Deep Dive: Exploring Healthcare in the South

By Michael Foley

As COVID-19 continues to ravage the United States, the flaws in our healthcare system have become all the more glaring. This is especially true across the South, where Black Southerners are especially susceptible. Southern states consistently rank toward the bottom in nearly all healthcare and wellness metrics. That’s largely due to a number of policies (or lack thereof) that disproportionately affect rural people living in poverty (a group which is, for a myriad of reasons beyond the scope of this article, disproportionately Black). If better policies had been in place before the outbreak started in early 2020, the outcome may have been less bleak. So, in preparation for the launch of this site, I took a deep dive into these issues to see where progress is being made in southern states, what health issues we continue to face, and what practical solutions can be implemented. Here’s what I found.

Insurance

Southerners are significantly less likely to have health insurance compared to the rest of the country, to the tune of a fifteen per cent uninsured rate versus a national uninsured rate of ten per cent. In fact, as much as eighty per cent of all uninsured Americans live in southern states. One reason? Southern states often impose more strict eligibility rules for programs like Medicaid and Children’s Health Insurance Program (CHIP), which are designed to ensure that people who can’t afford traditional health insurance still have coverage. And, without insurance, people are less inclined to seek medical attention because they’d rather not assume the crippling debt that comes with uninsured healthcare.

The most obvious example of this comes from the Affordable Care Act (ACA), often referred to as Obamacare. The ACA includes a provision allowing states to expand eligibility for Medicaid to any adults under the age of sixty-five who earn up to 138 per cent of the federal poverty level- essentially, offering Medicaid to anyone who cannot realistically afford traditional health insurance, even if they do not have children. Broadly speaking, without Medicaid expansion, adults without minor children are not eligible for Medicaid, no matter how little they earn. However, in 2012, before the ACA went into effect, the Supreme Court ruled that states could not be forced to expand Medicaid; they would have to voluntarily opt in, something which most non-southern states have since done. Unsurprisingly, most states that have adopted the Medicaid expansion have seen notable declines in their uninsured rates.

So, why have Alabama, Mississippi, South Carolina, North Carolina, Georgia, Texas, Florida, and Tennessee (four of which rank in the top six uninsured rates in the country) all thus far refused to expand Medicaid expansion? There are several answers, but the largest, unsurprisingly, involves money. One of the stipulations of the ACA Medicaid expansion was that until 2020, the federal government would absorb all costs associated with the expansion. After that point, however, states are responsible for ten per cent of the costs. In Mississippi, that would translate to an estimated annual cost of $100 million. To the ruling Mississippi conservatives, the benefits of a billion dollars in federal assistance and coverage for a quarter million Mississippians aren’t worth the cost, especially now that they have already missed the honeymoon period of complete federal coverage.

The story is similar across the South, but let’s continue to focus on Mississippi, where talks around Medicaid and ACA have been particularly contentious. In 2011, as he neared the end of his tenure as governor, Haley Barbour, who may well be deemed a RINO by today’s MAGA standards, complained that Medicaid recipients were driving around in BMWs, perpetuating Ronald Reagan’s racist myth of the welfare queen. Barbour made that comment in defense of his administration’s near-constant obstruction of Medicaid spending, and few Republicans in the state seemed to mind. They would only become more convinced of the evils of Medicaid spending as the next governor, Phil Bryant, assumed office.

Bryant and Tea Party Republicans launched a campaign against the newly passed ACA, decrying the costs associated with it. Blue collar Southerners often make pennies on the dollar compared to workers in more urbanized parts of the country, so Tea Party messaging of eliminating government spending to reduce taxes resonates with them, even when that government spending would benefit them in tangible ways. To that end, Bryant intentionally obstructed the implementation of all parts of ACA in Mississippi, openly feuding with the state’s insurance commissioner. The result? ACA enrollment was such a disaster that Mississippi was the only state in the country to see its uninsured rate rise in the year following ACA’s launch. Bryant, Tea Party members, and other ultra-conservatives pitched the idea that job creation and “personal responsibility” would be the proper solutions to the Southern healthcare crisis. More than eight years later, that idea still hasn’t panned out.

Opposition to Medicaid expansion in the South also harkens back to the days of Reconstruction, with many Southerners viewing the federal government as an evil entity seeking to interfere with and control the affairs of states that would prefer to be autonomous. The reality, however, is that southern states like Mississippi, which relies very heavily on assistance from Washington, would quickly crumble without federal support.

And Medicaid expansion would offer a huge amount of help to these states. Spurred by the COVID-19 outbreak, Oklahoma recently voted to expand Medicaid, which will help tremendously with their uninsured rate (currently the second-highest in the country) as 200,000 adults become eligible for Medicaid coverage. Virginia expanded Medicaid in 2019, granting coverage to more than 100,000 Virginians who would otherwise not have any access to insurance. Florida may put Medicaid expansion on the ballot in 2022, if the initiative can receive signatures totaling eight per cent of the total number of votes cast in the state in this November’s presidential election. Alabama’s uninsured rate would drop by forty-three per cent if they expanded Medicaid; instead, state legislators are actively seeking to make Medicaid more inaccessible. Texas has the highest uninsured rate in the country and largest group of people living in the coverage gap, but no plans to adopt the ACA’s Medicaid expansion. A Tennessee bill to expand Medicaid, the second in the state since the launch of the ACA, effectively died in committee earlier this year. South Carolina, North Carolina, and Georgia have all loosened Medicaid eligibility requirements, but they all fall short of the ACA’s Medicaid expansion, leaving swaths of Southerners uninsured.

If you live in a state that hasn’t enacted the ACA’s Medicaid expansion, consider contacting your state lawmakers to implore them to do so. That single piece of policy has likely saved thousands of lives through the current pandemic, and could have saved thousands more if more states had adopted it.

One last note on insurance: last year, U.S. Representative Lauren Underwood of Illinois (one of the architects of the ACA) introduced the Health Care Affordability Act. The most important point in this legislation is a mandate that no family have to pay more than 8.5 per cent of its adjusted gross income on healthcare premiums. That’s a very common sense method to ensure that insurance companies are keeping their rates reasonable, and may encourage people who don’t qualify for Medicaid to consider enrolling for traditional coverage. That bill hasn’t made it very far, but I can see no reason that policy wouldn’t work just as well on the state level. Consider floating the idea to your state legislators, and voicing your support of the Health Care Affordability Act to your representative on Capitol Hill.

Transportation

Transportation to and from appointments is one of the top barriers to healthcare for poor, rural Southerners. They are often very far from their healthcare providers and don’t have driver’s licenses. Even if they do have driver’s licenses, they may not be able to afford a vehicle. Even if they do have a vehicle, they may not be able to afford gas to cover the trip. This barrier translates to fewer medical screenings for things like cancer, heart disease, diabetes, and, in our current medical climate, COVID-19. And that same problem will keep thousands of rural Southerners from having access to COVID-19 vaccines if and when they become available, just as it keeps them from being able to get annual flu vaccines. Currently, the most important piece of policy addressing that issue is Medicaid’s Non-Emergency Medical Transportation (NEMT) program. As its name implies, NEMT provides free transportation to and from medical appointments by reimbursing transportation companies for the trips. If the Medicaid expansion discussed above were adopted in more southern states, hundreds of thousands more rural Southerners would have access to NEMT.

Instead, hundreds of thousands of Southerners may in fact lose their access to NEMT, as the Trump Administration has made multiple attempts to give states the option to waive the NEMT benefit to save cash, and, if Donald Trump is reelected, will attempt to do so again next year. Make no mistake: healthcare access for many Southerners is on the ballot this November. If Trump does succeed, the imperative lies on all of us to implore our state lawmakers to preserve the NEMT benefit.

Unfortunately, even with NEMT in place, there still exists an inherent reliance on transportation companies that are compliant with state Medicaid requirements being present in the recipient’s area. To that end, Arkansas passed a significant piece of legislation last year, allowing Medicaid to reimburse for ridesharing apps like Uber and Lyft to get to and from medical appointments.

Still, none of these measures are perfect. Citizens and legislators at all levels of government must continue to brainstorm ways to make healthcare transportation accessible to all.

Telehealth

Closely related to providing transportation to appointments is bringing the appointments directly to the patient through telemedical services, allowing patients to interact with physicians over their phone or computer. The telehealth industry has exploded during the COVID-19 outbreak as people become more reluctant to sit in a potentially germ-infested clinic waiting room, and will continue to play an important role in the American healthcare system, but states still have to take the action to require insurance companies to cover telehealth appointments.

Luckily, many have. So far, Arkansas, Louisiana, Tennessee, Mississippi, Georgia, Virginia, Texas, and Kentucky have all passed telehealth parity laws. In 2016, Alabama passed legislation to grant parity for telehealth insurance for mental health services, but has not expanded the law to medical services. Florida has established practice standards for telemedicine, but has not passed coverage parity legislation. North Carolina and South Carolina, meanwhile, have both implemented telepsychiatry networks in hospitals across the two states; these measures have definite benefits, but still, neither state requires telehealth coverage parity.

If you live in a state that hasn’t enacted telemedicine parity laws, consider calling or writing your legislators to discuss the issue. On the federal level, you can voice your support for the Protecting Access to Post-COVID-19 Telehealth Act, which will ensure that Medicaid recipients always have telemedicine coverage.

As is the case with NEMT, telehealth parity is far from a silver bullet. By design, most forms of telemedicine require a high-speed Internet connection, which many poor, rural Southerners lack. But southern healthcare systems are far better off with telehealth parity than without it.

School-Based Health Centers

School-based health centers are exactly what you think they are: primary care clinics on the campuses of elementary, middle, and high schools, owned and operated by the governing school district. They are an incredibly effective tool for ensuring the health of children who may not otherwise have regular access to medical care, but I’ll start by pointing out their obvious flaw: when schools are closed (be it for holidays, summer break, or something like the COVID-19 outbreak), school-based health centers are, too.

Still, the evidence behind the effectiveness for school-based health centers is overwhelming: increased healthcare access, reduced disparities by gender and ethnicity, lowered depression and suicide rates, better school attendance, higher immunization rates, fewer urgent care and emergency room visits, and much more.

Of course, these centers aren’t cheap, and we have already established that the conservatives who currently rule much of the South are resistant to taking on new expenses. Startup costs range from $50,000 on the low end to $125,000 on the high end, with annual operating costs from $90,000 to $150,000. On the other hand, those benefits listed above can translate to as much as nearly a million dollars in annual savings for the government.

And, luckily, there are plenty of ways to fund them. Section 330 of the Public Health Services Act created the Health Center Program, which grants federal capital for just this sort of project. Federally Qualified Health Center Funding and Title X Public Health Services Act Family Planning offer similar resources. School districts can also secure funding from benevolent foundations or local corporations looking for some good publicity. With all these opportunities available, costs absorbed by county and city governments can be minimal. There are plenty of great tool-kits available for guidance on setting up these centers, like these two.

Unfortunately, school-based health centers aren’t inherently designed to be free. Children will still need to be insured to receive care, unless state governments swallow their pride and open their wallets to include the Free Care Rule Reversal in their Medicaid State Plan, which allows schools to charge Medicaid for services rendered to all students, not just those insured by Medicaid. Plenty of conservative politicians have and will continue to decry the costs of such an idea, but they will be hard-pressed to find a voter who doesn’t think that the health of our children is worth any cost.

In a perfect world, every school in the country would have its own health center, but that’s not likely to happen in my lifetime. State health departments and lawmakers can, however, work with school boards to identify the areas that a school-based health center can make the biggest difference.

LGBTQ+ Considerations

As tolerance (slowly) grows in the South, members of the LGBTQ+ community are migrating from the South to more progressive states with less frequency. But they still face a number of unique challenges in healthcare, not the least of which is the fact that gay and bisexual men are at the highest risk of contracting HIV/AIDS. That means that they desperately need insurance, which, like so many of the things we’re talking about here, ties back to the need for Medicaid expansion.

In fact, more than half of all new HIV diagnoses come from southern states. Georgia, Florida, Louisiana, Mississippi, Texas, and South Carolina all rank in the top ten for HIV/AIDS cases. According to Southern Equality, “the South is the modern-day epicenter of the HIV crisis in the United States.” I really cannot stress enough how big of a factor lack of insurance plays here. One of the most important measures someone at risk for contracting HIV can take is to use a drug type called pre-exposure prophylaxis (PrEP), which is covered by most insurance plans, including Medicaid. Without insurance, however, PrEP costs somewhere in the ballpark of $1300 per month, and sometimes more. One of the best defenses against contracting HIV/AIDS is completely cost prohibitive to most uninsured men who have sex with men. That’s why expanding Medicaid is an essential step to addressing the HIV crisis plaguing the South.

Matters only get worse for the LGBTQ+ community in places like Mississippi, whose lawmakers passed the Protecting Freedom of Conscience From Government Discrimination Act in 2016. That law, despite a name denoting protection from discrimination, grants doctors the right to refuse to treat members of the LGBTQ+ community. Defenders of the law will argue that there is no evidence that any doctors have exercised the right, and as far as I have been able to find, that’s true. But if that actually is the case, then the legislation is pointless and may as well be revoked. More importantly, though, even if no doctors are exercising that right, its existence can deter members of the LGBTQ+ community from seeking treatment in the first place, out of fear of facing discrimination. Many conservatives will claim that the fear is unfounded, that no doctor would ever do such a thing, but the very existence of the law validates the fear. Mississippians, please speak out against this law.

It’s not all bleak, of course. As I said, tolerance and acceptance of the LGBTQ+ community is on the rise. States like Florida are using funding from the Trump Administration’s Ending the HIV Epidemic Initiative to increase testing, which is an important first step. But without taking action to get at-risk people access to preventive medicine, and connecting HIV-positive people with adequate healthcare, this approach falls short. The HIV epidemic will rage on, long after COVID-19 is gone.

Smoking

I’ll start this section with a disclaimer: I am a regretful smoker. Maybe it seems hypocritical for a smoker to opine on the public health challenges wrought by tobacco, but I feel I would be negligent in outlining healthcare problems in the South to leave it out.

The risks of smoking are so clear that I won’t waste much space to outline them here. That’s why most Americans have stopped smoking, or opt never to start in the first place. But, as is the case in so many categories, southern states lag behind. The fact is, West Virginia, Kentucky, Arkansas, Tennessee, Mississippi, Louisiana, and Oklahoma all rank among the top ten states for adult smokers. A full quarter of all adults in West Virginia smoke. Unsurprisingly, all seven of those states rank in the top eight for heart disease (more on that in the Obesity section below).

We’ll likely never be able to eradicate smoking altogether. Some people will always smoke. But there are a few policies that demonstrably impact just how many people smoke. One particularly effective solution is implementing smoke-free laws, limiting where people are allowed to smoke. Research shows that these policies not only protect nonsmokers from secondhand smoke, but also encourage smoking cessation. The more the act of smoking becomes a chore, the less appealing it is. Of course, most local governments have already implemented laws banning smoking inside public buildings, but these regulations aren’t uniform. For instance, smoking in restaurants and clubs is still allowed along much of the Mississippi Gulf Coast, including most casinos. Banning indoor smoking statewide can have a major impact.

But the best way to drive down smoking numbers is to keep people from ever starting, and most smokers start young. To that end, Oklahoma, Mississippi, Texas, Louisiana, Tennessee, South Carolina, Virginia, and West Virginia have all moved their minimum tobacco purchase age from eighteen to twenty-one. Kentucky and Arkansas desperately need to follow suit.

Beyond that, the best strategies to reduce smoking rates in southern states may be to increase tobacco taxes to make cigarettes and other tobacco products more cost prohibitive for consumers, and then invest that revenue into public education about tobacco use, with a focus on teens.

Obesity

Look, I know we have some great food in the South, but we have a bit of a weight problem. Mississippi, Louisiana, West Virginia, and Alabama rank as the four most obese states in the country, with Oklahoma, Arkansas, South Carolina, Kentucky, and Texas all in the top ten. Obesity, of course, has a strong correlation with heart disease (as alluded to earlier, the top eight states in heart disease are all southern) and many types of cancer.

The problem doesn’t just lie in our diets, though. Georgia, West Virginia, Tennessee, Oklahoma, Louisiana, Alabama, Kentucky, Arkansas, and Mississippi make up nine of the ten least physically active states in the country. To combat this, governments (federal, state, county, and municipal) can and should subsidize building more sidewalks in larger cities, and pair that with zoning laws that are pedestrian- and bicyclist-friendly. (In addition to encouraging physical activity, this is also an important way to reduce a city’s carbon footprint. That’s why cities like San Francisco and Paris are moving toward the Fifteen-Minute City Model.) Of course, that’s not realistic for more rural communities, which is why governments should also consider subsidizing more recreational walking trails for those communities.

But for many people, habits associated with obesity start in childhood. Local school boards and state education departments should take a look at their curriculums. The country’s current educational shift in focus toward STEM and STEAM is undeniably great for preparing our children for the future, but we have increasingly abandoned physical education, health, nutrition, and cooking. In Mississippi, for instance, high schoolers are only required to earn half a credit in health education, with no requirements for PE, nutrition, or cooking.

There are plenty of other policies to consider. A federal ban on marketing junk foods to children, as has been discussed in Congress for years, would be monumental, and I encourage everyone to contact their U.S. Representatives and Senators about that. In the meantime, schools should look to ban sales and marketing of junk foods on campus. Just like with smoking, obesity starts early.

Infant Mortality

For a region whose leaders generally claim to be pro-life, the South sees an awful lot of infant deaths. The top nine states in infant mortality are Mississippi, Louisiana, Arkansas, South Carolina, West Virginia, Oklahoma, Georgia, Alabama, and Tennessee. Despite holding the top two spots on that list, Mississippi and Louisiana have some of the strictest abortion laws in the country. Their legislators and governors can make claims to care about sanctity of life, but they do little to protect lives outside the womb. In fact, the lack of abortion access leads to many high-risk births in the two states. Loosening those restrictions even a little bit could go a long way for the infant mortality rate numbers.

There’s also a clear correlation between this list and the smoking list; that’s largely because tobacco use during pregnancy is a major risk factor for birth complications. Reducing the number of smokers, as discussed above, will make a difference in the infant mortality rate.

The infant death numbers are also closely tied to teen birth rates: seven of those top nine states in infant mortality also rank in the top ten for teen births. That shouldn’t be surprising. When a state’s sex education curriculum is abstinence-only, and the state severely limits access to abortion, and the state provides few resources on how to remain healthy during pregnancy or care for a baby, the results will often be tragic.

Abstinence-only education doesn’t work, and in the age of the Internet, providing frank education about safe sex is more important than ever. School boards have to catch up if we ever want to lower the teen birth rate and, by extension, infant mortality rate.

Southern states need to make a serious investment into promoting healthy pregnancies. Passing legislation requiring health insurance providers to cover prenatal supplements like folic acid can prevent a large number of premature births and birth defects. Putting money and resources into education for expectant parents can help prepare them for the stresses of caring for a newborn.

That education can continue past pregnancy, too. Home visit programs, in which a trained nurse, social worker, or early childhood education specialist visits the home of new parents to provide advice, have a proven laundry list of benefits. If state lawmakers really wanted to show that they care about sanctity of life, anteing up by funding a voluntary home visit program for all new parents would be a perfect place to start.

Closing Thoughts

This list is hardly comprehensive. I haven’t even mentioned the national healthcare worker shortage, or the fact that Mississippi, Texas, Florida, and Georgia have the worst vaccination rates in the country. But I think that I have accurately represented the most severe challenges disproportionately affecting southern states.

Southern politicians often like to pretend that there is no particular reason that their states rank so poorly across so many different metrics. They treat it like an unexplainable phenomenon. But these things don’t just happen. It takes a lot of terrible policy to give a state so many bad outcomes. No single solution that I’ve mentioned will fix the healthcare system of a given state, but a carefully planned series of policy reforms can make a dramatic difference.

Throughout this article, I have encouraged Southerners to contact their legislators to discuss these issues and solutions. And I genuinely hope that you do. But the sad truth is, there’s a very good chance you’ll be ignored, especially if you’re suggesting progressive policies to a conservative politician. Our best course of action is to elect people who are already championing these ideas.

We have a chance to change the narrative about the South. We have a chance to develop healthcare policies that the rest of the country seeks to model. We just have to rise to the challenge.