Opposition to Medicaid Expansion Thaws in an Unexpected Place: The Deep South

For more than a decade, some Southern states have resisted Medicaid expansion under the Affordable Care Act, even though data suggest it could help their residents. Today, the large majority of uninsured Americans who would gain coverage under Medicaid expansion — and who would benefit from affordable access to care — live in non-expansion states in the South.

But the politics are shifting. North Carolina expanded Medicaid in December, after a years-long lobbying campaign by the state’s Democratic governor and hospital industry persuaded the Republican-controlled legislature to pass a bill. 

The Tar Heel State’s move may have helped thaw opposition in Alabama, Georgia and Mississippi, where Republican state House speakers have recently indicated they’re open to expansion options, which could lead to new insurance coverage for more than 650,000 people.

And though resistance remains firm in the seven other states that have so far refused expansion, some analysts predict they’ll inevitably acquiesce. 

“It’s just a question of when,” said Joan Alker, executive director of the Center for Children and Families at Georgetown University. 

Thanks to North Carolina, where expansion has meant government health insurance for more than 346,000 low-income people so far, the prospect has become “politically safer to consider,” said Frank Knapp, president of the Small Business Chamber of Commerce in South Carolina. Republican lawmakers in his state are considering forming a committee to study the idea.

Under Medicaid expansion, adults earning up to 138 percent of the federal poverty level, or about $35,600 for a family of three, qualify for coverage. Nearly 3 million Americans would become newly eligible for Medicaid if all holdout states expanded, according to KFF.

Strong public support for Medicaid in non-expansion states, and lobbying from influential sectors of the health-care industry — especially hospitals — has eroded some of the opposition. 

There’s also more money on the table. President Biden’s 2021 pandemic-relief law offered states that increased eligibility for Medicaid a financial incentive for two years, more than offsetting the cost of expansion for the period, according to a KFF analysis. But even as discussion builds in statehouses that once quashed any talk of Medicaid expansion, formidable opposition remains. Republican governors in South Carolina and Mississippi, for example, still oppose expansion. Several other non-expansion states appear to have little to no legislative momentum.

In Kansas, Gov. Laura Kelly (D) is once again pressing her state’s Republican-controlled legislature to adopt Medicaid expansion, saying it would lower health-care costs for all consumers and protect rural hospitals.

But Republican House Speaker Dan Hawkins, in a video address to Kansans posted on YouTube, dismissed Kelly’s expansion plan as “billions in new state and federal spending to increase welfare for able-bodied, working-age people.”

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