AARP

MAY 2023
updated July 2023

PUBLIC POLICY INSTITUTE

Fact Sheet

Medicaid in Midlife: A Profile of
Enrollees Ages 50 to 64

James McSpadden and Sari Siegel
AARP Public Policy Institute

Key Takeaways

v Adults ages 50 to 64 ("midlife adults") make up 12 percent of the Medicaid population.

¥ Midlife adult Medicaid enrollees are racially and ethnically diverse, although this age group is more

homogeneous than the total Medicaid population.

¥ States that expanded Medicaid as part of the Affordable Care Act enrolled an average of 22 percent of the
midlife adult population in Medicaid, whereas states that did not expand Medicaid enrolled an average of only

10 percent.

Y Nearly three-quarters of midlife adult Medicaid enrollees live in urban areas, although variation exists in

expansion and nonexpansion states.

¥ Midlife adults who are dually enrolled in Medicaid and Medicare, most often due to a disability or chronic
disease, make up nearly half of midlife Medicaid enrollees in nonexpansion states. As a result, midlife
Medicaid enrollees in nonexpansion states may be sicker and require more care than midlife enrollees in

expansion states.

The Medicaid program provides health
insurance coverage for millions of low-income
Americans. The program is funded jointly

by states and the federal government; states
manage all aspects of the program-within
federal parameters-for their eligible residents.
In 2019, more than 11 million adults ages 50 to
64 (hereafter referred to as "midlife adults")
depended on Medicaid coverage for health
care. This represents 18 percent of the total
population ages 50 to 64.' Despite the sizeable
number of midlife Medicaid enrollees, research
to date on this population has been sparse."

AARP contracted with the independent
research organization NORC at the University
of Chicago to help fill this gap in knowledge
and to shine a light on midlife Medicaid
enrollees in all 50 states and the District of
Columbia. NORC examined data from both
state-reported data from the Centers for

Medicare & Medicaid Services' Transformed
Medicaid Statistical Information System
(T-MSIS) and the Census Bureau's American
Community Survey (ACS) and uncovered a
unique profile of older Medicaid enrollees
across the states.*

This Fact Sheet establishes a profile of midlife
Medicaid enrollees. It explores how Medicaid
eligibility rules impact midlife adults, noting
enrollment trends and calling specific
attention to the differences between states that
have and have not expanded Medicaid to cover
previously ineligible adults-an option created
by the federal Affordable Care Act (ACA).°5
Additionally, it highlights how midlife Medicaid
enrollees differ in important ways from the
broader Medicaid-enrolled population as well
as from those midlife Americans who are not
enrolled in the program.
Medicaid eligibility for older Americans

Whether an adult 50 to 64 years of age is
eligible for Medicaid depends on where

they live. Typically, adults must fall into an
eligibility group-either one of the federally
required covered groups (¢.g., individuals with
a disability) or a group that the state optionally
elects to cover-have incomes below a certain
threshold €.g., 133 percent of the federal
poverty level) and possess limited assets. In
2019, states enrolled half of midlife Medicaid
enrollees as individuals with disabilities, over
one-third as newly (due to expansion) eligible
adults, and the remainder as other eligible
adults. Comparatively, among all Medicaid
enrollees in the same year, individuals with
disabilities and newly (due to expansion)
eligible adults made up a much smaller share
of enrollees (table 1). These enrollment data
show that more than half of individuals with
disabilities within the Medicaid population are
midlife adults.

States that chose to expand Medicaid raised
the income cap to 138 percent of the federal
poverty level, thus making coverage available
to significant numbers of low-income adults,
most of whom were previously ineligible. As of
2019, 33 states and the District of Columbia had
expanded Medicaid; 17 states had not.' Of the
12.3 million adults (ages 18+) whom expansion
states enrolled into Medicaid between 2013 and
2020, 81 percent were newly eligible.* Because

TABLE 1
Medicaid Enrollee by Eligibility Category, 2019

    
   

Medicaid Enrollees Ages 50-64

MAY 2023
updated July 2023

 

Example of State Variation in
Medicaid Eligibility

A 55-year-old woman earning 130 percent of

the federal poverty level with assets totaling
less than $2,000 could qualify for Medicaid in
New Jersey but not in Wyoming.

 

older nondisabled adults in nonexpansion
states are still subject to pre-ACA Medicaid
eligibility requirements, state of residence is a
pivotal Medicaid enrollment differentiator for
midlife adults.

Medicaid enrollment trends among
adults ages 50 to 64: expansion versus
nonexpansion states

To fully appreciate the profile of midlife
Medicaid adults, it is helpful to think about this
population relative to two groups: all midlife
adults ages 50 to 64 and other Medicaid
enrollees. And because states' determinations
of Medicaid eligibility impact midlife adult
eligibility, we further stratified our analysis by
state Medicaid expansion status.°

Midlife adults among all Medicaid enrollees

As summarized in table 2, 12 percent of all
Medicaid enrollees nationally were midlife

      

  

All Medicaid and CHIP Enrollees

 

 

     

 

    
     
    

Description % Number of People % Number of People
Individuals with Disabilities 42% 4,672,000 11% 10,041,000
Medicaid Expansion Adults 45% 5,000,000 21% 19,959,000
Other Eligible Adults 12% 1,344,000 16% 15,145,000
Children and Seniors 0% 27,000 48,769,000

   
 

    
 

Total Enrolled Population

11,043,000

   
 

   
 

93,914,000

Source: AARP and NORC at the University of Chicago analysis of T-MSIS enrollment data. Enrollment numbers are rounded to the

nearest 1,000 and, as such, percentages may not equal 100.
MAY 2023
updated July 2023

TABLE 2
Comparative Enrollment of Midlife Adults in Medicaid

   
 
  

  
 

Percent of Midlife Medicaid Enrollees
Among all Medicaid Enrollees Among all Midlife Adults

 

 
  

Nationally 12% 18%
Expansion states 14% 22%
Nonexpansion states 9% 10%

 

Source: AARP and NORC at the University of Chicago analysis of T-MSIS enrollment data.

adults.!° Unsurprisingly, expansion states,
which have adopted broader eligibility
criteria, have a greater proportion of Medicaid
enrollees who are midlife adults (14 percent) AK, AR, AZ, CA, CO, CT, DC, DE, HI, IA, IL, IN, KY,

than nonexpansion states (9 percent). LA. MA. MD. MA. MI. MN. MT. ND. NH. NJ. NM

The percentage of Medicaid enrollees who NY. OH, OR. PA. RI. VA, VT. WA, WV
were midlife adults varies by state, ranging 0
from 6 percent (Texas) to 17 percent (Rhode ; ;
Island and District of Columbia) (figure 1). SC

The 30 states with the highest enrollment AL. FL. GA. ID. KS. MO. MS. NC. NE. OK. SC. SD
percentages were all expansion states. CS
Conversely, midlife adults made up less US, Hess I, th Ca
than 10 percent of Medicaid enrollees in

Expansion States in 2019

 

FIGURE 1

Midlife Adults as a Proportion of Medicaid Enrollees, 2019
VT
15%

| =... :
CS wae

14%
1X 2019
6% r 17%

6%

   
    
     
  
 

Source: AARP and NORC at the University of Chicago analysis of T-MSIS enrollment data.
MAY 2023
updated July 2023

nonexpansion states. Regionally, we see a
smaller proportion of midlife adults enrolled

in Medicaid in the Southeast and Plains states
compared with the Northeast and West Coast,
which mirrors Medicaid enrollment differences
between states that expanded Medicaid and
those that did not.

Midlife Medicaid enrollees among all
midlife adults

In 2019, 18 percent of all midlife adults had
Medicaid coverage (table 2). However, the
distribution of these individuals is uneven
across the US. Our analysis indicates that, in
expansion states, an average of 22 percent
of midlife adults were Medicaid enrollees,
whereas only 10 percent of this age group
living in nonexpansion states were enrollees.

More granularly, the percentage of midlife
adults enrolled in Medicaid in 2019 varied
widely by state-from 5 percent (Wyoming) to
46 percent (District of Columbia) (figure 2).
Seven of these states and the District of
Columbia enrolled more than one-quarter of

FIGURE 2

all midlife adult residents in Medicaid. Among
nonexpansion states, more than half (nine)
enrolled less than 10 percent of midlife adult
residents.

Demographic characteristics of midlife
Medicaid enrollees

Race and ethnicity

Notably, state reporting of race and ethnic
data for Medicaid enrollees is incomplete,
missing, or of poor quality for over one-fifth
of midlife adult Medicaid enrollees. While
additional investigation is needed to further
validate the findings of this analysis, existing
data show that, nationally, midlife adult
Medicaid enrollees are slightly less diverse
than the overall Medicaid population and
slightly more diverse than the overall 50-
to-64 population. According to our analysis
of state-reported aggregated T-MSIS data,
midlife white adults make up the largest
segment of enrollees (44 percent), followed by
Black adults (17 percent) and Hispanic adults
(15 percent)." That is only slightly different

Proportion of Residents Ages 50-64 Enrolled in Medicaid, 2019

   
      
 

NH 10%
aa
x RI21%
CT 21%
NJ 15%

DE 20%
MD 17%
DC 46%

Source: AARP and NORC at the University of Chicago analysis of T-MSIS enrollment and ACS data.
MAY 2023
updated July 2023

TABLE 3

Demographics of Midlife Medicaid Enrollees Compared to Other Groups, as Percentages

 

ret) Midlife
Medicaid Medicaid
Tel ry Enrollees Enrollees
Vere Medicaid All Medicaid (Expansion (Nonexpansion
pve te Enrollees il ce) (1-53 states) states)
White 68 44 36 45 40
Black 12 18 18 16 24
Hispanic 13 14 21 15 9
Race and .
Ethnicity Asian 5 5 4 6 1
American Indian 1 1 1 1 1
Other** 1 1 1 2 <1
Unknown 17 19 15 25
Female 51 5S 55 53 55
Gender
Male 49 47 45 47 45
Age 57 57 57
Urban 85 84 85 86 75
Geography
Rural 15 16 15 14 25
Disability/Dual Enrollment* 27 27 14 22 49

 

* Disability/dual enrollment" for most columns refers to dual enrollment in Medicare and Medicaid, which requires a qualifying
disability except for the "all midlife adults" column, which refers to the percentage of adults ages 45-64 with any disability.

** "Other" is multiracial and Pacific Islander individuals.

Source: AARP and NORC at the University of Chicago analysis of T-MSIS enrollment and ACS data.

from the overall Medicaid population where
white adults make up just over one-third of
enrollees, and Hispanic adults make up the
next largest segment of enrollees (21 percent),
followed by Black adults (18 percent). Among
the entire midlife adult population, white
adults constitute a larger segment (68 percent),
followed by smaller segments of Hispanic,
Black, and Asian adults.

The racial and ethnic profile of midlife
Medicaid enrollees looks similar in

expansion and nonexpansion states. White
individuals made up the majority of midlife
enrollees (54 percent in both expansion and
nonexpansion states), followed by Black adults
(15 percent in expansion states vs. 20 percent
in nonexpansion states), and Hispanic adults
(8 percent in expansion states vs. 6 percent in

nonexpansion states). The higher enrollment
rates for Black adults are likely due in part
to a larger population of Black adults in
nonexpansion states.

Gender and age

The midlife Medicaid population splits
somewhat evenly along gender lines. Slightly
more midlife women (53 percent) than men
(47 percent) are enrolled in Medicaid. Data
show that this gender split was consistent
across expansion and nonexpansion states.
Furthermore, the split in the midlife Medicaid
population largely mirrors the overall midlife
population-51 percent women and 49 percent
men.

The average age of midlife Medicaid enrollees
in 2019 was 58.2 years. This was consistent
MAY 2023
updated July 2023

nationwide. All states had averages between
57.7 and 58.6 years with no significant
differences between expansion and
nonexpansion states.

Geographic location

Although midlife Medicaid enrollees live

in nearly every county in the US, the vast
majority (84 percent) live in urban areas." In
2019, 84 percent lived in densely populated
areas, with 50 percent residing in metropolitan
counties with greater than 1 million residents.
In contrast, just 16 percent lived in rural areas.

The geographical distribution of midlife
Medicaid enrollees aligns with the national
distribution of midlife adults. In 2019,

85 percent of all midlife adults lived in
metropolitan areas and 15 percent lived

in rural areas. The distribution of midlife
Medicaid enrollees in nonexpansion states,
however, is more rural than the overall midlife
Medicaid adult population. Fully one-quarter
of this population is rural.

Disability

Midlife Medicaid enrollees who have received
Supplemental Security Disability Insurance
for 24 months or who have a certain disability
can qualify for Medicare." Once enrolled in
both Medicaid and Medicare, midlife Medicaid
enrollees are considered dually eligible
enrollees ("duals"). In 2019, 2.1 million midlife
Americans ages 50 to 64 were dually enrolled,
representing nearly a quarter (24 percent) of
dual enrollees of all ages.

The proportion of midlife duals in 2019,
relative to the midlife adult population, was
small across all states, ranging from 2 (Utah)

to 10 percent (Mississippi). Dual enrollment
among this age group tended to be higher in
states in the South, although two-thirds of all
dually enrolled midlife adults (65 percent) lived
in expansion states. Available county residency
information confirms the concentration of
midlife duals in the South as well as in Maine,
New Mexico, and northern California (figure 3).

The proportion of midlife duals, relative
to the midlife Medicaid population, varied

significantly from state to state (figure 4). In
2019, this proportion ranged from 14 percent
(California) to 64 percent (Mississippi). At
the low end of the range are states that
expanded Medicaid and opened eligibility
to all qualifying adults; at the high end are
nonexpansion states, which have more
limited eligibility criteria and fewer midlife
Medicaid enrollees. The average proportion
of dual enrollees among expansion states
was 24 percent. Meanwhile, the average for
nonexpansion states was 50 percent.

Because most midlife dual enrollees qualify for
Medicare based on a disability, Figure 4 points
to a concentration of disabled midlife Medicaid
enrollees in nonexpansion states. Medicare fee-
for-service health data confirm this portrait.
Enrollees in nonexpansion states have at

least a 4-percentage point higher prevalence
of hypertension, chronic kidney disease,
hyperlipidemia, arthritis, and ischemic heart
disease compared with enrollees in expansion
states."

Conclusion

Nationally, the average midlife Medicaid
enrollee is a 58-year-old white woman living
in a metropolitan area. However, our analysis
illustrates that this profile varies dramatically,
depending on the state of residence and its
Medicaid expansion status. For example,

in California, the average midlife Medicaid
enrollee is a 57-year-old urban-dwelling
Hispanic woman, whereas in Mississippi, the
average midlife Medicaid enrollee is a dually
enrolled Black woman living in an urban area.

This Fact Sheet analyzes the most recent
reliable Medicaid enrollment subpopulation
data. However, Medicaid enrollment sharply
increased across the US during the COVID-19
public health emergency (PHE) that began in
2020. Researchers estimate that 12.9 million
adults enrolled in Medicaid during the PHE.*

The profile of midlife Medicaid enrollees has
relevance in the spring of 2023. As the PHE
expires on April 1, 2023, and its moratorium
on Medicaid eligibility redeterminations draws
MAY 2023
updated July 2023

FIGURE 3
Proportion of Midlife Adults Dually Enrolled, 2019

 

FIGURE 4
Proportion of Midlife Medicaid Adults Dually Enrolled, 2019

 
MAY 2023

updated July 2023
to a close, states will begin redetermining significant. This, in turn, can inform efforts
eligibility. Experts expect that significant to retain eligible midlife adults in Medicaid
numbers of enrollees will lose coverage." beyond the PHE. Further, this can inform long-
As the redetermination process unfolds, term efforts to enroll eligible midlife adults
understanding the profile of midlife Medicaid and help identify how certain policies can
enrollees in their state can help officials support the unique needs of midlife Medicaid

identify where the drop-off of midlife adults enrollees.
in Medicaid enrollment is likely to be more

 

1 Allfigures in this Fact Sheet, unless otherwise noted, reflect AARP's analysis of T-MSIS enrollment data and ACS geographic data as
provided by NORC.

2 "How Medicaid Work Requirements Will Harm Older Adults & Family Caregivers," Justice i in Aging, April 2018,

 

Caregivers.paf

3 Jamie Ryan and Melinda K. Abrams, "Medicaid Cuts Would Affect Older, Sicker Americans," To the Point (blog), Commonwealth
Fund, April 6, 2017, https://doi.org/10.26099/zd6t-ej02.

4 T-MSIS data are state reported, and not all states submit data equally. The analyses in this Fact Sheet are based on available data.

5 National Federation of Independent Business (NFIB) v. Sebelius effectively made Medicaid expansion a state decision. Under the ACA,
if states chose to expand Medicaid, they received an enhanced Federal Medical Assistance Percentage (FMAP) for coverage of adults
up to 138 percent of the federal poverty level. See "A Guide to the Supreme Court's Decision on the ACA's Medicaid Expansion,"

Kaiser Family Foundation, August 2012, https://www.kff.org/wp-content/uploads/2013/01/8347.pdf.

6 Categorical enrollment numbers may differ from other sources because of categorization. See "Medicaid Enrollees by Enrollment
Group: 2019, " Kaiser Family Foundation, accessed March 1, 2023, https://www.kff.org/medicaid/state-indicator/distribution-of-

 

 

7 Asof March 1, 2023, 39 states and the District of Columbia have expanded Medicaid. See "Status of State Medicaid Expansion
Decisions: Interactive Map," Kaiser Family Foundation, accessed March 1, 2023, https://www.kff.org/medicaid/issue-brief/status-

 

8 "Medicaid Enrollment Changes Following the ACA," MACPAC, accessed March 1, 2023, https://www.macpac.gov/subtopic/
medicaid-enrollment-changes-following-the-

9 This Fact Sheet considers expansion states as those states that implemented expansion before January 1, 2019. Included in this
group are 33 states and the District of Columbia. Seventeen states had not implemented Medicaid before January 1, 2019, including
Idaho and Utah, which passed Medicaid expansion in 2019.

10 The proportion of Medicaid midlife enrollees of all Medicaid enrollees has remained consistent over the past decade. In 2013,
12 percent of Medicaid enrollees were ages 45 to 64. See "Medicaid Charts," Chronic Conditions Warehouse, accessed March 1,

2023, https://www2.ccwdata.org/web/guest/medicaid-charts.

11 T-MSIS race and ethnicity data are subject to state reporting, and the quality of state data is varied. In 2019, race and ethnicity data
were missing for 1.7 million midlife Medicaid enrollees, which is 15 percent of all midlife Medicaid enrollees. More than two-thirds
of states provided race and ethnicity data for more than 80 percent of midlife Medicaid enrollees. However, a handful of states
provided limited or no data.

12 We derived our estimates of rural and urban midlife Medicaid enrollees from pairing ACS data with the most recent (2013) US
Department of Agriculture (USDA) Rural-Urban Continuum Codes (RUCC). The USDA has nine RUCC. We considered any individual
living in a county with a RUCC of 1, 2 or 3 (counties with more than 1 million residents, between 250,000 and 1 million residents, and
fewer than 250,000 residents, respectively) as urban and anyone living in a county with a RUCC between 4 and 9 as rural.

13 To qualify for Medicare before age 65 due to a disability, a person must have received Social Security Disability Insurance for 24
months, have end-stage renal disease, or have amyotrophic lateral sclerosis (ALS). For more about eligible populations, see "Dually

Eligible Beneficiaries," MACPAC, accessed March 1, 2023, https://www.macpac.gov/topics/dually-eligible-beneficiaries/.

14 NORC at the University of Chicago analysis of Medicare enrollment and chronic condition data.
MAY 2023
updated July 2023

15 Rachel Dolan et al., "Medicaid Maintenance of Eligibility (MOE) Requirements: Issues to Watch," Kaiser Family Foundation,
December 17, 2020, https://www.kff.or -brief/m -of- i i

watch/.

16 This figure is based on the Kaiser Family Foundation's estimate that Medicaid enrollment will increase by 22.2 million individuals
because of the PHE and that 58 percent of these individuals are 18 years or older. Elizabeth Williams, Robin Rudowitz, and Bradley
Corallo, "Fiscal and Enrollment Implications of Medicaid Continuous Coverage Requirement During and After the PHE Ends," Kaiser
Family Foundation, May 10, 2022, https://www.kff.org/medicaid/issue-brief/fiscal-and-enrollment-implications-of-medicaid-

continuous-coverage-requirement-during-and-after-the-phe-ends/.

17 Ibid. See also Matthew Buettgens and Andrew Green, "What Will Happen to Unprecedented High Medicaid Enrollment after the
Public Health h Emergency?, " Urban stitute, September 2021, nithsil/waiwirban.org/s| reside fault /Mles/oubl cation/104785/what-

   

 

 

Fact Sheet 1611603
May 2023 (updated July 2023)

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