Gov. Tate Reeves delivers the State of the State address on the steps of the Capitol on Jan. 26, 2021. Credit: Vickie D. King /Mississippi Today

Note: This article is part of Mississippi Today’s ongoing Mississippi Health Care Crisis project. Read more about the project by clicking here.

While running for governor in 2019, then-Lt. Gov. Tate Reeves was quizzed at a Capitol Press Corps luncheon whether his opposition to expanding Medicaid coverage to working-poor Mississippians was softening.

“I am opposed to Obamacare expansion in Mississippi. I am opposed to Obamacare expansion in Mississippi. I am opposed to Obamacare expansion in Mississippi. I don’t know how many ways I can explain this to y’all,” Reeves said.

Reeves’ fellow Republican House Speaker Philip Gunn has frequently given equally deep and erudite explanations of his steadfast opposition to accepting $1 billion a year in federal money to help the working poor and Mississippi’s distressed hospitals.

“From what I know about it, we cannot afford it,” Gunn said tersely to questions as the 2021 legislative session ended, obviously not wanting to discuss the issue further.

For more than a decade, despite most other states expanding Medicaid and despite hospitals, doctors, economists and experts saying it would be a net benefit to the poorest, sickest, most uninsured and most federally dependent state in the country, most of Mississippi’s top elected leaders have refused the offer.

As some hospitals across the state close their doors and others struggle on the brink of collapse — even as the state budget sees record gains from other federal spending — Mississippi leaders’ recalcitrance growingly appears more political than pragmatic.

Reeves and Gunn, who can block expansion from their posts, remain steadfast in their opposition. Republican Lt. Gov. Delbert Hosemann has said he’s open to the idea, as are a small but growing number of legislative Republicans. But Hosemann avoids even saying the words “Medicaid expansion” and hasn’t pressed his colleagues on full expansion. He has, unsuccessfully, pushed for expanding postpartum Medicaid coverage for mothers.

Q&A: What is Medicaid expansion, really?

Notably, all three top leaders declined interviews or comments for this story. Medicaid expansion hasn’t gotten a real hearing with the Legislature in years, even as the federal government has tried to sweeten the deal and counter arguments against expansion.

At times, including recently, some state leaders have said they would instead prefer people to have good jobs that provide private insurance. But this has proved elusive, with Mississippi seeing slow job growth, the lowest median income in the nation and among the highest rates of uninsured people.

Mississippi Today compiled a list of the main arguments against Medicaid expansion that opponents have given over the last decade, with counterpoints from proponents:

We can’t afford it/it will tank the state budget

“I don’t see Medicaid expansion as something that is beneficial to the state of Mississippi,” Gunn said in 2021. “I just don’t think the taxpayers can afford it. That is what it boils down to is the taxpayers. It is their money. I just don’t have the taxpayers calling saying we want you to raise taxes so we can expand Medicaid.”

So far, Medicaid expansion hasn’t tanked any states’ budgets, nor have any been forced to raise taxes to cover ACA Medicaid expansion.

Numerous studies, including those by Mississippi’s state economists, say the state — including government coffers — would see a net economic benefit, including growth in GDP and population and the creation of thousands of jobs.

Studies in Arkansas, Kentucky, Louisiana, Michigan, Montana and Virginia showed the states saw a net reduction of more than 4% in spending on their traditional Medicaid programs after expansion. Louisiana’s Medicaid expansion in 2016 brought a 33% reduction in uncompensated care costs for hospitals, including a 55% reduction for rural hospitals.

READ MORE: Here’s what experts say about expanding Medicaid in Mississippi

The federal government will quit paying its share

“For us to enter into an expansion program would be a fool’s errand,” then-Gov. Phil Bryant said in 2014. “I mean, here we would be saying to 300,000 Mississippians, ‘We’re going to provide Medicaid coverage to you,’ and then the federal government through Congress or through the Senate, would do away with or alter the Affordable Care Act, and then we have no way to pay that.”

But the Affordable Care Act, including Medicaid expansion, has survived through three presidents, including Republican Donald Trump who wanted to do away with it, and through multiple congresses, including two under Republican control of both chambers. It has survived numerous court challenges (Mississippi has joined in at least a couple of those).

Mississippi leaders made the same argument to postpone adopting the Medicaid program when it was created in the 1960s. It was one of the last states to do so, in 1969. Arguments that the feds would stop funding it and leave Mississippi in the lurch have proved erroneous, and the Magnolia State has enjoyed the highest rate of federal reimbursement for its existing Medicaid program for many years.

It’s subsidizing people who won’t work/it’s more welfare

“We believe all able-bodied folks ought to get off the couch and go to work,” state Agriculture Commissioner Andy Gipson, a longtime former lawmaker, said at the Neshoba County Fair in July, mirroring comments many other leaders have made over years. “This is why we oppose Medicaid expansion.”

By its definition, covering people who make up to 138% of poverty level income, Medicaid expansion is aimed at helping the working poor.

“These are people that are working,” said Tim Moore, president of the Mississippi Hospital Association. “By definition, to be at 138% above poverty, you have to have income from somewhere. In fact these are people that are often working multiple jobs, but still don’t have the discretionary income to afford the high cost of premiums.”

“Medicaid expansion is not about putting people on the welfare rolls,” state Insurance Commissioner Mike Chaney said last year. “This is about expanding health care availability to the poor, the disabled, the folks that fall through the cracks, that are not able to get on the Affordable Care Act.”

READ MORE: How Medicaid expansion could have saved Tim’s leg and changed his life

It would drive up private insurance costs, especially if hospitals help pay for expansion

“If hospitals are going to pay for it, that means that your cost when you go to the hospital is going to go up,” Reeves said during a 2019 gubernatorial election debate, referring to Mississippi hospitals offering to pay the state’s share of expansion. “If you have private insurance, that means that your insurance rates are going to go up.”

Others over the years have warned that expansion in general would drive up private insurance premiums.

But driving down uncompensated care costs for Mississippi hospitals, which has hovered around $600 million a year (lowered temporarily a bit recently because of federal COVID-19 relief money) would allow hospitals to lower prices, Moore said. One recent study said expansion would cut Mississippi hospitals’ uncompensated care by an average of $251.6 million a year from 2020-2030. The same study projects private premiums paid each year would also fall by $52.6 million over the same period.

“Treating people with no coverage forces the costs onto everyone else,” Moore said. “Plus, if people have coverage, they get care in a more timely, more efficient manner. You have less chronic problems, less higher-cost problems.”

As for hospitals paying the state’s share of expansion, as MHA proposed with the MS Cares plan in 2019, Moore said that’s a moot point now, because Mississippi hospitals are struggling so bad financially now that they couldn’t afford to do it.

Medicaid is broken, full of fraud and provides poor health outcomes

When Mississippi lawmakers in 2017 passed an act aimed at preventing fraud in Medicaid and welfare, one concern cited during debate was that there were dead people on Medicaid rolls.

“Are you talking about dead people on the rolls of Medicaid?” one lawmaker asked then-Senate Medicaid Chairman Brice Wiggins, R-Pascagoula. He responded: “I am talking about everybody, yes. It doesn’t matter if it is dead people. It doesn’t matter if it is people double dipping. They need to be following the law.”

Medicaid doesn’t provide money to beneficiaries. It provides health care, and money goes to providers. As several lawmakers pointed out at the time, it would be hard for dead people to be receiving health care.

Many, including some state politicians, appear to conflate Medicaid with “welfare.” Medicaid is a state-federal health insurance program that, in Mississippi currently, is available only to the disabled, elderly poor people, poor pregnant women and poor children. An able-bodied adult cannot simply be poor and qualify for Medicaid.

Mississippi has been plagued with fraud, corruption or misspending in Medicaid, welfare and other government programs. But this has been mostly committed by politicians, bureaucrats, business people, or large corporations. Beneficiary fraud in all these programs would appear to be a smaller problem.

It is true that Mississippi Medicaid beneficiaries have very poor health outcomes. But given that a large portion of qualifying beneficiaries are very sickly and poor to begin with, this would appear self-fulfilling prophecy. The aim of expansion is to cover the healthier, working poor and provide more preventive care.

“If you start early and provide health care, the outcome is better,” Moore said. “If you put off treating a condition, it gets worse. Diabetes is an example. You have an individual that doesn’t have health care coverage and they have neuropathy but put off treatment. They get a hole in the foot that gets infected. Then they lose a leg. Or they lose eyesight or have renal failure. Then all of a sudden they have a disability and can’t work, and they have to be taken care of. But we could have prevented it, and we could have managed the cost much better.”

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Geoff Pender serves as senior political reporter, working closely with Mississippi Today leadership on editorial strategy and investigations. Pender brings 30 years of political and government reporting experience to Mississippi Today. He was political and investigative editor at the Clarion Ledger, where he also penned a popular political column. He previously served as an investigative reporter and political editor at the Sun Herald, where he was a member of the Pulitzer Prize-winning team for Hurricane Katrina coverage. Originally from Florence, Mississippi, Pender is a journalism graduate of the University of Southern Mississippi and has received numerous awards throughout his career for reporting, columns and freedom of information efforts.