Mississippi’s first serious attempt to expand Medicaid under the Affordable Care Act collapsed Thursday night, after an agreement reached by state lawmakers earlier in the week disintegrated and last-minute scrambling for a compromise failed.
The outcome dashed any hope of movement this year to unlock a torrent of federal funds that could have provided largely free health care to as many as 200,000 low-income residents, and possibly resuscitated financially strapped rural hospitals.
The main point of contention was the insistence by Republicans in the State Senate that people could not qualify for the coverage unless they were working.
“I’m disappointed that we couldn’t close the deal,” State Representative Missy McGee, a Republican who was one of the most vocal proponents of expansion, said in a statement. “I’m disappointed that for many, winning an ideological debate was more important than helping Mississippians.”
The push for Medicaid expansion, steered by Republicans in a State Legislature where the party has a supermajority, illustrated the degree to which attitudes about the Affordable Care Act have evolved. The law — which many Republicans around the country reviled and attacked for years as a signature achievement of the Obama administration — has found grudging acceptance. All but 10 states have expanded their Medicaid programs to cover most poor adults in the decade since that option became available under the law.
“The country is not going back,” Jason White, the Mississippi House speaker, said in a recent radio interview.
But the failure to arrive at a compromise underscored the divisions that remain in Mississippi.
Some lawmakers refused to budge on a work requirement for most adults receiving Medicaid coverage, even though the Biden administration would probably refuse to allow such a restriction.
But any bill would first have faced another significant hurdle: Gov. Tate Reeves, a Republican who has remained intensely opposed to Medicaid expansion. Mr. Reeves would almost certainly have vetoed any such bill that reached his desk, and it was not clear whether the legislature would have had enough votes to override a veto.
In a statement earlier this week, Mr. Reeves said that supporting Medicaid expansion “goes against the principles of our party and the tried and true economic principles that built the greatest country in the history of mankind.” He has criticized expansion as a form of “welfare” and has opposed the added expense to the state, even though the federal government pays 90 percent of the new costs.
For supporters of expansion in Mississippi, who have been pushing for years without gaining traction, the twists and turns during the legislative session — and over the past week in particular — were a whipsaw between optimism and frustration.
“Believe us when we say we’re angry and disappointed,” the House Democratic caucus said in a statement on Friday.
“We will leave Jackson without a plan to solve our state’s increasingly dangerous health care crisis. Again,” the lawmakers said. “We will kick the can down the road. Again. And lawmakers will have caved to political pressure from a governor who has yet to provide his own plan to provide a long-term solution to the health care crisis. Again.”
The prospect of Mississippi joining the 40 states that have expanded Medicaid gained new viability this year, as a broad coalition of business and religious leaders urged lawmakers to act and polls showed overwhelming public support. Mr. White, the new House speaker, was a major proponent.
In February, the House passed a bill that would offer coverage to people with incomes up to 138 percent of the federal poverty level, or just over $20,000 a year for a single person. The bill included a work requirement, but it also contained a provision ensuring that the expansion could move forward if the federal government rejected the work requirement.
Then the Senate approved its own scaled-back version, limiting eligibility to people below the federal poverty line. The Senate version would have taken effect only if the Biden administration allowed the work requirement.
On Monday night, an agreement between the chambers materialized: Coverage would be extended to people with incomes up to 138 percent of the federal poverty level, as called for under the Affordable Care Act, but new recipients would be required to work at least 25 hours a week to get benefits.
The deal started to wobble almost immediately. Some Democrats promised to vote against it, saying the work requirement would stymie federal approval.
“We were never going to support a bill that would’ve placed us in a state of permanent expansion limbo just to be able to say we did something,” the House Democratic caucus said in its statement.
Then Mr. White, the speaker, announced that he wanted to put the question directly to voters. “It became apparent that opinions still differed on the best way to address our health care crisis,” he said in a statement.
He proposed a two-part ballot initiative that would ask residents if they supported Medicaid expansion, and if so, whether it should include a work requirement. But the suggestion was dismissed by state senators.
Work requirements have long been central to the Republican goal of instilling a sense of “personal responsibility” in people who benefit from government programs. Data suggests that the majority of Medicaid enrollees have jobs. But in Arkansas, thousands of people lost Medicaid coverage after the state imposed a work requirement in 2018, largely because of the onerous paperwork and reporting obligations.
“I remain committed to finding ways to increase access for working Mississippians who otherwise do not have the resources for a simple checkup or an extended hospital stay,” Lt. Gov. Delbert Hosemann, a Republican who presides over the State Senate, said in a statement.
He indicated that expanding health care access would be a priority again next year. Still, he added, a work requirement would remain “a bottom line for many senators.”