Democrats in the Mississippi Legislature have a gun to the head of their hostage—in this case, the state’s entire Medicaid program—and they’ve made their demands: Give us a debate and vote on the Affordable Care Act’s Medicaid expansion or we’ll pull the trigger.
The language might sound hyperbolic, but those are the stakes as the minority Democrats seek a vote on the federal law’s biggest insurance coverage expansion.
Here’s the deal: Periodically, state lawmakers have to reauthorize Mississippi’s Medicaid program to keep waivers in place and funding flowing so it can continue to operate. The current program expires July 1. A reauthorization bill was introduced in January in the House, but House Democrats, who have enough votes to block legislation but not pass any on their own, killed it by mid-February.
They say they want a debate and vote on the Medicaid expansion before they’ll reauthorize the whole program. But right now House Republicans aren’t giving it to them. Speaker Philip Gunn intentionally blocked a Senate-passed reauthorization bill that included a section in which Democrats could have proposed the expansion. Instead, he pushed a different reauthorization bill without such a section, and that’s the one that Democrats killed last month.
Now each side is settling in and watching the clock tick toward that July 1 deadline.
“It's sort of like we're at the Alamo. We're here, we're dug in and we're going to stay,” says Democrat Bobby Moak, the House Minority Leader. “Because we think that's the only way there continues to be a conversation about this issue. If we move, then we lose the conversation and we think the program is too important to do that.”
Would Mississippi Dems really let their state’s single biggest entitlement program expire just to make a philosophical point? As Moak points out, they've done it before. In 2004, the GOP-led legislature passed and then-Gov. Haley Barbour signed legislation that significantly reduced Medicaid eligibility, removing 65,000 older and disabled Mississippians from its rolls. Later that year, Democrats pledged to block reauthorization of the State Department of Human Services, which houses the Medicaid program, unless Barbour allowed them to undo the cuts. Barbour refused, and the department’s authorization expired in late 2004, forcing Barbour to seek a court order that would allow the agency to keep operating. After simultaneous court battles over reauthorization and the Medicaid cuts, Barbour relented and the legislature passed a bill in 2005 to restore eligibility to those 65,000 people.
Moak hopes that memory is still fresh for some of his Republican colleagues.
“They’ve been talking about it,” he says. “They know we’ve got a history.”
It’s the nuclear option, to be sure. Roughly 750,000 of Mississippi’s 2.9 million residents are enrolled in Medicaid, and the program pumps more than $4 billion annually into the state’s economy. But the ultimate decision on the expansion will have major consequences, too: About 19 percent of the state’s population is uninsured and more than 300,000 would gain insurance coverage through Medicaid under the ACA. An estimated $15 billion in federal dollars would flow into the state over the next 10 years as the federal government picks up most of the tab for the expansion.
What would expiration actually mean for Medicaid? At the least, it'd be a administrative and legal headache for Gov. Phil Bryant and his administration. In a worst-case scenario, people would stop receiving benefits, which could lead to a public outcry—like the one seen in 2004—that Democrats hope would force Republicans to come around.
So far, GOP leaders aren't bending. But there are hints that some kind of compromise could be found without letting the whole Medicaid program expire. Rep. Bobbie Howell, a Republican who chairs the Medicaid committee, says he has some proposals in the works, including a temporary extension of the program to allow for more information-gathering and debate around the ACA expansion specifically.
Republicans could also be interested in a deal like the one Arkansas has struck with the U.S. Department of Health and Human Services (HHS), Howell says. In that state, Gov. Mike Beebe has proposed using Medicaid money to pay for people to purchase private insurance on the marketplaces created by the ACA. HHS has preliminarily signed off on the idea, and other Republican states have expressed interest in doing something similar.
But the legislative session is scheduled to end on April 7, so time is running out to find an alternative path. The only option after that is for Bryant to call a special session to get something passed.
“It's to nobody's advantage for us to leave without at least a basic Medicaid program in place. We need to find some agreement that would move us down the road,” Howell says. “There are a number of different things that different states are doing to best suit their needs. We need some time to look at that.”