Mississippi: Schrödinger's Medicaid Expansion sets up Biden for Sophie's Choice

February 16th:

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.

February 28th:

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.

As I noted at the time, however, there's one rather large elephant in the room: The bill includes work requirements, which have consistently been a non-starter under both the Obama and Biden Administrations. There's one Trump-era approved exception to this which managed to slip through the cracks in Georgia, except that...

...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.

Sure enough, as reported in the Mississippi Free Press on March 28th:

...The Senate version would require people to work at least 30 hours per week to become eligible for expanded benefits, up from the 20-hour work requirement approved by the House. Blackwell said the Senate made that change because it ensures able-bodied adults would need to work “basically full time” to receive Medicaid.

Mississippi ranks at the bottom of virtually every health care indicator and at the top of every disparity. Hospitals are struggling to remain open. The state also has one of the nation’s lowest labor force participation rates. Expansion proponents have said the policy could help improve these conditions.

...Republican legislature leaders have said Georgia offers a model for Mississippi to pass a narrow version of Medicaid expansion.

...Georgia’s program has seen abysmal enrollment. Only 2,350 people enrolled in the program from July 1 to mid-December, far fewer than the 100,000 that Gov. Brian Kemp’s administration projected the program might cover.

When I last checked in on the situation, the Mississippi Senate version of the bill was headed to "conference" with the previously-passed MS House version to split the differences between them.

Which brings us to this evening:

NEW: The Mississippi House & Senate have reached a compromise to expand Medicaid. But it includes a mandatory work requirement — something the Biden admin will never approve. It requires the state to keep applying each year until CMS approves it with the work requirements.

...Even if the work requirement *was* approved, it contains a provision killing Medicaid expansion if a future administration comes in and tries to strip work requirements.

— Megan Messerly (@meganmesserly) April 30, 2024

From the text of the bill itself:

Individuals eligible for coverage under this section shall be persons who are not less than nineteen (19) years of age but less than sixty-five (65) years of age, who currently reside in households that have an income of not more than one hundred thirty-eight percent (138%) of the federal poverty level, and to the extent approved by CMS in the Section 1115 waiver, who are:

So far, so good...they're agreeing to expand it to the full ACA expansion population...

(i) Employed for at least one hundred (100) hours per month in a position for which health insurance is not paid for by the employer;
(ii) Enrolled as a full-time student in secondary or post-secondary education;
(iii) Enrolled full-time in a workforce training program;
(iv) Enrolled for at least six (6) credit hours, or its equivalent, as a student in secondary education, post-secondary education, or a workforce training program and is employed for at least sixty (60) hours per month in a position for which health insurance is not paid for by the employer;
(v) The parent or guardian and the primary caregiver of a child under six (6) years of age;
(vi) A person who is physically, mentally or intellectually unable to meet the requirements of subparagraphs (i) through (iv) of this paragraph (a) as documented by a medical professional; or
(vii) The primary caregiver for a disabled child, spouse or parent, provided that such disabled person qualifies for  Medicaid coverage in accordance with the federal Social Security  Act.

(sigh) annnd there you have it: They're requiring enrollees to work at least 25 hours per week unless they're a full-time student, disabled, etc. (Or at least 15 hours/week if they're a part-time student).

As has been pointed out time and time again, the vast majority of those enrolled in Medicaid expansion already fall into one of those categories, so it's really a work reporting requirement, which has been proven to involve massively complicated administrative costs for the state to track and a huge administrative burden for the enrollees, thus causing enrollment to be a tiny fraction of what it would otherwise be, which mostly defeats the entire point of the program.

Case in point, Georgia again:

Georgia Gov. Brian Kemp’s plan for a conservative alternative to Obamacare’s Medicaid expansion has cost taxpayers at least $26 million so far, with more than 90% going toward administrative and consulting costs rather than medical care for low-income people.

...Since July, when the program began, about 3,500 people have signed up, according to state officials. That’s a small fraction of the Georgians who could enroll if the state expanded Medicaid without such requirements.

By comparison, if Georgia had simply expanded Medicaid under normal ACA provisions, up to 359,000 low-income Georgians would be enrolled by now.

As Messerly notes, the Biden Administration will now have two choices:

1. Approve the waiver including the work requirement provision, which would set a precedent for every other GOP-controlled state to pounce on as well (including those whose existing expansion waivers expire over the next few years); or...

2. Shoot down the work reporting requirement provision of the bill, which would allow Mississippi Republicans to then try to pin the blame on him for expansion not happening.

UPDATE: Welp. GOP Governor Tate Reeves is urging Republicans to still vote against the bill even with the work requirements...while also, sure enough, setting up Biden to take the blame if they pass it anyway:

Today, the Mississippi House and Senate will vote on FULL Obamacare Medicaid Expansion.

Up to 138%.
Just like Obama-Biden wanted!

I urge the true Republicans in the Legislature to vote NO on Obamacare Medicaid expansion in Mississippi. Voting yes goes against the principles of our party and the tried and true economic principles that built the greatest country in the history of mankind.  Did you send a Republican to Jackson to represent you? Or did you send someone that you thought was a Republican? After today, we will know…

— Governor Tate Reeves (@tatereeves) April 30, 2024