Gov. Tate Reeves, Senate leaders and other Mississippi Republican officials who oppose expanding Medicaid to provide health insurance for the working poor can thank Democratic President Joe Biden for bolstering their argument.

One of the primary arguments used by Reeves and others is that if Medicaid expansion is enacted, it will result in thousands of Mississippians losing private coverage from the health insurance marketplace exchange.

They argue that working poor Mississippians already are being covered through private health insurance policies at little or no cost on the exchange. If Medicaid was expanded, those who had private health insurance at little or no cost on the exchange would be forced under federal law to relinquish those policies and receive health insurance through Medicaid.

The reason that working poor Mississippians can receive those policies at such favorable rates is because of Joe Biden. Those favorable rates were part of two pieces of legislation Biden pushed through Congress — first the American Rescue Plan Act and then the Inflation Reduction Act. Biden did not support the enhanced benefits as a way to prevent states from expanding Medicaid. He supports Medicaid expansion, but he viewed the enhanced benefits as just one way to provide help for those who had to turn to the exchange for health care coverage.

All Republicans in the Congress voted against both bills providing the enhanced marketplace benefits. That is important because the enhanced subsidies that are available to acquire health insurance on the exchange are scheduled to expire at the end of 2025. And it is questionable at best whether they can be extended.

It is unlikely a President Trump, if elected, will extend the benefits. And it also is questionable whether a Democratic President Harris, if elected, can again get such legislation through a divided Congress.

But what we know will be available after 2025 is Medicaid expansion like 40 other states already have enacted, in which the federal government pays the bulk of the cost to provide health care for the working poor.

During the 2024 Mississippi legislative session, Reeves, much of the Senate leadership and others cited the health insurance policies available on the exchange as a reason not to expand Medicaid. Ultimately that group opposed to Medicaid expansion prevailed.

Both Medicaid expansion and the health insurance marketplace exchange are components of the Affordable Care Act, known by some as Obamacare.

A little history of the ACA might be helpful.

Under the original ACA legislation passed in 2010, the intent was that states would be required to expand Medicaid. But the U.S. Supreme Court in a ruling upholding the constitutionality of the ACA said that states could not be forced to expand Medicaid.

Under the original intent of the ACA before the Supreme Court ruling, people up to 138% of the federal poverty level (about $20,500 annually for an individual) would receive health insurance via Medicaid expansion. Those above 138% of the federal poverty level who did not have insurance through their employers could purchase insurance on the exchange with the help of federal subsidies.

But the Supreme Court ruling changed the ACA. After the Supreme Court ruling, states could not be forced to expand Medicaid but people between 100% and 138% of the federal poverty level could purchase insurance on the exchange in states, like Mississippi, that did not expand Medicaid. And federal subsidies would be available to help people with lower income with the cost of purchasing a policy through the exchange.

Those subsidies were substantially enhanced under legislation passed in recent years under Biden. For people below 150% of the federal poverty level, thanks to the Biden legislation, they can receive a policy with no monthly premiums opposed to having to pay roughly 2% of their annual income as they had to under the original ACA. Plus, out-of-pocket expenses and deductibles are much lower under the Biden legislation than under the original ACA, though there are still out-of-pocket expenses and deductibles that make the policies cost prohibitive for many low income people. But regardless, those enhanced subsidies, which were cited by Reeves and others as a reason not to expand Medicaid, are slated to end at the end of 2025.

Importantly, under the ACA after the Supreme Court ruling, those earning less than 100% of the federal poverty level are out of luck in states like Mississippi that have not expanded Medicaid because they are not eligible to get coverage through the exchange.

If Mississippi continues to be among the minority of states not expanding Medicaid, the only hope for those under 100% of the federal poverty level is that the Congress and president, whomever that might be, will provide them some type of relief.

This article first appeared on Mississippi Today and is republished here under a Creative Commons license.