When it comes to the provision of public health care in Mississippi, the partisan political considerations have changed little since Democratic former President Barack Obama signed his Affordable Care Act into law.

Democrats favor it. Republicans oppose it.

Republicans have generally opposed Medicaid expansion in Mississippi, citing budget considerations and fears over future changes in Medicaid coverage and reimbursement rates. Mississippi Democrats have generally supported the health care policy initiatives of their party under the ACA. Still, both parties have worried about how such possible fiscal impacts would influence an old legislative truism. Once state government agrees to provide a service and constituents come to depend upon it, it’s politically difficult to take that service away.

Historically, Mississippi lawmakers have been fine with the federal government paying the lion’s share of health care provision for the poor, the aged, the blind and children, but they are wary of being left holding the fiscal bag should Congress or a future White House administration change the Medicaid rules.

Mississippi Gov. Tate Reeves and Republican Mississippi House Speaker Philip Gunn have repeated their opposition to Medicaid expansion in recent days. Gunn was characteristically direct in his comments on the topic to Mississippi Today: “I don’t see Medicaid expansion as something that is beneficial to the state of Mississippi. I just don’t think the taxpayers can afford it. That is what it boils down to is the taxpayers. It is their money. I just don’t have taxpayers calling saying we want you to raise taxes so we can expand Medicaid.”

Twelve states have yet to adopt Medicaid expansion: Mississippi, Wyoming, Texas, South Dakota, Wisconsin, Tennessee, Alabama, Georgia, North Carolina, South Carolina, Kansas and Florida.

As noted often before when discussing Mississippi’s public health care, taxpayers will continue to pick up most of the tab. The only real mystery is whether federal, state or local taxpayers bear the lion’s share of those costs or — and this is the more likely outcome — a combination of all three with varying percentages of responsibility.

Currently, Mississippi “pays” for that health care through Medicaid dollars and the delivery of uncompensated care. Nationally, uncompensated care in the U.S. is estimated to comprise 55% of all emergency care delivered. In Mississippi’s state-owned rural hospitals, that percentage is believed to be significantly higher.

The Mississippi Supreme Court is considering a legal challenge questioning the legality of Secretary of State Michael Watson’s certification of the state’s successful medical marijuana initiative placed on the 2020 ballot based on the contention that it was done in violation of Section 273 of Article 15 of the Mississippi Constitution. The outcome of that case looms large over the future of a new initiative effort to sidestep the Legislature and put Medicaid expansion to a statewide vote.

Spurring the Medicaid expansion initiative efforts are congressional efforts to offer non-expansion states like Mississippi substantial additional fiscal incentives to expand the program.

Many dominoes must fall to get to that possible initiative, but if it eventually transpires, what about legislative concerns over the fiscal ramifications of Medicaid expansion in Mississippi?

A 2020 National Bureau of Economic Research working paper by Massachusetts Institute of Technology economist Jonathan Gruber and Harvard economist Benjamin Sommers offered the following assessment from the non-partisan, non-profit think tank:

“We find that Medicaid expansion increased total spending in expansion states by 6% to 9%, compared to non-expansion states. By source of funds, federal spending in the states increased by 10% in the first year of Medicaid expansion, rising to 18% in 2018. Changes in spending from state funding were modest and non-significant, with less than 1% change from baseline annually in the most recent years, 2017 and 2018.

“Meanwhile, we find no evidence that increased Medicaid spending from expansion produced any reductions in (state) spending on education, corrections, transportation, or public assistance.”

Sid Salter is a syndicated columnist. Contact him at sidsalter@sidsalter.com.