Some Southern states rethink Medicaid
GOP lawmakers consider adopting expansion
As a part-time customer service representative, Jolene Dybas earns less than $15,000 a year, which is below the federal poverty level and too low for her to be eligible for subsidized health insurance on the Obamacare marketplace.
Dybas, 53, also does not qualify for Medicaid in her home state of Alabama because she does not meet the program requirements. She instead falls into a coverage gap and faces hundreds of dollars a month in out-of-pocket payments to manage multiple chronic health conditions, she said.
“I feel like I’m living in a state that doesn’t care for me,” Dybas said.
The Affordable Care Act’s expansion of Medicaid, the government health insurance program for people who are low-income or disabled, has reduced uninsured rates in rural areas, improved access to care for low-income people and lowered uncompensated care costs for hospitals and clinics, according to KFF analyses of studies.
Under Medicaid expansion, adults earning up to 138% of the federal poverty level, or about $35,600 for a family of three, qualify for coverage.
Alabama is one of 10 states that have refused to adopt it.
But Republican lawmakers in Alabama, Georgia and Mississippi are reconsidering their opposition in light of strong public support for Medicaid expansion and pleas from powerful sectors of the health care industry. Expansion in those three states could grant coverage to more than 600,000 people, according to KFF data.
All three have experienced a large number of hospital closures, particularly in rural areas, and a new crop of conservative leaders is grappling with their states’ persistently high rates of poor, uninsured adults.
Many holdout states in the South – where death rates for heart disease, cancer and diabetes are mostly worse than the norm – see growing disparities between the health of their citizens and those of neighboring states that have expanded Medicaid, said Lucy Dagneau, a senior director for the American Cancer Society’s advocacy arm, which lobbies for expanded coverage.
Neighbors like North Carolina, whose Republican-controlled legislature voted last year to expand the program.
Among the more than 346,000 newly covered North Carolinians is Patrick Dunnagan, 38, of Raleigh. The former outdoor guide said he hasn’t been able to work for years because of kidney disease and chronic pain. He has relied on support from his family and said his medical debt stands at more than $5,000. Medicaid coverage will provide financial security.
Dunnagan said people with chronic health conditions in non-expansion states “are accumulating medical debt and not getting the care they need.”
Lawmakers in nearby states are taking notice.
Medicaid expansion has become “politically safer to consider,” said Frank Knapp, president of South Carolina’s Small Business Chamber of Commerce.
There’s also an incentive: Under the 2021 American Rescue Plan Act, the federal government pays newly expanded states an additional 5 percentage points in the matching rate for their regular Medicaid population for two years. It would more than offset the cost of expansion for that period.
But considerable obstacles remain. “A lot of things need to come together in any given state to make things move,” said Robin Rudowitz, director of the Program on Medicaid and the Uninsured at KFF.
Nathaniel Ledbetter, Alabama’s Republican House speaker, has suggested that he’s open to debating options for increased coverage. So many hospitals are in “dire straits,” he said at a Montgomery Area Chamber of Commerce meeting in January. “We’ve got to have the conversation.”
Ledbetter prefers a public-private partnership model. He pointed to Arkansas, which uses federal and state money to pay for commercial insurance plans on the Obamacare marketplace for people who would be eligible for Medicaid under expansion.
Alabama lawmakers have introduced a plan that would tax gaming revenue and could help fund health insurance coverage for adults with incomes up to 138% of the federal poverty level.
Robyn Hyden, executive director of advocacy group Alabama Arise, which supports Medicaid expansion, has seen progress on efforts to increase coverage. “The devil’s going to be in the details,” she said.
Mississippi’s new House speaker, Jason White, a Republican, has said he wants to protect hospitals and keep residents from seeking regular care through the emergency room. More than 120,000 uninsured people in Mississippi would become newly eligible for Medicaid under expansion, according to KFF data.
White told KFF Health News in a written statement that improving access to health care is a priority for business leaders, community officials and voters.
“The desire to keep Mississippians in the workforce and out of the emergency room transcends any political party and is a vital component to a healthy workforce and a healthy economy,” he said. State legislators are determined to work with Gov. Tate Reeves on the issue, he said.
In Georgia, House Speaker Jon Burns, another Republican, commented on the issue in a Jan. 8 speech.
“Expanding access to care for lowerincome working families through a private option – in a fiscally responsible way that lowers premiums – is something we will continue to gather facts on,” he said.
Burns has said that he’s open to a proposal for an Arkansas-style plan. He emphasized Gov. Brian Kemp’s commitment to his recently launched plan requiring low-income adults to work, volunteer or receive schooling or vocational training for 80 hours a month in exchange for Medicaid coverage.
South Carolina lawmakers are considering legislation forming a committee to study expansion.
State Sen. Tom Davis, a Republican who sponsored the bill and previously opposed expanding Medicaid, said he’s neither endorsing nor opposing expansion at this time.
“We need to have a debate,” Davis said at a January committee meeting.
KFF HEALTH NEWS