If they only knew then what they know now.
In hindsight, Mississippians who supported Medicaid expansion would have been better off had they accepted a work requirement in the 2024 legislative session.
Instead, many Democrats in the Mississippi House helped block a bill that would have enacted Medicaid expansion in the state to provide health insurance for primarily the working poor, but only if it included a work requirement.
At the time, House Democrats rightfully pointed out the administration of former President Joe Biden would not have approved the work requirement, thus preventing the bill from becoming law. Additionally, Democrats argued that some states had tried to implement work requirements in their expansion plans but were shot down by federal courts under the first administration of President Donald Trump.
But now, thanks to since-reelected Trump’s “One Big Beautiful Bill,” as it is called, all Medicaid adults under the age of 65, except for certain groups such as parents of young children, students and the disabled, must work to receive Medicaid coverage.
If the bill had passed in the 2024 session of the Mississippi Legislature, the state would have Medicaid expansion now providing health care to many poor, working Mississippians — at least those earning up to $21,579 per year for an individual and up to $44,363 annually for a family of four.
And regrettably for Mississippi, the “Big Beautiful Bill” is repealing a component passed during the Biden administration that would have provided a significant additional financial incentive for Mississippi and the other nine holdout states to finally expand Medicaid. That financial incentive equated to about $700 million for Mississippi.
If Mississippi had expanded Medicaid in 2024 with the work requirement, the state would have gotten a large portion of those financial incentive funds. Now, if Mississippi expands Medicaid, it will not get that financial incentive.
But importantly, the federal government still pays 90% of the health care costs for people on Medicaid because of expansion. That is a substantial financial incentive on its own that is not going away.
In reality, the reason Medicaid expansion did not pass in 2024 is much more nuanced than just blaming legislative Democrats. After all, Republicans hold a two-thirds supermajority in each chamber of the Mississippi Legislature. They have the votes to pass whatever they want.
But because not all Republican lawmakers were on board with Medicaid expansion in Mississippi, it is far from certain that any proposal — including the early ones House Democrats and others opposed — could have passed the state Senate even with the work requirement. House Speaker Jason White said at the time there were not enough Senate Republicans on board to pass the bill.
And it should be pointed out House Democratic leaders, trying to solve the impasse and get Medicaid expansion over the finish line in 2024, made the offer to vote for a Medicaid expansion proposal with a work requirement if the bill provided the opportunity to pass Medicaid expansion in future years without the work requirement. They feared that a Democratic presidential administration or courts would reject a work requirement every year and expansion would never come to fruition.
As it turned out, though, Trump won the election, and congressional approval of his “Big Beautiful Bill” makes the work requirement the law of the land.
Perhaps more onerous than the work requirement is the burdensome, often duplicative paperwork Medicaid recipients and others receiving federal aid must navigate and the fees recipients might have to pay to receive services. It almost seems “Big Beautiful Bill” supporters are opposed to people receiving health care.
The new law also has other components that are related to the 2024 Medicaid expansion debate in the Mississippi Legislature. Legislative Democrats had been trying for years to expand Medicaid. Republicans, with their supermajority, blocked those Medicaid expansion efforts.
But by 2024, new Republican House Speaker White and some other Mississippi Republican legislators, though not all, were amenable to some type of Medicaid expansion.
But other Republicans argued that Medicaid expansion was not needed because some of the working poor, though not the poorest, could receive private insurance through the federal Affordable Care Act exchanges with the federal government paying most of the costs.
Many hospital administrators argued the federal exchanges did not guarantee them as much of a revenue stream as did Medicaid expansion.
But those arguments now are moot because the Biden-era enhanced federal benefits that were provided for people who received insurance through the exchanges lapsed and were not extended by the “Big Beautiful Bill.”
But the upshot of all this is that despite Trump’s “Big Beautiful Bill,” Mississippi still has an opportunity to expand Medicaid with the federal government paying most of the costs.
For poor working Mississippians with no health insurance and for struggling hospitals, that still could genuinely be a big, beautiful thing.
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