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Mississippi lawmakers look to other states’ Medicaid expansions. Is Georgia worth copying?

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mississippitoday.org – Sophia Paffenroth – 2024-03-28 10:58:47

As the Mississippi Republican-led Legislature considers expanding Medicaid for the first time after a decade-long debate, Senate have referenced other Southern states' expansion plans as alternatives to full expansion. 

On Wednesday, the Senate Medicaid Committee passed the House Republican expansion bill with a strike-all and replaced it with its own plan, which Medicaid Chairman Kevin Blackwell, R-Southaven, called “expansion light.” The Senate is expected to take the bill up for a floor vote Thursday, with a plan that's nearly identical to Georgia's. 

Problems with “Georgia Pathways”

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care policy experts don't think Georgia's plan is worth emulating. The state's plan, called “Georgia Pathways,” misses out on the increased federal match of 90% that the to newly expanded states, and it also doesn't qualify for the additional $690 million federal dollars that would make expansion free to Mississippi for four years.

And the plan, touted as a conservative alternative to what critics call “Obamacare,” has cost state taxpayers $26 million so far, with more than 90% of that going toward administrative and consulting costs, according to KFF Health . Implementing work requirements is costly and labor intensive because it involves hiring more staff and processing monthly paperwork to confirm enrollees are employed. 

“Georgia's plan has proven to be very profitable for large companies like Deloitte (the primary consultant for Georgia's project) but has provided health care to almost no one who needs it,” said Joan Alker, Medicaid expert and executive director of Georgetown University's Center for and Families. “It's been a terrible waste of taxpayer dollars so far.”

If the Senate plan were signed into law, Mississippi would fare the same – receiving its regular federal match of only 77% instead of 90% – and risk large administrative costs for enforcing a 120-hour-a-month work requirement and a provision that says recipients must be recertified four times a year.

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Work requirements ‘costly' to enforce

In theory, a work requirement isn't controversial. A majority of Mississippi lawmakers in both chambers want to reserve Medicaid coverage for those who are working or exempt, with legislation that incentivizes employment in the state with the lowest labor participation rate. The problem, experts say, is that in practice, it can do more harm than good. 

Policing and enforcing the work requirement costs more than it would cost to insure the small population of unemployed people who would become eligible for Medicaid under traditional expansion, explained Morgan Henderson, principal data scientist at the Hilltop Institute, a nonpartisan research group that conducted several studies detailing what Medicaid expansion would look like in Mississippi. 

“Medicaid work requirements are costly to implement,” Henderson said. “States have to develop new administrative systems which can cost millions, or tens of millions, of dollars. Additionally, employment reporting requirements can be confusing and burdensome for individuals, so people who are legitimately employed and income-eligible for Medicaid may be denied coverage – thus, hurting the exact individuals who are supposed to qualify for Medicaid with work requirements.”

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In Georgia, only 3,500 people have signed up since the program began in July – despite the millions of dollars taxpayers have paid to run the program and ' previous estimate that roughly 25,000 people would sign up in the first year and 52,000 by the fifth year. 

Lt. Gov. Delbert Hosemann said in an interview in February that the Mississippi Senate plan likely wouldn't be as strict as Georgia's, calling their work requirement “onerous.” 

But the Senate plan is even stricter than Georgia's, calling for at least 120 hours of work a month instead of the 80 hours required in Georgia. 

In Arkansas, a work requirement was briefly implemented in 2018 before it was overturned.

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A study by the New England Journal of Medicine found Arkansas' work requirement to be unsuccessful at increasing employment. The main consequence of the state's work requirement was an increase in the number of uninsured persons compared to full expansion and “no significant changes” in employment associated with the policy, according to the study. 

In addition, “more than 95% of persons who were targeted by the policy already met the requirement or should have been exempt.”

What's next?

The only expansion bill still alive in the Mississippi Legislature is House Bill 1725, authored by Speaker Jason White, R-, and Missy McGee, R-Hattiesburg, which is now before the Senate. The bill, as passed by the House, has a provisional work requirement, but would expand Medicaid to 138% of the federal poverty level – even if a work requirement is not approved by federal Centers for Medicare and Medicaid Services. 

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That's important because during the Biden administration, the federal   has rescinded work requirement waivers previously granted under the Trump administration and has not approved new ones. 

But the Senate version is entirely contingent on the work requirement, calling for a minimum of 120 work hours a month and quarterly recertification. Eligibility also only goes up to 100% of the federal poverty level. 

If the Senate were to stand firm on the work requirement, expansion might not go into effect until well into 2025. That is, if a new administration takes office. 

A provision in North Carolina's recent expansion bill could prove useful as Mississippi lawmakers debate the details of expanding Medicaid.

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A North Carolina expansion bill passed in 2023 is a mostly-traditional expansion plan with a unique work requirement provision. Expansion originally passed without a work requirement, but included a provision that says if or when a federal administration that favors the concept takes office, the state will change Medicaid eligibility rules and adopt the work requirement. 

If Mississippi were to include this kind of language in its own bill, it could expand Medicaid in 2024 or at the start of 2025, instead of waiting well into a new presidential term.

In theory, work requirements make sense, Henderson said. But they haven't produced the desired outcome of increasing the labor force participation rate in other states. That fact, coupled with the costly administrative burden of enforcing them and the unfortunate consequence of eligible enrollees losing coverage make the work requirement an unworthy pursuit, Henderson and Alker conclude. 

“In theory, it's true that, under Medicaid expansion, individuals earning slightly more than 138% of the federal poverty level could have an incentive to reduce their earnings in order to qualify for Medicaid,” said Henderson. “However, there are reasons to believe that this will be rare.”

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The three reasons Henderson gives are: “First, not all workers know their exact income as a fraction of the current federal poverty limit, which changes every year and is a function of household size. Second, not all workers can control their hours. Third, individuals earning just above 138% of the federal poverty level have access to generous subsidies through the insurance marketplace, which could reduce the incentive to reduce income to qualify for Medicaid.”

And in practice, Henderson said, “no studies I'm aware of have found evidence of Affordable Care Act Medicaid expansions adverse effects on employment outcomes.”

The Senate is expected to vote on House Bill 1725 on Thursday. While the bill only needs a three-fifths vote to pass the floor, it realistically needs a two-thirds majority from both chambers to show it has the potential to override a threatened veto from Republican Gov. Tate Reeves.

This article first appeared on Mississippi Today and is republished here under a Creative Commons license.

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Mississippi Today

On this day in 2007

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MAY 10, 2007

Left to right, John Lewis, Ralph Abernathy, Martin Luther King Jr. and Andrew Young attended the 1965 funeral of Jimmie Lee , whose inspired the Selma march to Montgomery. Credit: AP

An Alabama grand jury indicted former trooper James Bonard Fowler for the Feb. 18, 1965, killing of Jimmie Lee Jackson, who was to protect his mother from being beaten at Mack's Café.

At Jackson's funeral, Martin Luther King Jr. called him “a martyred of a holy crusade for and human dignity.” As a society, he said, “we must be concerned not merely about who murdered him, but about the system, the way of , the philosophy which produced the murderer.”

Authorities reopened the case after journalist John Fleming of the Anniston Star published an interview with Fowler in which he admitted, despite his claim of self-defense, that he had shot Jackson multiple times. And Fleming uncovered Fowler's killing of another Black man, Nathan Johnson. In 2010, Fowler pleaded guilty to second-degree manslaughter and was to six months behind bars.

This article first appeared on Mississippi Today and is republished here under a Creative Commons license.

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‘This doesn’t need to be a slap on the wrist,’ DA says of Noxubee County case

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mississippitoday.org – Jerry Mitchell and Ilyssa Daly – 2024-05-09 13:45:26

A capital murder investigation helped to unrelated federal charges against former Noxubee County Sheriff Terry Grassaree and his deputy that involved the sexual abuse of a jailed woman.

On Tuesday, Grassaree pleaded guilty to lying to the FBI when he denied receiving nude photos and from a woman locked in his jail. He faces up to five years in federal prison when he is Aug. 7.

Ex-Noxubee County Sheriff Terry Grassaree heads into federal court where he will plead guilty, Tuesday, May 7, 2024 in .

His former deputy, Vance Phillips, pleaded guilty last year to bribery, which experts say could have been the perks the woman received, including a contraband cellphone. No date has been set for his sentencing.

District Attorney Scott Colom said Thursday he would like to see serious punishment for Grassaree for such abuse. “This doesn't need to be a slap on the wrist,” he said.

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He said the discovery of this abuse began with a capital murder case. In 2015, Kristopher Haywood died in a convenience store attack in Macon when someone blasted the 28-year-old twice in the head with a shotgun.

A Noxubee County grand jury indicted Jonathan Shumaker, his girlfriend, Elizabeth Layne Reed, and Justin Williams and his brother, Joshua, on capital murder charges. Shumaker was also found in possession of a shotgun and charged with possession of a firearm by a felon. (These charges were dropped last year after an audio recording surfaced that exonerated them.)

But when Colom inherited the case as the new district attorney in 2016, he said he discovered the evidence and some of the witnesses contradicted the description of what happened.

Three years later, as he prepared for trial, he said his office interviewed Reed, who shared that deputies had been having sex with her inside the jail, “but you're not going to do anything about it.”

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Colom promised that he would.

He said he reached out to federal authorities in 2019 for assistance out of concern that it might be difficult to investigate enforcement in such a small county. 

He said his office took the lead. One of his workers messaged Deputy Phillips from Reed's Facebook page a photograph of a positive test for pregnancy.

“That's how we got Vance to corroborate that Reed was telling the truth about the unlawful sex,” Colom said. “We knew we had a serious problem then.”

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Any sex that an officer has with someone behind bars is a felony under Mississippi law and carries up to five years in prison. The maximum penalty under federal law is also five years.

There is no way for those behind bars to give consent, Colom said. “They're in a vulnerable situation. Their liberty and freedom can be used against them.”

Reed told Colom's office that the sex began with Phillips after he began transporting her to ' visits. He first took her to his trailer to have sex and then had sex with her while the female correctional officers were at lunch, Colom said.

The encounters also took place in deputies' offices, the interrogation room and even the evidence shed, he said.

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The deputy continued to demand sex with her on an almost weekly basis between May 2017 and October 2019, according to a lawsuit she filed against Noxubee County and the sheriff's office. “Reed, under the coercion of Phillips' authority and her incarceration, acquiesced in Phillips' demands.”

Another deputy, Damon Clark, who gave her cigarettes and a touchscreen cell phone, took her up front to a shower, where “he laid me on the floor [and] got on top of me,” she told authorities.

Clark has never been charged. “I never coerced Reed into sex,” he wrote in his response to the lawsuit, but he never answered whether he had sex with her.

Reed told authorities that one other deputy digitally penetrated her and another groped her and “sexted” her.

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Colom said their investigation into sexual abuse corroborated much of what Reed alleged. It was then, he said, “we realized we had a serious problem with the Noxubee County Sheriff's Office under the regime of former Sheriff Terry Grassaree.”

Their investigation showed Grassaree knew about his deputies' activities, but rather than referring the matter to authorities, he sought to “get in on the action himself,” Colom said.

Reed's lawsuit said Grassaree demanded “a continuous stream of explicit videos, photographs and texts” from her in jail. She also alleged in the lawsuit that Grassaree touched her in a “sexual manner.”

The county settled the lawsuit for an undisclosed amount.

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Colom said he decided to turn over his investigation to federal authorities with the agreement they would prosecute since they could pull far more potential jurors. Getting enough people to serve as jurors has long been a problem in Noxubee County, which has a population of less than 10,000, much less finding impartial jurors, he said.

On July 13, 2020, an FBI agent interviewed Grassaree, who denied that he received nude photos and videos from Reed in jail.

Two years later, reporters from the Mississippi Center for Investigative Reporting at and The New York Times began asking Colom about the case. Colom responded that he was waiting for federal authorities to prosecute as they agreed. Afterward, he contacted federal authorities again and told them reporters had reached out to him, asking questions.

In October 2022, a federal grand jury finally indicted Grassaree and Phillips.

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Colom said federal authorities “never gave me a good reason for why they took so long.”

He said even more troubling in his investigation was the discovery of “illegal activities” by the sheriff's office “that were unrelated to sex.” There have been no indictments in that case.

Noxubee County residents already have a lot of skepticism toward law enforcement, he said, “so when you actually do have corruption, it has to be aggressively handled. We can't have police forces where the people we are trusting to protect and serve are only concerned about themselves and their own illegal agendas.”

He still hopes federal authorities will prosecute, he said. “It would send a strong message to the citizens in Noxubee County that you care about them.”

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Asked if his office could bring charges now, he said that was impossible because “the statute of limitations has .”

Federal authorities have a five-year statute of limitations, but the statute of limitations in Mississippi is only two years.

Colom said he didn't move sooner because federal “had agreed to prosecute the charges and kept telling me they were going to do something.”

A spokesperson for the U.S. Attorney's office in Jackson responded Thursday, “The Department of Justice follows the facts, law, and principles of federal prosecution when determining how to proceed in an investigation and what charges, if any, can be filed. Federal agents and prosecutors will continue working hard every day to hold public officials in Mississippi, like Sheriff Grassaree, accountable for corrupt use of their office and efforts to mislead investigators.”

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Mike Hurst, U.S. attorney for the Southern District of Mississippi

Former U.S. Attorney Michael Hurst, who served from 2017 to 2021, said prosecuting public corruption was one of his top priorities, especially when it involved law enforcement who “violated their oath and victimized our citizens.”

He said if the U.S. attorney's office had sufficient evidence beyond a reasonable doubt to prosecute, “we prosecuted them, no matter who they were, period. In many instances, federal prosecutors are the last line of defense in our society of ensuring that our citizens are protected, their rights are upheld, and that criminals — especially corrupt public officials — are held accountable.”

This article first appeared on Mississippi Today and is republished here under a Creative Commons license.

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Medical residents are increasingly avoiding states with abortion restrictions

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mississippitoday.org – Rachana Pradhan, KFF and Julie Rovner, KFF Health News – 2024-05-09 12:27:53

Isabella Rosario Blum was wrapping up medical school and considering residency programs to become a family practice physician when she got some frank advice: If she wanted to be trained to abortions, she shouldn't stay in Arizona.

Blum turned to programs mostly in states where access — and, by extension, abortion training — is likely to remain protected, like California, Colorado, and New Mexico. Arizona has enacted a law banning most abortions after 15 weeks.

“I would really like to have all the training possible,” she said, “so of course that would have still been a limitation.”

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In June, she will start her residency at Swedish Cherry Hill hospital in Seattle.

According to new statistics from the Association of American Medical Colleges, for the second year in a row, graduating from U.S. medical schools were less likely to apply this year for residency positions in states with abortion bans and other significant abortion restrictions.

Since the Supreme Court in 2022 overturned the constitutional right to an abortion, fights over abortion access have created plenty of uncertainty for pregnant patients and their . But that uncertainty has also bled into the world of medical education, forcing some new doctors to factor state abortion laws into their decisions about where to begin their careers.

Fourteen states, primarily in the Midwest and South, have banned nearly all abortions. The new analysis by the AAMC — a preliminary copy of which was exclusively reviewed by KFF Health News before its public release — found that the number of applicants to residency programs in states with near-total abortion bans declined by 4.2%, compared with a 0.6% drop in states where abortion remains legal.

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Notably, the AAMC's findings illuminate the broader problems abortion bans can create for a state's medical community, particularly in an era of provider shortages: The organization tracked a larger decrease in interest in residencies in states with abortion restrictions not only among those in specialties most likely to treat pregnant patients, like OB-GYNs and emergency room doctors, but also among aspiring doctors in other specialties.

“It should be concerning for states with severe restrictions on reproductive rights that so many new physicians — across specialties — are choosing to apply to other states for training instead,” wrote Atul Grover, executive director of the AAMC's Research and Action Institute.

The AAMC analysis found the number of applicants to OB-GYN residency programs in abortion ban states dropped by 6.7%, compared with a 0.4% increase in states where abortion remains legal. For internal medicine, the drop observed in abortion ban states was over five times as much as in states where abortion is legal.

In its analysis, the AAMC said an ongoing decline in interest in ban states among new doctors ultimately “may negatively affect access to care in those states.”

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Jack Resneck Jr., immediate past president of the American Medical Association, said the data demonstrates yet another consequence of the post- era.

The AAMC analysis notes that even in states with abortion bans, residency programs are filling their positions — mostly because there are more graduating medical students in the U.S. and abroad than there are residency slots.

Still, Resneck said, “we're extraordinarily worried.” For example, physicians without adequate abortion training may not be able to manage miscarriages, ectopic pregnancies, or potential complications such as infection or hemorrhaging that could stem from pregnancy loss.

Those who work with students and residents say their observations support the AAMC's findings. “People don't want to go to a place where evidence-based practice and human rights in general are curtailed,” said Beverly Gray, an associate professor of obstetrics and gynecology at Duke University School of Medicine.

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Abortion in North Carolina is banned in nearly all cases after 12 weeks. Women who experience unexpected complications or discover their baby has potentially fatal birth defects later in pregnancy may not be able to receive care there.

Gray said she worries that even though Duke is a highly sought training destination for medical residents, the abortion ban “impacts whether we have the best and brightest coming to North Carolina.”

Rohini Kousalya Siva will start her obstetrics and gynecology residency at MedStar Washington Hospital Center in Washington, D.C., this year. She said she did not consider programs in states that have banned or severely restricted abortion, applying instead to programs in Maryland, New Hampshire, New York, and Washington, D.C.

“We're physicians,” said Kousalya Siva, who attended medical school in Virginia and was previously president of the American Medical Student Association. “We're supposed to be giving the best evidence-based care to our patients, and we can't do that if we haven't been given abortion training.”

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Another consideration: Most graduating medical students are in their 20s, “the age when people are starting to think about putting down roots and starting families,” said Gray, who added that she is noticing many more students ask about politics during their residency interviews.

And because most young doctors make their careers in the state where they do their residencies, “people don't feel safe potentially their own pregnancies living in those states” with severe restrictions, said Debra Stulberg, chair of the Department of Family Medicine at the University of Chicago.

Stulberg and others worry that this self-selection away from states with abortion restrictions will exacerbate the shortages of physicians in rural and underserved areas.

“The geographic misalignment between where the needs are and where people are choosing to go is really problematic,” she said. “We don't need people further concentrating in urban areas where there's already good access.”

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After attending medical school in Tennessee, which has adopted one of the most sweeping abortion bans in the nation, Hannah Light-Olson will start her OB-GYN residency at the University of California-San Francisco this summer.

It was not an easy decision, she said. “I feel some guilt and sadness leaving a situation where I feel like I could be of some help,” she said. “I feel deeply indebted to the program that trained me, and to the patients of Tennessee.”

Light-Olson said some of her fellow students applied to programs in abortion ban states “because they think we need pro-choice providers in restrictive states now more than ever.” In fact, she said, she also applied to programs in ban states when she was confident the program had a way to provide abortion training.

“I felt like there was no perfect, 100% guarantee; we've seen how fast things can change,” she said. “I don't feel particularly confident that California and New York aren't going to be under threat, too.”

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As a of a scholarship she received for medical school, Blum said, she will have to return to Arizona to practice, and it is unclear what abortion access will look like then. But she is worried about long-term impacts.

“Residents, if they can't get the training in the state, then they're probably less likely to settle down and work in the state as well,” she said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

This article first appeared on Mississippi Today and is republished here under a Creative Commons license.

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