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September 22, 2018 01:00 AM

Could deep-red Miss. expand Medicaid? 2019 will tell

Susannah Luthi
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    Derrick T. Simmons, Mississippi state senator

    GREENVILLE, Miss.—Politically verboten in Mississippi for years, Medicaid expansion keeps simmering in the state Legislature because of one senator. And it could start bubbling up again if next year's governor's race breaks for Democrats.

    Medicaid expansion's most ardent champion in the Legislature is Democrat Derrick T. Simmons, one of three state senators representing the gerrymandered Delta districts. Simmons, a native of Greenville in the heart of the Delta, has pushed for expansion against political tides since 2013.

    But in those years the state has pulled in the opposite direction. And in 2018, the Division of Medicaid applied to the Trump administration for permission to add work requirements to its Medicaid population. The state already imposes some of the strictest limits in the country.

    Now the state government faces a potential shift as GOP Gov. Phil Bryant, a firm expansion opponent, nears the end of his term limit. Mississippi Attorney General Jim Hood, the only Democrat in statewide elected office, is polling in a dead heat with GOP Lt. Gov. Tate Reeves as a likely contender to replace Bryant. Because he has not formally announced his candidacy for the November 2019 election, Hood has not taken a stance on Medicaid expansion. However, close observers think he would likely support it.

    That fact, along with an April statewide poll that showed more than 52% of Mississippians support expanding Medicaid, signals that Simmons' proposal now could have a chance.

    'They don't understand Medicaid'

    The Simmons & Simmons law office sits at the heart of downtown Greenville, where Main Street meets the levee. Family Dollar and Dollar Trees stores and neighborhoods of taped-together houses lie on its outskirts, as well as elegant, pillared old homes shaded by magnolias. The Simmons brothers are trying to revive century-old buildings downtown, but some are crumbling anyway. People with desperate cases who need help or luck or both filter in throughout the day and wait on Naugahyde furniture underneath the massive framed portrait of the brothers standing as mirror images. Derrick, the state senator, wears a bow-tie; Errick, the mayor, wears a straight tie.

    The brothers specialize in criminal defense cases. In his public policy work, Derrick Simmons said he prioritizes two things: access to healthcare and education funding—two items that are usually at odds in state budgets. He won his state Senate seat in 2011 and as soon as Obamacare passed in Congress, he set his sights on Medicaid expansion and drafted a bill.

    “The Republicans had a supermajority in the Legislature,” Simmons said. “Even before I authored the (expansion) amendment it was known: our Gov. Phil Bryant said he would not support it. Lt. Gov. Tate Reeves said he would not support it. The speaker of the House, Philip Gunn, said he would not even participate.”

    Rep. Stephen Holland, a Democratic, said the state Legislature opposes expansion because lawmakers don't understand how Medicaid works.

    “The only thing that saves Medicaid among this group is so many of their mothers and grandmothers are in nursing homes funded by Medicaid,” Holland told Modern Healthcare in June. “But they don't understand Medicaid. They talk a big game about how they want to cut back on welfare queens, but they don't do it. It's not right, politically not right, but they don't expend enough energy to understand Medicaid.”

    Simmons attributes the opposition to something deeper.

    “In Mississippi, we have a dark past, a dark history, and for a lot of people it's subconscious,” he said. “A lot of people, they don't even realize that they use religion when it's convenient. I think some people know that they use it when it is convenient, and I think other people don't. But I believe that as a Christian you would want to help your sister and brother, and I believe that if you are as religious as you purport to be, then Medicaid expansion was it.”

    He noted that expansion opponents argue that they don't want to take money and mandates from the federal government.

    "But we already take money from the federal government at a rate of 3-to-1," he said. "Look at the farm bill—you don't want to take subsidies, but look at the farm bill and what it does for Mississippi's economy. The only reason you are not critical of that is because of who it's going to.”

    The day Derrick Simmons introduced his Medicaid expansion measure in 2013, he walked around the Senate floor asking every single senator to sign on as a co-sponsor. About 15 Republicans told him they wanted to join but said: “You know we can't.”

    One big reason, lawmakers and close observers of the Legislature said, was Reeves. The lieutenant governor serves as president of the Senate and can steer legislation. He sent Simmons' bill to two GOP committee chairmen who would kill it on their panels.

    Laura Hipp, Reeves' spokesperson, said Reeves was opposed because the state couldn't afford its share of the cost.

    “Medicaid in Mississippi accounts for more than $1 billion of the state's $6 billion general fund budget,” she said. “Taxpayers simply could not afford an expansion of Obamacare that would pull limited resources from public schools and public safety and add burdensome regulations on the state's job creators.”

    Playing politics

    One of the Delta's other state senators, Republican Eugene “Buck” Clarke, chair of the Senate's appropriations committee, said Medicaid expansion “is not even being talked about” in the Legislature now. He, for one, is focused on some prosperity in the Delta which he said lifts some of the pressure off Medicaid.

    “I'm really looking at the historic low unemployment numbers and the effect on Medicaid numbers, and we're all kind of excited,” Clarke said.

    Unemployment in the Delta has steadily fallen over the past five years, although at 6.8% it is still more than a percentage higher than the statewide rate.

    Clarke directs his Medicaid efforts to pilot programs, like a project by the not-for-profit Delta Health Alliance to curb pre-term births and diabetes among Medicaid enrollees.

    “With the pilot programs and we're in uncharted territory with this many people working in the state—I hate to sound like I'm salivating over new revenue coming in—but it's encouraging,” Clarke said.

    Roy Mitchell is executive director of the Mississippi Health Advocacy Program in Jackson which helps people who don't qualify for Medicaid or who are otherwise falling through the cracks to get care. He called the idea that people can afford health coverage once they start working a myth because few employers offer it, particularly in the Delta.

    “When they do offer it, the wages are so low that it doesn't assume people can afford it,” Mitchell said. “In terms of adult coverage, we found it common for counties to have a 30% uninsured rate for adults, and 10% uninsured rate for children.”

    In the long shot chance that the state sees a political turnover in the near future, it's unclear how the healthcare industry—poised to reap financial gain from expansion—will respond. An early lobbying effort by hospitals resulted in a shakeup of the state hospital association, according to several observers of Mississippi politics, and hospital executives don't want to talk about it.

    “They took a back seat to lobbying, even though if you would talk to individual hospitals, the rural hospitals would hurt more without it,” Simmons said of the state's hospitals. “It was the political retaliation that people have to endure in Mississippi. If you don't have a level of security or independence, it's easy for you to feel like the retaliation is going to get to you.”

    Mitchell said the hospitals' unwillingness to take a stance has sunk them in the public's approval.

    “It is frustrating to me,” he added. “I don't really understand: Mississippians vote against their own interests, but if we take it to another level, the hospitals vote against their own interests. The hospital association is dominated by the urban (provider) market, but lack of expansion hurts all of them. The reputation hospitals and doctors have in the community—it's well-earned.”

    RELATED STORIES:

    Medicaid blues: Hospitals, insurers wage political battle over managed-care dollars

    AIDS patient's struggle to get care shows gaps in Medicaid program

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