Louisiana expanded Medicaid by a Democratic governor’s executive order. Conservatives in the ‘ruby-red’ state have embraced it.

Republican Louisiana state Sen. Fred Mills, a former pharmacist, was a strong proponent of the expansion in the Louisiana legislature. Mills, photographed at his office in Breaux Bridge, La., in addition to his support for the Medicaid expansion also spearheaded the effort to get medical lmarijuana use legalized in Louisiana. Dwayne Fatherree/MCIR

By Dwayne Fatherree
Mississippi Center for Investigative Reporting

FRANKLIN, La. — As Mississippians struggle over the merits of Medicaid expansion, patients to the west in ruby-red Louisiana are already seeing the benefits after Democratic Gov. John Bel Edwards implemented the program five years ago.

Proponents of the plan, which expands Medicaid insurance coverage to include all citizens with incomes below 138% of the federal poverty level, fought for years with former Republican Gov. Bobby Jindal over putting it in place. Jindal stood firm in refusing the program, largely for political reasons, as he positioned himself to run for higher office.

The resistance did not come solely from the then-governor. Conservatives statewide were loathe to promote what they saw as another giveaway program.

One person who disagreed with that position was Dr. Gary Wiltz, CEO of the Teche Action Clinic and a co-chairman of Edwards’ health care transition team, which oversaw the underpinnings of the Medicaid expansion in 2016. A strong advocate of community health clinics, he had been involved in the effort to decentralize access to medical care for four decades, working not only as a physician bringing that care to rural St. Mary Parish but also as an advocate at the national level.

“Some of the ones who were resisting it, I don’t know how they could sleep with themselves, because I treated a lot of their ‘servants,’ if you will, that they didn’t provide health insurance for,” said Wiltz. “And you say these people are like family to you. ‘Old Mary, she’s been working for us for years,’ When you take the family Christmas picture, you want her in there just like the family dog, but you are voting to deny her coverage that you aren’t paying for.”

When the state finally expanded its Medicaid coverage in 2016, it was not because of the Louisiana legislature. It took the election of a Democratic governor, Edwards, to change the course of health care for low-income families. He moved forward via executive orders to bypass the legislative logjam.

Insuring the masses

Medicaid expansion, as laid out in the Affordable Care Act, became available to states on Jan. 1, 2014. Its aim was to make insurance available to those most in danger of losing everything as a result of a medical stay or illness, namely the poor, the indigent and the working poor. The ACA also relieved financial pressure on hospitals and clinics, from urban medical centers to rural hospitals and community health clinics.

Republican state Sen. Fred Mills, a former pharmacist who was a strong proponent of the expansion in the legislature, experienced that pressure firsthand while working in Parks, Louisiana, a small town on the Bayou Teche where he had established his pharmacy. Like Wiltz in Franklin, some 40 miles south on the bayou, his clientele was largely made up of the working poor, either farmers or service industry employees from the oilfields that dotted the Louisiana coast.

“From my vantage point, I was in a drug store six days a week,” said Mills. “When I’d have a guy call me up and he can’t even fill a prescription because he’s a working poor guy, there’s no plan B. When that guy comes in and he’s got a $100 prescription, he has no coverage. He can’t get it filled. So, he doesn’t take it, and then he is in the emergency room a few weeks later. Now that $100 prescription is a $5,000 bill at the emergency room, and the hospital’s got to eat it.”

The need was even more severe in the health clinics where many of the poor received their only primary care. Wiltz had similar experiences in his clinic, where he worked to provide as much care as possible for patients based on the resources they had available.

Sometimes there were no resources, leaving the clinic providing services knowing the cost would never be recouped.

“In our world, in the community health clinic side of the world, we had clinics where 65% of the patients were not insured,” said Wiltz.

In the studies done in preparation for the expansion of Medicaid in 2014, Wiltz said proponents had worked out how the implementation would affect the state’s costs over the first five years. The plan would “significantly decrease state general fund expenditures over five years and increase total Medicaid programmatic expenditures over the same period,” according to the legislative summary created in support of the expansion.

The summary also predicted 298,000 people would be added to Medicaid rolls, a number that would increase as implementation began two years later.

A long fight

The challenge of bringing health care to those who cannot afford it predates the ACA by decades, Wiltz said.

“Obama was not the first one who tried to do this,” said Wiltz. “If you look back historically, all the way from Teddy Roosevelt to Harry Truman, they tried to do it. Ted Kennedy, he was the one that helped the community health center movement. When Nixon was in office, he was ready to sign a national care plan, but Kennedy held out (for a better deal). Then Nixon resigned.”

Dr. Gary Wiltz, CEO of the Teche Action Clinic in Franklin, La., was a co-chairman of Gov. John Bel Edwards’ health care transition team, which oversaw the underpinnings of the Medicaid expansion in 2016. In the corner of his office is a bust of the late Sen. Teddy Kennedy, whom Wiltz said was a strong supporter of expanding health care through community clinics like the one he founded. Dwayne Fatherree/MCIR

In 2014, the biggest issue facing proponents of Medicaid expansion was getting conservatives to vote for anything associated with President Barack Obama.

“Jindal was opposed because he was working on his campaign for president,” said Mills. “What was hard at the time — what was really hard at the time — is that they (Republicans) resisted it because it had ‘Obamacare’ in the title.”

There were other arguments, the biggest being the cost would place an undue burden on taxpayers. But Mills said that argument, when dissected, did not hold water.

“One of the arguments that just killed me — I was always vocal on it — was, ‘We got all these people, and they’re going to need a colonoscopy, or they are going to need a stress test, and that is just going to put a stress on the system,’” Mills recalled. “And I said, ‘Did you hear what you just said? Somebody is in desperate need of a colonoscopy to prevent cancer.’ That’s an argument that I can’t even respond to that, it’s so silly.”

Conservatives, both in the legislature and at think tanks like The Pelican Policy Institute in New Orleans, argued that the anticipated enrollment figure underestimated the total number of people who would enroll in the program. There were also concerns voiced over the future of the federal funding that made the expansion of services possible. Under the ACA expansion, reimbursement rates for services would rise between 90 and 100%. Under the Federal Medicaid Assistance Program reimbursement in effect at the time, the state recouped only 70% of costs.

“Well, with Medicaid expansion, for the first year the feds would pay at 100%,” Mills said. “The Republicans came back with, ‘We can’t afford the 10%’ for the third year. Well, you are paying the 10%. You are paying 30%. You are paying to keep a hospital afloat, keep a provider afloat. All the way around, you’re paying it.

“Another thing was, ‘Where will the federal government be in five years?’” Mills continued. 

“What’s funny is the only thing they couldn't make a decision on is medical (reimbursement). You can accept coastal money, accept road dollars, but can’t accept medical (funding) because you don’t know where federal funding will be in five years? It’s a no-brainer.”

Despite the legislative arguments, there was some legislative activity to set the stage for the expansion. In June 2015, legislators passed House Concurrent Bill 75, which established a fee hospitals would charge to cover the state’s portion of the Medicaid expansion.

On Jan. 12, 2016, Edwards signed the first of several executive orders needed to expand Medicaid in Louisiana.

Video by Dwayne Fatherree/MCIR

Turning the masses

To say that a large number of Louisiana’s conservative citizens did not take kindly to the new governor’s embrace of the expansion would be understating the situation greatly. Mills said the projected average Medicaid expansion patient was White, making $15 an hour with no insurance.

“They are our working poor,” Mills said.

Nonetheless, the response from the public also carried a veneer of racism.

“The emails, the calls, the hate mail was horrible,” Mills said. “I’d ask, ‘What are you going to do with a White person making $15 an hour doing hair? What are you going to do with them?’”

“They’re White?” they’d ask.

“Yes. Whatcha you gonna do with them?” Mills would respond.

“Oh, they’re White? Yes. Well, I guess it’s OK now that you explain it to me.”

And, as much of a benefit as the program was to the medically underserved, it was equally beneficial to the state’s medical service providers.

“I sat on a hospital board in St. Martin Parish for years,” Mills said. “Our collection rate at one time was that for every dollar we billed, we collected 10 cents.”

After the implementation of the expansion, those numbers began to move.

“It has a major trickle-down effect for the providers,” Mills explained. “You talk to hospitals, ambulance providers, pharmacies, anybody out there — at least there is some coverage for folks as far as paying the bill. Before, it was either denial or the hospital had to eat it, ‘cause they gotta see ‘em. The ambulance has to pick them up. So, from the provider standpoint, they are like, ‘What is wrong with this?’ And when you get into a logical debate, everyone is like, ‘This makes sense, but the political thing is crazy.’”

Wiltz said the experience on the ground level, operating a rural community health clinic, was similar.

“I can’t tell you how many patients I would see who had preexisting conditions that the (insurance) premiums were so prohibitive they could never get treated,” Wiltz said. “They lacked access to care. In the 2013 numbers, the uninsured rate for Blacks was 42%. For Whites, it was 41%. Fast forward to 2018, and the uninsured rate (for Blacks) is 14%. And in the White population, it is 16.5%.”

As the expansion rolled out, the calls of condemnation faded. Instead, people began to seek information on the program instead of trying to blow it up.

“It is amazing the people who just beat the crap out of me over it who called me to ask how to apply,” Mills laughed. “I found, once it was done, the chatter went away, the politics went away. And this is what started happening: An anti-person would call (and say), ‘Fred, my uncle needs Medicaid. How do you get it?’ When I remind them they were against it, they say, ‘I didn’t know it was that good.’”

Expected hiccups

As conservatives expected, the number of patients seeking coverage has climbed beyond the 298,000 projected. As of December 2019, there were 484,000 people covered, almost a third of the state’s 1.6 million Medicaid patients.

That was down from a high of 505,000 in April 2019, largely due to people being pushed off the expansion after it was discovered they continued to receive coverage after their income had risen above the 138% of the federal poverty level.

The discovery brought screams of protest from the right. Louisiana Sen. John Neely Kennedy notably referred to Louisiana Department of Health as a “department of dunces,” and its management of the Medicaid program “a dumpster fire.”

The eligibility issues were discovered, however, as the department took steps to identify problems, eventually removing 51,000 patients who were no longer eligible. The issue arose when the Louisiana Department of Health, which oversees the state’s Medicaid program, implemented a new computer check designed to determine ongoing financial eligibility.

The initial run of the system discovered 37,000 patients whose income had increased since they had initially qualified, making them ineligible for the expansion program. "Because of the commitment of this administration, Louisiana now has an eligibility and enrollment system that is more robust than what had been in place for decades," a spokesman said in a statement announcing the new procedure’s rollout.

Wiltz said problems like that should be expected.

“There are unintended consequences with anything you try to do. That’s why you have amendments. You tweak it. It’s like the Clintons said, ’Don’t end it, mend it,’” Wiltz said, referring to Bill and Hillary Clinton.

While those growing pains were being addressed, the Louisiana Department of Health and Tulane University released a joint study that revealed positive results from the expansion.

According to the report, the number of patients not taking their medication as prescribed — instead of trying to stretch it out to last longer — dropped by 6.9% and the number of low-income adults who could not see a doctor dropped by 4.2%. Both outcomes were directly attributed to Medicaid expansion.

A safety net indeed

Gov. John Bel Edwards bypassed the legislative logjam on Medicaid expansion with an executive order. Louisiana Governor's Office

In Edwards’ 2019 re-election campaign, his opponents shied away from saying they’d seek to dismantle the program, instead accused him of mismanaging expansion, with rampant fraud and abuse. They cited legislative audits that showed money was spent on ineligible services and that suggested millions could have been spent on people who earned too much for the coverage. 

“The governor made the decision to take one of the worst versions of Medicaid expansion available, rushed it to market knowing full well that they did not have the tools available to administer or ensure that the people that were enrolling were even eligible,” said one of his challengers, then-U.S Rep. Ralph Abraham.

Edwards’ won re-election.

If there was ever to be a stress test of the Medicaid expansion, Louisiana saw it in 2020.

The state was still suffering through an ongoing oil and gas sector slowdown in the Gulf of Mexico when the COVID-19 pandemic arrived, forcing shutdowns, curfews and, for some, the permanent closure of their businesses.

In March 2020, Medicaid expansion enrollment in the state stood at 473,784. By the end of April, it jumped to more than 505,000. It would continue to grow by more than 10,000 a month for the rest of the year, ending 2020 with more than 600,000 patients. This total included 64,000 patients who were kept on the rolls through the pandemic even though they had increased income and were no longer eligible, had other disqualifying issues or simply did not confirm their eligibility. This was due to conditions in the CARES Act funding passed last spring which boosted the state’s Medicaid system with an influx of some $250 million.

Where to from here?

As has been discovered at the national level, governing through executive action is not a permanent fix. In a deeply Republican state like Louisiana, where Donald Trump won in 2020 with 58.5% of the vote, the 2023 gubernatorial elections carry significance for the Medicaid expansion. Edwards is in his second term, and Louisiana governors may serve only two consecutive terms.

Mills said he hopes the incoming governor will be unwilling to change a system that has been accepted and proven already, not only by patients but also at the provider level.

“I would hope that the forces that come into play, like the state universities that have public-private partnerships, (will) help the new governor in seeing the sustainability of the Medicaid expansion,” Mills said. “I would hope the hospital industry would see it has been a savior for them.”

The biggest challenge to gaining support for a move to rescind the expansion, Mills said, is putting together a plan that is better than the one in place. For decades, the great conservative health care plan has been right around the corner, but has yet to make its debut.

“I think it would just be hard (to repeal the expansion) philosophically,” Mills said. “I don’t believe in it without a plan. You have all the managed care organizations that manage the Medicaid population. So, you know you got the Aetnas and the Blue Crosses and all of those folks. I just don’t know how you are going to unravel it unless you have a good argument and a good plan.”

This report was produced in partnership with the Community Foundation for Mississippi’s local news collaborative, which is independently funded in part by Microsoft Corp. The collaborative includes the Clarion Ledger, the Jackson Advocate, Jackson State University, Mississippi Center for Investigative Reporting, Mississippi Public Broadcasting and Mississippi Today.