With last week’s election of Tate Reeves as Mississippi’s next governor, it would appear that Medicaid expansion is off the table for the forseeable future.

During his tenure as lieutenant governor, the Republican expressed no interest in accepting the federal government’s offer to pay most of the cost to extend the health insurance to the state’s working poor.

And early during this year’s campaign, he called the offer “Obamacare expansion” and signaled that opposition to most anything associated with the former Democratic president would be a hallmark of his time as governor.

“I’m opposed to Obamacare expansion in Mississippi,” he told reporters last January, repeating himself two times for emphasis.

What sounds unequivocal during a campaign, though, is not always so unequivocal afterward. Or at least that’s what some observers wondered after hearing Reeves take a somewhat more conciliatory tone on election night about Medicaid expansion.

The belief is that Reeves, having won the election, may be willing to bend a little on this issue since the next lieutenant governor, fellow Republican Delbert Hosemann, sounds open to expanding Medicaid coverage in some fashion.

Given the politics of the past year, it’s hard to see that happening, but it may depend on how willing Hosemann is to push the matter, and in what form such an expansion might take.

Hosemann has indicated an interest in the variation implemented in Arkansas, which uses federal Medicaid dollars to help uninsured people buy private health insurance. Arkansas also has work requirements and cost-sharing for certain Medicaid beneficiaries.

One option talked up for the last six months has been the plan offered by the Mississippi Hospital Association. It would cover the state’s 10% match by taxing the hospitals and charging a $20 per month premium to the new enrollees.

Although cost-sharing philosophically makes sense, Mississippi would have to be careful that whatever costs are passed on to potential Medicaid enrollees don’t prove counterproductive. The hospitals now pinched by too much uncompensated care would only see that burden significantly reduced if most of those eligible for the coverage actually signed up.

Recent studies cited by the Mississippi Center for Justice, a public interest law firm and advocacy group, show that even modest premiums can reduce participation in Medicaid.

One study, for example, found that premiums set at just 1% of family income reduced public insurance coverage by 15%, and those set at 3% cut enrollment by about 50%, Beth Orlansky, advocacy director for the Mississippi Center for Justice, recently wrote.

She said the Indiana model, on which the Mississippi Hospital Association plan is based, has had issues getting enrollees to consistently pay their premiums. In 2017, according to Orlansky, 18% of Indiana’s enrollees lost their Medicaid coverage entirely for failure to pay premiums.

All of this may be a moot discussion if Reeves isn’t willing to budge and Hosemann can’t command enough votes to override him.

But if the governor-elect comes to his senses and sees how economically foolish it is for Mississippi to remain one of 14 states not to expand, it’s probably a fair guess that he and other Republicans will want the enrollees to have “some skin in the game” — that is, to pay for a fraction of their coverage, just as most workers covered by their employers’ plans do.

Determining how much “skin” is the right amount would be a tricky proposition.

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