Children with household incomes above the Medicaid thresholds are eligible for CHIP if their household incomes are up to 214 percent of poverty
- Pregnant women are eligible for Medicaid if their household income does not exceed 199 percent of poverty.
How do I enroll?
- You can enroll through HealthCare.gov, either online or by phone at 1-800-318-2596.
- You can fill out the PDF version of the Mississippi Medicaid Application Form and either click the application submit button, or save the completed PDF and email it to firstname.lastname@example.org
- You can also print out the PDF application, complete it by hand, and fax, mail, or deliver it in person. You can fax it to 601-576-4164. You can mail it to 550 High Street, Suite 1000, Jackson, MS 39201. Or you can take it to your nearest Mississippi Division of Medicaid regional office.
Enrollment grows by 8 percent
13,779 HealthCare.gov applicants in Mississippi enrolled in Medicaid or CHIP between October 2013 and April 2014. During the second open enrollment period (for 2015), 10,699 Mississippi residents enrolled in Medicaid or CHIP. All of these enrollees were already eligible for Medicaid under the existing guidelines, but had not enrolled prior to the opening of the ACA exchanges.
Medicaid enrollment is year-round though, and people can also apply directly through the Mississippi Division of Medicaid (enrollment tends to increase during the ACA’s general open enrollment period due to outreach and education activities on the part of enrollment assisters). As of July 2016, total Medicaid/CHIP enrollment in Mississippi was 8 percent higher than it had been prior to October 2013. Net enrollment increased by 49,990 people during that time period. But by the end of 2017, net enrollment in Mississippi Medicaid/CHIP was only 4 percent higher than it had been in 2013.
Prior to 2014, more than a fifth of Mississippi’s residents (22.4 percent) were uninsured. According to a Gallup poll, that number had only fallen to 20.6 percent by mid-2014, but was down to 14.2 percent by mid-2015. However, by the end of 2015, the Gallup data indicated that Mississippi’s uninsured rate had crept up slightly, to 14.7 percent. US Census data puts the state at a lower overall uninsured rate in both 2013 and 2014. The census found that the uninsured rate in 2013 was 17.1 percent, and that it had fallen to 11.8 percent by 2016. But even with the lower uninsured rate in the census data, only eight states had a higher uninsured rate than Mississippi in 2016.
Given that 30 percent of Mississippi’s remaining uninsured population is in the coverage gap, there is no doubt that Medicaid expansion would significantly reduce the uninsured rate in the state. Instead, Mississippi officials are seeking federal permission to implement a Medicaid work requirement that’s expected to reduce Medicaid enrollment by about 5,000 people per year.
Missing out on billions in federal funding
As the ACA was written, it called for Medicaid expansion in every state for residents with incomes up to 133 percent of poverty (plus a 5 percent income disregard, bringing the effective eligibility threshold to 138 percent of the poverty level). But in 2012, the Supreme Court ruled that states could not be penalized for opting out of expansion, and Mississippi is one of 19 states that has not yet moved forward with Medicaid expansion.
In states that expand Medicaid, the federal government pays the full cost of expansion through 2016. After that, the state gradually starts to pay a share of the expansion cost, but the federal government will always pay at least 90 percent. As a result, states that reject Medicaid expansion are leaving billions of dollars on the table.
From 2013 through 2022, if Mississippi continues to reject Medicaid expansion, the state will give up $14.5 billion in federal funding that would otherwise have been available to the state to help provide medical care for low income residents.
And since residents in states not expanding Medicaid still have to pay federal taxes, Mississippi residents will end up subsidizing Medicaid expansion in other states. Over a decade, people in Mississippi will pay $1.7 billion in federal taxes that will be used to pay for Medicaid expansion in other states.
Hospitals in Mississippi that treat uninsured patients will be especially hard-hit, as their federal Disproportionate Share Hospital funding will start to dry up over the next few years (it was supposed to be replaced by Medicaid funding) but unless the state accepts federal funding to expand Medicaid, those hospitals will still be treating significant numbers of uninsured patients.
Will Mississippi expand coverage?
Governor Phil Byrant, a Republican, is opposed to Medicaid expansion because he claims that the state wouldn’t be able to bear the cost if the federal government were ever unable to uphold its promise to pay at least 90 percent of the cost. He’s referred to accepting Medicaid expansion as a “fool’s errand.”
But contrary to the position Mississippi politicians have taken, states that have expanded Medicaid have seen substantially smaller growth in state Medicaid spending than states that haven’t expanded Medicaid.
Mississippi’s share of traditional Medicaid costs climbed from $763 million in fiscal year 2012 to $949 million in fiscal year 2017. Lawmakers have highlighted this as a reason for not expanding coverage, but they’re missing the point (whether purposely or not) that Medicaid expansion is funded under different rules from traditional Medicaid. Under Medicaid expansion, the cost to cover newly eligible residents was fully funded by the federal government through the end of 2016. In 2018, states are paying 6 percent of the cost, and will eventually pay 10 percent by 2020, but it will stay at that level going forward.
In June 2013, Republicans in both chambers of the Mississippi legislature voted against Medicaid expansion. They did vote to continue the state’s existing Medicaid program, which came within days of expiring and had to be dealt with in a special legislative session called by Bryant. The issue of Medicaid expansion might not have even made it to a vote except that Democrats threatened to withhold their votes for renewing the existing Medicaid program unless Republicans would agree to take the issue of Medicaid expansion to a vote. No Republicans voted for Medicaid expansion, although one, Senator Billy Hudson of Hattiesburg, said that he would eventually vote for Medicaid expansion, “but not today.”
The Mississippi State Medical Association put forth a resolution in August 2016 calling for “expanded coverage” but didn’t use the words “Medicaid expansion” in their draft, knowing that the issue is too politically charged.
It’s possible that Mississippi might eventually pursue a modified version of expansion, most likely relying on a waiver proposal similar to those used in a handful of other Conservative states. But for now, although the state has gone through the process of drafting a work requirement waiver proposal, it does not include any sort of proposed expansion of coverage. In the nation’s poorest state, the poorest residents have no access to health coverage at all.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.