After Obamacare made its way through Congress in 2009, triggering the Tea Party rebellion, Republican-controlled Southern statehouses became a redoubt of opposition to what critics saw as meddlesome socialist overreach.
Three years later, when the U.S. Supreme Court ruled that the Obama administration couldn't force states to enact a key Obamacare provision--expanding Medicaid to cover more low-income residents--most Southern states took advantage of the decision and didn't.
Today, nine of the 14 states that haven't expanded Medicaid are in the South, leaving more than 2.3 million low-income Southerners who would qualify for Medicaid without health care coverage, according to researchers at the Kaiser Family Foundation.
But there are some signs that the blanket opposition to expanding Medicaid in the South may be retreating, albeit slightly and slowly.
Louisiana and Virginia expanded Medicaid after electing Democratic governors in 2017. In Arkansas and Kentucky, where expansion passed under Democratic governors, it has endured despite their replacement by more skeptical Republicans.
In Florida and Oklahoma, petition drives are underway to put expansion on the ballot in 2020, doing an end-run around recalcitrant GOP leaders. And in Mississippi, a Democrat is trying to use expansion as a wedge issue to end a 16-year Republican lock on the governor's office.
In states with expanded Medicaid, low-income people making up to 138 percent of the federal poverty level--about $17,000 for an individual--can get coverage. In states without expansion, the income limit for a family of three is just under $9,000; single people are excluded entirely.
Most of the singles and families who are not eligible for traditional Medicaid don't make enough money to get the tax credits they need to buy insurance on the Obamacare insurance exchanges. According to estimates from Kaiser, 92 percent of all Americans who fall into this coverage gap live in Southern states that haven't expanded Medicaid, including nearly 800,000 people in Texas, 450,000 in Florida, 275,000 in Georgia, and 225,000 in North Carolina.
The federal government pays 90 percent of the cost of Medicaid expansion; states must pick up the rest. Republican leaders who oppose the idea have balked at making a financial commitment to such an open-ended entitlement, which Congress could change at any time.
But that argument didn't hold in Virginia after Democrats campaigning on expansion nearly took control of the legislature in 2017. When expansion came up for a vote, 18 House Republicans who survived that blue wave joined Democrats to pass it.
Louisiana Governor John Bel Edwards, who issued an executive order on his first day in office to expand Medicaid, is now running for re-election touting that decision; voters will give their verdict in October.
In Mississippi, Attorney General Jim Hood is also making expanded Medicaid the centerpiece of his gubernatorial campaign this year, arguing that his state, with the nation's highest poverty rate, is cutting off its nose to spite its face by refusing to extend coverage to people who would benefit from it.
In Arkansas and Kentucky, where Democratic governors managed to push through expansion in 2014, the Republicans who replaced them have left the programs essentially intact, although they have fiddled at the edges by imposing premiums and work requirements on recipients. (Federal judges have blocked those changes.)
Die-hard Obamacare opponents have not been able to scuttle the program in either state--even in Arkansas, where the program has to be reauthorized annually by a three-fourths majority in both houses of the legislature.
In Florida and Oklahoma, supporters of expansion--including groups representing doctors, nurses and hospitals--are trying to put constitutional amendments expanding Medicaid coverage on the ballot in 2020.
Those ballot measures will be a key test of whether the public mood is more sympathetic to the idea of expansion than are the states' conservative leaders, who have argued that the program is unaffordable and discourages people from seeking employment to secure health care.
However, the strategy of pursuing ballot initiatives is of limited use in the South because among states that haven't expanded Medicaid, only Florida, Oklahoma and Mississippi allow the public to put measures on the ballot via petition. Texas, Georgia, Alabama, Tennessee, North Carolina, and South Carolina do not.
In Florida, the ballot measure will also need to get approval from 60 percent of the voters to pass.
The question to be answered this year and next is whether the fiscal and philosophical arguments against expansion will hold against the argument that low-income Southerners--rural and urban, black and white--deserve health-care coverage and will benefit from it, in spite of its association with Obamacare.
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Rich Shumate is the founder and editor of ChickenFriedPolitics.com, where this article first appeared. He is a journalism professor at Western Kentucky University and a former Arkansas resident.
Editorial on 07/12/2019