Mississippi: Schrödinger's Medicaid Expansion passes MS House!

Two weeks ago:

As I concluded in the last piece:

I strongly suspect that at least one of the remaining holdout states will join the expansion crowd this year, most likely Georgia, Mississippi or Alabama...but it likely will be some state-specific variant as described above. Stay tuned...

...As I noted, however, in all three [states] it's pretty likely they'll go with at least a partially privatized version as Arkansas has instead of a "clean" expansion of Medicaid proper.

Of course, as one Alabama-based advocate put it...

Mississippi better not beat us to expand.

— Jane Adams (@janeadamsid) February 16, 2024

Well, it looks like Ms. Adams may end up being disappointed...

BREAKING: The Mississippi House just passed Medicaid expansion by a 96-20 vote.
That's more than enough to overcome a veto from Gov. Tate Reeves.
It now heads to the Senate.

Background: https://t.co/exDyzFAcJX

— Ashton Pittman (@ashtonpittman) February 28, 2024

From the linked article in Pittman's tweet:

Mississippi is one step closer to what would be a landmark shift in health care policy, with the Republican-led House preparing to debate expansion of Medicaid benefits to hundreds of thousands more residents in one of the poorest states in the U.S.

The House Medicaid Committee on Tuesday advanced the bill, which would increase eligibility for Medicaid, a health insurance program that covers low-income people. Those making up to 138% of the federal poverty level, or $20,120 annually for a single person, would be eligible under the proposal. The measure could extend benefits to about 250,000 people.

...McGee touted a financial incentive for expanding Medicaid provided by Congress in the American Rescue Plan. The bonus helped with the passage of Medicaid expansion in North Carolina.

OK, sounds good so far...except for one thing:

...At the center of the debate is a provision that requires people to work at least 20 hours per week in order to become eligible for the expanded benefits. Among the 10 states that haven’t expanded Medicaid, only Georgia has managed to tie a work requirement to a partial expansion of benefits.

...But the Biden administration could likely refuse to grant a waiver for Medicaid expansion that includes a work requirement. If that happened, Mississippi could sue the federal government or adopt expansion without a work requirement.

As I noted last week, this is not a minor issue:

...on the one hand, most of those prior work requirement provisions have been struck down by the courts. On the other hand, one of them slipped through in Georgia, although that version has only managed to enroll a few thousand people after over six months. I'm guessing whatever bill goes through in Mississippi would either be some other type of partial expansion or, if it fully expands the program, would be intended to challenge the Biden Administration on the work requirement provision, hoping to force him to either approve it as is (opening up the floodgates for other red states to start imposing them as well again) or shoot it down & then presumably be blamed for expansion not going through in the state at all.

Annnnd sure enough, that seems to be what's going on here...except there's a couple of interesting twists.

According to the actual bill language, the Medicaid expansion program include...

To Provide That The Coverage Group For Eligibility Under Hmw Shall Be Individuals Who Are 19 Through 64 Years Of Age Whose Income Is Not More Than 138% Of The Federal Poverty Level, And To The Extent Approved In The Waiver

• i.e., the eligible population includes the standard ACA expansion population

...Employed For At Least Twenty Hours Per Week In A Position For Which Health Insurance Is Not Provided By The Employer Or Enrolled As A Full Time Student In Secondary Or Post-secondary Education Or Enrolled Full Time In A Workforce Training Program;

• There's the 20-hr/week work requirement provision, which CMS will likely shoot down...and they have to work for an employer who doesn't provide healthcare coverage, which seems rather self-evident but more on that in a moment...or they can be a full-time student. Again, on paper that may all sound reasonable but in practice the reporting requirements have proven to be administrative nightmares in every other state where it's been tried.

To Provide That The Coverage Group Shall Not Include Individuals Who Have Health Insurance Coverage Through Their Employer Or Private Health Insurance And Who Voluntarily Disenroll From That Health Insurance Coverage Until Twelve Months After The Ending Date Of That Coverage

• Again, they seem to be really hung up on the idea of people throwing crappy employer coverage away in favor of that sweet, sweet Medicaid coverage, to the point that if you voluntarily drop out of ESI you have to wait 12 months to become eligible to enroll in Medicaid instead. Pretty sure that won't pass the smell test to CMS, and it's also ironic since most conservatives insist that Medicaid sucks while employer insurances is wonderful (by which logic this shouldn't be an issue!)...

To Provide That The Coverage Group Shall Not Include Non-united States Citizens Who Are Ineligible For Medicaid Benefits

• This one made me roll my eyes; it states that undocumented immigrants are ineligible to enroll and therefore they are ineligible to enroll, which...um...yeah. OK, I think you made that pretty clear.

To Provide That All Individuals In The Coverage Group Shall Be Enrolled In And Their Services Shall Be Provided By The Managed Care Organizations (mcos), Coordinated Care Organizations (ccos) Provider-sponsored Health Plans (pshps) And Other Such Organizations Paid For Services To The Medicaid Population On A Capitated Basis By The Division

• OK, more MCOs. 80% of Medicaid enrollment is privately administered as it is, so this isn't a big surprise.

To Provide That All Individuals In The Coverage Group Enrolled Under Hmw Must Pay A Copayment Of Ten Dollars For Nonemergency Use Of The Emergency Room, Which Copayment Will Be Waived Under Certain Circumstances

• $10 copays. Not ideal but fine, whatever.

To Provide That Individuals In The Coverage Group Enrolled Under Hmw Who Are 19 Or 20 Years Of Age Will Receive All Epsdt Benefits To Which They May Be Entitled Under Federal Law And Regulation

• OK, good for 19 & 20 yr olds...

To Provide That Individuals Enrolled Under Hmw Who Are 21 Through 64 Years Of Age Will Have Access To The State Plan Benefit Package For Adults Eligible Under The Federal Affordable Care Act

• I presume this just clarifies that this is full Medicaid expansion in terms of comprehensiveness, and doesn't have partial benefits.

To Provide That If The Federal Matching Fund Proportion For Medical Services Provided To The Hmw Population Ever Falls Below 90%, The Waiver For Hmw Shall Be Discontinued To Coincide With The Effective Date Of Such A Decrease In The Federal Matching Fund Proportion

• Fair enough. One of the arguments against expansion Republicans have always given is concern over a bait 'n switch on the 90% federal matching rate (of course the only ones who've ever threatened to repeal the ACA, including that 90% match, are...Republicans)

To Provide That The State Matching Funds For Hmw Shall Include Contributions From Hospitals That Are Generated Through An Assessment On Hospitals And Contributions From Mcos, Ccos, Pshps And Other Such Organizations In The Form Of An Assessment As Provided In This Act

But here's the buried lede, brought to my attention by my colleague Louise Norris:

To Provide If The Waiver As Described In This Act Is Not Substantially Approved Before September 30, 2024, Or If The Waiver Is Approved But Is Subsequently Terminated, Then The Division Shall Allow For Medicaid Coverage In Mississippi For Individuals Described In The Federal Affordable Care Act, To Be Known As The Healthy Mississippi Works (hmw) Category Of Eligibility, And Shall Move With All Deliberate Speed To Submit The Required State Plan Amendments To Effectuate Medicaid Coverage For Those Individuals

• WHOA. Now THAT'S really, really interesting...and this is the part of the bill which both gives me hope and also makes me scratch my head.

In other words, unless we're both misreading the language here, it sounds like Mississippi would go ahead with expanding Medicaid whether the work requirement provisions are approved or not...and since the Biden Administration is obviously opposed to work requirements, why on earth would they approve them if the state is gonna just expand Medicaid either way??

This article from the Mississippi Free Press claims that...

...the Biden administration could likely refuse to grant a waiver for Medicaid expansion that includes a work requirement. If that happened, Mississippi could sue the federal government or adopt expansion without a work requirement.

McGee said the state Division of Medicaid would do its best to negotiate with the Centers for Medicare and Medicaid Services, the agency that would need to approve a waiver for a work requirement.

...but again, the text doesn't say that The Division Of Medicaid could adopt expansion without a work requirement, it seems to say it would do so.

Huh.

In any event, after over a decade of never even getting a committee vote, the bill easily passed right through the Mississippi House with overwhelming support in 15 minutes flat today. It still has to pass the state Senate (and be signed into law by Gov. Tate, although if it gets the same overwhelming approval it'll be veto-proof), and then I guess we'll see what happens when it falls into CMS's lap...