Surprise, surprise, the federal government is pushing the states to expand Medicaid. Should President Obama win re-election, look for that pressure to intensify regardless the opinion of the nation’s highest court.

When the Supreme Court ruled that the federal government can’t threaten or withhold funding for the state’s existing Medicaid program simply because the state fails to expand Medicaid as dictated by the Obama health care reform act, conservatives in the Mississippi Legislature and Gov. Phil Bryant breathed a sigh of relief.

Republican leaders in both the executive and legislative branches of state government are on record opposing the Medicaid expansion for budgetary reasons. Gov. Phil Bryant said funding a Medicaid expansion would require substantial budget cuts in education, transportation, corrections and other essential functions of state government.

Republican Lt. Gov. Tate Reeves said adding 400,000 people to Medicaid would cost about $1.7 billion over a decade. GOP House Speaker Philip Gunn called the expansion a “budget-buster” for the state.

Democrats, public health advocates, and the Mississippi Hospital Association disagree, citing the belief that as the poorest state in the union Mississippi can ill afford to turn down that infusion of public health care dollars both from the standpoint of public health and that of the state’s stagnant economy.

Medicaid in Mississippi is nearly a $5 billion annual proposition utilizing both federal and state dollars that serves some 641,454 Mississippians. It is also the most heavily subsidized Medicaid program in the nation. In the fiscal year that ended June 30, 2011, for every $1 the state spent on medical care for the poor, the federal government spent $5.61. In the fiscal year that ended June 30, 2012, the ratio dropped to $3 in federal funds for every $1.

On the short term, Medicaid expansion would seem a wonderful thing in Mississippi. But the fear among Republicans is that with the federal government drowning in debts and deficits from entitlement programs that are already in dire fiscal danger, betting the future on yet another expanded entitlement is not only a danger to the federal government’s stability but to the state’s fiscal well-being as well.

Under the Affordable Care Act or “Obamacare” legislation, federal taxpayers will pay the full cost of covering the new Medicaid enrollees for three years, from 2014 to 2016, and the federal share would then gradually decline to 90 percent in 2020. In poor states with large Medicaid populations like Mississippi, state officials worry that future costs will be shifted to the states to pay for the increased enrollments.

Veteran state lawmakers know one thing for certain from a political standpoint: It’s far easier to never give a government service to someone than to give it to them, and then take it away. That’s particularly true of public health care.

Critics of Medicaid expansion opponents argue that they simply don’t care about the poor, the blind, the aged and the disabled.  That makes for incendiary political rhetoric, but the fact is that Mississippi lawmakers have historically authorized a far more generous and expansive Medicaid program than the state could actually afford given the tax structure — then paid for it on the back end by deficit appropriations, dipping into “one-time” special funds, or by windfalls of state revenue from litigation, federal infusions or the like.

That’s the existing Medicaid program I’m talking about, not the expanded program envisioned by the ACA. Medicaid and how Mississippi pays for it has been a dominant theme throughout the three-plus decades I’ve observed Mississippi politics and that theme is likely to continue.

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