Series 14: State Implementation of Work Requirements
A 29-year-old woman in Lowndes County works two part-time jobs, one at a fast-food restaurant and one cleaning offices at night. She earns approximately $11,000 annually. She has diabetes that remains untreated because she cannot afford insulin or doctor visits. She has no dependent children. She earns too much for Mississippi Medicaid, which caps parent eligibility at 24% of the federal poverty level and categorically excludes childless adults. She earns too little for marketplace premium subsidies, which begin at 100% of poverty. She represents one of approximately 70,000 Mississippians in the coverage gap: the deepest poverty in the nation, yet excluded from coverage because the state chose not to expand Medicaid.
H.R. 1, signed July 4, 2025, transformed Medicaid work requirements from a state-option policy experiment into a federal mandate affecting approximately 18.5 million expansion adults nationwide. The law requires 80 hours monthly of work, education, training, or qualifying community engagement activities, with semi-annual redetermination cycles for adults aged 19-64 who gained Medicaid eligibility under the ACA’s optional expansion. States that expanded Medicaid face a January 1, 2027 implementation deadline, though good-faith extensions are available through December 31, 2028 for states demonstrating genuine progress toward compliance infrastructure.
Mississippi is not subject to these federal work requirements because Mississippi never expanded Medicaid under the ACA. By declining expansion since 2014, the state ensured that no residents gained coverage through the expansion pathway that now carries work requirement conditions. The federal mandate applies exclusively to expansion adults, a population that does not exist in non-expansion states. This creates a profound paradox: Mississippi’s Republican leadership has long demanded work requirements as a precondition for expansion, characterizing Medicaid without work conditions as welfare expansion. The federal government now mandates work requirements for expansion populations. Yet Mississippi still has not expanded, even with the conditions leadership previously demanded now federally required.
Mississippi operates the nation’s deepest poverty combined with the most restrictive Medicaid access. The state has the highest poverty rate nationally, the highest uninsured rate, the lowest life expectancy, and the worst health outcomes across multiple metrics. Approximately 70,000 adults fall in the coverage gap with incomes below 100% FPL, unable to access either Medicaid or marketplace subsidies. Full expansion would cover an estimated 123,000 to 125,000 uninsured adults. The 2024 legislative session produced the closest Mississippi has come to expansion, with a House bill passing 98-20, a veto-proof supermajority. The bill died in Senate conference committee when chambers could not reconcile differences over work requirement implementation details. The 2025 legislative session saw multiple expansion bills filed but all died in committee by early February, signaling continued political deadlock.
Traditional Medicaid Eligibility: Among the Nation’s Most Restrictive#
Mississippi Medicaid serves approximately 667,000 children and adults, predominantly children (52%), pregnant women, elderly, and disabled populations. The program’s eligibility structure for working-age adults creates coverage gaps nearly as severe as Texas, though slightly less extreme.
Parents with dependent children qualify only with household incomes up to 24% FPL, approximately $488 monthly for a family of three. This is one of the lowest thresholds in the country, exceeded in restrictiveness only by Texas and Alabama. A parent working even part-time at minimum wage ($7.25 per hour) rapidly exceeds this threshold. The practical effect is that most working parents are categorically excluded from Medicaid regardless of poverty level.
Children qualify with more generous thresholds: infants under one year up to 199% FPL, children ages one through five up to 148% FPL, and children six through eighteen up to 138% FPL. The Children’s Health Insurance Program covers additional children with household incomes up to 214% FPL. Pregnant women qualify up to 194% FPL during pregnancy, though post-partum coverage drops to 60 days, creating cliff effects for new mothers.
Adults without dependent children face complete categorical exclusion. A childless adult earning $0 per year cannot qualify for Mississippi Medicaid. Disability or age (65+) provides the only coverage pathway for this population. This policy choice creates the fundamental coverage gap: Mississippi Medicaid serves populations defined by categorical vulnerability (children, pregnancy, disability, age) rather than income-based need for able-bodied working-age adults.
The Coverage Gap: 70,000 in Deepest Poverty Without Coverage#
The ACA’s designers assumed all states would expand Medicaid, creating premium tax credits beginning at 100% FPL for marketplace coverage. This design created a coverage gap in non-expansion states where adults earn too much for traditional Medicaid but too little for subsidized marketplace plans. Mississippi operates this gap in the context of the nation’s deepest poverty.
The 70,000 adults in Mississippi’s coverage gap earn below 100% FPL, yet cannot access Medicaid due to the state’s restrictive eligibility criteria. These individuals would be immediately subject to federal work requirements if Mississippi expanded Medicaid. They are predominantly working-age adults (19-64) without dependent children, exactly the population H.R. 1 targets. Approximately 60% of coverage gap adults are already working. The median income approximates 56% FPL. They work in restaurants, retail, agriculture (Delta cotton and soybean operations, Gulf Coast seafood processing, poultry plants in northern Mississippi), and caregiving, industries that rarely offer employer-sponsored insurance.
The coverage gap population is disproportionately Black. Mississippi’s overall racial composition is approximately 60% Black, 35% white, 5% other, but Black Mississippians are overrepresented in the coverage gap due to concentrated poverty in the Delta region and lower rates of employer-sponsored coverage. The Mississippi Delta, 18 counties along or near the Mississippi River, has average poverty rates of 33% with some counties exceeding 48%. Black Americans comprise the majority in most Delta counties and face compounding barriers to healthcare access including poverty, rurality, transportation challenges, and healthcare workforce shortages.
The 2024 Legislative Near-Miss and 2025 Failure#
The 2024 Mississippi legislative session marked the closest the state has come to Medicaid expansion since the ACA’s passage. House Speaker Jason White, a Republican, signaled in fall 2023 that the legislature would finally address expansion directly. His statement acknowledged that Republicans had “probably earned a little bit of the bad rap we get on health care in Mississippi. Part of that is that we haven’t had a full-blown airing or discussion of Medicaid expansion. We’ve just said, ‘No.’”
House Bill 1725 passed the Mississippi House in February 2024 by a vote of 98-20, a veto-proof supermajority. The bill directed the Division of Medicaid to seek a federal waiver to implement expansion with a 20-hour-per-week work requirement. Critically, the House bill included a fallback provision: if CMS rejected the work requirement waiver, expansion would proceed without the work requirement from January 2025 through early 2029, with a sunset clause requiring reauthorization. This fallback reflected the political reality under the Biden administration that work requirement waivers would not be approved.
The Senate amended the bill substantially. Rather than accepting the House’s 138% FPL threshold with optional work requirements, the Senate version would expand coverage only to 100% FPL and would make expansion entirely contingent on federal approval of the work requirement. The Senate version would not have qualified for the enhanced federal matching rate available to expansion states, fundamentally undermining the fiscal case for expansion.
The House and Senate could not reconcile their differences in conference committee. The bill died without becoming law. Lieutenant Governor Delbert Hosemann, who oversees the Senate, expressed disappointment but maintained that he would not support expansion without a work requirement. Senator Kevin Blackwell, chair of the Senate Medicaid Committee, took the same position. Governor Tate Reeves remained opposed, characterizing expansion as “Obamacare” and “welfare” on social media.
The 2025 legislative session saw several Medicaid expansion bills filed in January, but all died in committee by early February. Additional legislation that would have directed the state to study the feasibility and impacts of expansion and work requirements also failed to advance. The political environment heading into future sessions shows no indication of change. If anything, the passage of H.R. 1 with mandatory work requirements may have complicated rather than simplified expansion politics.
The H.R. 1 Complication and Elimination of Financial Incentives#
The passage of H.R. 1 in July 2025 fundamentally changed the expansion calculation for Mississippi. The federal law now mandates work requirements for all Medicaid expansion adults beginning December 2026. Had Mississippi expanded in 2024, even with the House’s fallback provision that would have implemented expansion without work requirements initially, the state would now face mandatory federal requirements regardless. Senate Republicans’ insistence on making expansion contingent on work requirement approval proved prescient in one sense: work requirements are now federally mandated. Yet this has not produced expansion movement.
More significantly, H.R. 1 eliminated the enhanced federal incentive that the American Rescue Plan had offered to encourage expansion in holdout states. That provision would have increased the federal matching rate for Mississippi’s existing Medicaid population by five percentage points for two years if the state expanded. For Mississippi, with an FMAP around 74%, this would have meant hundreds of millions in additional federal funding during the two-year period. That opportunity is gone, lapsed before Mississippi could act.
The irony is substantial and worth stating explicitly: Mississippi’s Republican leadership demanded work requirements as a condition of expansion. The federal government has now mandated work requirements. The financial incentive to expand has diminished. The state still has not expanded. The work requirement debate that consumed the 2024 legislative session over whether to require work requirements, and what happens if CMS rejects them, is now moot. Work requirements are federally mandated for any future expansion. Yet political resistance to expansion persists.
Rural Hospital Crisis and Healthcare Infrastructure Collapse#
Mississippi faces among the most severe rural healthcare crises in the nation. The state’s refusal to expand Medicaid compounds financial pressures on hospitals already operating on minimal margins. According to the Center for Healthcare Quality and Payment Reform, 37 of Mississippi’s rural hospitals (55% of the total) are at risk of closure due to financial problems. Of these, 23 face immediate risk of closing within two to three years.
Since 2005, at least 14 rural hospitals have closed in Mississippi. Seven of these closures occurred in or near the Delta, the region with the highest poverty and uninsured rates. The Delta has the lowest life expectancy in the United States, the highest overall mortality rates, and the highest mortality rates associated with cancer, heart disease, and stroke. Only 25% of rural Mississippi hospitals currently offer labor and delivery services, forcing pregnant women to travel long distances for childbirth, creating maternal health risks that contribute to Mississippi having the highest maternal mortality rate nationally.
The Mississippi Hospital Association has consistently supported expansion, with CEO Richard Roberson noting that hospitals continue seeing patients who lack any form of insurance, creating uncompensated care burdens of several hundred million dollars annually. Governor Reeves passed enhanced Medicaid hospital payments in the eleventh hour of his heated 2023 reelection campaign, temporarily stabilizing some rural hospitals. These enhanced payments, established through the Mississippi Hospital Access Program (MHAP) in 2015 and dramatically increased in July 2023, raised Medicaid reimbursements to hospitals to approximately 80% of average commercial rates for both inpatient and outpatient care. State funding for MHAP increased from $533 million annually during fiscal years 2016-2022 to over $1.5 billion annually for fiscal years 2024-2026.
These enhanced payments provide temporary relief but do not address the fundamental coverage gap issue. Hospitals still provide uncompensated care to coverage gap residents who cannot pay. The enhanced Medicaid payments help hospitals financially but do not reduce the number of uninsured patients presenting for care. Without expansion, continued rural hospital closures remain “very possible” according to hospital leadership.
What H.R. 1 Means for Mississippi#
Although work requirements do not apply to Mississippi’s current Medicaid population, other H.R. 1 provisions impact the state’s healthcare infrastructure. Disproportionate Share Hospital (DSH) payment reductions, accelerated under H.R. 1, particularly affect Mississippi’s safety-net hospitals. With reductions now in effect as of October 2025, hospitals face intensified financial pressure.
The $50 billion Rural Health Transformation Fund established under H.R. 1 provides alternative federal funding. Mississippi must compete with other states for these limited funds, and the funding sunsets after five years while structural challenges persist. The fund may provide temporary relief but does not address the fundamental coverage gap.
H.R. 1 reduces retroactive Medicaid coverage from 90 days to 60 days beginning January 2027, affecting all Medicaid beneficiaries including Mississippi’s existing population. The requirement for semi-annual eligibility redetermination beginning December 2026 will affect Mississippi’s existing Medicaid population. Children, pregnant women, elderly, and disabled populations will face more frequent verification requirements, creating procedural disenrollment risks.
Managed Care Landscape and Implementation Capacity#
Mississippi operates MississippiCAN, a coordinated care program serving approximately 70% of Medicaid enrollees through three Coordinated Care Organizations (CCOs): Magnolia Health (Centene subsidiary, largest by enrollment), Molina Healthcare, and TrueCare (newest CCO, began operations July 1, 2025). UnitedHealthcare Community Plan exited the MississippiCAN and CHIP programs as of June 30, 2025.
This managed care infrastructure provides a foundation that could support expansion implementation if Mississippi ultimately expands, but the infrastructure currently serves only traditional Medicaid populations. If Mississippi expanded with work requirements, CCOs would need to build verification systems, exemption processing, and compliance monitoring capabilities essentially from scratch. The state has no institutional knowledge of work requirement implementation beyond what can be learned from other states’ experiences.
Mississippi faces unique implementation challenges that would complicate any future expansion. With 58% of Medicaid enrollees in rural areas, the highest concentration nationally, rural verification would be exceptionally difficult. Digital verification would require addressing the digital divide that leaves many rural Mississippians without reliable internet access. In-person verification approaches would be impractical given transportation barriers in the Delta, where residents face the longest travel times to specialty care.
Community organizations capable of providing navigation and enrollment assistance are sparse in Mississippi, particularly in the Delta. Building navigation capacity would require substantial investment. The hospital system cannot absorb additional coverage losses. Any work requirement design that produces significant coverage losses through procedural failures would accelerate an already critical rural hospital closure crisis.
Tribal Healthcare and the Mississippi Band of Choctaw Indians#
The Mississippi Band of Choctaw Indians operates the Choctaw Health Center, a tribally controlled healthcare facility serving approximately 11,000 tribal members across eight central Mississippi counties in the state’s central region. The 180,000 square-foot facility provides comprehensive services including primary care, pharmacy, prenatal care, dentistry, and behavioral health.
Medicaid is an important funding source for the Choctaw Health Center, particularly for services requiring referral outside the tribal system. The Indian Health Care Improvement Act provides states a 100% Federal Medical Assistance Percentage for Medicaid services provided through Indian Health Service and tribal health facilities. The Division of Medicaid maintains regular consultation with the tribe regarding State Plan Amendments and policy changes.
Because federal work requirements apply only to expansion populations, tribal members currently enrolled in Mississippi Medicaid would not be affected by H.R. 1’s community engagement requirements. However, if Mississippi ever expanded, tribal members gaining coverage through expansion would face the same requirements as other expansion adults, though tribal-specific exemptions in the federal law provide protections for enrolled tribal members.
Looking Forward: Continued Non-Expansion With Unchanged Politics#
Mississippi will most likely remain a non-expansion state through December 2026 and beyond, meaning federal work requirements will not directly affect its Medicaid program. The 2024 legislative near-miss created momentum that dissipated in 2025 when expansion bills died in committee without serious debate. The political environment shows no indication that 2026 or subsequent sessions will produce different results.
If Mississippi were to expand in the future, the state would immediately become subject to mandatory work requirements for expansion adults. The H.R. 1 framework specifies that expansion adults must demonstrate 80 hours monthly of community engagement. Mississippi would need to build verification and exemption infrastructure from scratch. Several observations apply to a hypothetical future expansion.
Mississippi’s coverage gap population already works. An estimated 60% of coverage gap residents are employed but lack employer-sponsored coverage. Work requirements would verify what is largely true: this population is working. The compliance burden would fall on people already demonstrating the behavior requirements seek to incentivize. Administrative infrastructure does not exist. Unlike states with prior work requirement experience or existing systems for similar verification, Mississippi would need to build systems entirely new.
The timeline pressure would be significant. Rural verification would be exceptionally difficult. With 58% of Medicaid enrollees in rural areas and severe transportation barriers in the Delta, in-person verification approaches would be impractical. The hospital system cannot absorb additional coverage losses. Community organizations are sparse in Mississippi, particularly in the Delta.
For now, Mississippi remains outside the work requirements framework entirely. The state’s 70,000 coverage gap residents have no pathway to coverage, with or without work requirements. The work requirement debate that nearly produced expansion in 2024 proved unable to overcome fundamental political resistance. The federal mandate of work requirements has not changed this calculus. The deepest poverty in America continues without the safety net that work requirements were designed to condition.