The absolute nightmare that has been the Obama administration’s rollout of the Affordable Care Act has provided additional ammunition – both from a political and policy standpoint – to Mississippi Republicans opposed to Medicaid expansion in Mississippi through the ACA or “Obamacare.”

And while the Democratic minority in the Mississippi Legislature will continue to try to force the state to “opt-in” to ACA’s Medicaid expansion, they have neither the votes nor the clout to move the needle on that issue at this time.

The HealthCare.gov. Web site intended to empower President Barack Obama’s signature legislation – developed at a cost of more than $634 million – simply didn’t work, but that wasn’t the worst of it. When the web site was eventually accessed, it gave inaccurate, misleading information to the people the program was purported to be helping.

The web site glitch alone isn’t the only problem with the ACA rollout and it’s a gross over-simplification to suggest that it is. But the confusion generated by that glitch was enough to make Southern governors like Mississippi Gov. Phil Bryant feel justified in their decision to reject Medicaid expansion.

The promise of the ACA is almost intoxicating. Reduce the shameful number of uninsured with the federal government paying the freight for the lion’s share of the public health care coverage.
But the fiscal reality is more complicated. First, the more the Medicaid program expands, the larger the total state appropriation necessary to fund the state’s portion of the expanded Medicaid program. Second, the nation’s fiscal house isn’t in order to take on yet another open-ended entitlement program for which no dedicated funding mechanism has been put in place.

Finally, there’s the uniquely Mississippi quandary over Medicaid: What do we do 15 years down the road if Congress changes their mind about the ACA’s funding formula and we’ve expanded Medicaid in Mississippi by another 300,000 patients?

State lawmakers know from hard experience the political consequences of changing the Medicaid program. And from those experiences, they see the political impossibilities of taking expanded Medicaid coverage away a decade or two down the road if Congress increases the required state match to a level that’s unsustainable in Mississippi.

The fact is that 1 in 7 or some 476,000 Mississippians don’t have health insurance. Expanding Medicaid as provided for in the ACA could put between 1 in 4 and 1 in 3 Mississippians on Medicaid. At the current match rates in ACA, the state looks foolish to forego Medicaid expansion.

Yet if Congress changes those Medicaid match rates in the future, the view changes. Mississippi Republicans will hold sway on the Medicaid issue for the foreseeable future.

Another card in the hands of the GOP leadership in state government is a slowly improving economy. State tax revenues are improving and beating the revenue estimate most months – and some months the surplus has been impressive.

But all of those positives for the GOP on the Medicaid expansion issue don’t trump that fact that Mississippi remains the poorest state in the union. Public budgeting in Mississippi for decades has centered on financing public education and public health care first, then every other function of state government with what’s left.

Political rhetoric to the contrary aside, Mississippi’s dependence on federal funds isn’t likely to change dramatically in the near term. More than half the state’s total budget comes from the federal government. As the Democrats did while they ran the show and as the GOP has done since they wrested control of Mississippi’s government away from the Dems, Mississippi will continue to accept federal Medicaid dollars not directly related to the ACA.

What Democrats will do at every opportunity for the next few years is repeat to all who will listen among the state’s uninsured or underinsured that it was a state government decision to deny expansion of the Medicaid program in Mississippi and that the GOP now runs state government. The GOP won’t dispute that.

But the numbers to watch in the Medicaid expansion debate from the long view in Mississippi is that of the rising cost of uncompensated care – which taxpayers and health insurance ratepayers also subsidize. In the final analysis, only that number will determine whether or not the state expands Medicaid under ACA.

(Sid Salter is a syndicated columnist. Contact him at 601-507-8004 or sidsalter@sidsalter.com.)