Democratic representatives will file a bill to expand Medicaid eligibility to working-class Mississippians — after years of failed attempts and as rural hospitals reach their breaking point.

Though Democrats have fought for years to expand Medicaid, they hope their more pragmatic proposal this session and the new House speaker’s pledge to seek a bipartisan solution on health coverage will finally yield a realistic plan to expand coverage.

“I think a majority of people in Mississippi would like to see … coverage for working Mississippians who don’t have coverage and providing the uncompensated care funding that hospitals need to stay open,” House Democratic Leader Robert Johnson III said. 

The bill, the first major Medicaid expansion proposal this year, would expand traditional Medicaid coverage eligibility and includes a private insurance option for Mississippians who make up to twice as much as the federal poverty level.

There’s also a component that would help subsidize premiums for people who are on or are offered insurance through their jobs. 

It’s a plan that, Democrats say, favors women and small businesses. It would cover more people than traditional expansion because it’ll be easier to qualify for coverage, but more people would be partially paying premiums in a tiered system, dependent on income.

The Affordable Care Act passed in 2010, increased health insurance coverage for millions of low-income people across the country by expanding eligibility to qualify for Medicaid, a federal-state program that provides health coverage to millions of people.

Since 2014, states have had the option to expand Medicaid eligibility even further to the working poor. In states that have not done so, it’s challenging to qualify for Medicaid coverage solely based on income. In Mississippi, non-disabled adults without children are not eligible for Medicaid coverage, regardless of their income. Parents in Mississippi are eligible only if their incomes don’t exceed 24% of the federal poverty level — for context, that’s at most $587 monthly for a family of four, according to the Mississippi Division of Medicaid website. 

Mississippi is one of 10 states that has not expanded Medicaid coverage to the working poor. Meanwhile, the state’s hospitals are foundering. 

One report puts nearly half of Mississippi’s rural hospitals at risk of closure, largely due to uncompensated care costs, or money spent treating patients who are uninsured. Because emergency rooms cannot legally turn down patients, regardless of their insurance status, it’s often the only resort for health care for uninsured people. 

That means without health insurance, preventative care is generally out of reach. 

Research shows expansion would insure the approximately 250,000 people who fall into the state’s coverage gap, meaning they make too much to qualify for Medicaid now but too little to afford private insurance. The policy’s adoption would also generate billions of dollars for Mississippi, directing much-needed money to the state’s struggling hospitals, and allow for more timely health care, likely improving health outcomes in one of the country’s sickest states. 

Despite most Mississippians’ support of Medicaid expansion, Republican Gov. Tate Reeves and former Republican House Speaker Philip Gunn staunchly opposed the policy over the last four years. Even as medical experts sounded the alarm over the financial future of hospitals, Reeves has ignored the policy’s benefits, reducing expansion to “welfare.”

Democratic Rep. Zakiya Summers of Jackson said that Mississippi’s abysmal health outcomes are well documented, and the state cannot afford to “kick the can down the road” any further on expanding coverage to more people. 

“I think we’ve heard a lot of talk about wanting to do something around Medicaid expansion, but we haven’t actually seen pen being put to paper,” Summers said. “What we have developed is a really good opportunity to say, ‘Here is something that we can take a look at and have conversations about.’”

But the Democrats’ latest plan is not a typical Medicaid expansion bill. 

The measure both expands eligibility for traditional Medicaid coverage and includes a private insurance option for people who fall into a certain federal poverty level threshold. If passed, the hybrid policy would cover more Mississippians than a traditional Medicaid expansion bill, which usually covers people up to 138% of the federal poverty level. 

“Our program is going to incorporate people up to 200% of the federal poverty level,” Johnson said. 

Rationalizing the private option, he said, “Asking the government to pay all of the funds to make sure we cover people up to 200% of the poverty level is I don’t think reasonable and I don’t think it’s acceptable or winnable.” 

The bill would:

• Expand Medicaid coverage eligibility for all adults who are at or below 95% of the federal poverty level. In 2024, that is $14,307 gross annual income for a childless individual. 
• Allow adults with no children who make more than that, up to 200% of the federal poverty level or $30,120 gross annual income, to qualify for private health plans through the federal marketplace or offered by the state. 
• If they’re employed and make between 96% and 200% of the federal poverty level, their premiums would be covered at varying degrees by the division. 

Democratic leaders are hopeful the plan — which includes incentives to join the workforce — will gain traction in the Capitol, but they know the Republicans who hold a supermajority in both chambers won’t outright adopt their bill in the coming weeks.

Instead, Johnson hopes that Republicans will at least realize the minority party’s proposal is sensible and include portions of it in a final version and pass it. 

“If it ever gets passed in its final form, it’ll probably have my name nowhere near it,” Johnson said. “But if it means that we get a plan that really provides coverage to people in the state of Mississippi, I don’t care what they call it or whose name is on it.”

The person who wields the most immediate power over the Legislature’s solution to giving health insurance to more Mississippians is House Speaker Jason White, a Republican whose rural district is majority-white and financially disadvantaged.

The speaker has been candid about the need for Mississippi, one of the poorest and sickest states in the country, to consider expanding Medicaid and has said state Republicans deserve criticism for refusing to debate the merits of the program. 

Johnson told Mississippi Today that he and the speaker have maintained an open dialogue this session about Medicaid policy, and he believes White truly wants to shepherd meaningful legislation through the House. 

White told Mississippi Today last week that he and other House leaders are forming a Medicaid plan of their own, but he intends to examine Johnson’s plan to see where the two parties can agree.

“I think we’ll find bipartisanship,” White said. “I’m going to be disappointed if we don’t.”

Arkansas in 2013 voted to adopt a version of Medicaid expansion that includes a private insurance option. As other Southern states consider expansion, the Arkansas model is often referenced.

Though echoes of Arkansas’ version of Medicaid expansion are obvious in the Democrats’ proposal, Johnson said their bill caters to Mississippi’s specific health care and population factors.

Adam Searing, an associate professor at Georgetown University’s McCourt School of Public Policy’s Center for Children and Families whose work focuses on Medicaid, said the Democrats’ bill is a “perfectly reasonable starting place.”

“Expanding Medicaid is a political debate,” he said. “In states that haven’t already done it, there are going to be some compromises.”

Searing said that while Georgia’s initial attempt at expansion only covered part of the population in their coverage gap — subsequently making them ineligible for full federal financial rewards — Mississippi’s bill takes everyone into account.

The federal government will pay 90% of the cost to expand Medicaid to people who are at or below 138% of the federal poverty level, and for people up to 200%, they will pay the federal medical assistance percentage match of the expansion costs. Mississippi has the highest FMAP in the country at 76.9% because of the state’s high poverty rate. 

Additionally, the federal government would pay Mississippi more than $600 million over two years as an incentive for expanding Medicaid. 

There’s no estimate yet for how much the Democrats’ plan would cost the state because the bill hasn’t made it to the Legislative Budget Office, but researchers estimate that Medicaid expansion would generally bring in $1 billion a year in federal money to Mississippi. 

“What I look for in these plans, what makes this one nice, is that the goal is to cover everyone in the coverage gap,” Searing said. “This is where you want to start. I think it’s exciting that someone is putting in a plan, and it’s realistic.”

A significant part of this coverage gap is small business owners who sometimes cannot afford to provide health insurance to their employees. 

Democratic Rep. Bryant Clark, D-Pickens, believes if the proposal were to become law, it would save business owners in his district, most of which is in the impoverished Delta, from paying hundreds of dollars each month in an employer-sponsored health plan.  

“That might not mean much to Amazon or Nissan, but for a mom-and-pop business, that can make a difference in whether you’re in the black or in the red,” Clark said. “If you raise the limit up to 200% in my district, that will probably cover the vast majority of people that are employed in District 47.” 

Democrats said their proposal gives special consideration to women’s health.

Mississippi is one of the most dangerous states in the country to give birth, both for mothers and their babies. A lack of timely preventative and prenatal care is a driving cause of these abysmal outcomes. 

Democrats say upwards of 20,000 more women would be eligible for Medicaid under their plan compared to traditional Medicaid expansion.

“Instead of only addressing women’s health when it comes to taking away their choice, or saying the issues they face aren’t real, let’s come together on a bipartisan level and say we’re going to prioritize women this time … and make sure they have their needs met in this state,” Summers said. “We want to make sure women don’t just survive in Mississippi, but they thrive in Mississippi.”

As evidenced by the Medicaid expansion bill, maternal, infant and reproductive health remain a top issue for lawmakers. But the head of Medicaid, an agency under Reeves’ purview, and other political allies have tried to thwart those efforts.

An additional bill the Democrats are filing could shift that power — the legislation seeks to establish a commission that would manage the agency, allowing it to be run in a way that’s “apolitical,” Johnson said. 

The proposal is currently being vetted by attorneys in the Legislature. Once the bill is introduced, the speaker will refer it to a legislative committee for consideration. 

It’s unlikely legislative leaders will embrace the Democrats’ plan, and White has suggested  Republicans will introduce a Medicaid plan of their own. The process for the House and Senate to agree on a final Medicaid expansion bill will likely take months if they agree at all.

Mississippians’ health and financially bleeding hospitals can’t wait much longer, Johnson said. 

“It’s a broken record, but we have the worst health outcomes in the country … we ought to be flooded with doctors because there’s such a need,” he said. “We’re losing population and losing opportunity.”

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