\n\tDaniel Chang and Andy Miller<\/span><\/p>\n

As a part-time customer service representative, Jolene Dybas earns less than $15,000 a year, which is below the federal poverty level and too low for her to be eligible for subsidized health insurance on the Obamacare marketplace.<\/p>\n

Dybas, 53, also does not qualify for Medicaid in her home state of Alabama because she does not meet the program requirements. She instead falls into a coverage gap<\/a> and faces hundreds of dollars a month in out-of-pocket payments, she said, to manage multiple chronic health conditions.<\/p>\n

\u201cI feel like I\u2019m living in a state that doesn\u2019t care for me,\u201d said Dybas, a resident of Saraland, a suburb of Mobile.<\/p>\n

Alabama is one of 10 states that have refused to adopt the Affordable Care Act\u2019s expansion of Medicaid, the government health insurance program for people who are low-income or disabled.<\/p>\n

But lawmakers in Alabama and some other Southern states are reconsidering their opposition in light of strong public support<\/a> for Medicaid expansion and pleas from powerful sectors of the health care industry, especially hospitals.<\/p>\n

Expansions are under consideration by Republican legislative leaders in Georgia and Mississippi, in addition to Alabama, raising the prospect that more than 600,000 low-income, uninsured people in those three states could gain coverage, according to KFF data.<\/p>\n

Since a 2012 Supreme Court ruling rendered the ACA\u2019s Medicaid expansion optional, it has remained a divisive issue along party lines in some states. Political opposition has softened, in part because North Carolina\u2019s Republican-controlled legislature voted last year to expand the program. Already, more than 346,000<\/a> residents of the Tar Heel State have gained coverage.<\/p>\n

And lawmakers in nearby states are taking notice.<\/p>\n

\u201cThere has certainly been a lot of discussion of late about Medicaid expansion,\u201d said Georgia House Speaker Jon Burns, a Republican, in a speech<\/a> to the state chamber of commerce shortly after the legislative session began on Jan. 8.<\/p>\n

\u201cExpanding access to care for lower-income working families through a private option \u2014 in a fiscally responsible way that lowers premiums \u2014 is something we will continue to gather facts on in the House,\u201d Burns said.<\/p>\n

In addition to Georgia, state House speakers in Alabama and Mississippi have indicated a new willingness to consider coverage expansion. All three states have experienced a large number of hospital closures, particularly in rural areas.<\/p>\n

Medicaid expansion has become \u201cpolitically safer to consider,\u201d said Frank Knapp, president of South Carolina\u2019s Small Business Chamber of Commerce. In his state, Republican lawmakers are weighing whether to appoint a committee to study expansion.<\/p>\n

It\u2019s the kind of momentum some health policy analysts view as a favorable shift in the political discourse about expanding access to care. And it comes as a new crop of conservative leaders grapple with their states\u2019 persistently high rates of poor, uninsured adults.<\/p>\n

An additional incentive: Under President Joe Biden\u2019s 2021 American Rescue Plan Act, the federal government pays newly expanded states an additional 5 percentage points in the matching rate for their regular Medicaid population for two years, which would more than offset the cost of expansion for that period.<\/p>\n

But even as new discussions take place in legislatures that once froze out any talk of Medicaid expansion, considerable obstacles remain. Republican Mississippi Gov. Tate Reeves, for example, still opposes expansion. And several nonexpansion states appear to have little to no momentum.<\/p>\n

\u201cA lot of things need to come together in any given state to make things move,\u201d said Robin Rudowitz, director of the Program on Medicaid and the Uninsured at KFF.<\/p>\n

Under Medicaid expansion, adults earning up to 138% of the federal poverty level, or about $35,600 for a family of three, qualify for coverage.<\/p>\n

Expansion has reduced uninsured rates in rural areas, improved access to care for low-income people, and lowered uncompensated care costs for hospitals and clinics, according to KFF analyses<\/a> of studies from 2014 to 2021<\/a>. In states that have refused to expand Medicaid, all of those challenges remain acute.<\/p>\n

Alabama\u2019s legislative session began Feb. 6. Republican House Speaker Nathaniel Ledbetter has suggested that he\u2019s open to debating options for increased coverage. So many hospitals are in \u201cdire straits,\u201d he said at a Montgomery Area Chamber of Commerce<\/a> meeting in January. \u201cWe\u2019ve got to have the conversation.\u201d<\/p>\n

Expansion could make as many as 174,000 uninsured people in Alabama eligible for coverage, according to KFF data. Still, Ledbetter prefers a public-private partnership model, and has looked at Arkansas\u2019 program, which uses federal and state money to pay for commercial insurance plans on the Obamacare marketplace for people who would be eligible for Medicaid under expansion.<\/p>\n

In Alabama, lawmakers have introduced a plan<\/a> that would levy a state tax on gaming revenue and could help fund health insurance coverage for adults with annual incomes up to 138% of the federal poverty level.<\/p>\n

Robyn Hyden, executive director of advocacy group Alabama Arise, which supports Medicaid expansion, has seen progress on efforts to increase coverage. \u201cThe devil\u2019s going to be in the details,\u201d she said.<\/p>\n

Mississippi\u2019s new House speaker, Jason White, a Republican, has said he wants to protect hospitals and keep residents from seeking regular care through the emergency room. More than 120,000 uninsured people in Mississippi would become newly eligible for Medicaid under expansion, according to KFF data.<\/p>\n

White told KFF Health News in a written statement that improving access to health care is a priority for business leaders, community officials, and voters.<\/p>\n

\u201cThe desire to keep Mississippians in the workforce and out of the emergency room transcends any political party and is a vital component to a healthy workforce and a healthy economy,\u201d he said. State legislators are determined to work with Reeves on the issue, he said.<\/p>\n

Burns, the Georgia House speaker, has said that he\u2019s open to a proposal for an Arkansas-style plan. Republican Gov. Brian Kemp said he would reserve comment until after the legislative process, according to spokesperson Carter Chapman.<\/p>\n

He emphasized Kemp\u2019s commitment to his recently launched plan<\/a> requiring low-income adults to work, volunteer, or receive schooling or vocational training for 80 hours a month in exchange for Medicaid coverage. As of mid-January, the cumulative enrollment was right around 3,000. Expansion could make at least 359,000 uninsured people in Georgia newly eligible for Medicaid, according to KFF data.<\/p>\n

In South Carolina, Republican lawmakers are considering legislation that would allow them to form a committee to study expansion. State Sen. Tom Davis, a Republican from Beaufort who sponsored the bill and previously opposed expanding Medicaid<\/a>, said he\u2019s not endorsing or opposing Medicaid expansion at this time.<\/p>\n

\u201cWe need to have a debate,\u201d Davis said during a committee meeting in January.<\/p>\n

The state legislature would likely have to work with Gov. Henry McMaster, a Republican, who, according to spokesperson Brandon Charochak, remains opposed to Medicaid expansion.<\/p>\n

North Carolina started enrolling residents under its expansion Dec. 1. They included Patrick Dunnagan, 38, of Raleigh. The former outdoor guide said he hasn\u2019t been able to work for years because of kidney disease and chronic pain.<\/p>\n

He has relied on financial support from his family and said his medical debt stands at more than $5,000. Medicaid coverage will provide financial security.<\/p>\n

Dunnagan said people with chronic health conditions in nonexpansion states \u201care accumulating medical debt and not getting the care they need.\u201d<\/p>\n

Bills proposed in Texas\u2019 legislature didn\u2019t get a vote last year. And the state doesn\u2019t allow voter-initiated referendums, which have been a route to expansion in some Republican-led states. An estimated 1.2 million uninsured people would be eligible for coverage \u2014 more than in any other state still holding out \u2014 if Texas expanded.<\/p>\n

Republican lawmakers in Tennessee and Florida have said they won\u2019t allow Medicaid expansion. In Florida, advocates have launched a petition drive for a ballot initiative, but the earliest it could go to voters is 2026.<\/p>\n

In Kansas, Gov. Laura Kelly, a Democrat, is once again pressing her state\u2019s Republican-controlled legislature to adopt Medicaid expansion, calling it a \u201ccommonsense proposal\u201d that would lower health care costs for all consumers and protect rural hospitals. But the state\u2019s House speaker remains opposed to Medicaid expansion.<\/p>\n

Advocates believe it\u2019s only a matter of time before Medicaid expansion happens nationwide as opposition eases and people continue to suffer the consequences of being uninsured.<\/p>\n

For Dybas in Alabama, the prospect of gaining coverage is enough to make her consider relocating. In Minnesota, where she once lived, \u201cI wouldn\u2019t have this problem,\u201d Dybas said.<\/p>\n

Perhaps, as in Arkansas, conservatives will adopt models that rely more heavily on commercial insurance.<\/p>\n

But many holdout states in the South \u2014 where death rates for heart disease<\/a>, cancer<\/a>, and diabetes<\/a> are mostly worse than in other states \u2014 see growing disparities between the health of their citizens and those of neighboring states that have expanded, said Lucy Dagneau, a senior director for the American Cancer Society\u2019s advocacy arm, the Cancer Action Network<\/a>. The group lobbies state legislatures for expanded insurance coverage.<\/p>\n

\u201cThere will be a tipping point for all these states,\u201d she said.<\/p>\n

KFF Health News South Carolina correspondent Lauren Sausser and senior correspondent Renuka Rayasam contributed to this report.<\/em><\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

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