July 8, 2020

Between a Rock and a Hard Place: Medicaid in Southern States

Ever since the Affordable Care Act was signed into law, the Academy has kept close watch on individual states and their responses, especially the Medicaid expansion provision, which would provide health care coverage for millions more Americans, many of whom are affected by HIV. The coronavirus pandemic underscores the need to expand coverage to the most vulnerable.  

On June 30, Oklahoma – by a 50.5 percent vote – became the first state to expand its Medicaid program since the onset of COVID-19. This narrow victory comes as a relief to Oklahomans whose state, until now, had the country’s second largest uninsured population, exceeded only by Texas. Their new law will enable over 200,000 more residents to enroll in Medicaid at the annual cost of $1.3 billion, of which $164 million is expected to be paid by the state.

These numbers will be affected as unemployment rates climb and people lose their work-related insurance due to economic shutdowns. A staunch opponent of Medicaid expansion, Governor Stitt of Oklahoma complained that, “We have to come up with $200 million. With unemployment increased because of COVID-19 and the oil-and-gas (downturn), it could be more.”

The election result, however, confirmed Oklahomans’ rejection of the status quo. Amber England, leader of the state’s Medicaid Expansion Campaign, said, “in the middle of a pandemic, Oklahomans stepped up and delivered lifesaving care for nearly 200,000 of our neighbors, took action to keep our rural hospitals open, and brought our tax dollars home to protect jobs and boost our local economy.”

The political motivations that still prevent 13 states from adopting Medicaid expansion are confusing. According to the New England Journal of Medicine (NEJM), “Medicaid expansion appears to be a win-win from the states’ perspective — giving health insurance to millions of low-income adults and offering financial support to safety-net hospitals, without any adverse effects on state budget… Skyrocketing number of uninsured, and fragility of our health care system offer compelling reasons for non-expansion states to take another look,” they conclude.

Texas has the largest uninsured population of all US states. Five million Texans are currently unable to access affordable health care. Florida follows with 2.73 million residents who would be eligible for Medicaid if their state accepted Medicaid Expansion. The remaining eleven states still rejecting it are AL, GA, KS, MO, MS, NC, SC, SD, WI, TN and WY.

Texas Governor Gregg Abbott has accused the federal government of coercively trying to force Medicaid expansion upon his state. The Texas Medical Association replied with a blunt declaration that, “those [Texans] who lack insurance coverage typically enjoy far worse health status than their insured counterparts.” Their assertion is bolstered by national research done at University of Michigan and published in the National Bureau of Economic Research. It showed that 15,600 deaths were averted when 3.7 million low-income Americans who had been uninsured received coverage through Medicaid expansion. The annual rate of Texan deaths alone that could have been averted per year were 730.

Of the 13 states who have not expanded Medicaid, only four are located outside of the south. In the southern states refusing Medicaid expansion, 12% or more of the population are uninsured and HIV rates in the region have been rising in the last few years. In 2019, the CDC’s annual HIV Prevention Progress Report listed “persons residing in the southern United States” as a population at increased risk of acquiring HIV— along with people of color, men who have sex with men, etc.

Chris Beyrer, Public Health Professor at Johns Hopkins University and a past president of the International AIDS Society, says that this phenomenon is “a function of the refusal of the red-state political leadership to expand Medicaid through the ACA.” He added that, “Now the places we’re really most concerned about are East Texas, Louisiana, Mississippi, Alabama, Georgia and Florida. There, what you’re seeing is many more people living with the virus untreated, very, very low rates of PrEP access and PrEP uptake, and real problems in health disparities that are structural and social.”

Emory University Professor Patrick Sullivan, formerly of the CDC, works on AIDSVu, an HIV mapping project that documents HIV transmission across various settings to identify factors correlated to its spread. In a recent interview, Sullivan pointed out the relatively small number of red dots (on his map identifying HIV cases) surrounding clinics offering PrEP. Only one clinic is located within the adjacent deep-purple zone, where the red dots are so numerous that they merge. These purple mass are almost inevitably in areas without Medicaid expansion.

Dr. Sullivan’s maps are used both to assess the epidemic’s progress and to guide the development of the administration’s “Ending the HIV Epidemic” initiative. This suggests a sincere commitment on the part of Trump Administration to reduce HIV transmission.

Meanwhile, however, the Administration’s Department of Health and Human Services (DHHS) is not encouraging the 13 states that have not yet expanded Medicaid to do so. Last January, DHHS’ Center for Medicare and Medicaid Services offered states (with or without Medicaid expansion) a chance to convert their state Medicaid programs for adults into federal block grants, a new plan the administration calls the Healthy Adult Opportunity (HAO) Initiative. This proposal allows states to cap the amount of federal funding available for adults on Medicaid and to use their resulting HAO funding as they see fit.

When implemented, the waiver could allow a state to deny adults on Medicaid the prescription drugs they need and to impose higher copayments on people in poverty. In states that hire Medicaid Managed Care (MMC) programs to administer their Medicaid, previous state standards may be altered to accommodate an HAO Medicaid plan. The HAO waivers will likely reduce health care access for people who rely on Medicaid coverage – about five million of whom have disabilities, including among them people with HIV. Tennessee is the first state to take up the HAO offer.

View the latest Policy Update here.