Why Medicaid expansion failed in Mississippi and Alabama this year: Shots

For Dr. Roderick Givens, Medicaid expansion isn’t just about politics. He’s a radiation oncologist practicing in a rural area of ​​the Mississippi Delta and he sees how Medicaid coverage could help his uninsured patients on a daily basis.

“I can’t give you the number of patients I see who have advanced disease and have full-time employment,” Givens said. “They haven’t seen a doctor in years. They can’t afford it. They don’t have coverage.”

This spring, the Mississippi Legislature considered but ultimately failed to pass an expansion that would have extended coverage to about 200,000 low-income residents. It is one of 10 remaining states that has not expanded Medicaid.

Seven of these states are in the South. As more red states adopt it, the “drumbeat” of support, as one Southern state lawmaker put it, gets louder. But opposition to expansion is strongly political.

Givens, also board chairman of the Mississippi State Medical Association, which supports Medicaid expansion, said it is long overdue in Mississippi, especially as the federal government in would pay the vast majority – and that most Mississippians support it.

“Why doesn’t this translate into policy?” » asked Givens. “It’s called the stupidity of politics. Period.”

The coverage gap

In states that have not adopted Medicaid expansion, hundreds of thousands of people fall into what is called the coverage gap, that is, they earn too much to qualify for Medicaid but are not eligible for subsidies to help pay for private insurance.

And many also can’t afford the premiums and other out-of-pocket costs associated with employer-sponsored insurance.

The failure of the Mississippi expansion would have included some 74,000 people in this gap.

The coverage gap exists only in states that have not adopted Medicaid expansion, which covers those at up to 138 percent of the poverty level, or about $20,000 a year for an individual. In states that have expanded, people who cannot qualify for subsidized private plans can benefit from Medicaid, which now provides health care to about 80 million low-income Americans.

Givens pointed to Arkansas as a potential model for Mississippi because the state has similar demographics and expansion has been in place there for a decade. “Look at what worked for them and what needs to be changed,” he said. “To me, it’s just common sense.”

The policy of “Obamacare”

For the first time in Mississippi, the state Senate and House of Representatives proposed expansion bills, but ultimately the effort failed and died in the last minute of the legislative session , may’s beginning.

Republican House Speaker Jason White, who favors expansion, acknowledged the political obstacles. “This is President Obama’s signature piece of legislation. It’s known as Obamacare,” White said. “So there are a lot of political dynamics centered around this project that probably never allowed it to get off the ground.”

White said this year has been different because of increased support from the business community.

“I joked with some of my fellow Republicans. I said, come for the savings, if you want, and then you can stay for the salvation and the good things that that brings to improve people’s lives,” he said. White said. “If you can’t make it because it’s the right thing to do or out of compassion to help these people, go ahead because it makes sense from a business perspective.”

In neighboring Alabama, politics also thwarted expansion attempts this year. Although the state legislature has not discussed any direct expansion bills, there has been an attempt to include expansion provisions in a casino gaming bill – a provision aimed at allocating a portion of gaming profits to rural health systems.

But ultimately the bill was scrapped and funding for rural health was cut.

If Alabama adopted traditional Medicaid expansion, at least 174,000 more people would be covered, according to KFF. But the Obamacare connection remains a sticking point in the Republican-dominated Alabama State Legislature.

“The sheer partisan nature of this case is definitely a problem,” said Regina Wagner, a political science professor at the University of Alabama. Wagner noted that most Alabama voters support expansion and that other states have adopted the programs after growing public pressure.

“A lot of rural voters are Republican, so your own voters are affected by this and you’re not paying attention to it,” Wagner said. “If the pressure gets big enough and the sentiment changes, that might be enough to push them.”

Debate over work requirements

The main disagreement in the Mississippi state legislature revolved around work requirements: Recipients had to prove they were working part-time or studying.

White said many of his Republican colleagues view expanding health coverage through Medicaid as “a form of welfare, a form of giveaway, a form of government expansion.”

Opponents of Medicaid expansion in Alabama also worry about the potential impacts of “free health care” on the workforce.

“If you open this subsidized federal program to hundreds of thousands of people, it could actually hurt the labor force participation rate, give them another reason not to go to work, to stay home,” said Justin Bogie, senior director of the tax department. policy at the Alabama Policy Institute, a research group that says it is committed to limited government.

The federal Centers for Medicare and Medicaid Services would have to approve an expansion plan with a work requirement — something the Biden administration has not done.

Mississippi moved closer to a compromise bill that would have included a work requirement. If a CMS waiver is denied, the expansion would not go into effect and the state would have to reapply each year, in hopes of being approved by a future – potentially more conservative – administration.

This is what happened in Georgia. In 2020, the Trump administration approved a waiver of a work requirement as part of a limited expansion effort. CMS later rescinded the waiver, leading to legal action. A federal judge ruled in favor of Georgia, reinstating the work requirement provisions.

However, only about 2,300 people are enrolled, less than half a percent of the more than 430,000 uninsured Georgia adults who could have access if Medicaid were fully expanded, according to KFF. The state’s alternative expansion plan also cost taxpayers at least $26 million, according to KFF, with almost all of it going to administrative and consulting costs, not medical care for low-income people. income.

Lessons from North Carolina

As public support for expansion continues to grow in holdout states, North Carolina could offer a glimpse of future efforts. It is the most recent Southern state to adopt traditional Medicaid expansion. Since its passage last year, more than 600,000 people have become eligible.

“But it still took a while,” said Robin Rudowitz, KFF vice president and director of the Medicaid and Uninsured Program. “It took the governor continually supporting the expansion, and the legislature finally approving and passing the expansion.”

Rudowitz noted that the tax incentive provided by the American Rescue Plan Act also played a role in moving the needle in North Carolina and could help spark debate in other holdout states. But ultimately, she said, the reasons the ACA was created continue to be the strongest motivators.

“Without expansion, more and more people are uninsured. Hospitals and other providers can’t get reimbursement because individuals are uninsured,” Rudowitz said. “These are the underlying issues that existed before the ACA and continue to exist, particularly in states that have not adopted the expansion.”

This article was produced in partnership with the Gulf States Newsroom and KFF Health News.