In a notable departure from its traditional stance, Mississippi's Republican-led legislature is moving to enact Medicaid expansion with the passage of House Bill 1725. Led by House Medicaid Chair Missy McGee, this bipartisan endeavor aims to extend healthcare benefits to Mississippi's working and low-income families. With a resounding 98-20 vote in the House, the bill now advances to the Senate, reflecting a growing momentum for reform.

The Patient Protection and Affordable Care Act (ACA) of 2010 allows states to expand their Medicaid programs to nonelderly adults making up to 138% of the federal poverty level. Under the ACA, the federal government picks up 90% of the costs of Medicaid expansion. Republican lawmakers have historically been against such expansion, citing heavy costs for the government and taxpayers alike. Over time, however, more traditionally red states have made moves towards expansion. Presently, only ten states have not expanded Medicaid. In Mississippi, Medicaid expansion became a popular campaign issue due to constituents' concerns over rural hospital closures.

Mississippi's recent advancement towards Medicaid expansion prompts a range of questions and concerns, particularly about potential impacts and implementation challenges. Foremost among these is the question of a work requirement. In 2023, the US House of Representatives passed H.R. 2811, which included a nation-wide work requirement for certain adults enrolling in Medicaid. Under this stipulation, “enrollees ages 19-55 would need to work or participate in other qualifying activities (like community service or job training) for at least 80 hours per month.” Proponents of a work requirement, such as Arkansas Governor Sarah Huckabee Sanders, argue that the requirement reduces government dependance and could save the federal government up to $109 billion over the next decade. Opponents of the proposition worry that a work requirement could put people with disabilities at risk of losing their health insurance coverage and increase the number of uninsured Americans substantially. 

At the moment, H.R. 2811 has yet to pass the Senate. Five states have been approved to independently implement work requirements in the coming years. Utah has successfully implemented such requirements, though these have been on pause due to the COVID-19 pandemic.

There have been additional concerns about the capacity of Mississippi's strained health care delivery infrastructure, which would need to effectively accommodate an influx of approximately 49,000 newly eligible individuals. Even with the additional funding Medicaid expansion would bring, such growth could potentially strain resources and exacerbate existing disparities in access to care. On the legislative level, the outline of a final agreement between Mississippi’s legislative chambers remains murky. Further, Republican Governor Tate Reeves, who has opposed expansion, has not indicated if he would consider changing his position.

Still, state and federal leaders appear to be optimistic. “[Mississippi’s] health metrics will improve, we’ll see greater access to care, and hopefully start to see a healthier Mississippi where our folks are getting treatment earlier rather than later,” Chair McGee stated.

The Biden administration is encouraging the move, with Health and Human Services Secretary Xavier Beccara telling attendees at an event in Jackson, “You’ve got to pick up the bootstraps of your state until your state finally cares for all of its families.”

Additional federal funds provided to states that expand Medicaid have likely sweetened the deal. Provisions included in President Biden’s landmark American Rescue Plan Act (ARPA) essentially authorize the federal government to give states a payout in return for expansion. Although these payouts could have a significant impact on the federal budget, they have mitigated some worries from those concerned about state budget impacts.

Observers should closely follow Mississippi's Medicaid expansion for its potential to influence health care access and policy in the Deep South. This departure from traditional Republican opposition marks a shift that could inspire states such as Alabama and South Carolina to expand their Medicaid programs. Notably, Mississippi’s progress has only come after North Carolina, itself governed by a Republican legislature, expanded Medicaid and reaped the financial rewards – about $8 billion per year, with an additional $1.5 billion in ARPA incentives over the first two years.

With the Biden administration's encouragement and additional federal funds, Mississippi's approach may serve as a blueprint for expanding health insurance coverage in what would be only nine remaining states.