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December 2019 (Volume 97)
Quarterly Article
David K. Jones
December 2024
Dec 19, 2024
Back to The Milbank Quarterly
Scholars and pundits have predicted that every state ultimately would expand Medicaid, arguing that the opportunity to have the federal government pay 90%‐100% of the costs for insuring large numbers of people would be too good to pass up. To date, 37 states have taken the deal. However, a block of states in the Deep South continues to resist.
Southern states are home to an estimated 92% of the 2.5 million people who fall into the Medicaid coverage gap—people who would be eligible for coverage if their state were to expand Medicaid but who are too poor to qualify for subsidies on a health insurance exchange.1 Will these states ever expand Medicaid? What political factors would need to come together for this to happen?
This is an ideal time to ask these questions, as three southern states hold their gubernatorial and legislative elections in the off year between the national midterm and presidential elections. This November, incumbent governors are running for re‐election in Kentucky and Louisiana—two Southern states that have expanded Medicaid—and Mississippi will elect a new governor. Medicaid politics has played an important role in all three states in ways that illustrate four key points about the future of the program.
Medicaid Expansion Remains a Divisive Issue
John Bel Edwards in Louisiana demonstrated that a Democrat in the Deep South could run for election on Medicaid expansion and win. Governor Edwards followed through on his campaign promise by signing an executive order almost immediately after taking office in January 2016, with expanded enrollment beginning that summer. Statewide polling in Louisiana is limited, but the expansion seems popular and has been an asset for Edwards’ re‐election campaign. At the same time, supporters of Medicaid should be cautious in interpreting what Edwards’ election means about the program’s popularity. The most important factor in the 2015 gubernatorial election was not health reform politics, but that the Republican nominee, David Vitter, had a history of soliciting prostitutes.
Jim Hood in Mississippi is hoping to become the next Democrat in the South to be elected while campaigning for Medicaid expansion, but if he wins, it likely will be in spite of this position, not because of it. A candidate for the Republican nomination supported Medicaid expansion but lost by 15 points in the final round of the primary to Lt. Governor Tate Reeves, who strongly opposes expansion. Medicaid remains highly divisive in Mississippi.
The Path to Medicaid Expansion is Varied, but Narrow
Medicaid politics in the South is intertwined with issues of race, class, and party in ways that make approval by these legislatures unlikely. There are pockets across the South where support for expansion is high, but the geographic concentration of people who are poor, uninsured, black, and Democratic allows for legislative district maps to be drawn such that legislators from these areas have little ability to shape state policy.2
Supporters of Medicaid expansion may consider using a ballot initiative, as has been done in Maine, Idaho, and Utah. However, these cases show that even if voters approve expansion, it may not be the final word. Governors can delay implementation by initiating legal battles, and the partisan incentives for conservative legislators in gerrymandered districts to oppose the Affordable Care Act (ACA) are strong even if it means going against a statewide referendum.
The likeliest path to Medicaid expansion in southern states would be to follow the blueprint of Kentucky and Louisiana, in which a governor issues an executive order. However, no Republican governor has been willing to circumvent the legislature by expanding Medicaid through executive order, and the first case is not likely to occur in the South. The southern states where Democrats may have the best chance of winning a gubernatorial election—Florida and Georgia—do not vote again until 2022. Jim Hood is unlikely to win in Mississippi this November unless the share of white voters willing to elect a Democrat increases from around 10% to 20%, a historically high hurdle.
Even if Hood does win, the Republican‐controlled legislature might look to how Wisconsin and North Carolina handled a similar transition, pre‐emptively stripping powers from the governor. The Mississippi constitution—developed in 1890 in response to Reconstruction—is already notorious for having weakened the governor’s ability to develop policy without legislative approval. Drafters were concerned about the suddenly large number of black voters being able to elect a governor who could tilt power away from the state’s wealthy white farmers.2
Expansion or Retrenchment?
The key question in many southern states is not whether Medicaid will expand, but whether it will be retrenched. Governor Matt Bevin in Kentucky illustrates that it is possible to win while campaigning on taking away Medicaid. His challenger this year is Andy Beshear, the son of Steve Beshear, who was the governor that expanded Medicaid by executive order. Governor Bevin did not follow through on threats to repeal the expansion, but he did try to eliminate the state’s insurance exchange and has tried to establish work requirements for Medicaid eligibility. That Bevin is running against his predecessor’s son emphasizes to voters that this election is, in part, a referendum on each governor’s approach to the ACA.
Leaders in other southern states are also attempting to establish work requirements for Medicaid beneficiaries. These include Alabama, Mississippi, Tennessee, and South Carolina—none of which have expanded Medicaid. If approved, this would be a dramatic turning point in the program. Although the legality of such requirements is still not clear, they have been accepted in Indiana and Iowa as a political tradeoff that made it possible for conservatives to support expansion. Adopting work requirements in nonexpansion states would impose another burden on the historically low categorical eligibility thresholds for Medicaid. For example, childless adults in Mississippi are ineligible no matter how poor they are, and parents need to make less than 26% of the federal poverty level to qualify.3
The Limits of the Program
Supporters of Medicaid need to grapple with the program’s limits. Yes, expansion would increase the number of people with coverage. But the gaps in the health care systems across much of the South are so severe that major access challenges would persist. Consider Issaquena County, Mississippi, where 18% of residents are currently uninsured and the median income is $28,810. There is not a single primary care doctor in the county, meaning that people have to drive 45‐60 minutes to get care.4 At the same time, 15% of households are without a car.5 Having an insurance card will remove one barrier, but other policy steps are needed to strengthen the health care safety net and improve population health.
The ACA’s reliance on federalism has meant that the reform’s accomplishments over the past 10 years have been shaped largely by individual states. Each election cycle has proven to be an important turning point in this process. Elections this November in Kentucky, Louisiana, and Mississippi will likely shape the future of Medicaid in these and neighboring states for years to come.
References
Disclosure: No external funding was used to support this analysis.
Published in 2019 DOI: 10.1111/1468-0009.12430
David K. Jones, PhD, is an associate professor in the Department of Health Law, Policy and Management at Boston University School of Public Health. His recent book, Exchange Politics: Opposing Obamacare in Battleground States (Oxford University Press, 2017), focuses on how states made decisions around what type of health insurance exchange to establish as part of the Affordable Care Act’s implementation. He is working on a new book using Photovoice to examine the social determinants of health in the Mississippi Delta, retracing Robert Kennedy’s steps in the region. He also studies Medicaid, Children’s Health Insurance Program, and health reform in France. He has been cited in the New York Times, the Washington Post, and the Wall Street Journal, among other places. He testified before the Michigan legislature’s House Health Policy Committee during its consideration of a health insurance exchange. He has been awarded the Association of University Programs in Health Administration’s John D. Thompson Prize for Young Investigators, AcademyHealth’s Outstanding Dissertation Award, and the Boston University School of Public Health Excellence in Teaching Award. Jones earned a PhD from the University of Michigan in health services, organizations, and policy. He holds a master of arts in political science from the University of Michigan, a master of science in public health from the University of North Carolina at Chapel Hill, and a bachelor of arts from McGill University. September 2020
