Written by Daniel Chan and Andy Miller | KFF Health News
As a part-time customer service representative, Jolene Dibas makes less than $15,000 a year, which is below the federal poverty level and too low to qualify for subsidized health insurance in the Obamacare marketplace. It's too much.
Divas, 53, also doesn't qualify for Medicaid in his home state of Alabama because he doesn't meet the program's requirements. Instead, she said, she has fallen into a coverage gap and faces hundreds of dollars a month in out-of-pocket costs to manage multiple chronic health conditions.
“I feel like I live in a state that doesn't care about me,” said Dibas, who lives in Saraland, a suburb of Mobile.
Alabama is one of 10 states that has rejected the Affordable Care Act's proposed expansion of Medicaid, the government health insurance program for people with low incomes and disabilities.
But lawmakers in Alabama and other Southern states are reconsidering their opposition, given strong public support for Medicaid expansion and pleas from powerful sectors of the health care industry, particularly hospitals.
In addition to Alabama, Republican legislative leaders are considering expansions in Georgia and Mississippi that could provide coverage to more than 600,000 low-income uninsured people in those three states, according to KFF data. There is a growing expectation that there is a possibility that
Since a 2012 Supreme Court ruling made the ACA's Medicaid expansion optional, it has become a polarizing issue in some states along partisan lines. Political opposition has eased in part because North Carolina's Republican-controlled legislature voted to expand the program last year. More than 346,000 Tar Heel State residents are already covered.
And lawmakers in neighboring states are also paying attention.
“There has certainly been a lot of discussion lately about expanding Medicaid,” Georgia House Speaker John Burns (R) said in a speech to the state Chamber of Commerce shortly after the legislative session began on Jan. 8. Stated.
“The House will continue to gather facts on expanding access to care for low-income working families through private options that lower premiums in a fiscally responsible manner,” Burns said. .
In addition to Georgia, state House speakers in Alabama and Mississippi have also expressed renewed willingness to consider expanding coverage. In all three states, many hospitals have closed, especially in rural areas.
Frank Knapp, president of the South Carolina Small Business Chamber of Commerce, said expanding Medicaid is “now politically safer to consider.” Republican lawmakers in the state are considering whether to appoint a commission to study expansion.
Some health policy analysts see this momentum as a positive shift in the political debate about expanding access to health care. And it comes as new conservative leaders grapple with the state's persistently high rates of poor and uninsured adults.
Additional incentive: Under President Joe Biden's American Rescue Plan Act of 2021, the federal government will pay newly expanded states an additional 5 percentage points on their regular Medicaid population matching rate for two years. , which more than offsets the costs of Medicaid expansion. period.
But significant hurdles remain, despite renewed debate in Congress, which previously froze all discussion of Medicaid expansion. For example, Republican Mississippi Governor Tate Reeves remains opposed to expansion. Also, some non-expansion states appear to have little momentum.
“A lot of things need to come together in every state to get things moving,” said Robin Ludowitz, director of KFF's Medicaid and uninsured population program.
Under Medicaid expansion, adults with incomes up to 138 percent of the federal poverty level, or about $35,600 for a family of three, would be eligible for coverage.
A KFF analysis of studies from 2014 to 2021 found that Medicaid expansion reduced rural uninsured rates, improved access to care for low-income people, and reduced uncompensated care in hospitals and clinics. The cost is said to have decreased. The challenges remain serious.
Alabama's legislative session began on February 6th. Republican House Speaker Nathaniel Ledbetter has signaled he is open to discussing options to expand coverage. Too many hospitals are in “dire straits,” he said at a Montgomery Area Chamber of Commerce meeting in January. “We need to have a discussion.”
The expansion could leave up to 174,000 uninsured people in Alabama, according to KFF data. Still, Ledbetter favors a public-private partnership model, pointing to an Arkansas program that uses federal and state funds to pay for commercial insurance plans in the Obamacare marketplace for people eligible for expanding Medicaid.
In Alabama, lawmakers introduced a plan to levy a state tax on gaming income to help fund health insurance for adults with annual incomes up to 138% of the federal poverty level.
Robin Heiden, executive director of Alabama Arise, an advocacy group that supports Medicaid expansion, has seen progress in efforts to expand coverage. “The devil is in the details,” she says.
Mississippi's new House speaker, Republican Jason White, said he wants to protect hospitals and prevent residents from receiving routine care at emergency rooms. More than 120,000 uninsured people in Mississippi will become newly eligible for Medicaid under the 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 stakeholders and voters.
“The desire to keep Mississippians in the workforce and out of the emergency room transcends political parties and is essential to a healthy workforce and a healthy economy,” he said. He said state lawmakers are determined to work with Reeves on this issue.
Burns, the Georgia House speaker, said he is open to proposing an Arkansas-style plan. Republican Gov. Brian Kemp said he would reserve comment until the legislative process is over, according to press secretary Carter Chapman.
He emphasized Kemp's commitment to a recently launched plan that requires low-income adults to work 80 hours a month, volunteer, or receive schooling or job training in exchange for Medicaid coverage. As of mid-January, the cumulative number of registered users was just close to 3,000. The expansion could make at least 359,000 uninsured people in Georgia newly eligible for Medicaid, according to KFF data.
In South Carolina, Republican lawmakers are considering a bill that would allow them to create a commission to study expansion. State Sen. Tom Davis, a Republican from Beaufort who proposed the bill and previously opposed Medicaid expansion, said he does not support or oppose Medicaid expansion at this time.
“We need to have a discussion,” Davis said at the January committee meeting.
The state Legislature will likely have to work with Republican Gov. Henry McMaster, who remains opposed to expanding Medicaid, according to spokesman Brandon Charochak.
North Carolina began registering residents on December 1st as part of the expansion. Among them was Patrick Dunagan, 38, of Raleigh. The former outdoor guide said he was unable to work for years due to kidney disease and chronic pain.
He said he relies on financial support from his family and has more than $5,000 in medical debt. Medicaid coverage provides financial security.
Dunagan said people with chronic health conditions in non-expansion states are “accumulating medical debt and are unable to get the care they need.”
A bill proposed in the Texas Legislature failed to get a vote last year. The state also does not allow voter-initiated referendums, which have been a path to expansion in some Republican-led states. If Texas expands, an estimated 1.2 million uninsured people will be covered, more than any other state.
Republican lawmakers in Tennessee and Florida said they would not support Medicaid expansion. In Florida, advocates have started a petition drive for a ballot initiative, but it won't go to voters until 2026 at the earliest.
In Kansas, Democratic Gov. Laura Kelly told the Republican-controlled state Legislature to expand Medicaid, calling it a “common sense proposal” that would lower health care costs for all consumers and protect rural hospitals. We are pressing for its introduction again. However, the state House speaker remains opposed to Medicaid expansion.
As opposition wanes and people continue to suffer the effects of being uninsured, advocates believe it's only a matter of time before Medicaid expansion happens nationwide.
For Devas, an Alabama native, the prospect of getting coverage is enough to make her consider moving. “We wouldn't have had this problem” in Minnesota, where he used to live, Divas said.
Perhaps, like in Arkansas, conservatives will adopt a model that relies more on commercial insurance.
But many holdout states in the South, where death rates from heart disease, cancer, and diabetes are worse than other states, have widening disparities in the health status of their citizens and in neighboring states, and the disparities are widening. senior Lucy Danault said. Director of Cancer Action Network, advocacy arm of the American Cancer Society. The group is lobbying state legislatures to expand insurance coverage.
“There's going to be a tipping point for all of these states,” she said.
KFF Health News South Carolina correspondent Lauren Saucer and senior correspondent Renuka Rayasam contributed to this report.
This article was created by KFF Health Newsa national newsroom that produces in-depth journalism on health issues, is one of our core operating programs. KFF. Reprinted with permission.
