Mississippi lawmakers reach tentative deal to expand Medicaid

Mississippi lawmakers reached a deal late Monday on a proposed Medicaid expansion under the Affordable Care Act, providing largely free health coverage to an additional 200,000 low-income residents in the troubled state serious health problems and numerous rural hospitals facing financial collapse.

The state Senate and House of Representatives, both of which have Republican supermajorities, reconciled their competing plans by agreeing to extend coverage to people with incomes up to 138 percent of the federal poverty level, or just over $20,000 per year for a single person, but new recipients would be required to work at least 25 hours per week.

The proposal still faces daunting obstacles, including a possible veto by Gov. Tate Reeves, a Republican who opposes Medicaid expansion, and strong resistance from the Biden administration to work mandates.

Still, the deal represents a breakthrough for Mississippi, where a coalition of hospital leaders, the broader business community, faith groups and a bipartisan bloc of elected officials have pushed lawmakers to join the 40 other states that have expanded Medicaid over the past decade. Besides Kansas and Wyoming, all the hardy states are in the South.

We know this is landmark legislation, Rep. Missy McGee, the Republican chairwoman of the House Medicaid Committee, told reporters during the negotiations.

For years, Republican officials in Mississippi have been among the most vocal opponents of expanding Medicaid, a program that has played a crucial role in the Affordable Care Act’s success in reducing the number of Americans without health insurance. In his State of the Union address last year, Mr. Reeves attacked what he described as a Democratic-led campaign to expand Obamacare, welfare and socialized medicine, using language that many other Republicans across the country abandoned as the law gained traction .

In this legislative session, however, many Republican lawmakers, including new House Speaker Jason White, were ready to welcome the increased federal funds that would come with the expansion and use the money to increase access to health care and strengthen hospitals with ties to the states. By law, the federal government covers 90 percent of the cost of the expansion.

Wow, what a difference! said Reverend Dr. K. Jason Coker, the national director of Together for Hope, a rural development coalition led by the Cooperative Baptist Fellowship.

He credited a change in the leadership of the Chamber with the arrival of Mr. White, who represents a rural area north of Jackson, as perhaps the biggest factor paving the way for expansion this year. Eight months ago, we never thought we’d be having this conversation, Dr. Coker said.

The broader support among Mississippi Republicans underscores how far the party has shifted on the Affordable Care Act. No other federal policy drew as much Republican ire in the first years after President Barack Obama enacted it.

Opponents have resisted making more residents dependent on government programs and the state paying even 10 percent of the cost.

But a number of Republican-led states gradually embraced Medicaid expansion as pressure grew from hospitals, businesses and religious leaders, who called it a moral imperative. This year, Republican leaders in Alabama and Georgia, as well as Mississippi, have expressed renewed openness to expanding Medicaid, which before the health law took effect a decade ago generally did not cover childless adults and without disability, no matter how poor they were.

The country will not go back, said Mr. White, the speaker, in an interview last week with state radio station SuperTalk Mississippi.

But the excitement of getting to this point has been tempered by the very real possibility that the proposal will be rejected by the governor or the federal government. Both chambers are expected to vote on the proposal this week. In a statement on Tuesday, Mr. Reeves said, I urge true Republicans in the Legislature to vote no.

Medicaid work requirements were a signature policy of the Trump administration, which passed them in more than 10 states. Federal and state health officials at the time argued that they encouraged a kind of accountability among potential recipients who might not have worked.

But state efforts to impose work requirements were repeatedly struck down in court, including in Arkansas, New Hampshire and Kentucky.

In Arkansas, thousands of lower-income people lost Medicaid coverage after the state imposed a work requirement in 2018, with enrollees and health policy experts blaming burdensome paperwork and reporting requirements .

All of these work requirement waivers serve to put barriers in front of eligible people, said Jennifer Tolbert, a Medicaid and state health policy expert at KFF, a nonprofit health policy research group.

In Georgia, which has yet to expand Medicaid under the Affordable Care Act, a costly new health program that involves a work requirement has enrolled only a small fraction of the residents that Gov. Brian Kemp, a Republican, intended to cover in first year The Biden administration has tried to block the program, but a federal judge ruled in 2022 that it could go ahead.

Legal battles have not stopped Republicans from trying to include work requirements in Medicaid expansion proposals, arguing that recipients would have too little incentive to find or keep jobs if they had free health insurance.

Gov. Laura Kelly of Kansas, D-Kansas, said in an interview last month that instead of rejecting work requirements for Medicaid recipients, the Biden administration should consider policy constraints in states that may have no other options . Legislators in his state debated similar legislation to Mississippi’s bill last month, but voted against sending it to the floor, killing its prospects for passage at least until the next legislative session.

“The way I look at it is, if this is the only way Kansas can expand Medicaid, and we can get 150,000 Kansans covered,” said Ms. Kelly, referring to the number of people expected to receive coverage under the expansion plan.

But Ms. Tolbert, the KFF expert, said the Biden administration was in a difficult position when considering Ms. Kelly’s argument. Pass one and you have a long list of states that have already done expansion without work requirements that are ready to submit their waivers to impose work requirements, he said. We could see millions of currently covered eligible people lose coverage.

Although there are hurdles, the proposal is the closest Mississippi lawmakers have come yet to expanding Medicaid.

It was a dominant theme during last year’s gubernatorial race. Brandon Presley, the Democratic candidate, focused his campaign on pushing for expansion. A Mississippi Today/Siena College poll conducted during the campaign showed 72 percent of voters supported the expansion and more than 90 percent were concerned about rural hospital closings.

Mississippi has death rates that are among the nation’s highest for heart disease, stroke, diabetes and cancer. The vast majority of state hospitals operate at a loss.

We have to face the fact that we have the highest rate of preventable deaths, which means more Mississippians are dying needlessly than anywhere else, Ms. McGee told the House. And the reason these things often happen is poor access or lack of access to care.

Still, some expansion advocates said that while the solution they’ve long sought seems very close, it wasn’t close enough.

Mississippi workers are the losers, and they’re the losers because the state government hasn’t worked for them, Dr. Coker said, predicting the plan would not go into effect. The people of Mississippi lose, and it is so simply devastating.