For Dr. Roderick Givens, Medicaid expansion isn't just a policy issue. He's a radiation oncologist practicing in a rural area in the Mississippi Delta and he sees how Medicaid coverage could help his uninsured patients on a daily basis.
"I can't tell you the number of patients who I see who come in with advanced disease, who have full-time jobs," Givens said. "They haven't seen a physician in years. They can't afford it. They don't have coverage."
This spring, Mississippi's legislature considered but ultimately failed to adopt expansion, which would have extended coverage to around 200,000 low-income residents. It's one of 10 remaining states that haven't expanded Medicaid.
Seven of those states are in the South. As more red states adopt it, the "drumbeat" of support, as one Southern state lawmaker put it, grows louder. But the opposition to expansion is heavily political.
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Givens, also the board chair of the Mississippi State Medical Association, which supports Medicaid expansion, said it's long overdue in Mississippi, especially since the federal government would pay for the vast majority of it — and most Mississippians support it.
"Why does that not translate when it comes to policy?" Givens asked. "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's known as 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 can't afford premiums and other out of pocket costs on employer-sponsored insurance either.
Mississippi's failed 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 making up to 138% of the poverty level, about $20,000 a year for an individual. For states that have expanded, people who aren't able to get subsidized private plans can get on Medicaid, which now provides health care to around 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 has worked for them and what needs to be tweaked," he said. "For me, that's just common sense."
The politics of 'Obamacare'
For the first time in Mississippi, both the State Senate and House of Representatives proposed expansion bills, but in the end, the efforts fizzled and died at the last minute of the legislative session, in early May.
Republican House Speaker Jason White, who supports expansion, acknowledged the political hurdles. "It's President Obama's signature piece of legislation. It's known as Obamacare," White said. "So there are a lot of political dynamics centered around it that probably never allowed it to get off the ground."
White said this year was different because of increased support from the business community.
"I kidded some of my fellow Republicans. I said, Come for the savings, if you will, and then you can stay for the salvation and the good things that it does to improve people's lives," White said. "If you can't get there because it's the right or compassionate thing to do to help these individuals, get there because it makes sense from a business standpoint."
In neighboring Alabama, politics also thwarted expansion attempts this year. Although the state legislature didn't discuss any direct expansion bills, there was an attempt to include expansion language in a bill about casino gambling — a provision to allocate some gaming profits to rural health systems.
But ultimately, the bill was stripped down, and the funding for rural health was removed.
If Alabama adopted traditional Medicaid expansion, at least 174,000 more people would be covered, according to KFF. But the connection to Obamacare remains a stumbling block in Alabama's Republican-dominated state legislature.
"Just the partisan nature of this is definitely a problem," said Regina Wagner, professor of political science at the University of Alabama. Wagner noted that most Alabama voters support expansion, and other states have adopted the programs after mounting public pressure.
"A lot of rural voters are Republicans. And so your own constituents are being hit by this and you're not addressing it," Wagner said. "If the pressure gets high enough and sentiment shifts, maybe that's going to be enough to push them."
Work requirements debate
The main disagreement in the Mississippi state legislature revolved around work requirements — recipients would have to show they were working part-time or in school.
White said many of his Republican colleagues view extending health coverage through Medicaid as "some form of welfare, some form of giveaway, some form of expanding government."
Opponents of Medicaid expansion in Alabama are also concerned about the potential impacts of "free health care" on the workforce.
"If you open up this federal subsidized program for hundreds of thousands of people, then it could actually hurt that labor participation rate, give them another reason not to go to work, to stay at home," said Justin Bogie, senior director of fiscal policy at the Alabama Policy Institute, a research group that says it's committed to limited government.
The federal Centers for Medicare & Medicaid Services would have to approve an expansion plan with a work requirement — something the Biden administration hasn't done.
Mississippi came close to a compromise bill that would have included a work requirement. If denied a waiver from CMS, expansion would not go into effect, and the state would have to reapply every year, hoping for approval under a future — potentially more conservative — administration.
That's what happened in Georgia. In 2020, the Trump Administration approved a waiver for a work requirement as part of a limited expansion effort. CMS later rescinded the waiver, leading to a lawsuit. 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 gain access if Medicaid were fully expanded, according to KFF. The state's alternative expansion plan has also cost taxpayers at least $26 million, according to KFF, with nearly all of it going to administrative and consulting fees, not medical care for low-income people.
Lessons from North Carolina
As public support for expansion continues to mount in holdout states, North Carolina may offer a glimpse of future efforts. It's the most recent Southern state to pass traditional Medicaid expansion. Since its adoption last year, more than 600,000 people have become eligible.
"But it still took a long time," said Robin Rudowitz, vice president at KFF and director of the Program on Medicaid and the Uninsured. "It took the governor who continually supported expansion, and the legislature finally came to endorse and pass the expansion."
Rudowitz noted that the fiscal incentive under the American Rescue Plan Act also played a role in moving the needle in North Carolina and may help ignite debate in other holdout states. But ultimately, she said, the reasons the ACA was established continue to be the strongest motivators.
"Without expansion, there are more people who are uninsured. Hospitals and other providers are not able to get reimbursement because individuals are uninsured," Rudowitz said. "Those are the underlying issues that existed pre-ACA and continue to exist, particularly in states that haven't adopted expansion."
This story was produced in partnership with the Gulf States Newsroom and KFF Health News.
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