In this Jan. 23, 2019 file photograph, Roy Mitchell, executive director with the Mississippi Health Advocacy Program, comments on a Medicaid update presentation before the House Medicaid Committee at the Capitol in Jackson, Miss. (AP Photo/Rogelio V. Solis, File)

Mississippi leans heavily on federal money. It takes in a larger share than most other states. 

But when it comes to accepting around $1 billion per year in health care assistance from the feds, Mississippi steadfastly refuses. Leaders say they are trying to fix the state’s health woes, from a last-ranked health care system and the highest percentage of residents with past-due medical debt. Yet they reject a free-flowing federal money spigot that experts say would quickly improve those rankings. 

This federal money is tied to extending Medicaid insurance coverage to a larger share of Mississippi’s population. It’s a step Republican officials have long been hesitant to take, but a growing number of advocates say the state has waited long enough, especially as Mississippi seeks to recover from the pandemic. 

They are exploring several options to expand coverage and accept the federal money, from ballot initiatives to a proposal where hospitals would help the state pay for its share of the costs. 

“The COVID-19 pandemic highlighted existing health disparities and a lack of access to healthcare for many Mississippians,” said Linda Dixon, health law director for the Mississippi Center for Justice. “Now is the time we can expand Medicaid to ensure coverage for all Mississippians.”

Mississippians in the gap

For decades Medicaid was intended for pregnant women, low-income seniors, people with disabilities and poor children. But the 2010 Affordable Care Act allowed states to expand access to low-income adults. 

There are approximately 170,000 Mississippians who could qualify, according to one estimate by the Kaiser Family Foundation. These are mostly working folks who earn up to 138% of the federal poverty line, or about $17,600 for one person.

Credit: Bethany Atkinson

Without Medicaid expansion, they fall into a coverage gap. They make too much money to qualify for traditional Medicaid coverage, yet not enough to qualify for cheaper plans in the Affordable Care Act insurance marketplace. 

If it extended coverage to these people, Mississippi would be on the hook for 10% of the program’s costs. The feds would pay the rest of the tab. Some estimates suggest this could run the state $75 million to $100 million annually. 

State leaders, especially Republicans, have often questioned how Mississippi could possibly come up with those funds in its notoriously lean budget.  

The Mississippi Hospital Association’s plan

But the Mississippi Hospital Association has suggested this money doesn’t actually need to come from state coffers. 

Instead, the group proposes paying the state’s share from a combination of taxes paid by hospitals themselves, as well as fees paid by the program’s enrollees $20 per month per person, plus copayments. It calls the plan Mississippi Cares.

Hospitals are willing to pay a tax for Medicaid expansion because it would cost them less money than constantly treating patients who don’t have insurance and can’t afford to pay out-of-pocket, said Tim Moore, the association’s CEO. In 2019, he said, Mississippi’s hospitals gave out $616 million worth of this free care. 

That’s up by about $100 million over the past decade. The high price tag is no surprise: Mississippi has one of the highest uninsured rates in the nation, according to Kaiser.

An analysis commissioned by the Hospital Association in 2019 found the Mississippi Cares plan could generate thousands of jobs as well as $200 million more in state revenue per year. And it estimated it could reduce the hospitals’ uncompensated care price tag by $250 million. 

Credit: Bethany Atkinson

“This is basically an insurance policy that is paid for by hospitals that are already seeing these patients anyway,” Moore has said of the proposal. 

Because the hospital plan would be customized for Mississippi, the state would need to request approval from the Centers for Medicare and Medicaid Services. CMS has approved such waivers in other states, including in Indiana when Vice President Mike Pence was governor, a fact Moore brings up frequently.

He said the Hospital Association plans to be “more aggressive” about promoting their expansion plan during the 2021 legislative session, which began this month. In a presentation to lawmakers late last year, he saved his Medicaid expansion pitch for last, saying leaders need to make a “simple choice.” 

“Are we going to continue to turn our backs on a plan which would generate hundreds of millions of dollars in straight revenue, would help hundreds of thousands of Mississippians of low income — working adults — and the Mississippi hospitals and healthcare providers who serve all of us?”

Polling and murky politics

Public support has only grown for Medicaid expansion in recent years. A Millsaps College and Chism Strategies poll from a year ago found 60% supported expansion, up from 52% two years prior. 

Recent polls — including a January survey from Millsaps and Chism — shows Mississippians are more worried about health costs and access than any other state issue. Those concerns have prompted Medicaid expansion to be popular campaign trail issues for Democrat and Republican candidates alike. 

But the political path to expansion in Mississippi remains rocky because Republican Gov. Tate Reeves continues to strongly oppose the idea and would almost surely veto an expansion bill. To force it through, two-thirds of the GOP-controlled Legislature would need to vote to override Reeves. 

“I remain adamantly opposed to Medicaid expansion in Mississippi. I firmly believe that it is not good public policy to place 300,000 additional Mississippians on government-funded health care,” Reeves wrote in his recent budget recommendation, adding the state money for such a program would be better spent elsewhere, including on raising teacher pay. 

His statement, which cited a high-end estimate for how many people might benefit from the program, didn’t mention the Hospital Association’s plan, which would cover the state’s costs. 

“We can’t even discuss it” with the governor, Moore said of the hospital plan. 

Still, Lt. Gov. Delbert Hosemann — a Republican who advocated for expansion when he ran for the office in 2019 — recently told reporters he remains open to expansion even though it was not among his top list of priorities for this session. He said the Hospital Association’s plan is worth considering.  

And he said he will allow Senate Public Health and Welfare Chairman Hob Bryan, a Democrat, to choose whether to advance expansion legislation. 

“In my conversations with him, I didn’t sense he was going to bring up an expansion of health care this year,” Hosemann said of Bryan. “But I did sense that was on his radar.” 

Bryan is an avid supporter of Medicaid expansion. But in an interview, the Democrat said such a bill would more likely be considered by the Senate’s Medicaid committee, and even if it was assigned to his committee, it is destined for eventual failure given Reeves’ adamant opposition. 

“Elections have consequences,” Bryan said of Reeves’ victory in 2019. “That’s a mighty important factor.” 

Medicaid expansion generally remains a topic many legislative Republicans avoid, even as Democrats have introduced dozens of bills in recent years. 

A spokeswoman for House Speaker Philip Gunn, R-Clinton, did not answer questions about where he stands on the Hospital Association’s proposal or similar Medicaid expansion ideas before the session. The Republican leaders of both the House and Senate Medicaid committees also declined to weigh in.   

What the research says

Bryan said that the economic and health benefits of expansion are clear. 

Indeed, a Kaiser literature review of 404 studies found generally positive outcomes for states that expanded. Expansion reduces how many people in a state are uninsured, especially helpful in rural areas. It helps increase access to care, which some studies suggest translate into more diseases and conditions caught earlier. 

And in terms of state economics, the studies find state revenues and overall economic growth increase following expansion. “Multiple studies suggest that expansion can result in state savings by offsetting state costs in other areas,” the review says. 

Meanwhile, the authors write, a “growing number of studies show an association between expansion and gains in employment as well as growth in the labor market.” 

Lingering Republican opposition, Bryan argued, is due to only one factor: Medicaid expansion was made possible thanks to the Affordable Care Act — or Obamacare. 

Bryan said it’s the biggest policy failure he’s seen in his legislative career, which dates to 1984.

Will a ballot initiative get traction?

Advocates say the pandemic is the time to press the issue. Roy Mitchell, executive director of the Mississippi Health Advocacy Program, noted the coronavirus reinforces how critical Medicaid coverage is for people who lost their jobs and need testing and treatment. 

Mitchell’s program has joined several other policy and health experts in the state who are exploring a possible Medicaid expansion ballot initiative.  

The next step in that process, he said, is to commission a fiscal analysis of expansion in the state, including the potential larger economic benefits. These figures are needed to make a more robust pitch to voters, he said. 

Moore said the Hospital Association’s board of directors has also discussed the possibility of a Medicaid expansion ballot initiative. 

Ballot initiatives have been a winning strategy in other states, including conservative ones such as Oklahoma and Missouri, where voters recently approved expansion programs. Mississippi is one of 12 states not to expand.  

“Obviously there’s shifting attitudes towards expansion in the South, and in general,” Mitchell said. 

Advocates acknowledge they will likely need more broad support from state medical organizations and doctors for a successful initiative effort. 

A Mississippi State Medical Association spokeswoman did not respond to messages seeking an interview about expansion. The group has largely stayed quiet about the debate; its political arm endorsed Reeves for governor in 2019. 

However, the group’s president recently told lawmakers they have waited far too long to approve expansion.

“Inexcusably, we have forgone billions in federal assistance that would’ve helped our most vulnerable citizens,” Dr. Mark Horne said. “We ask the legislature to act on expanding coverage in the upcoming session.”

This report was produced in partnership with the Community Foundation for Mississippi’s local news collaborative, which is independently funded in part by Microsoft Corp. The collaborative includes the Clarion Ledger, the Jackson AdvocateJackson State UniversityMississippi Center for Investigative ReportingMississippi Public Broadcasting and Mississippi Today.

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Luke Ramseth previously reported for the Clarion Ledger and is still a reporter in Mississippi covering the statehouse and other news.