Medicaid expansion in the states under the Patient Protection and Affordable Care Act, aka Obamacare or ACA, is scheduled to take effect in 2014. Under the new federal policies, Mississippi could receive $9.9 billion in federal funds to cover between 148,000 and 370,000 people who do not currently have health insurance.
Gov. Phil Bryant says he's going to turn it down.
It didn't take him long to make up his mind. As he wrote on his website last summer, he doesn't want the federal government to interfere with Mississippi's sovereignty by sending more money. ("Since when did the federal government ever give free money without asking for something in return?" he asked.) He also thinks the poor haven't earned the right to health care. ("[E]ach of us must assume personal responsibility for our own health and our own choices," he continued.)
In the context of Mississippi politics, these reactions aren't policy positions. They're political reflexes.
A September study by The New England Journal of Medicine, titled "Mortality and Access to Care among Adults after State Medicaid Expansions," gives us some indication of how costly these political reflexes might be. By studying state-level Medicaid expansions, the authors came to the conclusion that Medicaid expansion reduces the relative risk of death among adults by 6.1 percent.
"Our results," the authors wrote, "correspond to 2,840 deaths prevented per year in states with Medicaid expansions, in which 500,000 adults acquired coverage. This finding suggests that 176 additional adults would need to be covered by Medicaid in order to prevent 1 death per year."
That was in New York state. If the ratio holds true in Mississippi (a far poorer and less healthy state), that translates to 2,102 lives saved every year under a full, 370,000-adult Medicaid expansion. Put another way, an estimated 14,714 Mississippians who would otherwise die between 2014 and 2020 could survive because of the Medicaid expansion--and more than 350,000 Mississippians could live healthier, more productive lives once they are given access to affordable preventive care.
If Bryant allows Medicaid expansion to proceed, it will be an act of political courage. His party has, by and large, obstructed the Affordable Care Act at every turn for three years. His decision to set a new course would surprise me, as it would no doubt surprise many other political observers, but it would set a powerful precedent.
Whether the Legislature approves Medicaid expansion or not, the state government will need to revisit its current health-care funding system. Under the original version of the Affordable Care Act, the federal government will phase out reimbursements to hospitals for unpaid medical bills (most of which come from uninsured patients) as a logical response to a decrease in the number of the uninsured due to Medicaid expansion. The U.S. Supreme Court's ruling in National Federation of Independent Business v. Sebelius granted states the option to decline additional Medicaid funds--but the reduced reimbursements to hospitals remain in effect.
If the state declines additional Medicaid funding and the number of uninsured Mississippians remains at its current level, rural hospitals in low-income areas (that rely heavily on federal reimbursement) will go bankrupt due to unpaid bills. Large areas of the Mississippi Delta will lose hospital access completely. There are no studies dealing with the possible impact of widespread hospital closures in already-underserved, low-income rural areas, but it is difficult to imagine an outcome that would not be tragic, horrifying, and monstrous in scope.
The actions of the Mississippi Legislature over the next session will have a lasting effect on our state's health-care policy. Gov. Bryant has a historic opportunity to dramatically improve the health-care system of America's poorest state--the state that has the most to gain from Obamacare, and the state that has the most to lose by rejecting it. He also has the opportunity to make our heath-care crisis substantially worse. It is likely that his decision on this matter will determine his political legacy more than any other decision he has made or will make as a public official. More importantly, it is likely that his decision will have a profound effect on the lives of Mississippians.
He should proceed thoughtfully.
Tom Head is a Jackson native. He covers civil liberties for About.com, and has written or co-written 24 nonfiction books.