“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

Martin Luther King Jr.
Uninsured Adults in Southern Non-Expansion States Who Would Be Eligible for Medicaid if Their States Expanded Using Funds from the American Rescue Act – In All States Federal Revenue Exceeds Expense
* The “100%-138% FPL” category presented here uses a Marketplace eligibility determination for the lower bound (100% FPL) and a Medicaid eligibility determination for the upper bound (138% FPL) in order to appropriately isolate individuals within the range of potential Medicaid expansions but also with sufficient resources to avoid the coverage gap. Totals may not sum due to rounding. SOURCE: KFF analysis based on 2020 Medicaid eligibility levels and 2019 American Community Survey. Original KFF.org table can be found here and here.



Most Americans don’t view Florida, one of our largest states, as being backwards or poor. Yet, Florida is one of the worst states in the nation regarding provision of insurance to its population. There are 445,000 adults in the “coverage gap”. As of 2017, 16% of the state’s population was uninsured as compared to 10% nationwide (figures for minorities are much greater). Only Texas is worse.

Medicaid is a popular program, with 75% of Americans supporting it, including 65% of Republicans. Recently, Medicaid expansion bills were introduced in both Florida’s Senate and House. With its popularity, you would think Medicaid would have a good chance of being expanded. Unfortunately, the bills were introduced by Democrats with little GOP support and, therefore, have no chance of succeeding.

Since last month was Black History Month, I thought it appropriate to look at the health care issue in regard to systemic racism.And, although Trump clearly exacerbated the situation, I believe the problem predates the current hostility between the two parties regarding racial issues.

Although they deny it, all political parties are motivated by the quest to obtain power. In the 1970s, the Republican Party came up with a strong, if clearly immoral, strategy to get and maintain power. Their idea was to convert the “Solid South,” a conservative Democratic stronghold since the Civil War, into a sure vote for Republicans.

Nixon’s “Southern Strategy” was formulated by Harry Dent of South Carolina, a colleague and friend of Sen. Strom Thurmond, a well-known racist. The strategy dictated that the GOP ignore the history and needs of poor blacks while appealing to the insecurities of Southern whites, especially working-class people.

A lay preacher who knew better, Dent felt guilt in his later years, stating, “When I look back, my biggest regret now is anything I did that stood in the way of the rights of black people.” Too late, the South has been with the GOP for the last 50 years, but for all the wrong reasons.

The idea was further refined by Lee Atwater of South Carolina when he worked for Ronald Reagan. In Atwater’s own words: “By 1968 you can’t say ‘n*****’, that hurts you. Backfires. So, you say stuff like forced busing, states’ rights and all that stuff.”

How does this “states’ rights” philosophy affect healthcare today? The resistance by Florida’s governor and legislature to Medicaid expansion, which inordinately affects people of color in Florida, is a perfect example of “code word” ideology overriding common sense.

If Medicaid had been expanded initially, the cost of expansion would have been borne entirely by the federal government, for the first three years. Even now, the Feds pick up 90% of the bill. Objectively, that’s a great deal.Plus, expansion of Medicaid would create tens of thousands of solid permanent jobs, almost all in the private sector, at a time of substantial unemployment and underemployment, especially among minorities.

The cost to Florida of expansion would be worth it when considering that hundreds of thousands of Floridians, many minorities, are uninsured. These uninsured citizens currently receive inadequate health care services, affecting their quality of life and mortality rates (especially now with COVID). But, pandering to what is now the Trump base of working-class whites, DeSantis and Florida’s legislature don’t seem to care.

Florida has a Governor who is so intent on seeing his own political star rise among blue collar and senior Trump supporters that he ignores the healthcare needs of other Floridians. Plus, there is also a clear tendency for Florida’s GOP controlled legislature to break down the electorate into “them” (minorities) and “us” (middle-class white people).

Under Trump, the GOP nationally continued with the Southern Strategy, playing to the baser instincts of the white electorate, dividing the citizenry and violating Judeo-Christian concepts regarding taking care of the downtrodden. Now that he is finally gone from Washington, and Medicaid expansion financial incentives included in the COVID Relief bill, my hope is that GOP party leaders will realize both the moral inconsistency of this path and its long-term political consequences for the GOP given the changing demographics of the nation. Maybe then Florida will finally enact Medicaid expansion.


Status of State Action on the Medicaid Expansion Decision (KFF.org)

US Map Showing the Status of State Action on the Medicaid Expansion Decision

Key States with Expansion Activity

States Summary of Activity
United States Coverage under the Medicaid expansion became effective January 1, 2014 in all states that have adopted the Medicaid expansion except for the following: Michigan (4/1/2014), New Hampshire (8/15/2014), Pennsylvania (1/1/2015), Indiana (2/1/2015), Alaska (9/1/2015), Montana (1/1/2016), Louisiana (7/1/2016), Virginia (1/1/2019), Maine (1/10/2019 with coverage retroactive to 7/2/2018), Idaho (1/1/2020), Utah (1/1/2020), Nebraska (10/1/2020), Oklahoma (planned for 7/1/2021), and Missouri (planned for 7/1/2021).
Arizona, Arkansas, Indiana, Iowa, Michigan, Montana, Nebraska, New Hampshire, New Mexico, Ohio, and Utah have approved Section 1115 waivers to operate their Medicaid expansion programs in ways not otherwise allowed under federal law. Some of these Section 1115 waivers include work requirements, which the Biden Administration has recently begun the process of withdrawing.
Arkansas On March 9, 2021, the Arkansas Senate voted to advance a bill that would replace the state’s current Medicaid expansion program, Arkansas Works, with the Arkansas Health and Opportunity for Me (HOME) program. If signed into law in Arkansas and approved by the federal government, Arkansas HOME would allow expansion enrollees who comply with work requirements and monthly premiums to enroll in private marketplace plans while enrollees who opt out of these requirements would receive traditional fee-for-service Medicaid coverage. Arkansas Works is set to expire at the end of 2021 and has faced legal challenges.
Kentucky On December 16, 2019, newly elected Democratic Governor Andy Beshear signed an executive order rescinding the Kentucky HEALTH waiver that had been set aside by the court in March 2019. The waiver had included a number of provisions including a work requirement, monthly premiums up to 4% of income, and coverage lockouts for failure to timely renew eligibility or timely report a change in circumstances. Kentucky’s expansion program was originally implemented and continues to operate under state plan amendment (SPA) authority.
Virginia The Virginia General Assembly approved Medicaid expansion as part of its FY 2019-2020 budget on May 30, 2018; Governor Northam signed the budget into law on June 7, 2018. Expansion coverage became effective under state plan amendment (SPA) authority on January 1, 2019 after enrollment began on November 1, 2018.
Oklahoma Oklahoma voters approved a ballot measure on June 30, 2020 which adds Medicaid expansion to the state’s Constitution. The amendment requires the Oklahoma Health Care Authority to submit a state plan amendment (SPA) and other necessary documents to CMS within 90 days of the ballot measure’s approval, and for expansion coverage to begin no later than July 1, 2021. Language in the approved measure prohibits the imposition of any additional burdens or restrictions on eligibility or enrollment for the expansion population. In line with the amendment, the Oklahoma Health Care Authority submitted a SPA to expand Medicaid on September 8, 2020.
Florida An initiative to put Medicaid expansion on the 2020 ballot was delayed by its organizing committee to the 2022 ballot.
Georgia On October 15, 2020, CMS approved an 1115 waiver called Georgia Pathways to Coverage which extends Medicaid coverage to 100% FPL for parents and childless adults with initial and continued enrollment conditioned on compliance with work and premium requirements and other eligibility and benefit restrictions at the regular state match rate. Although coverage under this eligibility extension is set to begin on July 1st, 2021, the Biden Administration has recently begun to withdraw waivers with work requirement provisions.
Mississippi Medicaid expansion was a key issue in the 2019 Mississippi gubernatorial election, dividing candidates in both the August 27 Republican primary and in the November 5 general election. Republican Lieutenant Governor Tate Reeves, who adamantly opposes expansion, ultimately won both races, making it unlikely that the state will take up expansion in the next four years.
North Carolina In March 2019, Democratic Governor Roy Cooper included Medicaid expansion in his biennial state budget proposal for State Fiscal Years 2020-2021 and subsequently vetoed the state budget passed by the Republican-controlled legislature when it did not include expansion. Senate Republicans were unsuccessful in securing the necessary votes for a veto override before the legislative session adjourned on October 31, 2019 without a new budget. After passage of multiple adjustment bills to the current operating budget in April 2020, Senate Republicans announced they would no longer attempt to override the budget veto due to the ongoing pandemic. In August 2020, Governor Cooper included Medicaid expansion in his proposal for coronavirus-related adjustments to the FY 2020-2021 budget, but the legislature has not included expansion in any of its coronavirus relief bills.
South Carolina On December 12, 2019, CMS approved two separate 1115 waivers for South Carolina which would extend Medicaid coverage from 67% to 100% FPL for its parent/caretaker relative groups and a new targeted adult group with initial and continued enrollment conditioned on compliance with work requirements at the regular match rate. Recently, the Biden Administration has begun to withdraw waivers with work requirement provisions.
Texas Editor’s Note: KFF did not include a status in their chart for Texas. Texas has not expanded Medicaid under Obamacare and has the greatest number of uninsured of any state. Lack of expansion has cost Texas more than $25 billion in Federal funding and caused poorer health outcomes.
The source for this graphic and information is KFF.org
Jack Bernard

Jack Bernard

Jack A Bernard is a retired SVP with a national healthcare corporation. He was Chair of the Jasper County, Ga Board of Commissioners and Republican Party. He was also on the Board of Health for Jasper County and is currently on the Fayette County BOH. Bernard has over 100 columns published annually, primarily in the South.