Methodology: Dual-Eligible Exposure in Michigan
How the county-level Medicare + Medicaid dual-eligible distribution is computed and why dual-eligible residents are exempt from P.L. 119-21 work requirements
Dual-eligible residents are exempt from P.L. 119-21 work requirements. This map shows where they live.
This page describes how the county-level dual-eligible distribution is computed and documents the provision-by-provision analysis supporting the exemption finding. Dual-eligible individuals qualify for Medicaid through the aged (65+) or disabled pathway — not through the ACA expansion group to which P.L. 119-21 §71119 work requirements apply. The feature documents geographic concentration, not coverage-loss exposure.
Sources
MACPAC Data Book December 2025 — Michigan Dual-Eligible Population
MedPAC/MACPAC, December 2025. macpac.gov — December 2025 Duals Data Book (PDF) — Michigan dual-eligible population: 405,000 total (360,000 full-benefit; 45,000 partial-benefit), CY 2022. This is the most recent administratively-derived figure published in a peer-reviewed government data book with a direct Michigan row. Used as the statewide range high endpoint. Accessed April 2026.
KFF State Health Facts — Number of Dual-Eligible Individuals (2024 and 2025)
Kaiser Family Foundation, 2024/2025. kff.org — Number of Dual-Eligible Individuals by State — Michigan: 353,820 total (2024, March enrollment); 334,716 total (2025, January enrollment). The KFF 2024/2025 figures are lower than MACPAC 2022 partly due to post-PHE Medicaid redetermination effects. Both figures are cited to establish the statewide range (DISPLAY_RANGE_LOW = 335,000 from KFF 2025; DISPLAY_RANGE_HIGH = 405,000 from MACPAC 2022). Accessed April 2026.
ACS B27010 5-year 2023 — County-Level Simultaneous Medicare + Medicaid Coverage
U.S. Census Bureau, American Community Survey 5-year 2023. data.census.gov — ACS B27010 5-year 2023 — Variables: B27010_046E (ages 35–64: With two or more types of health insurance including Medicare and Medicaid/means-tested public coverage) and B27010_062E (ages 65+: same). Sum of both variables per county = county acsDualEstimate. ACS API: /data/2023/acs/acs5?get=NAME,B27010_046E,B27010_062E&for=county:*&in=state:26. All 83 Michigan counties returned clean values. Statewide ACS total: 216,635 (denominator for county shares). Small-county ACS values (Keweenaw, Luce, Ontonagon, Schoolcraft) have high relative margins of error and should be treated as illustrative. Accessed April 2026.
Justice in Aging — How P.L. 119-21 Impacts People Dually Eligible for Medicare and Medicaid
Justice in Aging, 2025. justiceinaging.org — P.L. 119-21 impact on dual-eligible individuals — Authoritative analysis of which P.L. 119-21 provisions apply to dual-eligible individuals. Key finding: "Work requirements only apply to adults ages 19–64 enrolled in the Medicaid Expansion program. People dually eligible are not subject to work requirements." (§71119 scope). Also identifies retroactive coverage period reduction (3 months → 2 months for non-expansion, i.e., predominantly dual-eligible, population) and flags administrative disruption risk from §71107 redeterminations. Accessed April 2026.
CBO: Estimated Budgetary Effects of P.L. 119-21 (pub. 61570)
Congressional Budget Office, July 2025 (pub. 61570). cbo.gov — pub. 61570 publication landing page — National baseline for all P.L. 119-21 Medicaid provisions. Dual-eligible individuals are not subject to work requirements but are affected by the MSP streamlining rule delay (§71101): CBO estimated the blocked rule would have added approximately 860,000 new MSP enrollees nationally. Accessed April 2026.
KFF: Medicaid Changes in P.L. 119-21 Would Increase Costs for 1.3 Million Low-Income Medicare Beneficiaries (§71101 MSP streamlining rule delay)
Kaiser Family Foundation, 2025. kff.org — MSP/LIS changes affecting 1.3 million low-income Medicare beneficiaries — P.L. 119-21 §71101 prohibits CMS from implementing the September 2023 Medicare Savings Program (MSP) streamlining final rule until October 1, 2034. The blocked rule would have automatically enrolled SSI recipients into MSPs. KFF estimates 1.3 million current low-income Medicare beneficiaries nationwide face higher Medicare cost-sharing as a result. Michigan proportional estimate (derived, not published): Michigan has approximately 4% of the national dual-eligible population (405,000 / ~12M national). Applying 4% to the 860,000 national MSP enrollment gain blocked by CBO: approximately 34,000 Michigan residents who would have been newly enrolled in MSP are not enrolled due to §71101. This is a proportional derivation from national figures — no Michigan-specific figure has been published by CMS, KFF, MACPAC, or MDHHS for this provision. It is disclosed here as a scoped, labeled estimate and does not appear on the data page. Accessed April 2026.
MACPAC: Dual-Eligible Enrollment Pathways — Aged and Disabled Medicaid Eligibility
MACPAC, December 2025 Data Book (Exhibit 27 and context chapters). macpac.gov — December 2025 Duals Data Book — Documents that dual-eligible individuals qualify for Medicaid through the aged (65+) pathway or through SSI/SSDI (disability). These pathways are distinct from the ACA Medicaid expansion group (adults ages 19–64 up to 138% FPL) that P.L. 119-21 §71119 work requirements target. Of Michigan's 405,000 dual-eligibles: 360,000 are full-benefit duals (predominantly aged/disabled) and 45,000 are partial-benefit duals (QMB, SLMB, QI — Medicare cost-sharing assistance only). Accessed April 2026.
Technical steps
Plain language
We combine three published sources — MACPAC's CY 2022 administrative count (405,000), KFF's 2024 enrollment count (353,820), and KFF's 2025 enrollment count (334,716) — into a statewide display range of approximately 335,000–405,000 Michigan dual-eligible residents. We then distribute that range to all 83 Michigan counties using each county's share of the ACS B27010 5-year 2023 statewide simultaneous Medicare + Medicaid survey estimate. The result is a geographic distribution of a protected population — not a projection of coverage loss.
Technical steps
- State-level input range — Display range endpoints: DISPLAY_RANGE_LOW = 335,000 (rounded from KFF 2025 figure of 334,716); DISPLAY_RANGE_HIGH = 405,000 (MACPAC CY 2022). Both figures are administratively-derived enrollment counts cited directly to their sources. The range spans post-PHE redetermination variation (KFF 2025) to the most recent pre-redetermination administrative peak (MACPAC 2022).
- County denominator — ACS B27010 5-year 2023 variables B27010_046E (ages 35–64) and B27010_062E (ages 65+) are summed per county to produce each county's
acsDualEstimate. Statewide ACS total: 216,635 (sum of all 83 county estimates). This is used as the denominator for county shares — not as the absolute enrollment total. - Allocation formula — Each county's range is computed as:
county_share = county_acsDualEstimate / 216,635thenallocatedLow = Math.max(1, Math.round(335,000 × county_share))andallocatedHigh = Math.max(1, Math.round(405,000 × county_share)). TheMath.max(1, ...)floor prevents zero-display for very small counties (Keweenaw: ACS estimate = 50). - Exemption explanation — Dual-eligible individuals are enrolled in Medicaid through the aged (65+) or disabled pathway, not through ACA expansion. P.L. 119-21 §71119 work requirements apply exclusively to the ACA expansion group (adults ages 19–64 enrolled up to 138% FPL). Dual-eligible individuals are categorically exempt regardless of age, income, or employment status. The Justice in Aging analysis (source d above) is the primary authority cited for this determination.
- MSP §71101 scoped exposure finding — While dual-eligible individuals are exempt from work requirements, P.L. 119-21 §71101 delays the Medicare Savings Program (MSP) streamlining final rule until October 1, 2034. CBO estimates the blocked rule would have added 860,000 new MSP enrollees nationally. Michigan's proportional share (~4% of national dual-eligible population) implies approximately 34,000 Michigan residents who would have gained MSP enrollment are not enrolled due to this delay. This finding is documented on this methodology page only — it is a derived national-to-state estimate and does not appear as a figure on the data page, consistent with the editorial discipline applied to all V3 features.
What this does not do
- Does not model §71101 (MSP streamlining rule delay) county-level impact. No Michigan-specific published source quantifies this by county; the ~34,000 state figure is a proportional derivation from national CBO data.
- Does not distinguish full-benefit dual-eligible individuals from partial-benefit duals (QMB, SLMB, QI). Full-benefit duals (360,000 in MACPAC CY 2022) have Medicaid coverage for services; partial-benefit duals (45,000) receive only Medicare cost-sharing assistance.
- Does not separately capture dual-eligible individuals enrolled in Medicare Advantage Dual-Eligible Special Needs Plans (D-SNPs). D-SNP enrollment is a subset of full-benefit duals and is not separately identifiable in ACS B27010.
- ACS B27010 survey estimates capture simultaneous self-reported coverage, not the CMS administrative "dual-eligible" category. The ACS statewide total (216,635) is approximately 53% of the MACPAC administrative figure (405,000), reflecting ACS undercounting of low-income and Medicaid-enrolled populations. County shares, not absolute ACS values, drive the allocation.
- Small county ACS margins of error apply. For Keweenaw (50), Luce (186), Ontonagon (189), and Schoolcraft (198), ACS B27010 coefficients of variation are high (typically 30–60%). County-level allocations for these counties should be treated as illustrative only. Exact margins of error are available at data.census.gov table B27010.
- Does not capture state-specific Michigan Medicaid waiver programs or MI Health Link enrollment arrangements that may expand or alter the practical dual-eligible definition for Michigan-specific policy analysis.
Why we publish this
Michigan's dual-eligible population — residents enrolled in both Medicare and Medicaid simultaneously — is not evenly distributed across the state. Counties with high concentrations of dual-eligible individuals often face compounding resource questions: these residents disproportionately use long-term care services, HCBS programs, and nursing facility beds whose funding is under pressure from provider tax restrictions in P.L. 119-21 (§71115, §71117). No public source currently provides county-level estimates of Michigan's dual-eligible population distribution in a single accessible view. accessmi.org publishes this map as a planning input — a sourced, range-bounded distribution that a county health department, hospital administrator, or journalist can use to frame geographic questions. The exemption from work requirements is made explicit because misreading the coverage-at-risk maps to imply dual-eligible individuals face compounding work-requirement exposure would be incorrect. The methodology is public, the uncertainty is explicit, and the model will be updated when better data becomes available.
Change log
Every change to this methodology is recorded here with date and reason.