Work requirement doesn’t kill Medicaid expansion for one Republican state

Mississippi was not the only state where a Medicaid expansion work requirement was a hot topic during the 2024 legislative session.

South Dakota — a more conservative and more Republican dominated state than even Mississippi — debated the work requirement issue during the 2024 legislative session and came to a much different conclusion.

In Mississippi, of course, efforts to expand Medicaid to provide health care coverage for the working poor with the federal government paying most of the costs were unsuccessful. While there were several nuanced reasons the Mississippi Legislature did not expand Medicaid, perhaps the primary reason is the insistence of Lt. Gov. Delbert Hosemann and a majority of the Senate where he presides that any expansion plan include a requirement Medicaid enrollees had to be employed.

It should be pointed out, though, that it is not clear Medicaid expansion would have passed the Mississippi Senate even with a work requirement provision. But the fact that the Senate demanded a work requirement doomed Medicaid expansion efforts in Mississippi. Since the federal government has rejected approving Medicaid expansion work requirements, many argued there was no reason to pass a Mississippi proposal that would never go into effect because of the stringent work requirement.

The South Dakota legislature also debated a work requirement earlier this year and came to a much different conclusion than did lawmakers in Mississippi. Granted, the issues in South Dakota were different than those in Mississippi, but the fact that the two legislatures reached a different conclusion on a work requirement might say a lot about how policymakers from the two states view the importance of a good health care system.

South Dakota legislators decided having Medicaid expansion was more important than having a work requirement. On the other hand, Mississippi legislators — at least the Senate leadership — viewed having a work requirement as more important than providing health care coverage for the poor. They decided having the federal Medicaid expansion stream of money (more than $1 billion annually) for financially strapped hospitals and other health care providers was too important to pass up.

South Dakota already had Medicaid expansion when the work requirement was debated there. It was placed on the ballot through a citizen-sponsored initiative and approved by voters. This past session, the South Dakota legislators opted to put on the November 2024 ballot a proposal to allow voters to weigh in on a work requirement.

But here is the kicker: Even if voters approve the work requirement, that does not mean it goes into effect.

The proposal would give state officials the option to impose the work requirement. And, if the state officials imposed the work requirement and it was rejected by federal officials, then Medicaid expansion still would remain in effect in South Dakota.

Under the proposal offered by Hosemann and his leadership team, Medicaid in Mississippi would not have been expanded if the federal government did not approve a work requirement.

Many cite the work requirement as a logical fallacy or false issue. After all, Medicaid expansion provides health care coverage for people earning up to 138% of the federal poverty level or about $20,000 annually for an individual or $43,000 per year for a family of four. It is common sense that most people getting health care through Medicaid expansion in the 40 states that have expanded Medicaid are working or they would not be earning money.

The federal government has determined that it is a wasteful endeavor to try to enforce a Medicaid expansion work requirement. Studies have shown that Georgia officials, for instance, spent more money enforcing a work requirement than on providing health care coverage.

Most of the 10 states that have not expanded Medicaid are Republican-led states in the South. Many Republican-led states in other parts of the country have expanded Medicaid.

And many of those states are much more Republican than Mississippi. The Mississippi Senate is composed of 36 Republicans and 16 Democrats, while the House consists of 79 Republicans, 41 Democrats and two independents.

By contrast, the South Dakota Legislature is composed of 28 Republicans and only four Democrats with one vacancy, and the House consists of 63 Republicans and a mere seven Democrats with one vacancy.

Yet, despite that overwhelming Republican majority, the South Dakota Legislature opted not to mandate people be working to receive health care coverage through Medicaid expansion.