Occasionally, I come across a truly exceptional story about the Affordable Care Act. A CJR laurel is in order for Sarah Varney, a senior correspondent for Kaiser Health News, and Jeffrey Hess of Mississippi Public Broadcasting, who contributed research and reporting, for a “Letter from Mississippi” thoroughly and poignantly detailing “how the poorest, sickest state got left behind by Obamacare.” Varney and Hess provide a meticulous account, published in the November/December issue of Politico Magazine and on the Kaiser Health News website, of Obamacare’s year-long struggle for respectability and viability in the poorest state in the union. Their sharp-eyed reporting—Varney traveled the state last summer—brings Mississippi’s healthcare politics clearly into view and begins to answer the big, nagging question left over from the debate on the ACA: Can a private system of health insurance and subsidies for buying coverage work in a state with very poor people who have high rates of disease, lack education, and for whom buying insurance is like learning Turkish? Add to that an uncooperative political infrastructure, and the answer at this point seems to be no.
The first year of the Affordable Care Act in Mississippi was, by almost every measure, an unmitigated disaster. In a state stricken by diabetes, heart disease, obesity and the highest mortality rate in the nation, President Barack Obama’s landmark health care law has barely registered, leaving the country’s poorest and most segregated state trapped in a severe and intractable health care crisis.
Grim, indeed. So, how did we get here? Varney lays out how “the failure of Obamacare in Mississippi has many authors,” including “political infighting, an overwhelmed federal agency and a surprise decision from the Supreme Court.” There are, one of Varney’s sources notes, “wide swaths of Mississippi where the Affordable Care Act is not a reality.” Only about 20 percent of the state’s residents eligible for Obamacare coverage have signed up—the “most significant drag on sign-ups,” Varney writes, “was Mississippi’s decision not to expand Medicaid,” which left some 138,000 low-income residents, most of whom are black, without insurance options and, in turn, “fueled a negative feedback loop about the law” (as well as “strained” Mississippi hospitals “to a near breaking point.”) According to one analysis Varney cites, “Mississippi would be the only state in the union where the percentage of uninsured residents has gone up, not down.”
Varney boldly highlights the inequalities baked into the ACA from the beginning, exemplified by the high deductibles and other high cost-sharing requirements that are integral to the “affordable” policies that people with lower incomes can buy. She writes about a 54-year old waitress who got a policy for $129, only to discover she first has to pay $6,350 out of pocket. “This ain’t worth a tooth,” the waitress concluded, and cancelled the policy. Varney makes real for readers Mississippi’s “dirge of bleak statistics”—so familiar to residents—such as the highest rate of leg amputations in the country (for African Americans, this number is particularly “startling,” she writes) and a high rate of breast cancer deaths despite a low incidence rate. These were things the ACA was supposed to tackle. Not likely, as this piece makes clear.
The “Letter from Mississippi” is worth a read for anyone interested in the Affordable Care Act and for every journalist who reports on it. It raises some disturbing questions about the challenges and limitations of the law (and of our overall healthcare system) and its ability to make insurance widely accessible. Varney concludes, bleakly, that “there’s no clear way out for the people of Mississippi.” Several of the issues Varney details— like inequality, the loss of federal funds for safety-net hospitals, and the continuing political hostility to health insurance for the uninsured—are not unique to Mississippi and merit attention from reporters around the country.