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Lt. Gov. Delbert Hosemann is a good man who has dedicated his adult life to helping Mississippians.

That's why so many Mississippians are baffled by his dug-in position on Medicaid expansion, which right now threatens to kill one of the most transformative policy proposals that has moved through the Capitol since the 1980s.

Medicaid expansion would provide health insurance to 200,000 Mississippians, most of whom work in low-income, no-benefits jobs and cannot otherwise afford it. It would give so many of those people the chance to stay healthy and keep regular work for the first time in their lives. It would bring billions in additional federal money to the poorest state in the nation, where more than half our rural hospitals are on the verge of financial collapse and so many other needs are underfunded.

It would save lives and livelihoods, and it could legitimately change the trajectory of the state.

But Hosemann's stubborn position on one element of any potential expansion plan — requiring Medicaid recipients to work — jeopardizes the entire proposal. Across the nation, 13 states have tried to implement various forms of a work requirement for Medicaid recipients. The federal government, which runs and funds Medicaid, shot down all 13 efforts.

As legislative leaders will soon meet to try to agree on an expansion bill, Hosemann is doubling down on his insistence that any final plan include the work requirement, adding that its omission from a final bill will not get the Senate votes to pass. If he sticks to his guns, this would almost certainly mean Medicaid expansion dies in Mississippi.

“If you're not working, then you need to go get a job,” Hosemann said in a conservative radio interview just two days ago, reiterating his desire for a work requirement. “… We want them to be working. We have a 53.9% labor participation rate. That's horrific, the worst in the country … If you want a job in Mississippi, you can get one. And so we thought it was very important to have people who are working to have the opportunity to have health care. That's why we passed what we did.”

The state's labor participation rate is, indeed, dismal. But the lieutenant governor in the interview didn't mention the very legitimate reasons so many Mississippians, the unhealthiest American citizens with some of the nation's worst rates of chronic illnesses, cannot work. He did not detail the many financial barriers to those same Mississippians, who are the poorest in the nation, have to finding and keeping steady employment. He did not touch on the state's child care crisis, which for many Mississippians makes regular child care more expensive than what a person can make in a full-time minimum wage job.

READ MORE: To work, Selinda Walker needs health care. To get health care, she needs work.

The irony of Hosemann being the roadblock to passing Medicaid expansion is not lost on people who closely observe Mississippi politics. For years, Hosemann has been among the only prominent Republican leaders to express openness to it (though he has always refused to use the term “Medicaid expansion”). As he sat largely alone on that limb, conservative Republicans worked hard to use it against him, even helping earn him the moniker “Delbert the Democrat” from his 2023 GOP primary challenger Chris McDaniel.

On expansion and several other issues, Hosemann, who crushed McDaniel in that primary, has been a more moderate voice than most of his right-wing Republican counterparts. In a polarized state in a polarized political era, many people respect him greatly for that. Few modern Mississippi politicians could boast legitimate bipartisan support, but Hosemann certainly is on that list.

I've closely covered and gotten to know Hosemann for many years now. I've personally witnessed his strong character. I've taken up for him a great deal, even landing the nickname “Delbert's bootlicker-in-chief” from his political opponents last year. What I've seen is a measured, thoughtful and wildly intelligent leader. He's a true numbers guy and a policy wonk, and he's surrounded himself with smart advisers.

He's focused as much of his career on health care improvements as any modern Mississippi elected official. Before he entered public life, he was a legal adviser to health care organizations. Since he was elected, he's visited struggling hospitals and built strong relationships with the most important health leaders in the state, who have persistently talked with him about the benefits of expanding Medicaid. He even visited Arkansas before last year's legislative session to personally learn and study their unique expansion model. He knows what's at stake, and he knows the solutions.

Most people assumed Hosemann would be the out-front leader on expansion, but that has not yet happened. He appeared flat-footed when House Speaker Jason White pushed a traditional expansion plan through his GOP-controlled chamber with overwhelming ease. And what he proposed a month later is not an expansion plan at all.

Hosemann and his fellow Senate Republican leaders tossed aside the House proposal without public debate or serious consideration and proposed their own plan that would draw down hundreds of millions dollars less than the House's traditional expansion plan would. Additionally, the Senate plan would insure between 150,000-200,000 fewer Mississippians than the House plan.

But none of the differences in the House and Senate plans would matter at all if Hosemann keeps his heels dug in on the work requirement. The federal government will not approve it, and a federal court challenge — very much a shot in the dark during a big presidential election year — could cost state taxpayers millions and continue to leave people without health insurance and hospitals without financial help for years to come.

Across the nation, 20 Republican-controlled states expanded Medicaid even without being able to include their coveted work requirement. Those states came up with creative solutions that still drew down the full federal dollars and opened wide the door for increased health care access while instilling the value and importance of hard work.

READ MORE: These Republicans wanted a Medicaid work requirement but couldn't get approval. So they got creative.

Hosemann, often to his credit, has made a point to let Senate Republicans make their own decisions and not strong-arm them into unfavorable votes. But at the end of the day, some of the most transformative policy proposals require strong leadership. In North Carolina, for instance, the latest red state to expand Medicaid, bold and pragmatic leadership from the Republican Senate leader who previously stood against expansion prevailed.

“I felt that I had a certain responsibility — that if the reasons that I had articulated for 10 years no longer exist, then I had a responsibility to be honest with myself and be honest with other people about that,” Senate President Pro Tempore Phil Berger told The New York Times last year. “And so I talked to my members, and I told them where I was — and why.”

In 2020, Hosemann employed this exact strategy to help garner enough Republican votes to change the state flag, then the last in the nation containing the Confederate battle emblem. Those were tough votes for many Republicans, but one-by-one, Hosemann brought in the holdout senators, laid out his own position to them and asked them to consider changing their votes. It worked.

If Hosemann has a willingness to find creative solutions around the work requirement or talk to his Republican Senate colleagues about supporting a real Medicaid expansion program, he's not publicly expressed it. If he doesn't, lawmakers will likely go home without expansion in early May despite being closer to true transformation than ever.

Whether the effort passes or dies in the coming days will likely be in Hosemann's hands. But two major questions remain: Can the most prominent Republican champion of Medicaid expansion for years get it across the finish line? And does he even have the desire to?

READ MORE: Senate Republicans should know: This is literally life-or-death.

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