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Reconsidering Medicaid Expansion: Shift in Stance Among Southern Lawmakers


Jolene Dybas, a part-time customer service worker, earns less than $15,000, rendering her ineligible for Obamacare subsidized health insurance.

Dybas is 53 and does not qualify for Medicaid in Alabama. She has a coverage gap and pays hundreds of dollars a month for various chronic diseases.

“I feel like I’m living in a state that doesn’t care for me,” said Mobile suburb Saraland resident Dybas.

Alabama is one of 10 states that have rejected the Affordable Care Act’s Medicaid expansion for low-income and disabled people.

Due to overwhelming public support for Medicaid expansion and pressure from key healthcare sectors, particularly hospitals, Alabama and other Southern lawmakers are reconsidering their position.

Republican lawmakers in Georgia, Mississippi, and Alabama are mulling expansions. KFF research suggests this might cover over 600,000 low-income, uninsured people in those states.

The ACA’s Medicaid expansion has been controversial and party-lined in some states since the 2012 Supreme Court ruling made it optional. Since North Carolina’s Republican-controlled legislature approved the program extension last year, political resistance has decreased. More than 346,000 North Carolinians are covered.

Adjacent state lawmakers are taking notice.

“There has been a significant amount of talk recently about Medicaid expansion,” Republican Georgia House Speaker Jon Burns told the state chamber of commerce after the legislative session began on Jan. 8.

“We will keep gathering information on how to expand access to care for lower-income working families through a private option in a fiscally responsible manner that reduces premiums,” Burns said.

In addition to Georgia, state House speakers in Alabama and Mississippi are now receptive to increasing coverage. Hospital closures, especially rural ones, have increased in all three states.

South Carolina’s Small Business Chamber of Commerce president Frank Knapp says Medicaid expansion is now politically doable. Republican politicians in his region are considering organizing an expansion committee.

This momentum may be a beneficial change in the political conversation about boosting access to care, say health policy analysts. It coincides with a new generation of conservative politicians addressing high rates of destitute, uninsured adults in their states.

An extra benefit: President Joe Biden’s 2021 American Rescue Plan Act would more than offset the cost of expansion by giving expanded states a 5 percentage point increase in their regular Medicaid matching rate for two years.

Despite legislative bodies finally discussing Medicaid expansion, major issues remain. Mississippi Republican Governor Tate Reeves opposes expansion. Several states without expansion seem stalled.

“Many factors must align in each state to drive progress,” said KFF Program on Medicaid and the Uninsured leader Robin Rudowitz.

Medicaid expansion covers adults earning up to 138% of the federal poverty threshold, or $35,600 for a family of three.

According to 2014–2021 studies, the expansion has reduced rural uninsured rates, improved access to treatment for low-income individuals, and reduced hospital and clinic uncompensated care costs. All those issues exist in states that have not expanded Medicaid.

Southern States Weigh Medicaid Expansion Amid Challenges

A visitor speaks with workers at a table during a Medicaid expansion informational event held by New Hanover County Department of Health and Human Services at a library in Wilmington, North Carolina, US, on Saturday, Dec.16, 2023. North Carolina’s expansion of Medicaid began on December 1st, and its estimated that more than 600,000 people statewide are now eligible for healthcare coverage that they otherwise could not afford.

Alabama began its legislative session on February 6. Republican House Speaker Nathaniel Ledbetter is exploring coverage expansion. In January, the Montgomery Area Chamber of Commerce noted that several hospitals are struggling. “It’s essential that we discuss this.”

KFF research suggests the expansion might cover 174,000 uninsured Alabamans. Ledbetter prefers a public-private partnership and has analyzed Arkansas’ scheme, which uses federal and state monies to support Obamacare marketplace commercial insurance plans for Medicaid expansion recipients.

White wrote to KFF Health News that business executives, community leaders, and voters prioritize health care accessibility.

“Ensuring that Mississippians remain employed and healthy is crucial for both a strong workforce and a thriving economy,” he said. He says state legislators will work with Reeves on the matter.

Burns, the Georgia House speaker, is exploring an Arkansas-like idea. According to spokesperson Carter Chapman, Republican Gov. Brian Kemp will reserve comments until after the legislative process.

Kemp was praised for his new Medicaid policy, which requires low-income adults to work, volunteer, or attend school or vocational training for 80 hours per month. By mid-January, enrollment was around 3,000. According to KFF data, a Georgia expansion could make 359,000 uninsured people eligible for Medicaid.

Republican lawmakers in South Carolina are considering a bill to create an expansion committee. Beaufort Republican State Sen. Tom Davis, who sponsored the bill and had opposed Medicaid expansion, said he is neutral.

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