The final version of Medicaid expansion in the Legislature could leave tens of thousands of uninsured, working Mississippians waiting indefinitely for Medicaid coverage – unless the federal government makes an unprecedented move.

The compromise lawmakers reached minutes before a legislative deadline on Monday night makes expansion contingent on a work requirement. That means even if both chambers pass the bill, the estimated 200,000 Mississippians who would qualify for coverage would need to wait until the federal government, under either a Biden or Trump administration, approved the waiver necessary to implement a work requirement – which could take years, if ever.

Lawmakers in favor of the work requirement have not been open to allowing expansion to move forward while the work requirement is in flux. The House bill proposed expansion be implemented immediately but included a “trigger law” similar to North Carolina’s. The “trigger law” mandated that if the federal government ever changed its policy on allowing states to implement a work requirement, Mississippi would move to implement one immediately.

Senator Brice Wiggins, R-Pascagoula, one of the Medicaid expansion conferees, posted on social media “if CMMS wants people covered then it will approve (the work requirement). Nothing prevents them from approving it other than POTUS/CMMS philosophy.” 

But even in states where a work requirement was approved, litigation ensued, with the courts finding the approval of the work requirement unlawful for a number of reasons, according to a KFF report. 

Senate Medicaid Chairman Kevin Blackwell, R-Southaven, did not respond to Mississippi Today by the time the story published. 

Will a Biden – or Trump – administration approve the work requirement?

The Biden administration has never approved the waiver necessary for a work requirement and has rescinded ones previously granted under the Trump administration. Waivers granted under the Trump administration were not granted under the current circumstances as Mississippi. 

Mississippi Today reached out to the Centers for Medicare and Medicaid Services for comment but did not hear back by the time of publication. 

Joan Alker, Medicaid expert and executive director of Georgetown University‘s Center for Children and Families, explained that the Trump administration has never approved a work requirement up front for a traditional expansion plan like Mississippi’s.  

In states like Kentucky and Arkansas, Alker explained, the Trump administration approved work requirements as a means of limiting already-existing expansion plans. In Georgia, an outlier state that remains in litigation with the Biden administration for rescinding the state’s work requirement waiver, the Trump administration approved a work requirement for a plan that isn’t considered full “expansion” under the Affordable Care Act and doesn’t draw down the increased federal match rate.

“If the Legislature passed a bill with both of those requirements being non-negotiable, (the work requirement and the enhanced match) they need to know that there is no precedent for that kind of approval from either a Biden or a Trump CMS,” she said.

What happens if a work requirement is approved?

In the best case scenario – that a work requirement is approved by some administration in the near future – its implementation could mean an increase in administrative costs and a decrease in eligible enrollees getting the coverage for which they qualify. Georgia’s plan, for example, requires people document they’re in school, working or participating in other activities. The requirement has cost taxpayers at least $26 million, and more than 90% of that has gone toward administrative and consulting costs, according to KFF Health News.    

“Even if CMS does approve (it), actually implementing and administering work requirements is costly and complex,” explained Morgan Henderson, the principal data scientist on a study commissioned by the Center for Mississippi Health Policy and conducted by the Hilltop Institute at the University of Maryland, Baltimore County. “This would almost certainly significantly dampen enrollment relative to a scenario with no work requirements, and cost the state millions to implement.”

Many of the cases where work requirements were approved but then deemed unlawful were due to court rulings that found that the work requirement resulted in lower enrollment, counterproductive to the primary goal of Medicaid. 

In addition to lowering enrollment, the work requirements have not led to increased employment, the primary goal of the work requirement, explained Alice Middleton, deputy director of the Hilltop Institute and a former deputy director of the Division of Eligibility and Enrollment at the Centers for Medicare and Medicaid Services. 

“Recent guidance has been clear that work requirements would jeopardize health coverage and access without increasing employment,” Middleton said. “While a future Trump Administration may revisit these decisions and approve work requirements again, legal challenges are likely to follow …”

Senate leaders compromised with the House on a number of fine points regarding the work requirement: reducing the mandatory employment from 120 to 100 hours a month; reducing the number of employment verification renewals from four times to once a year; and removing the clause that would require the state to enter into litigation with the federal government, as Georgia did, if the federal government turns down the work requirement. 

“It was encouraging to see both sides compromising, but, ultimately, the inclusion of work requirements presents multiple sets of challenges to successful expansion,” Henderson said.

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