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Mississippi Medicaid expansion is at a crossroads over work requirement

The state is closer than ever to expanding Medicaid, but experts say requiring people to work could limit enrollment.
The Mississippi State Capitol in Jackson.
Mississippi legislators are considering expanding Medicaid in the state, which has some of the nation's worst health outcomes.Denis Tangney Jr / Getty Images

In Mississippi, the poorest state in the nation, Republican lawmakers have loosened their decadelong resistance to expanding Medicaid and making health insurance available to roughly 200,000 of the state’s low-income residents. 

But some Republican leaders have said they will not approve a bill without a work requirement, a provision critics say could still leave the most vulnerable Mississippians behind.

Medicaid expansion would bring coverage to state residents with incomes up to 138% of the federal poverty level — $20,783 for an individual, or $35,632 for a family of three. Currently, families of three with earnings up to 28% of the poverty level or $7,230 are eligible.

But many health policy experts, advocates and politicians say the work requirement would limit the bill’s reach. In a largely rural state, residents who lack employment, child care and transportation options could face insurmountable hurdles in meeting the work requirement and gaining access to Medicaid.

“There’s always this Gordian knot that poor people have to untie just to even get to the services they deserve,” said Leroy Johnson, a supervisor in Holmes County, where more than a third of residents live in poverty. 

Holmes City Supervisor Leroy Johnson
Holmes City Supervisor Leroy Johnson Holmes County, Miss. Board of Supervisors

“We don’t have the number of jobs we need in the county, so that means the folks got to go outside of the county,” which often means driving dozens of miles to larger employers, he said. “In order to have a good working vehicle,” he added, “you’ve got to have money to buy it.”

People with long periods of illness could also be shut out.

Jara Harvey, 26, worked as a nurse in a college town about 80 miles from her home outside of Jackson before a condition that causes extreme fatigue and difficulty walking hindered her ability to work. Her parents have covered her on a private insurance plan, she explained, but it costs them $281 per month. 

She’s applied for disability benefits but has been waiting months for approval. Legislators intent on a work requirement, she said, are ignoring people like her.

“If there was a requirement for me to work, there’s no way on God’s earth I would be able to do it,” she said.

The House bill, which passed on Feb. 28., includes a work mandate but would allow Medicaid expansion to advance without one. 

The Senate has until Thursday to vote on its own bill, which thus far is a placeholder, or “dummy bill,” without key details. Senate Medicaid Committee Chair Kevin Blackwell has said that he doesn’t think a deal can be reached without a stronger work requirement than the one passed by the House.  

Kevin Blackwell speaks inside the state Capitol.
Senate Medicaid Committee Chair Kevin Blackwell has said he would like to see a work requirement tied to health coverage.Rogelio V. Solis / AP

But that’s likely to bump up against resistance from the federal government, which has pushed to limit hurdles to enrollment. Thirteen states sought permission for work requirements under the Trump administration. Several backed away from them after legal challenges. Under the Biden administration, the Centers for Medicare and Medicaid Services has also revoked previous approvals for the requirements.  

Arkansas, which no longer has a work requirement, was the only state whose Medicaid program penalized beneficiaries who failed to work. At least 18,000 residents lost coverage while the requirement was in effect.  

Medicaid recipients were required to log their work hours online, presenting a challenge for those who lacked internet service. Researchers found that many low-income adults were unaware of the policy, putting them at risk of being wrongfully kicked off.  

In Georgia, the only state with an active work requirement, only 2,344 residents gained coverage in the first six months of the expansion, according to the state. The program, an alternative to traditional Medicaid expansion known as Georgia Pathways to Coverage, serves residents making up to 100 percent of the federal poverty line and doesn’t qualify for the federal government’s match that would pick up nearly all of the state’s tab.

As the South struggles with rural hospital closures, some advocates see Medicaid expansion as a way to help them keep their doors open. Growing a state’s share of insured residents can help decrease the amount of uncompensated care — treatment to patients who are uninsured or otherwise unable to pay — that hospitals provide.

Laura Harker, senior policy analyst with the Center on Budget and Policy Priorities, a nonpartisan research group, said the low enrollments in Georgia’s program have limited its impact.

“That’s more people than before, which is nice,” she said. “But for hospitals and health systems, that’s not making a big dent in their high uninsured rate and the rural hospital closure rate.”

In Mississippi, the future of Medicaid expansion is murky. Gov. Tate Reeves, a Republican, reiterated his opposition to the expansion on X, formerly known as Twitter, after President Joe Biden’s State of the Union address last week. “Our country is going broke and he wants to add millions more to the welfare rolls,” he wrote after the president praised the Affordable Care Act. “We have to stand strong in Mississippi! NO Obamacare Medicaid expansion!” 

Lawmakers would need the support of two-thirds of both chambers to override his veto.  

Still, House Minority Leader Robert Johnson, a Democrat, is not willing to dismiss the momentum of the first Medicaid expansion proposal to advance this far in the state. 

Robert L. Johnson III speaks during a hearing.
House Minority Leader Robert Johnson has advocated for Medicaid expansion.Rogelio V. Solis / AP file

For years, none were even brought up for a vote in committee. 

“We will fight to perfect a bill to make it as good as we can make it,” he said. “But at some point, we will realize this is as good as we can do, because some Medicaid expansion is better than no Medicaid expansion.”

CORRECTION (March 13, 2024, 9:17 p.m. ET): A previous version of this article misstated the income figure for 138% of the federal poverty level for an individual. It is $20,783, not $20,873.