Working around Republican resistance on Medicaid expansion

Over the course of the COVID-19 pandemic, Southern states have been among those that have done the least to protect their residents from contracting the deadly virus.

They were some of the last to impose mask mandates and among the first to reopen after temporary shutdowns. And many sectors in the region, like poultry processing, never shut down at all. That makes it particularly striking that essential workers in Southern states disproportionately fall in the Medicaid coverage gap. Not provided health insurance through their jobs and unable to afford it in the private market, these workers risk their lives to keep the economy running — and disproportionately die in the process. Eight of the 12 states that have refused to accept federal funds to expand Medicaid under the Affordable Care Act are located in the South: Alabama, Florida, Georgia, North Carolina, Mississippi, Tennessee, Texas, and South Carolina. All have Republican-controlled legislatures.

A recent report by the Center on Budget and Policy Priorities (CBPP) looked at data from 2019, the year before the pandemic hit, and calculated that over 550,000 people working in essential or frontline industries fall in the Medicaid coverage gap. The states with the greatest number of essential workers in the coverage gap are Texas (209,000) and Florida (98,000) — GOP-led states that have had notoriously ineffective public health responses to the COVID-19 pandemic. In total, over 2 million people living in Southern states fall into the gap.

"A large body of research demonstrates that Medicaid expansion increases health insurance coverage, improves access to care, provides financial security, and improves health outcomes," the report states.

CBPP also documented glaring racial disparities, finding that people of color make up 60% of those in the Medicaid coverage gap even though they account for only 41% of the non-elderly adult population in non-expansion states. In Texas, 74% of those in the coverage gap are people of color, while Black people account for a majority of people in the coverage gap in Mississippi and 40% in Georgia and South Carolina. At the same time, people of color face a higher risk of COVID-19 infection, hospitalization, and death.

The report notes that about three in 10 adults in the coverage gap have children at home. And a third are women of childbearing age, meaning that if they get pregnant they can apply for existing Medicaid coverage. However, the coverage would not begin until they are determined to be eligible, meaning they could miss out on critical prenatal care during the first months of pregnancy. CBPP points to an Oregon study that found Medicaid expansion was associated with an increase in early and adequate prenatal care.

In addition, CBPP calculates that about 15% of people in the Medicaid coverage gap have disabilities. That includes 7% with serious cognitive difficulties, and more than 6% who have difficulty with basic physical activities such as walking, climbing stairs, carrying, or reaching.

In the years leading up to the pandemic, states that expanded Medicaid cut their uninsured rates by half. That made them better prepared for both the ensuing public health crisis and consequent economic downturn, which resulted in an estimated 2 million to 3 million people nationwide losing employer-based coverage between March and September. 

Efforts are now underway in the Democratic-controlled Congress to find a way to bring Medicaid to more essential workers — and Americans in general — despite Republican resistance at the state level. 

U.S. Rep. Lloyd Doggett, a Texas Democrat, recently proposed the “Cover Outstanding Vulnerable Expansion-Eligible Residents (COVER) Now Act.” The bill, which already has over 40 cosponsors, would authorize the federal Centers for Medicare and Medicaid Services (CMS) to work directly with counties, cities, and other local governments to expand Medicaid coverage in states that have refused to do so. It's based on previous successful demonstration projects in several counties in California, Illinois, and Ohio, and it's won the endorsement of groups including the American Diabetes Association, National Alliance on Mental Illness, and the Texas Academy of Family Physicians.

"The COVER Now Act empowers local leaders to assure that the obstructionists at the top can no longer harm the most at-risk living at the bottom," Doggett said in a statement.

And over in the Senate, Raphael Warnock of Georgia this week announced that he is drafting a proposal that would bypass his state's Republican leadership while calling on the White House to include a "federal fix" in the next jobs package. Warnock told reporters that he's hoping to introduce legislation soon. The Georgia Recorder has reported that Gov. Brian Kemp (R) is pushing a plan to expand Medicaid to about 50,000 additional Georgians, but the Biden administration has put the brakes on it over concerns that it requires participants to rack up 80 hours of work, school, or other qualifying activity every month to gain and keep their coverage.

In a letter sent last month to Senate Majority Leader Chuck Schumer of New York and Minority Leader Mitch McConnell of Kentucky, Warnock and U.S. Sen. Jon Ossoff of Georgia suggested that one possible solution could be a federal Medicaid look-alike program run through the CMS.

"We have a duty to our constituents and a duty to those suffering from a lack of access to health care to provide for them when they are in need," Warnock and Ossoff said in the letter. "We can no longer wait for states to find a sense of morality and must step in to close the coverage gap and finally ensure that all low- and middle-income Americans have access to quality, affordable health care."