Why Medicaid expansion in the South failed Several Southern legislatures seriously considered full Medicaid expansion this year to get health insurance for hundreds of thousands of low income residents, but in the end they all failed.

Why Medicaid expansion in the South failed

Why Medicaid expansion in the South failed

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Several Southern legislatures seriously considered full Medicaid expansion this year to get health insurance for hundreds of thousands of low income residents, but in the end they all failed.

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Southern Republican-led states looked at expanding Medicaid this year to help cover more people who can't afford health insurance. And even though those efforts made some headway, they struggled to overcome the politics. Drew Hawkins of the Gulf States Newsroom reports.

DREW HAWKINS, BYLINE: Seven of the 10 states that have refused to adopt Medicaid expansion are in the South. Mississippi is one of them. This year, the state came so close, but in the end, expansion efforts fizzled and died in the legislature. So what's the deal? Why the hang-up? Well, one Mississippi doctor does not pull any punches with his answer.

ROGER GIVENS: It's called the stupidity of politics, period.

HAWKINS: Dr. Roger Givens is a radiation oncologist. He practices in rural Mississippi, in an area known as the Delta.

GIVENS: I mean, that's about as rural as it gets.

HAWKINS: He's also the board chair of the Mississippi State Medical Association, which wholeheartedly supports Medicaid expansion. Givens says it's long overdue, especially since most residents want it and other states in the South have already done it.

GIVENS: Look at Arkansas, which has a very similar population to us, and look at what has worked for them and what needs to be tweaked. For me, that's just common sense.

HAWKINS: Givens says people need health coverage. Because when they can't regularly see a doctor, bad things can happen.

GIVENS: I can't tell you the number of patients who come in with advanced disease who have full-time jobs. Plain and simple. That's the coverage gap.

HAWKINS: The coverage gap Givens is talking about only exists in states that haven't adopted Medicaid expansion. It's filled with thousands of people who make too much to qualify for Medicaid but too little to afford private insurance. But Mississippi lawmakers wanted this Medicaid coverage to come with a work requirement. Recipients would have to show they were working part time or in school.

JASON WHITE: That's just a place that I think you're going to see a conservative state come from.

HAWKINS: That's Mississippi Republican House Speaker Jason White. He supports expansion. And a work requirement makes it more palatable for Republicans because Medicaid expansion is part of the Affordable Care Act passed under President Obama.

WHITE: You know, no denying it's known as Obamacare.

HAWKINS: But work requirements weren't part of the original deal. And without a special waiver for that from the Biden administration, Mississippi can't get the money from the federal government. And that's why expansion failed. But White still thinks expanding Medicaid is the right thing to do because it would bring much-needed health care dollars to Mississippi. And that's been his message to his fellow Republicans.

WHITE: 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.

HAWKINS: Besides Mississippi, Alabama also tried to open the door to Medicaid expansion this year. The program would have focused narrowly on rural health, using casino gambling funds to pay for it, but it ultimately failed. And Republicans in Alabama remain wary of any new coverage that doesn't come with work requirements. Justin Bogie is with the Alabama Policy Institute, a conservative think tank.

JUSTIN BOGIE: So we think if you expand Medicaid and 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.

HAWKINS: More and more holdout states in the South are adopting or warming up to expansion. North Carolina extended coverage to around 600,000 people this year. But there's still opposition. In Georgia, the governor wants to see if his own alternative program that allows people who work to join traditional Medicaid can succeed. It's about three times more expensive per person for the state and right now only has just over 2,300 participants, less than 1% of people Medicaid expansion would cover. For doctors like Givens, the debate around work requirements seems unnecessary. Sixty percent of the uninsured Mississippians already have a job.

GIVENS: I'm confused on this whole argument about why does there need to be a work requirement if we're talking about employees who are working who need coverage?

HAWKINS: Studies show the South has high rates of chronic disease and poor health, and it's especially difficult for patients in the rural South. And that's why some Mississippi Republicans in favor of expansion say they'll try again next year with the momentum they've already built. For NPR News, I'm Drew Hawkins.

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