Journalist's work in four states shows how Medicaid expansion improves access to care

By Joseph Burns

Last year, April Simpson demonstrated what may be one of the most effective ways to write about the benefits of Medicaid expansion. A senior reporter covering racial equity for the Center for Public Integrity (CPI), Simpson wrote two articles showing how residents in Medicaid-expansion states gained better access to care than those living in neighboring states that did not expand eligibility for enrollment in Medicaid, as allowed under the Affordable Care Act.

In the first article, Simpson (@aprilleticia) compared health care access in Minnesota, a Medicaid expansion state, with more limited access in neighboring Wisconsin, which has not expanded eligibility for Medicaid. For that article, which CPI published in July, she had an ideal source: Jessie Peterson, CEO of the Lake Superior Community Health Center. As Simpson explained, the health center has operations in Duluth, Minnesota. and in Superior, Wisconsin. Although the two sites are just a few stoplights away across the Bong Memorial Bridge, the Wisconsin location has fewer financial resources and poorer health care access for low-income residents.

For Simpson’s second article, CPI partnered with The Guardian newspaper in December to compare access to health care in Mississippi, which has not expanded Medicaid eligibility, against health-care access in neighboring Louisiana, a Medicaid expansion state. In that article, “How Lack of Medicaid Expansion Fuels Rural Poverty in the Deep South,” Simpson addressed how racism has driven the decision not to expand enrollment in Mississippi’s Medicaid program for the poor and how the failure to expand eligibility for Medicaid enrollment fosters poverty in rural areas.

For both articles, Simpson wrote about how states that did not expand Medicaid eligibility have more uninsured adults than states that increased Medicaid eligibility, and most of those uninsured adults are poor and people of color.

Her work could serve as a model for journalists covering the complex issues in all 12 non-expansion states: Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin and Wyoming. Also, Simpson’s articles could serve as a template for journalists in the states adjacent to the non-expansion states.

Last fall, Simpson traveled to Mississippi to find residents on the western edge of the state who have experienced the negative effects of not expanding Medicaid. But then she went many steps farther to contrast what she found in Mississippi with the impact of Medicaid expansion in the eastern edge of Louisiana.

As she did with the article on Minnesota and Wisconsin, Simpson made clear that the contrast between the adjoining Southern states is stark. For her lede, she focused on Jabriel Muhammad, a self-employed carpenter and plumber who is black. As a childless adult, Muhammad is ineligible for Medicaid.

“In Mississippi, the poorest and blackest state in the United States, single adults without children like Muhammad are not eligible for public health insurance, regardless of how little they earn each year,” she wrote. “If he lived 30 miles west in Louisiana, across the Mississippi River, he could afford to see a doctor more often.”

A Mississippi native, Muhammad must pay as much as $40 every time he visits his doctor at the community health center in rural Jefferson County. That high cost means he can afford to go there only when very ill, Simpson noted. “But there’s another price to pay for not having health insurance,” she added. “In October, he was hit with a $1,394 hospital bill for an MRI scan to diagnose why he wasn’t breathing properly.”

“I wanted to go there because it makes a big difference to be there in person, especially when you’re reporting on folks who aren’t necessarily used to dealing with media,” she told me. “Plus, it’s always important to talk to people face to face.”

Initially, she was planned to focus on how funding from the Coronavirus Aid, Relief, and Economic Security (CARES) Act of 2020 was getting to rural hospitals to report on how those hospitals were serving communities of color and how the funding was affecting disparities in those communities. But measuring how CARES Act funding was going to rural hospitals was impossible at that time, she said.

That research led her to do a story about Medicaid expansion and health insurance access. “I thought it would be interesting to look at some of the border communities in Louisiana and Mississippi and Louisiana and Texas,” she said. “I wanted to see how many folks had health insurance in communities of color. Eventually, that led me to Madison Parish, La., and Jefferson County, Miss. Both are along the Mississippi River: Madison Parish near the Northeastern corner of Louisiana, and Jefferson County on the Southwestern border of Mississippi.

“In looking at that whole region, it seemed like those two areas—Madison Parish and Jefferson County—are demographically similar,” she said. “So, that seemed like a good place for my story.”

Key take-aways from Simpson’s reporting

Among the strengths in her reporting is Simpson’s focus on the disparities in the two states. She showed, for example, that in 2016, Louisiana hospitals spent 8.9% of their operating expenses on debt resulting from the cost for care for uninsured patients who couldn’t pay for their care. That figure declined to 5.5% in 2020, after Louisiana expanded eligibility requirements for Medicaid enrollment on June 1, 2016. Over those same years, the percentage of bad debt that Mississippi hospitals reported remained about the same at 7%, she noted. As of early last month, the Louisiana Department of Health reported that 713,000 state residents had health insurance through Medicaid.

Most of the 2.2 million Americans eligible for health insurance in the 12 states that have not expanded Medicaid live in eight states in the South, Simpson reported. In addition, she added, 78% of the Mississippi residents who would benefit from expanded Medicaid enrollment are like Muhammad in that they are poor adults without children.

Simpson also noted that the lack of Medicaid expansion in the South is tied to a history of racism there. In these states, she wrote, “the legacy of slavery continues to shape health care policies, efforts to alleviate poverty and the life circumstances for Black people.” Louisiana became an exception when it implemented Medicaid expansion.

Simpson’s work helps to explain some of the reasons behind not expanding Medicaid enrollment. For example, she quoted Don Simonton, a retired professor from Alcorn State University, a historically Black college in Mississippi. “The denial of Medicaid coverage is scandalous,” he told her. “It is so typical of the power structure of the South from slave days forward: ‘If you’re poor, you better make some money if you don’t want to die.’”

She also cited the Center on Budget and Policy Priorities, a nonpartisan policy and research center that supports policies to reduce poverty and inequality. “Many of the states that have refused expansion have a long history of policy decisions based on racist views of who deserves to get health care services,” the CBPP said.

In September 2021, Mississippi’s State Economist J. Corey Miller and Senior Economist Sondra Collins, PhD, published a report, “A Fiscal And Economic Analysis of Medicaid Expansion in Mississippi Under the Affordable Care Act,” Simpson noted. The report showed that Medicaid expansion would add 11,300 jobs over five years, significantly reduce hospital costs for unpaid care and pay for itself for at least a decade. “Yet Mississippi Gov. Tate Reeves insists that expanding Medicaid would be bad medicine,” Simpson wrote.

In addition to the articles she wrote comparing two Medicaid-expansion states with two neighboring non-expansion states, Simpson also covered how poor heath in rural areas of the South are linked to systemic racism and the legacy of slavery.

On the day CPI published Simpson’s work on Mississippi and Louisiana, the center published an article by Simpson’s former colleague, Alex Eichenstein, “What Medicaid expansion means and why it matters,” and CPI added information on how the American Rescue Plan Act helps the 12 non-expansion states pay for expanding Medicaid coverage. The act also provides increased funding to two states that recently implemented Medicaid expansion plans: Missouri and Oklahoma. In 2020, we covered how ballot initiatives led to Medicaid expansion in those two states.

More resources for journalists covering Medicaid expansion