As the 2024 Mississippi legislative session gaveled open in January, it appeared to be the start of a new era. Many Capitol observers expected it to mark an end of several years of intense GOP in-fighting between the House and Senate — led by former Speaker Philip Gunn and Lt. Gov. Delbert Hosemann, respectively.

It also appeared a boon for an issue that had loomed for a decade over Mississippi's poor, sickly population and struggling hospitals: Medicaid expansion and the billions of federal dollars available to address this, but for red-meat Republican “anti-Obamacare” politics led by Gunn and Gov. Tate Reeves.

Newly-elected House Speaker Jason White said Medicaid expansion would be on the table in his House and vetted with pragmatism, not politics. This appeared to align with Hosemann's stated openness to such policy. For years he had been the lone statewide Republican leader to even leave the Medicaid expansion door open, and he had suffered political slings and arrows from Gunn and Reeves and others in his own party. He had to fend off a serious primary challenge from the right last year that appeared to have tacit approval from Reeves.

Now it appeared two like-minded, reasonable Republican politicians would come together, eschew the far-right politics that had hamstrung efforts to address the state's health care crisis for years and work something out.

That didn't happen.

Early on, it became clear the two leaders and their lieutenants were not communicating much on Medicaid expansion (and other issues). They were on different trajectories and not only not on the same page, but not in the same book. And Reeves was working to sabotage any expansion efforts, particularly with rank-and-file members of the Senate over which he had presided as lieutenant governor for eight years.

The House held an open hearing on Medicaid expansion with testimony from experts — a sea change for a topic that had been taboo for legislative Republicans for much of the last decade. In February, with an overwhelming bipartisan vote, the House passed a Medicaid expansion plan, calling it a “moral imperative.”

But the Senate was circumspect and secretive about whatever work it might be doing on Medicaid expansion. It had an expansion bill, but it was only a “dummy” bill containing law code sections and no details. Right up to a mid-March deadline for its passage, the Senate leadership refused to detail any plans, leaving members, the House and the public in the dark and health experts worried whatever the Senate came up with could include elements that were unfeasible, costly and counterproductive.

It appeared that, despite Hosemann for years saying he was open to discussion on expansion, the Senate had not laid much groundwork for it.

As the clock ticked into late March, the Senate let its own dummy bill die, but eventually released details of its own proposal, which it used as a “strike-all” to rewrite its own version into the still-alive House bill a full month after the House had passed it.

READ MORE: Speaker White on Medicaid expansion negotiations: ‘Come for the savings, stay for the compassion'

‘Expansion lite' with a poison pill

The Senate proposed what it called “Medicaid expansion lite” in late March. It would only cover the poorest of the poor — about 40,000 Mississippians compared to the 200,000 or so the House plan would cover. It would not meet federal criteria for Medicaid expansion, so the Senate plan would continue to turn down over $1 billion a year in federal Medicaid money Mississippi could use for the program, plus another nearly $700 million over the first two years to help set it up and cover any state costs.

The Senate plan also contained what experts quickly pointed out would be a poison pill — a strict work requirement for enrollees with bureaucracy to police it. The federal government under the Biden administration had struck down previously approved work requirements and refused to grant any new ones. The Trump administration had granted some, but only as a means to rein in participation in already expanded Medicaid programs, not as a means to implement new expansion states.

The House plan had also included a work requirement, but House leaders realized it would likely never fly, so its plan would allow expanded coverage for the working poor to take effect even if the feds didn't approve the work stipulation.

READ MORE: ‘A matter of life and death': Hundreds rally at Capitol for full Medicaid expansion 

Hosemann and his Senate Medicaid Chairman Kevin Blackwell quickly made clear, publicly, that the Senate would not budge on a strict work requirement. They appeared to paint the Senate into this corner even as experts were saying it could prevent expanding Medicaid coverage indefinitely. Blackwell repeatedly said, “No work requirement, no expansion.”

They also, at least for a while, appeared pretty firm on only expanding coverage to those below the federal poverty level, thus ensuring the state would not receive billions of extra federal Medicaid dollars.

Hosemann, Blackwell and other Senate leaders expressed optimism that the Biden administration would be so pleased with longtime Medicaid expansion holdout Mississippi making an effort that it would approve a work requirement, or that the conservative federal 5th Circuit Court would approve it if litigated. Or, that Trump would be reelected and his administration approve it — never mind that this would mean anti-Medicaid expansion Trump expanding Medicaid in Mississippi over the wishes of its Republican governor, whom he supports.

Senate leaders made clear early on they barely had sufficient votes for their plan, and would not be able to pass anything nearly as expansive as the House proposal. Vote counting and whipping on the issue was important. An expansion bill would require a three-fifths vote of both chambers to pass, and more realistically a two-thirds vote to be able to override a threatened Reeves veto. Both the House and Senate have a three-fifths or better majority of Republicans, but with Medicaid expansion, a few far right members in each would never be onboard, meaning both White and Hosemann needed Democrats onboard as well.

Following Georgia's (bad) example?

Mississippi is one of the last 10 holdout states on Medicaid expansion. Lawmakers here had 40 other states, including 20 run by Republicans, to look to for best practices and tips on expansion and stacks of studies. There's a saying among health experts: If you've seen one state's Medicaid program, you've seen one state's Medicaid program.

The initial House proposal had a few minor twists, but otherwise was pretty standard fare for expansion, implementing many things other states have successfully done and, importantly, taking advantage of the billions of federal dollars available to provide health care for poor Mississippians.

The Senate, however, did not appear to emulate any other expansion states' plans or consult much with experts. Instead, it appeared to more closely model Georgia, whose efforts at an expansion-lite plan have been deemed by health experts and advocates a disastrous, expensive failure to date.

The Peach State attempted to cover only some of its poorest citizens — thus not receiving enhanced federal Medicaid money — and its insistence on a work requirement has it tied up in court against the federal government. To date, the program is providing coverage to only a few thousand of the 400,000 Georgians who lack health coverage. And of the millions spent so far, more than 90% has gone to administrative and consulting fees for setting up its work requirement monitoring bureaucracy and on legal fees, but not on providing health care.

The initial Mississippi Senate plan, experts said, closely resembled Georgia's, except for being a little worse — more strict on work monitoring. As health experts and Mississippi House leaders have noted, insuring people with income over the federal poverty level pretty much means they or someone in their household has a job, hence the income.

So, the Mississippi House and Senate got a late start on negotiations, largely due to the Senate dragging its feet on getting a proposal out. And they started out very far apart.

For those thinking House and Senate relations would be better with the new administrations taking office, they weren't. The GOP leaders in both chambers openly sparred over numerous major pieces of legislation and recriminations had been flying. Some lawmakers on both sides said it was the worst they had seen in years, although many lawmakers and observers say that most every session.

READ MORE: Hospitals, business leaders suffering FOT — Fear of Tate — on Medicaid expansion

The final nine days of negotiations

Both White and Hosemann had vowed to have negotiations on a final Medicaid expansion bill open to press and public, given its monumental importance.

The first conference meeting between House and Senate negotiators was held in public on April 23 — just six days before an April 29 deadline to agree a plan.

Blackwell, speaking for the Senate, warned House negotiators not to take a my-way-or-the-highway stance. They didn't. They offered a compromise, a “hybrid” plan drafted with help of consultants in effort to allay Senate concerns that expansion would pull people off the federal private insurance exchange. Similar to what some other states have done, the House compromise would cover the poorest Mississippians with traditional Medicaid, but use government subsidized private insurance on the exchange to cover the balance of working poor people.

The compromise would still allow the state to draw down the billions of federal Medicaid dollars available for expansion.

The Senate negotiators didn't reciprocate with any counter offer of compromise, saying only they would take the House counter back to Hosemann and other Senate leaders for consideration and casting doubt that they could gin up support for it.

That was the last of the open to the public negotiation hearings on expansion. House Medicaid Chairwoman Missy McGee scheduled another one, hoping for more public parlay with Senate negotiators and to get response on the House's counter proposal, but Senate negotiators didn't show up for the meeting.

The clock continued ticking on deadlines for passing legislation and the end of the Legislature's four-month session closing in.

READ MORE: House agrees to work requirement, Senate concedes covering more people in Medicaid expansion deal

Pingpong and Hail Marys

The Senate responded with its first counter offer, a hybrid similar to what the House had pitched that would garner the extra billions from the feds, but still with a strict work requirement. And despite offering a “compromise” to the House that he and two other Senate negotiators agreed to, Blackwell expressed doubt it could garner enough votes in the GOP supermajority Senate.

The House countered with a plan that would expand Medicaid with or without the work requirement, but would require the state continue to try to get such a requirement implemented. The Senate demurred.

In all the pingponging back and forth, the Senate would not back down on its demand for a work requirement, even if it prevented coverage from ever being expanded.

With only minutes to spare before an April 29 at 8 p.m. deadline to file an agreement, the House GOP leadership caved on the work requirement. It appeared a final deal had been struck.

But this angered the House Democratic Caucus, whose members said they had been clear with the leadership they would not go along with this. Most of the caucus — reportedly at least 29 members — vowed to vote against the proposal, enough to endanger its passage.

Democratic House leaders said they would not vote for a program that might never go into effect and would be “Medicaid expansion in name only.” They also shrugged off Republican efforts to blame Democrats for killing expansion, saying they were not to blame for the Republican supermajority not being able to work together or get a major initiative passed.

READ MORE: Why many House Democrats say they'll vote against a bill that is ‘Medicaid expansion in name only'

Speaker White said he would still have had the votes in the House to pass the compromise, even with the loss of a significant number of Democrats. But the speaker said he opted to send the proposal back to negotiations after being told by Senate leaders that the Senate only had 28 votes — not enough to pass it by a needed three-fifths majority. 

This prompted a GOP Hail Mary. The House and Senate both voted to recommit the measure on May 1, which bought another 24 hours to try to negotiate a deal. Then on that same night, Speaker White and the House leadership floated a new proposal: Let voters decide the issue. Put it to a statewide referendum, and let voters decide not only whether to expand Medicaid, but also whether to try to include a work requirement.

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

But late Wednesday night, Hosemann threw cold water on that proposal. He said the idea of a referendum had been run by senators and “was not well received.” He also appeared to call the issue dead for this year, issuing a better-luck-next-year statement.

But with the leadership expecting to end the 2024 legislative session as early as Friday, House Democrats tried one last Hail Mary on Thursday. House Minority Leader Robert Johnson III met directly with Senate Republican leaders and offered a final compromise.

Instead of the Senate's most recent plan, which would have required the state to request a federal waiver to implement a work requirement every year until it is approved, Johnson said House Democrats would agree to mandate the waiver request for just one year. Instead of potentially keeping expansion in limbo indefinitely with a work requirement, if it were to be rejected once, Johnson reasoned, lawmakers could revisit the issue.

But Johnson's last ditch pitch wasn't picked up by the Republican leadership in either chamber.

The final negotiations — to use that term loosely — on Medicaid expansion appeared to suffer from the same lack of communication between the House and Senate that the early efforts saw.

The Medicaid expansion measure, House Bill 1725, died Thursday night at an 8 p.m. deadline as the 2024 session neared its end.

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