Mississippi Doctors Want Medicaid Expansion, but Don't Call It That

Mississippi has long been the nation’s poorest state and one of its least healthy, and it can ill afford to lose places where people can go for medical care. So it’s not an exaggeration for president of the state medical association to say there’s a “public health crisis” after 4 community hospitals have closed in 3 years.

How has this happened? Mississippi remains among the 19 holdout states that have not expanded Medicaid to those earning up to 138% of the federal poverty level. According to the Kaiser Family Foundation, that is about $28,000 for a family of 3.

For doctors, endorsing Medicaid expansion might seem obvious. But as they discussed the issue at the annual meeting of the Mississippi State Medical Association last week, the doctors knew that taking on this political hot potato might not have the desired effect.

Governor Phil Bryant has steadfastly refused to expand Medicaid, despite his recognition that the state needs to up its game medically. So in the end, the doctors supported a resolution in favor of “expanded coverage,” but pulled the words “Medicaid expansion” from the final draft, according to news accounts.

Bryant’s opposition to expansion stands alongside his very public support for other healthcare causes. He appeared in person for the launch of a partnership between a new diabetes research center and the Cleveland Clinic. And he’s a cheerleader for the state’s innovative efforts in telehealth through the University of Mississippi Medical Center.

Like many other Republicans in the Deep South, Bryant opposes the Affordable Care Act and insists the share of expansion costs that will fall to the states after 2017 are something Mississippi cannot afford. But like other poor, mostly rural states, Mississippi is finding that the restructuring of federal dollars that came with the ACA is working against those states that decline expansion, and it gets worse over time.

The Mississippi Hospital Association had previously supported expansion, and at one point Democratic legislators refused to reauthorize Medicaid over the issue, creating an impasse that almost shut down the program.

The ACA never envisioned that some states would decline expansion—that only became an option with the 2012 Supreme Court ruling. The financial structures envision less direct aid to safety net hospitals as more of the working poor become covered by Medicaid. But when states decline to allow those people to join the program, and leave them in a coverage gap, they continue to seek care the only place it is available: in the emergency room. And without the cash flow of the past, finances turn ugly.

Bryant said the doctors’ action did not sway him. “We simply cannot afford to expand a program under a law that I hope will be repealed and replaced with the election of a Republican president,” he said in a statement.

Charlie Mitchell, the associate dean at the University of Mississippi journalism school whose column appears statewide, wrote today that “the core reason for the rejection is that Bryant and the state’s leadership believe in their heart of hearts that government already does enough for people and that people need to do more for themselves.” Mitchell goes on to point out that the target population of expansion are people with jobs that do not offer health coverage, or people with wages so low they cannot afford premiums.

The popularity of Medicaid expansion in neighboring Louisiana is putting pressure on Mississippi, as more than 250,000 people have signed up almost overnight, with some becoming eligible through their presence on the rolls for the Supplemental Nutrition Assistance Program. Another neighboring state, Arkansas, also has expansion through a waiver, which it recently revisited.

Mississippians are seeking care wherever they can. Susan Todd, executive director of 504HealthNet, an umbrella for providers in the Greater New Orleans area, told The American Journal of Managed Care in June that some uninsured patients from Mississippi’s southern counties come west to clinics in the network for care because they have no other options.

Mitchell writes that accumulating evidence on the early years of the ACA is that it’s had some good results, both in health and in financial benefits for the working poor.

“Thirty months into this deal, Mississippi’s doctors say expanding Medicaid is, on balance, the best strategy for now,” he wrote.