Mississippi is closer than ever to expanding Medicaid. What are the barriers?

If Mississippi were to expand Medicaid, Brandon Allred thinks he could finally get the cancer screens he is certain he needs.

Allred, 35, works full-time to support his family of six children in Tupelo, but doesn’t earn enough to afford health insurance for himself, something he has gone without for nearly a decade.

Advocates in Mississippi have tried for years to expand Medicaid, only to see those efforts collapse under political opposition, particularly from Republicans. The latest attempt, led by Republican lawmakers in the state House, has been the most promising yet. As the state Senate advances its own plan, supporters say the stakes are too high to let another opportunity for expansion fail. But the new version would leave hundreds of millions of dollars on the table and cover only a fraction of people who otherwise would remain uninsured, according to health experts.

“It’s not even considered expansion by federal guidelines,” said Mitchell Adcock, executive director for the Center for Mississippi Health Policy.

In Mississippi, a state that reports the lowest life expectancy and highest poverty rate in the United States and ranks among the most uninsured states in the nation, expansion could make a significant difference. Compared to residents of most other states, Mississippians are more likely to accrue medical debt, endure some of the worst health care access and services, and rely on care from hospitals that are growing more financially vulnerable.

Allred’s father died at age 55 from stage IV lung cancer in 2015 – a fate he wants to prevent for himself. He also knows he has to see a dentist. After losing multiple teeth over the years, Allred had to teach himself how to talk again. But the medical care he needs would cost too much.

If given a chance to climb out of the Medicaid coverage gap, Allred said having health insurance “would alleviate the ‘what-if’s, ‘can-I’s and ‘when-will-I-be-able-to’s.”

“What kind of future do I have in Mississippi if I’m not protected on a most basic level?” he said.

Since the Affordable Care Act became law in 2010, 40 states and the District of Columbia have expanded Medicaid. Those states receive more federal funding to offer health insurance to people who would otherwise fall into the coverage gap – adults without children and people who work, but earn too much to qualify for Medicaid and too little to afford their own health insurance premiums. Nationwide, 6 in 10 people who are on Medicaid also work, according to KFF. But Mississippi is one of 10 states that have not expanded access to Medicaid.

After letting the House-approved bill die earlier this month, the state Senate’s committee on Medicaid voted unanimously Wednesday in approval of its own expansion plan. This latest version would cover an estimated 80,000 Mississippians, still leaving more than 100,000 people without health insurance, Adcock said, and would require recipients to work at least 30 hours per week. Some exceptions were permitted, for example, for people caring for children under age 6, people enrolled full-time in school or workforce training. But the new plan does not meet federal thresholds, meaning the state’s “expansion lite” proposal would abandon at least $690 million in federal funding.

Sen. Kevin Blackwell, R-Southaven, who chairs the state Senate’s committee on Medicaid, distinguished their version as being a “conservative plan,” as opposed to the House bill, which he called “basically straight-up expansion.” Blackwell did not respond to multiple email and phone requests for comment from the PBS NewsHour.

Walking away from that money would be “fiscally irresponsible,” said Joan Alker, executive director of the Georgetown Center for Children and Families. On the other hand, the plan overwhelmingly approved by the House in February would have satisfied federal requirements to receive that money, she said.

A plan like the Senate’s “would do very, very little in terms of helping people get health insurance,” Alker said. “The state would be paying much more on a per-person basis than they need to be.”

On Thursday, the Senate passed its version of Medicaid expansion with a 36-16 vote, showing enough support to override a veto. Now, both chambers must work together to figure out what Medicaid expansion would look like in Mississippi.

The high cost of being uninsured

Mounting evidence shows that Medicaid expansion improves coverage rates and overall health. Hundreds of studies have found that states with expanded Medicaid report lower disease burden, higher life expectancy, better maternal and infant outcomes and less risk of medical debt.

Medicaid expansion alone is “not going to solve all of the problems of our health system,” Alker said. “But it’s an imperative piece of the puzzle.”

Mississippi has a “health literacy crisis,” Adcock said. People without insurance coverage avoid preventative care and “go only when they are very sick or have traumatic injury and that drives the cost up.”

Dr. Anita Henderson, a pediatrician in Hattiesburg, said Medicaid expansion could improve health outcomes for workers, boost workforce participation and lower rates of disability because more people could receive preventative care before health problems become catastrophic and costly.

“There is a moral obligation for caring for the poor, the needy and the sick in our state,” Henderson said.

Henderson has observed the absence of health coverage firsthand. Many of her young patients are covered by Medicaid, but their parents are uninsured. She said working mothers and fathers may suffer asthma or mental health issues that go unaddressed because their employers provide no coverage and they cannot afford the cost of insurance on their own.

Nurse practitioner Carolyn Coleman, who teaches nursing practice at the University of Southern Mississippi, said her patients are often on Medicaid or uninsured and have been turned away by local physicians. Coleman said a patient may come to her and report chest pains, but say they are unable to get an X-ray.

“People that don’t have insurance aren’t coming in for preventative care,” Coleman said. “They can’t afford to come in for wellness checks or labs.”

Medicaid expansion would allow nurse practitioners to provide services to patients who otherwise may not receive lab work because of out-of-pocket costs or the fear of medical debt.

Why some Republicans are now fighting for expansion

Nationwide, the aftermath of the COVID pandemic worsened hospitals’ financial burdens and led to numerous closures. Rural hospitals in particular often serve as safety-net health care facilities and have been hard-hit financially, according to Michael Topchik, national leader for the Chartis Center for Rural Health. He noted that 7 in 10 rural hospitals are operating in the red.

“Things are dire nationally for rural hospitals, and they’re particularly dire for Mississippi,” Topchik said. “Medicaid expansion has been one of those dimensions that has been really protective. When you don’t see Medicaid expansion, it’s highly predictive of vulnerability.”

Several of Mississippi’s hospitals are financially strained, further fraying the state’s already threadbare health care system. Since 2010, eight hospitals in the state have closed or ended inpatient care, Topchik said, leaving fewer than 75 rural hospitals to serve a population of about 1.5 million people living in non-metropolitan areas, or about half of all of the state’s residents. Currently, 18 more facilities are vulnerable to closure, and a growing number of those have shuttered labor and delivery departments and other vital specialty services, Topchik said.

Hospitals typically incur “some of the most enormous fixed costs of any industry you can think of,” including worker wages but also sophisticated technology, such as MRI machines and laboratory equipment, Topchik said. For hospitals that typically serve patients in rural parts of the country or from low-income households, programs such as Medicaid and Medicare become financial lifelines because these facilities “will not be able to cover their bases,” he said.

For years, legislators, including previous House Speaker Philip Gunn, refused to take up the issue, allowing the issue to flounder on the Capitol floor in Jackson. But Mississippi’s situation has become so dire that Republicans introduced and have fought for this latest version of Medicaid expansion. When the House passed its plan, it had a veto-proof 98-20 majority, in defiance of Republican Gov. Tate Reeves, who has vowed to oppose it.

“The Biden Team is overjoyed with what some in Mississippi are planning right now,” Reeves wrote in February on X, the platform formerly known as Twitter. “Count me amongst those ‘extreme MAGA Republicans’ who think Government should not run health care.”

A few Mississippi senators have said they are interested in emulating something similar to Georgia’s version of Medicaid expansion, which does not qualify for a federal match, relies on work requirements and has a huge backlog of applicants.

“Millions of dollars have been spent on consultants and litigation costs” in that state, Alker said. “Georgia has been litigating on their waiver nonstop.”

Medicaid expansion critics, including Reeves, argue that it would amount to the state writing a bad check, attempting to cover insurance costs with money that neither Mississippi nor the federal government have to spend and that Congress would withdraw its support, leaving the state with a new mountain of debt.

But Alker said that “Congress has never gone back and lowered the Medicaid match rate. In fact, the opposite has happened — Congress has now put more money on the table.”

In fact, research suggests Medicaid expansion can save state funds, according to the Center on Budget and Policy Priorities. In North Carolina, where legislators voted to expand Medicaid and the state began to enroll people on Dec. 1, “the state is reaping the benefits of the financial incentives,” said Allison Orris, a senior fellow at the CBPP.

What’s next?

Unlike in several states, Mississippians cannot raise the issue of Medicaid expansion — or anything else — through a ballot initiative. In May 2021, the Mississippi Supreme Court and lawmakers dismantled the ballot initiative process. That leaves the prospect of expanding Medicaid up to state legislators and the governor.

Now that the Senate has approved its version of Medicaid expansion, the bill goes to the House for vetting. Both chambers have until later in April to come to an agreement and pass a version of Medicaid expansion.

While “there’s a lot of distance between their two positions,” Adcock said, “the state was not talking about it a year ago. This year, in both houses, it’s being considered, so we’re one step closer” to Medicaid expansion.

Reeves could be a barrier – he has allowed bills, including others linked to Medicaid, to sit indefinitely on his desk without signature. On March 23, Reeves lobbied constituents on X, pressing them to call their state senators and demand that they vote down Medicaid expansion.

But doing nothing is not a sustainable solution, according to Dr. Henderson.

“Simply saying ‘no’ is not really a policy,” Henderson said. “It’s not going to move the needle for Mississippi.”

If Mississippi lawmakers do expand Medicaid, Adcock said the next step would be to educate health care providers, clinic networks and hospitals about this group of newly covered individuals and the kind of coverage they have, including opportunities to conduct wellness checks and offer preventative care.

The stakes are too high for inaction, said Rev. Jason Coker, president of Together for Hope, a social justice nonprofit organization that works across the Deep South, including Mississippi. On March 20, he attended a rally at the state Capitol with more than 50 ministers gathered from across Mississippi, all calling for the Senate to pass Medicaid expansion.

Coker warned that lawmakers “are playing with numbers there and what they don’t realize is that they’re actually playing with human lives. It’s life and death.”

Thinking of his family in Tupelo, Allred said that “a lot of people have lost faith.” He described feeling as if they “are stuck in a debt prison,” while deliberating between needed care for health issues or ignoring a potential problem and choosing to “hope for the best.”

“We shouldn’t be hoping for the best in 2024,” he said.

Coleman is optimistic about how far the Medicaid expansion effort has come, but, she said, it is clear to her what will happen to Mississippians if state lawmakers allow this latest effort to fall apart again.

“We’ll go back to the bottom as we always are, and stay at the bottom,” she said.