The rise and fall of efforts to expand Medicaid

When Kevin Blackwell (R-Southaven), chair of the state Senate’s Medicaid Committee, told the Mississippi Free Press this week that the state would not expand Medicaid this year, it marked the end of a period of rising hopes that such a measure would finally pass.

Blackwell’s stated reason was financial: President Donald Trump’s One Big Beautiful Bill Act, signed into law on July 4, 2025, restructured federal Medicaid funding in ways that made expansion impractical.

“There is no expansion,” Blackwell reportedly said. “The Big Beautiful Bill changed funding.”

The announcement marked the end of a legislative effort that, two years earlier, came closer to passage than at any point in the program’s history in Mississippi. It also reflected a shift in the federal landscape that has reshaped the Medicaid debate not only in Mississippi but across the United States.

Mississippi is one of 10 states that have not expanded Medicaid under the Affordable Care Act, which since 2014 has allowed states to extend coverage to adults earning up to 138 percent of the federal poverty level—roughly $20,000 for an individual.

An estimated 200,000 Mississippians fall into the resulting coverage gap, earning too much for traditional Medicaid but too little for affordable private insurance. The state ranks last among states in overall health system performance, according to the Commonwealth Fund’s 2025 scorecard, and more than 15 percent of its adults lack health insurance. Nearly 700,000 residents—including half the state’s children—rely on Medicaid and the Children’s Health Insurance Program.

Work requirement impasse in 2024

The 2024 legislative session produced the most significant movement on Medicaid expansion to date. House Speaker Jason White (R-West) made it a legislative priority. The House Medicaid Committee, chaired by Rep. Missy McGee (R-Hattiesburg), advanced a bill that, in a parallel to the ACA, would have extended coverage to adults earning up to 138 percent of the federal poverty level and draw down approximately $1 billion per year in federal funds. The House bill included a work requirement but contained a provision allowing expansion to proceed even if the federal government denied a waiver for that requirement. It passed 99-20.

The Senate’s approach differed in two key respects. The Senate bill, championed by Blackwell and Lt. Gov. Delbert Hosemann, covered only those earning up to 100 percent of the poverty level and made the entire program contingent upon federal approval of a 120-hour monthly work requirement. Without the waiver, expansion would not take effect. Hosemann described work requirements as essential to the program’s purpose, linking healthcare access to workforce participation.

“When people are healthy, they are working, raising their families, and contributing to their communities,” Blackwell said. He called his plan “a hand up, not a handout.” The Senate version passed 36-16 in late March 2024.

A late-session conference raised the income threshold to 138 percent of the poverty level while retaining the Senate’s work requirement trigger. But the compromise could not secure enough support. Gov. Tate Reeves, who has long opposed expansion, privately signaled he would veto the measure. The bills died at the end of the session.

Hosemann told reporters on May 2, 2024, that Medicaid expansion would have to wait for Trump’s return to office.

“We missed, in my mind, a golden opportunity to expand Medicaid at that time,” Rep. Omeria Scott (D-Laurel), told The Mississippi Independent. “I don’t think that is something that is going to occur.”

Federal landscape changes in 2025

Lawmakers entered the 2025 session with vehicle legislation in place that could have carried expansion language. But Blackwell and McGee both said they were waiting for the U.S. Senate to confirm Dr. Mehmet Oz, Trump’s nominee to lead the Centers for Medicare and Medicaid Services, before acting. They wanted clarity on the new administration’s Medicaid policies.

The session ended without a vote on expansion. Oz was subsequently confirmed. Then, on July 4, 2025, Trump signed the One Big Beautiful Bill Act into law.

The law made several changes relevant to Medicaid expansion. It eliminated a 5 percent increase in federal matching funds that the American Rescue Plan Act had offered as an incentive for non-expansion states to adopt the program. It required states to conduct eligibility redeterminations for expansion populations every six months rather than annually. Beginning in 2028, it mandated cost-sharing for expansion enrollees just above the poverty line. It also placed new limits on state-directed payment arrangements—the financing mechanism Mississippi had used since 2023 to nearly triple its Medicaid hospital reimbursements, from $500 million to $1.5 billion per year.

The Center on Budget and Policy Priorities estimated the law could remove between 9.9 million and 14.9 million Americans from Medicaid and CHIP by 2034, with projected cuts of $1.02 trillion from the programs’ federal budget. The Congressional Budget Office estimated 10.9 million Americans would lose health insurance coverage as a result of the law.

In Mississippi, even without expansion, the state is projected to lose an estimated $5.4 billion in federal Medicaid funding during the next decade. Roughly 46,000 current enrollees could lose coverage through the law’s new administrative and eligibility verification requirements. Beginning in 2029, the phasedown of state-directed payments will reduce hospital funding by approximately $160 million per year, according to the state Medicaid director.

Republicans in Congress included a $50 billion Rural Health Transformation Program in the law, which awarded Mississippi approximately $206 million for fiscal year 2026. Analyses have found the program would offset roughly one-third of the law’s projected cuts to rural healthcare funding.

In assessing the new fiscal landscape this week, Blackwell said the state faces difficult choices. “We have a limited pot of money, and we have a lot of services and a lot of people to provide care for, and so we’re just trying to balance that,” he said. He predicted that states that already expanded Medicaid would face pressure to scale back. “Those states that have expanded will probably be going back to their regular programs before expansion.”

Rep. Scott also filed two Medicaid expansion bills this session, House Bill 224 and House Bill 226, but both died on the Feb. 3, 2026, committee deadline without receiving a vote.

Conflicting views on what comes next

Mississippi’s Medicaid debate now unfolds in a different fiscal environment than the one that existed during the 2024 session. Federal matching incentives for expansion have been eliminated. New administrative requirements are expected to reduce enrollment in existing Medicaid programs. Rural hospitals face the prospect of significant funding reductions within the next several years.

Gov. Reeves has maintained that as a non-expansion state, Mississippi is partly insulated from the law’s most direct effects. “Many of the work requirements and other things that the federal government is talking about doing will have very little or no impact on those states that actually have chosen not to expand under Obamacare,” he said in a 2025 PBS interview. The provisions targeting expansion populations do not apply in Mississippi, where no expansion population exists.

But other provisions of the law apply regardless of expansion status, and healthcare advocates have warned that Mississippi’s system faces new pressures. Richard Roberson, president of the Mississippi Hospital Association, has described the state-directed payment program as “a lifeline” for rural hospitals. Its scheduled phasedown could affect facilities in a state where half the population lives in rural areas.

Scott, who has introduced Medicaid expansion bills in multiple sessions, described the situation in stark terms during a 2025 press conference. “Healthcare is a human right; it’s not a privilege,” she said. “And in Mississippi, where we are the poorest and the sickest of Americans, healthcare ought to be really at the height of our concern.”

Whether the legislature revisits Medicaid expansion in future sessions will depend in part on the federal funding environment and on whether state leaders develop alternative approaches to closing the coverage gap. For now, the estimated 200,000 Mississippians who would have been eligible for expanded Medicaid remain without coverage.

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Image: State capitol rotunda (credit R.L. Nave)