In 2015, Marguerite Casey Foundation’s Equal Voice storytelling visited the Mississippi Delta to listen to families about health insurance access. Many governors in the Deep South opposed expanding Medicaid.
IN THE MISSISSIPPI DELTA — A few weeks before Christmas in 2010, Gloria Owens was shopping in the Dirt Cheap Store in Yazoo City, Mississippi, when she collapsed. That is when Owens, now 59, learned she was suffering from untreated diabetes. A social worker here, she’d lost her health insurance after switching to part-time work in 2009. Private insurance was unaffordable. So, like millions of other uninsured across the country, Owens pinned her hopes on the Affordable Care Act, signed into law in March 2010.
But as the health care law’s third annual enrollment period gears up to open on Nov. 1, Owens remains uninsured, with little realistic hope of gaining coverage. Complications from her chronic diabetes have left her too weak to return to full time employment. In many states, her part-time earnings would qualify her for coverage under Medicaid. But Mississippi, like the rest of the Deep South, has declined to accept federal funds to expand the state’s Medicaid program, a core initiative of the Affordable Care Act as it was originally envisioned.
More than 8.5 million U.S. citizens and legal residents have gained health coverage since 2013, when the federal insurance exchanges first opened. But, as Congressional Republicans continue to battle the law, officials in 19 states have refused to expand Medicaid, citing the requirement for states to shoulder 10 percent of the additional costs.
In Mississippi, where Medicaid eligibility rules are among the most restrictive in the country, expansion would extend insurance coverage to an estimated 139,000 low-income residents. Many, like Owens, are the working poor. Gov. Phil Bryant, a Republican, has been adamant in opposing expansion, saying there would be “very little incentive” for people to seek work under the new eligibility rules.
“There is no one who doesn’t have health care in America,” he said in a 2013 interview with Kaiser Health News. “No one. Now, they may end up going to the emergency room. [But] there are better ways to deal with people that need health care than this massive new program.”
Owens, desperate for treatment, visits a rural clinic with sliding scale fees, often turning to friends and family for help making the payments. She has no primary physician, and doctors at the clinic have yet to diagnose the underlying reason for her dramatic weight loss — over 130 pounds since her collapse five years ago.
Though she’s a lifelong Mississippian, Owens is considering a move to Michigan, a Medicaid-expansion state where her sister lives, simply to get access to insurance coverage. “My health is declining rapidly,” she said. As a former social worker, Owens knows what services are available and how to navigate them. “But there’s no resource to connect me to here, because I’m in a state where the governor doesn’t want to do this, for whatever reason.”
State legislators from Mississippi’s Delta region, which leans Democratic, have struggled to convince the state’s Republican leaders, who control both houses of the legislature, to move forward with the expansion. Their hopes now rest on the upcoming governor’s election on Nov. 3, which will pit Bryant against Democratic candidate Robert Gray, a truck driver who himself does not have health insurance. Gray has promised to expand Medicaid if elected. He is considered the long shot.
“What shocks me is that Mississippi is known as the Hospitality State, yet we’re not being hospitable to each other,” state Rep. John Hines, a Democrat from the Delta, recently told me in his office at the state Capitol in Jackson, where the Confederate flag still flies as part of the Mississippi state flag. “I don’t want to say it’s a racial thing,” said Hines, who is Black. “But I can’t understand why a state would do this to its own people.”
Worried Life Blues
The Delta is not, technically, a river delta, but a floodplain between the Yazoo and Mississippi rivers, worn down over millennia by the regular floods of the Mississippi. The rich farmland is worked primarily by large-scale agribusiness, and poverty rates in the Delta are among the highest in the country.
Life expectancy in Mississippi is the lowest in the nation, and health outcomes are abysmal. For instance, the state has one of the highest rates of diabetes in the nation, and leg amputations — a gruesome outcome of advanced diabetes — are 70 percent more frequent in Mississippi than the national average.
Whitney Carter, 23, grew up in the Delta, and studies journalism at Delta State University, where she also works part-time in the university bookstore. Like Gloria Owens, Carter falls into the Medicaid gap — not eligible for Medicaid, but too poor to qualify for federal subsidies toward private insurance, which kick in for those making at least $11,490 a year.
Carter, who also suffers from diabetes, said that she routinely skips her doses of Metformin, a diabetes drug, to stretch the medication out. When we met in the DSU Student Union, she pointed out her visibly swollen ankles, a common symptom of diabetes and sometimes an early sign of kidney failure.
As a child, Carter had Medicaid through the children’s insurance provision, but aged out when she turned 19. “A lot of people may look down on it, but it really helped me,” she said of Medicaid. “Now I’m in my last year of college, trying to do something with my life. It would be nice if I could do that.”
I Don’t Want Your Money
The federal government pays roughly $11 billion a year to compensate hospitals for unpaid emergency room bills. One of the goals of the Affordable Care Act was to shift that spending toward health insurance, by extending Medicaid eligibility to those making less than 138 percent of the federal poverty level, and subsidizing private insurance for those making more than 100 percent. Proponents of the law hope to bring overall public costs down by promoting routine access to preventative health care.
Though the federal government has promised to foot at least 90 percent of the cost of Medicaid expansion, the program is jointly administered by the states. In 2012, a Supreme Court ruling gave states the option to turn down federal funds to expand Medicaid eligibility. State governors and legislators who were politically opposed to the Affordable Care Act found they had a potent weapon to fight it.
Though Republican governors in Ohio, Arizona, and elsewhere have agreed to accept federal expansion funds, 19 states, all with Republican governors or Republican-controlled legislatures, continue to opt out. More than 3 million people across the country fall into the resulting gap in coverage: they make too much to qualify for Medicaid in their state, and not enough to qualify for federal insurance subsidies. Of those in the Medicaid gap, nine out of 10 live in the South. They are disproportionately Black.
“We have had tremendous resistance from the Republican leadership” to Medicaid expansion, said Mississippi State Sen. Derrick Simmons, a Democrat from the Delta city of Greenville. “You started to get resistance before people even fully understood the provisions. That suggests it wasn’t about the actual law, it was about other things: race, and who’s currently in the White House.”
Standin’ at the Crossroads
In August, Mississippi voters shocked the state’s political establishment by nominating Robert Gray, a political unknown, as the state’s Democratic candidate for governor. Gray has made Medicaid expansion a key issue of his campaign.
“We’re gonna expand it,” he said in a recent phone interview. “People don’t understand how the economy works. It’s like a tree — you’ve gotta give water to the roots. If you don’t, it starts dying from the top down.”
It would be an understatement to call Gray a dark-horse candidate. When his mother went to vote in Mississippi’s state primary elections on Aug. 4, she was amused that one of the three nominees for governor had the same name as her son. She voted for him without realizing that she was actually voting for her own child.
Gray, a 46-year-old freight truck driver and former firefighter, had done no campaigning. He beat his opponents, both women who are active in state politics, by double-digit margins.
This unlikely candidate may be Mississippi’s lone, quixotic hope for Medicaid expansion in the foreseeable future. Gray, who is self-employed, has long gone without health insurance over cost concerns. Though he isn’t certain, he thinks his annual income after expenses would put him “pretty close” to falling in the Medicaid coverage gap.
Gray, the son of a Black mother and a White father, hopes to appeal across racial lines by emphasizing the economic benefits of Medicaid expansion.
“Money is money. It’s not a Black and White issue anymore,” he said.
You Live Your Life, And I’ll Live Mine
Bryant, Mississippi’s current governor, contends that expanding Medicaid would remove a significant incentive to seek work. He also sees expansion as unnecessary from a health care perspective.
The crux of Bryant’s opposition has centered on costs, though. Mississippi currently spends 13 percent of its tax revenue on Medicaid, less than the national average of 17 percent. But state officials argue that expansion would squeeze out other services. “We can’t fund the Medicaid population we currently have without two things — raising taxes or making tremendous cuts, draconian cuts, in education, transportation, public safety and job creation,” Bryant has said.
Medicaid expansion would cost Mississippi’s state government $1.1 billion over the next decade, and would bring in an additional federal contribution of $12.8 billion, according to an analysis from the Urban Institute, an independent research group.
Mississippi has long prided itself on fiscal conservatism and balanced budgets. But historically, state leaders haven’t seemed to mind accepting federal dollars, which account for more than 40 percent of the state’s annual budget — a higher share than any other state. Is this debate just about money?
One of the most vivid encounters I had in Mississippi was in the parking lot of a restaurant in Jackson, across the street from a state health department building. A woman in her mid 60s struck up a conversation with me and the photographer I was traveling with. She was slight, with feathered gray hair and oval, wire-rimmed glasses.
When I told her we were reporting on the state’s Medicaid policy, she became animated. “The Blacks want everything, but who is going to pay for it? How is that fair?” She went on, “They don’t want to work for nothing.”
“Now, don’t get me wrong,” she added. “One of my best friends is Black.”
The woman, who asked not to be named, is not alone in her sentiment. In February, Mississippi state Rep. Gene Alday told a local newspaper reporter, “I come from a town where all the Blacks are getting food stamps…. They don’t work.”
The idea that public assistance programs only benefit non-Whites is a “commonly held belief,” said James M. Thomas, an associate professor of sociology at the University of Mississippi. But in the U.S., 41 percent of Medicaid recipients are White, while 21 percent are Black. Those ratios are roughly reversed in Mississippi, where Black residents make up 38 percent of the population, about three times the national average.
Bryant, in a statement, called the idea that race plays a role in the Medicaid debate “reprehensible and utterly without merit.” Yet a poll from April found opposition to Medicaid expansion heavily split along racial lines in Mississippi, with more than twice as much support for expansion among Black residents (88 percent) as among Whites (44 percent).
Many of those most affected hear a familiar dog whistle in the Southern states’ refusal to participate in Medicaid expansion — racial animus of the kind that has driven the debate over public benefits since the days of the Great Society.
Whitney Carter, the journalism student who could not treat her diabetes, expressed frustration that a full-time student with a part-time job could not get adequate health care in the world’s richest nation. “Whose shoulders does that fall on?” said Carter, who is Black. “I feel like Black people are just tolerated, sometimes. We aren’t accepted, we’re tolerated.”
It was a bright Wednesday afternoon, and nothing was biting. Johnny Jenkins sat on an upturned bucket, fishing off the levee that slants sharply from downtown Greenville, a Delta town of 33,000, into Lake Ferguson, an oxbow lake curling off the eastern bank of the Mississippi River.
“There’s a whole different story to what they know in the capital and what’s happening in this world,” said Jenkins, 52. A former truck driver, Jenkins tried for years to get Medicaid coverage, until chronic hip problems forced him out of work. After staying out of work on disability for two years, he automatically became eligible for Medicare. He now has to have a double hip replacement, but at least he has insurance.
It’s a story I heard several times in the Delta — people who were forced out of work by untreated health issues gaining insurance coverage only after remaining on disability for two years.
Jenkins, who is Black, felt he’d been pushed out of the workforce by Mississippi’s health care policies. “The state of Mississippi is still back in the Jim Crow days. They can’t put on a hooded sheet anymore, and they can’t burn a cross in your yard, but they can still pencil whip you,” he said. “They can pencil whip you, and there ain’t nothing you can do.”
A New Leaf
After the Civil War, a group of freed slaves left the riverfront plantation of Joseph Davis, Jefferson’s older brother, and struck out into the Delta backwoods. The community they founded in 1887, Mound Bayou, remains intentionally and entirely Black.
“We have a unique experience that many Blacks cannot talk about,” Eulah Peterson, former Mound Bayou alderman and vice mayor, said in an interview at the First Baptist Church, where she’d requested we meet. “I never had to worry about could I go to school here, or I couldn’t go into that church.”
Peterson, 66, is a retired educator with a doctorate in special education administration, and speaks in the even, precise tone of a school principal who knows every excuse in the book. Her father moved to Mound Bayou in 1929, and worked as a printer. Her mother’s father was born into slavery, seven years before the end of the Civil War. “I’m that close to slavery,” she told me calmly.
In addition to a host of other civic activities that have filled Peterson’s retirement, she is lead human rights commissioner for the Southern Rural Black Women’s Initiative, which advocates on health care and other poverty-related issues.
“Health care as a human right is basic,” she said. The state’s decision not to expand Medicaid to include the working poor, she believes, “is creating a whole group of people who are on a slow death roll.”
Mound Bayou has long been a regional hub for health care. The all-Black Taborian Hospital operated here for four decades, before closing in 1983. Today, the Delta Health Center, a rural health clinic founded in the 1960s, sits on the western edge of town. The sliding-scale fee clinic served over 10,000 poor and low-income patients last year. Though most were Black, about 700 were White.
“I don’t know how we do it, but we need to flip that switch that makes White people realize that they’re being hurt too” by the failure to expand Medicaid, said Peterson, who like others, knows that cities suffer and long-term costs for everyone soar when health insurance is not an option.
“It’s not just for Blacks. You’re suffering, too.”
Keith Griffith is a journalist in New York City. His work has appeared in the Chicago Sun-Times, Chicago Reader and Business Insider. On Twitter, he is @keithgriff. This is a special report and part of “The Dignity of Living” series. Information from The Henry J. Kaiser Family Foundation was used in the accompanying video. The video also has been revised to include the correct last name for Gloria Owens.