Bryan, D-Amory, stated that while Medicaid expansion will not solve the state’s mental health services delivery problem, it would help. “More people would be able to get services because they would have some ability to pay for them, and they would be able to get services more quickly before they are in terrible shape.” Renewed discussions about expanding Medicaid are coming at a time when a federal court ruling in September slammed the state for over-institutionalizing people with mental illness by failing to provide adequate community-based services. According to Mental Health America’s 2020 Annual Report, 77,000 Mississippians are uninsured if they have a diagnosed mental, behavioral, or emotional disorder. Many people suffering from mental illness are not insured and their condition worsens. They may become disabled. Debbie Plotnick is Mental Health America’s vice-president for mental health advocacy and systems advocacy. They also experience repeated crises, which leads to them ending up in the emergency department or worse, the criminal justice system. When we think of diversion, we tend to think only about removing people with mental illness out of jail. We need to divert them away from disability. Plotnick stated that the best way to do this is to provide them with treatment and services before they become permanently disabled.” Medicaid expansion could also help alleviate the financial woes of Mississippi’s Regional Community Mental Health Centers and hospitals, which are struggling to cover the rising costs of uninsured patients. These providers derive significant revenues from Medicaid. Richard Roberson, general counsel for the Mississippi Hospital Association and vice president for policy advocacy and state advocacy, said that there have been instances when hospitals stopped providing inpatient psychiatric care because many of their patients were not insured adults. Roberson stated that $660 million was spent on uncompensated healthcare in 2018 by hospitals across the state. Five Mississippi’s rural hospitals were closed partly due to uncompensated care, and four have filed for bankruptcy. The compromise plan crosses the political divide Roberson spent several months touring the state in search of support for the hospital association’s plan, which would expand Medicaid via a waiver that would not cost any state money. Roberson stated that the plan addresses both the concerns of Republicans and Democrats, even though the waiver would need to be approved by the federal government. Plotnick stated that Medicaid expansion is a key component of the Affordable Health Care Act. It allows states to expand their Medicaid eligibility requirements to offer health insurance to adults who aren’t too sick or poor to be eligible for the federal-state program. Although Medicaid expansion is highly partisan, there are some red states like Indiana, which was governed by the former Governor. Mike Pence has adopted it through a waiver, which gives states more freedom in how they design their programs, such as a work requirement. Roberson stated that the plan of the association is modeled after the Pence program from Indiana. Contrary to popular belief, most Medicaid recipients are employed. Most of the people who would be eligible for Medicaid expansion are working adults with low-incomes. One-third of them are suffering from mental health issues, Plotnick stated. She said that most of these people work in low-income jobs but their employers don’t offer health insurance and cannot afford to buy insurance. This leaves them without options for insurance. Plotnick pointed out that Medicaid allows those who are unable to work due to a medical condition to receive the care they need to gain employment and maintain their job. Medicaid beneficiaries do not receive any money. According to data from Kaiser Family Foundation, Mississippi’s Medicaid beneficiaries are mainly working adults with low incomes. 68 percent of Medicaid spending goes toward the elderly and persons with disabilities. According to Kaiser officials, Mississippi is one of 14 states without expanding Medicaid. Bryan called the failure of Mississippi to expand Medicaid “one the most illogical public policies decisions that I’ve ever seen.” Brice Wiggins (R-Pascagoula), chairman of Senate Medicaid Committee, stated that expanding Medicaid would not solve Mississippi’s “antiquated” and poorly coordinated mental healthcare system. It would be spending more money in a poor government structure that rewards those who have the best of the current system. Wiggins stated that the infrastructure built over the years was constructed when institutionalization was the norm. Therefore, the Legislature’s dollars and requests reward that. “The Legislature hasn’t taken a forward-thinking approach to implement policies that will change that,” Wiggins said. Rep. Jarvis Dortch (D-Raymond), supports expansion, but shares Wiggins concerns. We have a poor system due to the choices we make about how we provide services and how we pay. Too much emphasis is being placed on institutional care. Dortch stated that community-based care should be given more attention. We need to create a better mental health system. It is more coordinated. It would also benefit other uninsured Mississippians. According to Kaiser 2017 data, there are 406,000 uninsured Mississippians. Bob Neal, senior economist at the state’s University Research Center said that 210,000 of these people would be eligible for Medicaid if Mississippi expanded its program. Phaedre Col, president of Mississippi Association of Community Mental Health Centers said that she supports expanding Medicaid because it would improve access to preventive and maintenance care for people suffering from mental illness. It would also reduce dependence on more costly emergency mental health services. The Community Mental Health Centers are also losing revenue due to uncompensated expenses. The Community Mental Health Centers collectively provide $33 million in indigent care each year. Cole is also the executive director at Life Help. He said that Region 6 provides $4.3 million. Region 6 is home to the community center, which provides services to 10,000 residents in 12 counties. The Delta is one of the poorest and most rural parts of the state. Cole stated that Medicaid expansion would provide additional funding to the centers to meet the federal court’s order to expand community-based services. To speed up the development of community-based services and to eliminate any disparities, the court ordered that state officials work with a special master. This is a court-appointed person who will ensure that judicial orders are complied with. Cole stated that Medicaid expansion is just one part of the solution. “We also require increased state funding and higher reimbursement rates from Medicaid,” Cole said. Kaiser policy analysts reviewed more than 320 studies and found that Medicaid expansion has led to improved access and significant reductions of uncompensated care for hospitals and clinics, as well as increased accessibility to care. Studies also showed that Medicaid expansion has resulted in a lower rate of unpaid medical bills in states than states that did not expand it. This has led to a rise in financial security for low-income people. The Urban Institute reported in 2015 that Mississippi had the highest amount of past-due medical bills due to its high uninsured rate. According to the U.S Census Bureau, Mississippi has the highest number of families living in poverty in America. According to Hannah Katch, senior policy analyst at Center on Budget and Policy Priorities, Mississippi receives approximately 77 percent of federal matching funds for its Medicaid program. This is the highest match in America, she said. Katch explained that this means that for every dollar Mississippi spends on Medicaid (or any other program), 77 cents are reimbursed by federal government. “Even without expanding Medicaid, the majority of Medicaid’s spending in Mississippi can be covered by the federal government.” For the expansion population, the federal match rate is higher. The federal government paid 100 percent of the costs for the three initial years of the expansion program. This was from 2014 to 2016. The states were required to contribute a small portion. The federal government will pay 90 percent of the costs for expansion population members who become eligible in 2020. According to a University Research Center 2012 study, the state’s fiscal burden for Medicaid expansion in 2020 would be approximately $65 million. Neal stated that the state would allocate about 1 percent of its general fund revenue to Medicaid expansion, based on the state’s $5 billion in general fund revenues. Matt Westerfield (director of communications for Mississippi’s Division of Medicaid) stated in a statement that the annual income limit for a Mississippi family of three for Medicaid eligibility is $5,676. Multiple requests for interviews were denied by officials with Medicaid and Department of Mental Health. According to Micah Dutro (legal director of Disability Rights Mississippi), Mississippi’s current requirements for Medicaid eligibility are that adults be not only poor but must also be older, pregnant, have a federally-approved disability, or have a dependent child younger than 18. He said that there are few exceptions. Wiggins stated that Medicaid expansion will not solve the problem of Mississippi’s rural doctors shortage or the difficulties the state faces in recruiting new physicians. “You can’t expand Medicaid if you don’t have the resources or psychiatrists in a county. You won’t have adequate community service.” Neal warned that adding 210,000 people to the Medicaid rolls would increase wait times and lead to physician burnout. Harold Pollack, a professor from the University of Chicago’s School of Social Service Administration countered that many states, including red ones, face similar issues in rural areas. They are now using Medicaid expansion to address these problems. He noted that there are shortages of mental health providers across the country. Roberson claimed that officials are being too shortsighted. Roberson said officials are being shortsighted. “Unless you have a sustainable source for funding to pay healthcare providers, then it is impossible to attract doctors, nurses, and pharmacists to the areas that need them.” Other states have had success in expanding Medicaid. They have been able provide more inpatient or outpatient treatment options in the community and have seen improved mental health and health outcomes. Roberson stated that the Mississippi Cares plan would offer insurance coverage to working adults between the ages of 19 and 64 who earn no less than 138 percent of the federal poverty line, which is $17,000 per person in Mississippi, and $35,000 for a four-person family. Roberson stated that the Mississippi True nonprofit hospital-owned corporation would manage the association’s Medicaid program, rather than the out-of-state managed-care companies that Mississippi contracted with to handle Medicaid reimbursement claims. It is expected that the program will create as many as 19,000 new jobs. Mississippi True unsuccessfully contested one of the managed-care contracts. In 2017, Medicaid sued Mississippi True alleging that the division’s scoring criteria were biased against it, its score wasn’t fair and that the former Medicaid director had a conflict with one of the winners. The case was dismissed voluntarily. Roberson will present the plan to Congress in January, when the new legislative session begins. Roberson stated that the program would be funded by the federal matching funds of 90 percent the association would receive if the waiver was approved. The remaining 10% would be paid by higher hospital taxes and a $20 monthly premium for beneficiaries. Based on income, some beneficiaries might pay less. Roberson stated that hospitals would be willing to pay more state taxes as part of their proposal to lower their uncompensated care costs by $300 million. If a federally qualified hospital, rural clinic or urgent care centre was within 20 miles of the hospital, beneficiaries would be required to pay $100 co-pay. Unemployed beneficiaries will also be required to take part in an educational or job-training program called community engagement. Roberson stated that certain people would be exempted, such as the disabled or parents of preschool-age children. Key stakeholders have supported the plan of the association. Some have raised concerns about some provisions, such as the requirement for poor people to pay a monthly fee in order to maintain coverage, and the requirement that they participate in community engagement. Plotnick stated that this is an euphemism to refer to a work requirement. Kaiser researchers discovered that Arkansas was the first state to introduce a work requirement. More than 18,000 people were denied coverage for failing to comply with the reporting and work requirements. In 2019, only a few people were able to regain coverage. In Indiana, data shows that about 25,000 people were removed from the rolls in October 2017 and October 2015 due to not paying their premiums. Officials in Indiana recently introduced a work requirement program. However, it is too early to determine how many people will be affected by this. Some providers are concerned about the exclusion of non emergency transportation services. This is because rural areas have limited access to transportation. “There are components of the plan that we don’t agree with and we think would cause fewer people to enroll in coverage, but by far their proposal is better than what Mississippi has today,” said Jesse Cross-Call, another senior policy analyst at the Center on Budget and Policy Priorities “Hands down, it would be better, because hundreds of thousands of Mississippians would gain health care coverage.” Dortch said he hopes everyone will work together to fine-tune the plan to improve health outcomes for Mississippians.