Stepping Into the Gap: Medicaid Expansion in the Deep South as a Lifeline to Care

Tina, a 58-year-old Black woman living in the Delta, is Mississippi born and raised.^[1] She raised four children and spent more than two decades working as a machine operator at a catfish plant. While she has Medicaid coverage now, there was a time when she felt she could not see the doctor because she could not afford it. Before Medicaid, she would ration or depend on her community to help her keep up with her prescriptions.

It took Tina six months to get her Medicaid application approved because of all the red tape in accessing the very program meant to help people with low incomes get health care. While Tina’s experience with Medicaid is unique, many people across the Deep South are in similar positions. Even still, Medicaid plays a critical role in ensuring people with low incomes — especially people of color — access health care they otherwise would not be able to afford.

Introduction

Annual wellness and school physicals. Monthly prescription refills. Urgent care sick visits. For many, these are routine matters made possible through access to quality health insurance. However, for far too many Black people across the Deep South, these health care benefits are out of reach due to inequities in our health care system — inequities that stem back to the very founding of our nation.

Indeed, the harsh living conditions, malnutrition, and other forms of torture enslaved Black people endured, coupled with their inability to access or afford health care, set the foundation for racial health disparities in this country for generations. This legacy of health care inaccessibility — and eventual poor health outcomes — is still profoundly felt by Black communities across the country. Today, Black women suffer from some of the highest levels of diabetes and high blood pressure in the country, Black men’s risk of a stroke is twice that of white men, and Black people are more than twice as likely to suffer from Alzheimer’s and other kinds of dementia compared to white people.

Importantly, the Deep South epitomizes these racial health disparities. For example, in 2023, Black Mississippians had the highest death rate from heart disease, high blood pressure, stroke and diabetes in the state — deaths that were all potentially preventable with proper medical treatment. Black Floridians were more likely to die from kidney disease compared to white Floridians. Indeed, with proper care, there could be many more people in the world to attend events with friends, many more to celebrate milestones with their loved ones, and fewer dining chairs left empty during family dinners. Clearly something must change at the systemic level to keep Black people from needlessly dying from treatable and preventable illnesses.   

The good news is, our nation has already established a solution to redress these racial disparities: Medicaid.

Medicaid is a government health insurance program whose primary purpose is to provide health insurance to people with low incomes and disabled people. Nearly 50 million people rely on this critical program to help them see the doctor, visit the emergency room, and receive long-term care. In the Deep South (Alabama, Florida, Georgia, Louisiana and Mississippi) alone, there were almost 9 million people enrolled in Medicaid as of 2023. Access to Medicaid in the Deep South is a crucial lifeline because the region has one of the highest percentages of people living in poverty in the United States. Notably, Medicaid covers populations of people who are less likely to be able to afford or have access to private insurance — the very reason the program was created in the first place.

Medicaid is administered by states but is jointly funded by both state and federal funds. Medicaid as it currently operates, however, is in dire need of reform to fully combat the racial disparities in health outcomes and health care access present across the Deep South. States have great flexibility to decide how to run their Medicaid programs — including what populations of people to cover. Of note, prior to the Affordable Care Act (ACA), most adults ages 19-64 with low incomes were generally excluded from eligibility. Medicaid expansion has been critical to reducing racial health disparities: Between 2013 and 2022, the gap in uninsured rates shrank by 67% between white and Black adults under age 65 in Medicaid expansion states. Additionally, Medicaid plays a critical role in ensuring people with disabilities, children, and rural communities get health care coverage — contributing to health equity. Despite the evidence that expanding health care coverage is a good thing, not all states have expanded — leaving many in health insurance limbo. Following the ACA in 2010, states can take advantage of federal incentives to expand the populations covered by Medicaid — a process commonly referred to as Medicaid expansion. As of 2025, 40 states and the District of Columbia have expanded access to their Medicaid programs beyond the narrowed pre-2010 populations. Prior to expanding Medicaid, states traditionally only covered people with low incomes, but eligibility for children in families with low incomes, older adults, disabled people and pregnant people was limited. Medicaid expansion includes coverage — and eliminates categorical eligibility (basing eligibility off predetermined categories) — for people with incomes up to 138% of the federal poverty line (about $20,780 a year for an individual and $35,630 a year for a family of three).

However, as a continuing result of partisan stances, several states across the Deep South^[2](including Alabama, Florida, Georgia and Mississippi) have failed to expand, leaving many in a “Medicaid coverage gap” — meaning they cannot afford private health insurance through companies, yet they do not qualify for Medicaid coverage in their state because their income is too high. Across Alabama, Florida, Georgia and Mississippi, there are over 1.1 million people who would become eligible for Medicaid if their states expanded. People living in the coverage gap are not a monolith, and expansion would help people across the board. In Deep South nonexpansion states like Florida, Georgia and Mississippi, more than half of the people in the coverage gap are people of color. This pattern is not unique to the Deep South. In fact, across the U.S., nearly half of people in the coverage gap are people of color.

Evidence continuously demonstrates that Medicaid is of vital importance to people and families across the country. However, the federal government has made numerous inroads to dismantle or severely limit federal funding for the Medicaid program, especially in the past couple of years. For example, the Trump administration made it a campaign promise to cut social safety net programs, and Medicaid cuts were a major part of the fiscal year 2025 budget reconciliation process. Regardless of the outcome of this year’s budget, states must step in to cover people in need of health care. 

Structural Racism in Early American Health Care

Inequitable health care access is embedded into the foundation of our nation, dating back to slavery. Enslaved people, subject to long and torturous work hours, did not have the agency to decide when to seek care for themselves and their families from a medical professional. In fact, many times medical care was only provided by enslavers as a last resort to protect their financial investment — not the enslaved person’s quality of life. After emancipation, Black people continued to have difficulty accessing health care; this barrier led to the creation of the Bureau for the Relief of Freedmen and Refugees, commonly known as the Freedmen’s Bureau. Established by the federal government, the bureau offered a range of support and resources that included emergency and temporary health care until states could assume permanent responsibility for their newfound citizens. This was one of the first documented efforts in the nation where the government attempted to redress some of the harm caused by structural inequity, such as health care disparities. However, factors such as limited funding, racism against formerly enslaved Black people, and mounting political pressure from Southern states forced the bureau to close in 1872 — just a few years after it was formed.

The Creation of Medicare and Medicaid

Before 1965, people who could not afford private insurance were dependent on states, localities or charities to provide health care access. During this same period, the use of health and hospital services also varied by race, as did the level of care segregated hospitals provided. In recognition of these disparities, President Lyndon B. Johnson signed two national health care programs — Medicare and Medicaid — into law in July 1965 to help equalize access to health care. After its creation, the Medicare program primarily covered people over age 65. At the same time, the Medicaid program provided coverage for certain people and families with low incomes. Both Medicare and Medicaid started as basic insurance programs for people who did not have health insurance. Both programs have evolved over time to include coverage for more medical services and groups of people — including children, parents, pregnant people, seniors, and people with disabilities — who otherwise would not be able to access health coverage.

Medicaid as a Lifeline Across the Deep South

Since its implementation, Medicaid has served as a critical source of health care coverage for many vulnerable communities, including people of color, people with disabilities, and members of the LGBTQ+ community. For example, after Medicaid’s enactment, access to health care expanded for Black people, with 1 in 5 Medicaid enrollees across the country being Black as of 2022.^[3] The top five counties with the highest number of Medicaid recipients in each Deep South state also have a high percentage of Black people living in the county. (See graphics that follow.)

States Perpetuate Racial Inequities in Medicaid Coverage

States have a large say in how their programs are conducted in part because of the Affordable Care Act (ACA). Under the Obama administration, the ACA was enacted in 2010, and it expanded eligibility for Medicaid by incentivizing states with the promise of increased federal funding to run their programs. Prior to the ACA, Medicaid only covered specified categories of people with low incomes: pregnant people, children, parents of dependent children, people with disabilities, and people aged 65 and older. States were required to cover individuals in these groups up to federal minimum income thresholds, but they also had the option to expand coverage to people at higher income levels if they wanted to.

Importantly, prior to the ACA, adults ages 19-64 with low incomes were largely excluded from Medicaid. The ACA attempted to require that all states cover nearly all people who had incomes at or below 138% of the federal poverty level ($15,415 per year for an individual in 2012). This included people under age 65, who were not pregnant, ineligible for Medicare, and were not described in an existing mandatory coverage group — also known as “Medicaid expansion under the Obama administration.”  However, this Medicaid expansion requirement and other parts of the ACA were quickly challenged in the courts as a federal overreach, in the National Federation of Independent Business v. Sebelius case.^[5]

In short, after Sebelius, the court effectively made Medicaid expansion a state-by-state option by holding that requiring states to expand under threat of losing their federal funding was outside of congressional authority. Although not mandatory, a state is incentivized to expand because the amount of federal matching dollars for its Medicaid program increases to cover additional people in those mandatory coverage groups.

As of 2024, 40 states and the District of Columbia have adopted Medicaid expansion, including Louisiana in the Deep South. However, there are still 10 states that have not adopted expansion, and at least four of those states are in the Deep South — Alabama, Florida, Georgia and Mississippi — despite increasing interest and recent legislative efforts to expand in some of these states.  For example, HB 1725, which attempted to expand Medicaid, passed the Mississippi House of Representatives by an overwhelming 99-20 vote in 2024 — even though the bill failed in the Senate.

Case Studies

Mississippi’s Rural Hospitals

Research shows expanding Medicaid is good for rural hospitals because expansion brings additional federal revenue. In rural communities, population loss means there are fewer people to utilize a hospital in the first place, and many patients who do go to rural hospitals do not have the ability to pay the out-of-pocket cost for their care, resulting in decreased profits to fund rural community hospitals. Indeed, in Mississippi, a 2025 report found nearly 60% of rural hospitals are at risk of closing immediately or within the next couple of years for these reasons. Further, rural hospital loss is not contained to Mississippi — neighboring Alabama is not far behind, with more than half of its rural hospitals at risk of closing as well.

Hospital closures have numerous consequences for the community, including income and job loss, inadequate maternal care, and decreased access to immediate care during emergent situations. Unfortunately, some rural residents have paid the ultimate price for not having emergency care within reach. In rural areas, the number of miles to the next emergency room can make the difference between life and death. Evidence finds that when a rural hospital closes, mortality in that community increases — contributing to the health disparities that rural communities already face with higher rates of some chronic diseases such as diabetes.

In Mississippi, where many birthing parents are already high-risk patients with chronic health conditions like diabetes and high blood pressure, emergency care can make a difference for both parent and child.

Tamara Stuckey’s story is one stark example of the consequences of rural hospital shutdown. Tamara was 32 years old and expecting her third child in 2019. One day, she began experiencing complications with her pregnancy and had to travel an hour away by ambulance to get emergency care. She lived in Yazoo City, Mississippi, known as a “maternity care desert” where there had not been any labor and delivery services in the area for almost 30 years. After being released that evening and making her way home, she experienced additional complications and had to travel another hour back to the hospital. Tamara’s baby was delivered stillborn and shortly thereafter, Tamara died from massive intrapartum hemorrhaging.

Georgia Pathways to Coverage Program

Health care should not be locked behind mandatory behavioral requirements. Georgia, however, has not abided by this dictate. Georgia is tied with Oklahoma for the second highest proportion of residents without health insurance in the country. In 2023, the state created an experimental program, the Pathways to Coverage program, to evaluate the impact accessing health care has for people who would not otherwise qualify for the state’s traditional Medicaid program. The Pathways program offers Medicaid to non-pregnant, nondisabled adults with low incomes in exchange for work or other state-approved activities. These work requirements — or requirements that certain nondisabled adults work, volunteer, attend school, or participate in other qualifying activities as a condition of program eligibility or coverage — already exist in some safety net programs such as TANF cash assistance and the Supplemental Nutrition Assistance Program (SNAP).

As an alternative to simply expanding Medicaid the traditional way, Georgia pursued a 1115 waiver from the federal government to develop the Pathways program. The waiver was a way for states to test state-specific approaches to better serve Medicaid populations using federal funding. Georgia submitted the waiver to examine the impact of offering people with low incomes a chance to affordably visit the doctor, get prescription medication, or go to the emergency room by overseeing their approved work activities.

However, research continues to show that that work requirements do not compel people to work, and certainly dangling health care access and one’s ability to meet work hours paints the picture of a horse chasing a carrot. Work requirements are also costly to institute — both for the person required to document they are working and for program staff to verify the paperwork.

These work requirements are based, in part, on racist narratives about Black people’s unwillingness to work and have historically been used to create needless barriers to cash assistance during times of financial crises. Additionally, the requirements funnel people with low incomes into the most available job opening — even if the role does not improve their financial outcomes and long-term goals. Though unspoken, another goal of work requirements is to disincentivize the use of safety net programs by making things like receiving cash or food assistance so difficult for the recipient that they decide to forgo the resource.

There are numerous studies demonstrating the ineffectiveness of work requirements. Despite this, there continue to be unsuccessful attempts to expand these requirements to other programs such as Medicaid. For example, in 2018, nearly 17,000 people in Arkansas with low incomes had their Medicaid coverage taken away for not meeting work requirements.

It has been over one year since the Pathways to Coverage program’s launch, and enrollment remains low despite a high number of people across the state without health coverage. There are an estimated 175,000 people in the Medicaid coverage gap in Georgia, yet as of October 2024, there are only 5,100 adults enrolled in the Pathways program.

As it stands, the Pathways to Coverage program does not create meaningful and responsive health care access for people in need of care. Rather than continue to invest in a costly program that locks affordable health care behind work requirements, Georgia should follow the direction of the District of Columbia and the 40 states — including Louisiana — that have successfully expanded their programs without instituting mandatory work requirements.

The Case for Preserving Current Medicaid Coverage Expansion

While we cannot change the policy choices made in the past, there is hope and a way forward — one that involves preserving current Medicaid coverage and expanding Medicaid for the states that have yet to do so, especially the states in the Deep South. There are several benefits to Medicaid expansion, such as increased access to health care for people of color and people with disabilities, the preservation of rural community hospitals, and ensuring marginalized communities have access to the basic health resources they need.

Further, investing in Medicaid expansion can generate significant economic activity for states too. Research finds that Medicaid expansion results in increased revenue as well as net savings due to decreased state spending on catastrophic care. In Louisiana, Medicaid expansion created 19,000 jobs and generated more than $3.5 billion in economic activity in the state.

For these reasons and more, the SPLC recommends that all states across the Deep South preserve current Medicaid coverage and expand Medicaid to more families in need by doing the following:

• Reject proposals that reduce state and federal money going towards Medicaid. Cutting funding for Medicaid will ultimately impact people experiencing poverty and their ability to receive potentially lifesaving health care. Additionally, the reduction of funds impacts care providers who depend on funds to be able to offer care to vulnerable communities.
• Expand Medicaid to include coverage for adults with low incomes at least up to 138% of the federal poverty level without added work requirements. Expansion would shrink the coverage gap and offer health care coverage and access to people ages 19 to 64, many of whom are more likely to have disabilities and work jobs that have no path to employer-sponsored coverage.
• Bundle Medicaid assistance with housing assistance to help people with low incomes who have disabilities get back on their feet. All people need access to health care and housing. States can seek waivers such as a Section 1115 demonstration from the Centers for Medicare and Medicaid Services to explore the impact of covering housing-related services to people experiencing homelessness under Medicaid. Some states like Arizona are already taking advantage of this opportunity with programs that focus on providing stable housing and health care to people with mental illness and chronic health conditions.

Illustration by Xinyue Chen.

Acknowledgments

The Southern Poverty Law Center would like to thank the organization’s Georgia and Mississippi policy teams, the Mississippi state office, Andrea McChristian, and Delvin Davis, interim policy research director, for their support in guiding and reviewing this report. Thank you also to “Anonymous” in Georgia and Tina in Mississippi for their contributions to the report.

This report includes hyperlinked citations instead of full endnote citations. Full endnote citations, however, are available here.

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[1] Video interview with Tina Payne conducted by Myisa Plancq-Graham, April 28, 2025, Leland, Mississippi.

[2] While included in the Deep South, Louisiana adopted Medicaid expansion in 2016. For more information regarding Medicaid expansion in Louisiana, see Kavita Patel, “From Worst to First: Louisiana Makes Great Waves with Medicaid Expansion,” Brookings Institution, January 15, 2016, https://www.brookings.edu/articles/from-worst-to-first-louisiana-makes-great-waves-with-medicaid-expansion/.

[3] Estimates based on the 2008-2023 American Community Survey, 1-Year Estimates.

[4] Louisiana adopted the Medicaid expansion in 2016.

[5] Of note, in the National Federation of Independent Business v. Sebelius case, the issue of Medicaid expansion as well as the individual mandate were challenged.