In Humphreys County, Mississippi — about 70 miles north of the state capital, in the heart of the fertile Delta region — a third of the residents live in poverty. In Belzoni, the county seat, there are just a handful of health care clinics. The town’s only major hospital closed more than a decade ago, around the same time its catfish industry collapsed.

Jobs in the area are scarce, said Wardell Walton, who was mayor of Belzoni from 2005 to 2013. But even if there were jobs, he said, a lot of Belzoni residents wouldn’t be able to get to them — they don’t own cars, and there is no public transportation.

Many people in Belzoni, and Humphreys County, would get free health care coverage if the state expanded Medicaid under the Affordable Care Act. But for a decade, Mississippi and nine other states have declined to do so. Republican opponents have long derided expansion as a government handout. They also have warned that the federal government would someday renege on its promise to cover nearly all of it.

Now there is growing momentum in deep-red Mississippi and several other holdout states to shift course, with many GOP lawmakers swayed by the prospect of giving a financial infusion to struggling rural hospitals.

But they support expanding Medicaid on one condition: that enrollees get a job.

Medicaid is a joint program run by states and the U.S. government, and the federal Centers for Medicare & Medicaid Services has to sign off on specific rules. That includes requiring recipients to work.

The Biden administration has repeatedly refused to give states permission to impose work requirements, and it has rescinded approvals granted by its predecessor. However, the prospect of a second Trump administration, which almost certainly would allow work rules, has sparked renewed GOP interest in Medicaid expansion.

“We all feel like politically and as an incentive to get Mississippians back to work, that it’s important to be in the bill,” said Mississippi Republican state Rep. Sam Creekmore, who chairs the House’s public health committee. Creekmore noted that Gov. Tate Reeves, a Republican, is still opposed to expansion. “If we’re going to have a veto-proof bill or a bill that can override a veto, the work requirement is going to have to be in there.”

Some states that already have expanded Medicaid, including Arkansas, Idaho and Louisiana, also are considering adding work requirements.

Meanwhile, some Democrats in holdout states see work rules as way to finally get expansion over the finish line. And if a second Biden administration strips them out later on, all the better.

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