‘Poor folks trying to make it as best we can’: surviving Mississippi’s miserly healthcare system
This story was published in partnership withthe Center for Public Integrity, a non-profit news organization that investigates inequality.
Jabriel Muhammad pays up to $40 when he sees a doctor at the community health center in Jefferson county in rural south-western Mississippi. And he goes to the center only when he is really ill. But there’s another price to pay for not having health insurance. In October, he was hit with a $1,394 hospital bill for an MRI scan to diagnose why he wasn’t breathing properly.
“We’re poor folks trying to make it as best we can,” said Muhammad, a 40year-old self-employed carpenter and plumber. “If I make $10,000 with the work that I do in a year, that’s a nice feeling to me.”
In Mississippi, the poorest and blackest state in the US, single adults without children like Muhammad are not eligible for public health insurance, regardless of how little they earn each year. If he lived 30 miles west in Louisiana, across the Mississippi river, he could afford to see a doctor more often.
Louisiana is the only deep south state that expanded Medicaid under the 2010 Affordable Care Act, which extended healthcare access for people who work but don’t have medical coverage. Most of the 2 million people in the US without expanded coverage live in eight states in the south, where the legacy of slavery continues to shape healthcare policies, efforts to alleviate poverty and the life circumstances of thousands of Black people.
In Mississippi, 78% of the people who would become eligible for health insurance if the state expanded Medicaid are poor adults without children, like Muhammad.
“The denial of Medicaid coverage is scandalous,” said Don Simonton, a retired professor from Alcorn State University, a historically Black college in Mississippi. “It is so typical of the power structure of the south from slave days forward: ‘If you’re poor, you better make some money if you don’t want to die.’”
The Center on Budget and Policy Priorities, a thinktank that supports policies to reduce poverty and inequality, says, “Many of the states that have refused expansion have a long history of policy decisions based on racist views of who deserves to get healthcare services.”
The pandemic and the racial justice uprising last year focused the nation’s attention on healthcare disparities that states have allowed to fester, even as the pandemic punctuated how those disparities can be deadly. That’s especially true in rural Black communities that lack adequate access to basic preventive healthcare services to treat chronic diseases.
Medicaid expansion was designed to reduce racial and geographic inequities in health insurance coverage. The expansion also sought to create a national standard; however, that didn’t happen because, as in the past, some states refused to participate.
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Jefferson county sits just downstream and across the Mississippi River from Madison parish, Louisiana. Both places, named for former presidents and slave owners, are among the poorest and blackest in the country. But in Madison access to health insurance has cut the amount of unpaid care costs from insurers and patients, demonstrating how access to healthcare can reduce longstanding racial disparities.
Before the Affordable Care Act, more than 20% of adults younger than 65 in both counties were uninsured. But then their paths diverged. Since 2015, a year before Louisiana expanded Medicaid under the ACA, the percentage of uninsured adults in Madison parish has plunged eight percentage points, while it has remained the same in Jefferson county.
Medicaid expansion has also extended a lifeline to some rural hospitals across the country that were threatened with closure because of charity care and bad debt. Since Louisiana expanded Medicaid in 2016, uncompensated care costs dropped 55% among the state’s rural hospitals, according to a study in the March 2021 issue of Health Affairs. And the hospitals are much better off than those in non-expansion states.
In Madison parish, local and hospital leaders are building a new facility that they hope will mean people won’t have to travel 20 or 30 miles to specialty clinics that treat conditions like diabetes or cancer.
Meanwhile, the Jefferson County Hospital & Behavioral Health unit in Mississippi has been limping along for years, in part because it’s being reimbursed at a rate that is too low to cover its costs.
“Our hospital had been for a long time one of the biggest concerns in the community,” said Anthony “Bruce” Walton, president of the Jefferson county board of supervisors. “Because if we lost our hospital, then it’s like a trickle-down effect. We can’t have our prison, our schools. Everything that we have in our small community pretty much revolves around the hospital.”
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Jefferson county, where Muhammad was born and raised, was one of Mississippi’s wealthiest counties, controlled by a few white families until the end of slavery and the civil war set it on a path to becoming among the nation’s poorest today. About 37% of its residents live below the poverty line, or $26,500 for a family of four. Nearly 70% receive some form of government assistance.
In September, Mississippi’s state economist released a report stating that Medicaid expansion would add 11,300 jobs between 2022 and 2027, significantly reduce hospital costs for unpaid care and pay for itself for at least a decade. Yet governor Tate Reeves insists that expanding Medicaid would be bad medicine.
“I firmly believe that it is not good public policy to place 300,000 additional Mississippians on governmentfunded healthcare,” Reeves, a Republican, wrote last year in his budget recommendation.
Jefferson county could benefit from jobs. Last year, the county had the fourth-highest unemployment rate in the country at 18.4%.
Highway 61, known as the “Blues Highway”, runs through Jefferson but bypasses the county seat of Fayette. Without the highway traffic, Fayette, like much of the county, feels isolated. Main Street is a mix of empty storefronts, low-income housing, singlefamily homes, a bank and government buildings. There’s a sprinkling of notable businesses, like a Muslim theatre and bakery.
Muhammad, a member of the New Nation of Islam, a Black nationalist group that supports reparations and advocates for self-determination, is like many residents here who create work for themselves because there aren’t enough good-paying jobs outside the school system, healthcare and government. The state has graded the school district an F. And people with four-year college degrees have trouble finding a job.
“I call it the modern-day slavery,” Alford Perryman, a local health insurance salesman said on a recent morning. He sat at a tall table at 61 One Stop, a Black-owned gas station and community gathering space in Fayette owned by Janell Edwards and her husband. “It’s the new way to keep us from progressively moving forward at a faster pace than they are,” he said, referring to white people with power.
Edwards chimed in: “It is a big conundrum of obstacles that really comes from the same source.”
“Four hundred years,” Perryman said. “Four hundred years,” Edwards replied, “of how we came to this country and then the mentalities that were birthed out of that.”
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Medicaid was launched in 1965, a critical year for civil rights. The seeds of the safety net program were in legislation aimed to advance the economic, legal and political rights of Black people and President Lyndon B Johnson’s Great Society, a massive social reform initiative that sought to end poverty, among other goals.
Access to healthcare was a critical part of combating poverty. Initially, the government had considered a federally run national healthcare program to serve vulnerable populations. But southern politicians, who opposed civil rights legislation, shaped federal health policy. Administering Medicaid as a state-run program promised to temper their resistance to what they considered federal overreach. Medicaid has been hamstrung ever since.
“Even while recognizing the pathbreaking value of Medicaid, we must concede that it has taken constant political struggle to keep the program alive,” Jamila Michener, co-director of the Cornell Center for Health Equity at Cornell University, writes in her book, Fragmented Democracy: Medicaid, Federalism and Unequal Politics. “The political compromises spawned by that struggle have paved the way for geographic inequities.”
The Medicaid program, which matches federal dollars to state money to provide healthcare to the most vulnerable, is of special benefit to Mississippi. For many states, the match is roughly dollar for dollar. But in Mississippi, for every $1 the state spends on Medicaid, the federal government spends $5.46, more than in any other state.
Federal law mandates that states cover certain qualified, low-income groups such as families, people with disabilities, seniors, pregnant women and children. But the state ultimately decides who else is eligible.
A 2012 US supreme court decision gave states the option to decline to expand eligibility. Their decisions fell largely along partisan lines. That left a coverage gap where some people were too poor to qualify for the health insurance subsidies made available under the Affordable Care Act, but not poor enough to meet state guidelines to receive Medicaid.
The American Rescue Plan Act signed by President Joe Biden in March 2021 also temporarily expands the ACA subsidies, extending them through next year to people with incomes above 400% of the poverty level, or $106,000 for a family of four.
Twelve states nationwide, including Mississippi and seven others in the south, have declined to expand healthcare coverage since the supreme court ruling.
Louisiana’s Democratic governor, John Bel Edwards, opted in by executive order, and since then Medicaid
coverage of adults in the state has increased by nearly 40%. In Mississippi and the southern states that stayed out of the plan, the proportion of the adult Medicaid population has stayed the same.
“There’s nothing inherently more deserving about the people in Louisiana,” said Michener. “We can say, ‘Well, it’s Mississippi’s choice.’ I think we always have to balance that logic, which is historically grounded in racism, frankly, and white supremacy. I think we always have to challenge that logic and hold it up to the other things we value.”
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In Madison parish, 46-year-old Alvin Brown risked crushing medical debt earlier this year when he found himself in the emergency room. The Medicaid program saved him from paying a whopping $9,000 hospital bill.
Brown’s ordeal began in late May. “All of a sudden, I just felt bad,” Brown said. His back hurt and it was painful to urinate. The next day, he visited the emergency room at Madison Parish hospital. A doctor told Brown he was passing a kidney stone and prescribed him medication.
Two days later, Brown was still feeling lousy. Ultimately, he was admitted to a hospital nearly an hour from where he lives.
“That was my first time ever being in the hospital,” he said about the weeklong stay. “I never had no [health] issues or nothing.”
It turns out that Brown was dehydrated. As a result, his kidneys began to malfunction. “It was kind of scary,” said Brown, a father of a 15-year-old boy.
He didn’t know he was qualified to receive Medicaid until a hospital employee asked him if he was interested in enrolling in the program. Brown stocks liquor and wine for retail outlets and has an annual household income of $28,000 for a family of three, just under the threshold to qualify for Medicaid coverage.
The coverage kicked in just in time to pay $7,000 toward his $9,000 hospital bill.
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There’s a deep bent toward selfreliance in Jefferson county that has helped the community withstand its economic challenges.
In 1969, Charles Evers, the brother of slain civil rights leader Medgar Evers, became mayor of Fayette. Despite white flight during his tenure, locals say, he managed to attract some industry to the area and helped launch the local community health center, a pioneer in the movement to provide free and low-cost healthcare.
“We’re not successful because we don’t have the tenacity or the determination,” Perryman said. “We’re not successful because we don’t have people in place that are vouching for us.”
Blocks away on Main Street in Fayette, the New Nation of Islam operates several small businesses with a vision of building a “beautiful, thriving Black community that will be a model for our people, all over the earth,” said the community’s spiritual leader, whose followers call him Son of Man.
A barber by trade, he does carpentry work to support the community’s efforts.
The members of the group support projects like a K-12 school, tucked away in an unincorporated area known as Red Lick. Muhammad is working on his biggest carpentry project to date – a furniture store in an old cleaners building.
The tight-knit community lives and works cooperatively. Son of Man is helping Muhammad pay off his hospital bill, filling the healthcare gap left by the state of Mississippi.
Muhammad is grateful, but he adds: “It hurts my pocket a little because that’s a good little piece of change for somebody who doesn’t make money every day.”