Mississippi Lawmakers Reach a Tentative Deal to Expand Medicaid

Mississippi lawmakers reached an agreement late Monday on a proposal to expand Medicaid under the Affordable Care Act, providing largely free health coverage to an additional 200,000 low-income residents in a state with dire health outcomes 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 a year for a single person, but the new recipients would be required to work at least 25 hours a week.

The proposal still faces daunting hurdles, including a possible veto from Gov. Tate Reeves, a Republican who opposes Medicaid expansion, and the Biden administration’s stiff resistance to imposing work mandates.

Even so, the agreement represents a breakthrough for Mississippi, where a coalition of hospital leaders, the broader business community, religious groups and a bipartisan bloc of elected officials have pressed lawmakers to join the 40 other states that have expanded Medicaid over the past decade. Besides Kansas and Wyoming, all of the holdout states are in the South.

“We know this is a historic piece of legislation,” Representative Missy McGee, the Republican chairwoman of the House Medicaid committee, told reporters during the negotiations.

For years, Republican officials in Mississippi were among the most vocally opposed to expanding Medicaid, a program that has played a crucial role in the Affordable Care Act’s success at reducing the number of Americans without health insurance. In his State of the State address last year, Mr. Reeves assailed what he described as a campaign led by Democrats for “the expansion of Obamacare, welfare and socialized medicine,” using language that many other Republicans around the country abandoned as the law gained popularity.

In this legislative session, though, many Republican lawmakers — including the new House speaker, Jason White — were willing to welcome the surge of federal funds that would come with expansion, and use the money to increase health care access and bolster the state’s strapped hospitals. Under the law, the federal government covers 90 percent of the cost of expansion.

“Wow, what a difference!” said the Rev. 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 House leadership — with the arrival of Mr. White, who represents a rural area north of Jackson — as perhaps the biggest single factor clearing the way for expansion this year. “Eight months ago, we never thought we would have this conversation,” Dr. Coker said.

The broader support among Mississippi Republicans underscores just how far the party has shifted on the Affordable Care Act. No other federal policy raised as much Republican ire in the initial years after President Barack Obama signed it into law.

Opponents have resisted having more residents rely on government programs and having the state pay even 10 percent of the cost.

But a number of Republican-led states gradually accepted 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 new openness to expanding Medicaid, which before the health law took effect a decade ago did not generally cover childless adults without disabilities, no matter how poor they were.

“The country is not going back,” Mr. White, the speaker, said in an interview last week with the statewide radio broadcaster SuperTalk Mississippi.

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

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

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 the onerous paperwork and reporting obligations.

“All these work-requirement waivers do is 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, an expensive new health program involving a work requirement has enrolled only a small fraction of the residents whom Gov. Brian Kemp, a Republican, aimed to cover in the first year. The Biden administration has tried to block the program, but a federal judge ruled in 2022 that it could go ahead.

The 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 look for or hold down jobs if they got free health insurance.

Gov. Laura Kelly of Kansas, a Democrat, said in an interview last month that rather than rejecting work requirements for Medicaid recipients outright, the Biden administration should consider the political constraints in states that might have no other options. Lawmakers in her state debated legislation last month that was similar to the Mississippi bill, but voted against sending it to the floor, killing its prospects for passage until at least the next legislative session.

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

But Ms. Tolbert, the KFF expert, said that the Biden administration was in a difficult position when considering Ms. Kelly’s argument. “You approve one, and you’ve got a long list of states that have already done expansion without work requirements who are ready to submit their waiver to impose work requirements,” she said. “We could see millions of eligible people currently covered losing coverage.”

Even though obstacles remain, the proposal is the closest Mississippi lawmakers have yet come to expanding Medicaid.

It was a dominant issue during the governor’s race last year. Brandon Presley, the Democratic candidate, centered his campaign on pushing for expansion. A Mississippi Today/Siena College poll taken during the campaign showed that 72 percent of voters supported expansion and that more than 90 percent were concerned about the closures of rural hospitals.

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

“We need to face the fact that we have the highest rate of preventable deaths, meaning more Mississippians die unnecessarily than anywhere else,” Ms. McGee said on the House floor. “And the reason these things often occur is poor access or no access to care.”

Still, some expansion proponents said that while the solution they have long sought feels tantalizingly close, it was not close enough.

“The working Mississippians are the losers, and they are the losers because the state government has failed to work for them,” Dr. Coker said, predicting that the plan would not go into effect. “The people of Mississippi lose, and it’s just so plain devastating.”