JACKSON, Miss. (AP) — A county-owned Mississippi hospital system that wants to put itself up for sale says one of its main financial challenges is the decision by the state’s elected officials not to extend Medicaid to provide insurance coverage for the working poor.

“Mississippi is one of 12 states that did not adopt a Medicaid expansion, which means the amount of income that would have gone to health systems in our state is slated to decrease, significantly impacting hospitals like Singing River that provide significant care for underinsured and uninsured populations,” Singing River Health System says in a website that promotes its reasons for seeking new ownership.

Singing River Health System is owned by coastal Jackson County. The system operates hospitals in Pascagoula, Gulfport and Ocean Springs. It also has about three dozen clinics and more than 3,500 employees. Trustees of the system announced June 1 that they had voted to put it up for sale or to seek a merger with another health system.

For years, Republican Gov. Tate Reeves and leaders of the Republican-controlled Mississippi Legislature have killed proposals to expand Medicaid, a government health insurance program funded by the federal and state governments. Although the federal government would pay most of the tab for expansion and that would put billions of dollars into the state, Reeves and others have said repeatedly that they don’t want to enroll more people in the public program.

Under the health care overhaul that then-President Barack Obama signed into law in 2010, states have the option of expanding Medicaid to low-income workers whose jobs do not provide private health insurance.

Even without expansion, Mississippi’s Medicaid enrollment has increased significantly during the COVID-19 pandemic. In a state with about 3 million residents, just over 670,000 people were enrolled in Medicaid in March 2020, the first month that COVID-19 cases were confirmed in Mississippi. Enrollment was just over 814,000 last month.

The Singing River Health System also says on its website that it faces financial challenges because Mississippi has a high poverty rate and a large number of uninsured residents.

Jackson County supervisors decided Monday to hold an Aug. 17 public hearing about the future of the Singing River Health System, news outlets reported. A question about selling the system would be put up for a countywide vote, possibly as soon as November, if at least 1,500 people sign a petition to call for an election.

Supervisors said if the hospital system is not sold, Jackson County would likely need substantial tax increases to keep the Singing River Health System in business.

Singing River officials told supervisors that the system needs $287 million over the next five years to cover increasing costs, the Sun Herald reported. Supervisor Ken Taylor said the amount needed to cover the hospital’s projected costs would exceed the legal limits on how much the county can increase taxes each year.