Mississippi Today
These Republicans wanted a Medicaid work requirement but couldn’t get approval. So they got creative.
When the North Carolina legislative session ends, Jim Burgin, a conservative Republican state senator who serves as chair of his state's Senate Health Care Committee, will go back to his daily life as a businessman.
The owner of an insurance company and a partner in a local car dealership group, Burgin fully understands the virtue of hard work. That's why when Medicaid expansion, the federal program that 10 states including Mississippi have refused to pass, came up for debate in his legislature over the past few years, he wasn't immediately sold.
“I don't think we ought to have any kind of government program that people stay on the rest of their lives,” Burgin told Mississippi Today in an interview this week. “Like most of my Republican colleagues, I wanted to put a work requirement in. But we realized the feds would never approve it, so we had to think about what we really wanted to do as it related to work.”
Many Mississippi Republican lawmakers currently face the same dilemma. Though Medicaid expansion is being seriously considered here for the first time, Senate Republicans, led by Lt. Gov. Delbert Hosemann, appear convinced that the only way the state should expand Medicaid is if a work requirement is in place. But with the federal government having shot down 13 states' previous efforts to implement a work requirement, Mississippi Today reached out to leaders in North Carolina, the most recent Republican-led state to expand, to see how they came to an agreement.
Burgin and his colleagues, knowing the feds wouldn't allow the work requirement, went to the drawing board to determine if they could come up with a Medicaid expansion bill that still promoted work without requiring it. They started with a “trigger law,” of sorts, to mandate that if the federal government ever changed their policy on allowing states to implement a work requirement, North Carolina would move immediately to adopt one. They also added a separate trigger that allowed the state to immediately drop out of the expansion program if Congress ever defunded it or changed its funding structure.
They also developed some creative ideas for spending the additional federal dollars the state would receive from the expansion program that were designed to promote work. Shortly after they expanded Medicaid, the North Carolina lawmakers designated hundreds of millions in expansion “signing bonus” funds on mental health reform. The state's mental health system was in crisis with major funding concerns, so Republicans appropriated $835 million — all money they got from the feds to expand Medicaid — to rebuild the crumbled system.
“That's going to help so many hospitals and law enforcement officers who often had nothing to do with mentally ill people but take them to emergency rooms, whether those people had health insurance or not,” Burgin said. “Hospitals will never have to treat or pay for care for people in those situations in ERs ever again.”
Additionally, North Carolina Republicans in the coming weeks will work on getting the federal government to grant a waiver to spend federal Medicaid dollars on providing free community college — and workforce skills training — to North Carolinians enrolled in the Medicaid expansion program. Additionally, some Republicans want to add child care vouchers to that list of offerings.
“This is all to get people jobs and to keep them working and ultimately to get them off Medicaid,” Burgin said. “Even though it can't be a requirement, we're promoting work. We want to make it easier and better for people to get work that they won't want to stay on Medicaid. They'll want a job and hopefully eventually get on a group health plan through their employer.”
So what ultimately convinced Burgin, who wanted the work requirement all along, to move forward on expansion even without it?
“Billions of dollars,” he said plainly. “Look, I'm a business guy. I don't spend money, I invest money. I looked at (Medicaid expansion) as a great investment. I had a fiduciary responsibility to my constituents to take that money. So we wrote a bill that said that if the feds changed the work requirement, if they change anything, we can add it here or opt out of our program altogether.
“I just couldn't turn down billions of dollars that we needed in so many areas,” Burgin said. “And we get to spend that on a wide variety of things, and all of it is designed to get people across this state working.”
READ MORE: Mississippi leaving more than $1 billion per year on table by rejecting Medicaid expansion
Republican state Rep. Donny Lambeth was the primary author of what became North Carolina's Medicaid expansion program.
For years before an expansion program actually passed, Lambeth filed numerous expansion bills that included work requirements.
“I was a big advocate for work requirements because, well, I felt like it was just one of those things,” Lambeth said. “We shouldn't want to just add more people to Medicaid rolls. You have to figure out how to help them and get them off Medicaid and into the workforce. But when we talked to people in Washington, it was obvious there was no way, if we went through all the trouble to get votes and get it passed, we would get a work requirement.”
READ MORE: How Medicaid expansion could have saved Tim's leg — and changed his life
So Lambeth, like Burgin, went to the drawing board. They wrote into their expansion plan a provision similar to red-state Montana: State government agencies would work with private partners who had experience with job training to create a program that would pay for Medicaid enrollees to get job training. They couldn't require people to participate, but they could make it worth their while.
“We looked at what other Republican states that had expanded had done,” Lambeth said. “What we came up with in lieu of the work requirement was an optional jobs training program. The idea was that even though you've got the vast majority of people on Medicaid working, they're working in low-income jobs. They couldn't afford health insurance even though they worked. The theory is that if you take advantage of expansion dollars from the federal government with a job training program like this, you can go back and further your education. You can then get a better job, have a higher standard of living, get off Medicaid and be able to afford your health insurance.”
Peg O'Connell, a health care advocate and consultant who for several years led North Carolina's push to expand Medicaid, explained how the jobs training program worked in Montana before her state included it in its program.
“A man had been a hit-or-miss carpenter and really wanted a commercial drivers license,” O'Connell said. “So the Montana caseworker under their expansion program helped get him his CDL. They paid for him to take the classes as well as lodging when he had to travel to take his exams, and they even bought him a pair of work boots. This man is now doing what he wants to be doing, he's got full-time employment with health insurance, and he has worked himself off the Medicaid program. That's the idea behind our program here.”
Lambeth, like Burgin, is a small business owner. He owns a logistics contracting company, and he “can't afford to offer my employees health insurance,” he said.
“Are there some quote-unquote deadbeats, people who are not working, playing off the system? Sure,” Lambeth said. “But we were able to identify the farmers in the east part of the state, small, mom-and-pop businesses that were growing at significant rates but couldn't quite afford to offer health insurance, hard-working people who desperately wanted and needed health insurance but couldn't afford it. We saw that the vast majority of these people are working, and the ones who weren't working, we felt like if we could get them training or education and child care, that would help get them off Medicaid.
“If we're really all about getting people working, then let's figure out ways to work within the system, draw down those billions of dollars, and use them to get them working,” he continued. “It was really that simple.”
Burgin and Lambeth both supported work requirements but saw they wouldn't get approval from the federal government. They listened to their constituents, they considered the heart of their desire to get North Carolinians working and they found creative solutions.
As Mississippi lawmakers consider Medicaid expansion over the next few days, what advice might the North Carolina Republicans offer to their counterparts here in the Magnolia State?
“You tell any of the hardest nos, the most conservative ones, that if they have any doubts, give them my number. My cell is 919-207-7263,” Burgin said. “I'll be happy to answer any question they may have and talk to them about why this is so beneficial. I've been tracking Mississippi. I testified the other day to Kansas lawmakers. We've already talked to folks in Georgia, Florida, Kansas and now Mississippi. All of these holdout states are looking at the same thing saying, ‘We've put it off. Why did you do it?' For me and my Republican colleagues, it came down to a business decision. How could we, in good faith, leave billions on the table?”
Lambeth answered the question with an anecdote.
“I heard from just dozens and dozens of North Carolinians while we were debating this,” Lambeth said. “But I got one letter, in particular, from a Christmas tree farmer in Ash County. She couldn't afford health insurance, and she was worried they were going to lose their farm because of out-of-pocket medical bills they had.
“These are real people. They're not the traditional Medicaid where they're poor and not trying to improve their lives. They are hard-working people just not able to afford health insurance. I promise the average Mississippian is not much different than the average North Carolinian in that way. Why would we be in the positions we're in and not help them? I mean really, why?”
READ MORE: The Christian argument for Medicaid expansion
This article first appeared on Mississippi Today and is republished here under a Creative Commons license.
Mississippi Today
Federal panel prescribes new mental health strategy to curb maternal deaths
For help, call or text the National Maternal Mental Health Hotline at 1-833-TLC-MAMA (1-833-852-6262) or contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.” Spanish-language services are also available.
BRIDGEPORT, Conn. — Milagros Aquino was trying to find a new place to live and had been struggling to get used to new foods after she moved to Bridgeport from Peru with her husband and young son in 2023.
When Aquino, now 31, got pregnant in May 2023, “instantly everything got so much worse than before,” she said. “I was so sad and lying in bed all day. I was really lost and just surviving.”
Aquino has lots of company.
Perinatal depression affects as many as 20% of women in the United States during pregnancy, the postpartum period, or both, according to studies. In some states, anxiety or depression afflicts nearly a quarter of new mothers or pregnant women.
Many women in the U.S. go untreated because there is no widely deployed system to screen for mental illness in mothers, despite widespread recommendations to do so. Experts say the lack of screening has driven higher rates of mental illness, suicide, and drug overdoses that are now the leading causes of death in the first year after a woman gives birth.
“This is a systemic issue, a medical issue, and a human rights issue,” said Lindsay R. Standeven, a perinatal psychiatrist and the clinical and education director of the Johns Hopkins Reproductive Mental Health Center.
Standeven said the root causes of the problem include racial and socioeconomic disparities in maternal care and a lack of support systems for new mothers. She also pointed a finger at a shortage of mental health professionals, insufficient maternal mental health training for providers, and insufficient reimbursement for mental health services. Finally, Standeven said, the problem is exacerbated by the absence of national maternity leave policies, and the access to weapons.
Those factors helped drive a 105% increase in postpartum depression from 2010 to 2021, according to the American Journal of Obstetrics & Gynecology.
For Aquino, it wasn't until the last weeks of her pregnancy, when she signed up for acupuncture to relieve her stress, that a social worker helped her get care through the Emme Coalition, which connects girls and women with financial help, mental health counseling services, and other resources.
Mothers diagnosed with perinatal depression or anxiety during or after pregnancy are at about three times the risk of suicidal behavior and six times the risk of suicide compared with mothers without a mood disorder, according to recent U.S. and international studies in JAMA Network Open and The BMJ.
The toll of the maternal mental health crisis is particularly acute in rural communities that have become maternity care deserts, as small hospitals close their labor and delivery units because of plummeting birth rates, or because of financial or staffing issues.
This week, the Maternal Mental Health Task Force — co-led by the Office on Women's Health and the Substance Abuse and Mental Health Services Administration and formed in September to respond to the problem — recommended creating maternity care centers that could serve as hubs of integrated care and birthing facilities by building upon the services and personnel already in communities.
The task force will soon determine what portions of the plan will require congressional action and funding to implement and what will be “low-hanging fruit,” said Joy Burkhard, a member of the task force and the executive director of the nonprofit Policy Center for Maternal Mental Health.
Burkhard said equitable access to care is essential. The task force recommended that federal officials identify areas where maternity centers should be placed based on data identifying the underserved. “Rural America,” she said, “is first and foremost.”
There are shortages of care in “unlikely areas,” including Los Angeles County, where some maternity wards have recently closed, said Burkhard. Urban areas that are underserved would also be eligible to get the new centers.
“All that mothers are asking for is maternity care that makes sense. Right now, none of that exists,” she said.
Several pilot programs are designed to help struggling mothers by training and equipping midwives and doulas, people who provide guidance and support to the mothers of newborns.
In Montana, rates of maternal depression before, during, and after pregnancy are higher than the national average. From 2017 to 2020, approximately 15% of mothers experienced postpartum depression and 27% experienced perinatal depression, according to the Montana Pregnancy Risk Assessment Monitoring System. The state had the sixth-highest maternal mortality rate in the country in 2019, when it received a federal grant to begin training doulas.
To date, the program has trained 108 doulas, many of whom are Native American. Native Americans make up 6.6% of Montana's population. Indigenous people, particularly those in rural areas, have twice the national rate of severe maternal morbidity and mortality compared with white women, according to a study in Obstetrics and Gynecology.
Stephanie Fitch, grant manager at Montana Obstetrics & Maternal Support at Billings Clinic, said training doulas “has the potential to counter systemic barriers that disproportionately impact our tribal communities and improve overall community health.”
Twelve states and Washington, D.C., have Medicaid coverage for doula care, according to the National Health Law Program. They are California, Florida, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, Oklahoma, Oregon, Rhode Island, and Virginia. Medicaid pays for about 41% of births in the U.S., according to the Centers for Disease Control and Prevention.
Jacqueline Carrizo, a doula assigned to Aquino through the Emme Coalition, played an important role in Aquino's recovery. Aquino said she couldn't have imagined going through such a “dark time alone.” With Carrizo's support, “I could make it,” she said.
Genetic and environmental factors, or a past mental health disorder, can increase the risk of depression or anxiety during pregnancy. But mood disorders can happen to anyone.
Teresa Martinez, 30, of Price, Utah, had struggled with anxiety and infertility for years before she conceived her first child. The joy and relief of giving birth to her son in 2012 were short-lived.
Without warning, “a dark cloud came over me,” she said.
Martinez was afraid to tell her husband. “As a woman, you feel so much pressure and you don't want that stigma of not being a good mom,” she said.
In recent years, programs around the country have started to help doctors recognize mothers' mood disorders and learn how to help them before any harm is done.
One of the most successful is the Massachusetts Child Psychiatry Access Program for Moms, which began a decade ago and has since spread to 29 states. The program, supported by federal and state funding, provides tools and training for physicians and other providers to screen and identify disorders, triage patients, and offer treatment options.
But the expansion of maternal mental health programs is taking place amid sparse resources in much of rural America. Many programs across the country have run out of money.
The federal task force proposed that Congress fund and create consultation programs similar to the one in Massachusetts, but not to replace the ones already in place, said Burkhard.
In April, Missouri became the latest state to adopt the Massachusetts model. Women on Medicaid in Missouri are 10 times as likely to die within one year of pregnancy as those with private insurance. From 2018 through 2020, an average of 70 Missouri women died each year while pregnant or within one year of giving birth, according to state government statistics.
Wendy Ell, executive director of the Maternal Health Access Project in Missouri, called her service a “lifesaving resource” that is free and easy to access for any health care provider in the state who sees patients in the perinatal period.
About 50 health care providers have signed up for Ell's program since it began. Within 30 minutes of a request, the providers can consult over the phone with one of three perinatal psychiatrists. But while the doctors can get help from the psychiatrists, mental health resources for patients are not as readily available.
The task force called for federal funding to train more mental health providers and place them in high-need areas like Missouri. The task force also recommended training and certifying a more diverse workforce of community mental health workers, patient navigators, doulas, and peer support specialists in areas where they are most needed.
A new voluntary curriculum in reproductive psychiatry is designed to help psychiatry residents, fellows, and mental health practitioners who may have little or no training or education about the management of psychiatric illness in the perinatal period. A small study found that the curriculum significantly improved psychiatrists' ability to treat perinatal women with mental illness, said Standeven, who contributed to the training program and is one of the study's authors.
Nancy Byatt, a perinatal psychiatrist at the University of Massachusetts Chan School of Medicine who led the launch of the Massachusetts Child Psychiatry Access Program for Moms in 2014, said there is still a lot of work to do.
“I think that the most important thing is that we have made a lot of progress and, in that sense, I am kind of hopeful,” Byatt said.
Cheryl Platzman Weinstock's reporting is supported by a grant from the National Institute for Health Care Management Foundation. 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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Mississippi Today
New law gives state board power to probe officer misconduct
The state's officer certification and training board now has the power to investigate law enforcement misconduct.
Gov. Tate Reeves signed the bill making it official.
Public Safety Commissioner Sean Tindell, who pushed for the legislation, said that House Bill 691 authorizes the Board of Law Enforcement Officer Standards and Training “to launch its own investigations into officer misconduct. This change, along with the funding to hire two investigators, will improve the board's ability to ensure officer professionalism and standards.”
The new law comes in the wake of an investigation by the Mississippi Center for Investigative Reporting at Mississippi Today and The New York Times into sheriffs and deputies across the state over allegations of sexual abuse, torture and corruption.
Tindell said the new law will “improve law-enforcement training in Mississippi by requiring all law enforcement officers to receive continuing training throughout an officer's career.”
Under that law, deputies, sheriffs and state law enforcement officers will join police officers in the requirement to have up to 24 hours of continuing education training. Those who fail to train could lose their certifications.
Other changes will take place as well. Each year, the licensing board will have to report on its activities to the Legislature and the governor.
Tindell thanked Reeves “for signing this important piece of legislation and the legislative leaders who supported its passage, including the author of HB 691, Representative Fred Shanks.”
Shanks, R-Brandon, praised the “team effort with some very smart people who want a top-notch law enforcement community.”
The new law creates a 13-member board with the governor having six appointments – two police chiefs, two sheriffs, a district attorney and the director of the Mississippi Law Enforcement Officers' Training Academy.
Other members would include the attorney general or a designee, the director of the Mississippi Highway Patrol, the public safety commissioner and the presidents of the Mississippi Association of Chiefs of Police, the Mississippi Constable Association, the Mississippi Campus Law Enforcement Association and the Mississippi Sheriffs' Association (or their designees).
“We obviously need checks and balances on how law enforcement officers conduct themselves,” said state Sen. John Horhn, D-Jackson. “This is a good first step.”
This article first appeared on Mississippi Today and is republished here under a Creative Commons license.
Mississippi Today
Lawmakers punt to next year efforts to expand college aid for low-income Mississippians
A bill to open a college financial aid program for the first time ever to Mississippians who are adult, part-time and very low-income students fell to the wayside in a legislative session dominated by fights over Medicaid and K-12 funding.
The effort to expand the Mississippi Resident Tuition Assistance Grant, called MTAG, died in conference after it was removed from House Bill 765, legislation to provide financial assistance to teachers in critical shortage areas. The Senate had attached MTAG's code sections to that bill in an attempt to keep the expansion alive.
This takes Jennifer Rogers, the director of the Mississippi Office of Student Financial Aid, back to the drawing board after years of championing legislation to modernize the way the state helps Mississippians pay for college.
“At the end of the day, there was no appetite to spend any additional money on student financial aid,” Rogers said. “Obviously, I'm disappointed.”
All told, the original proposal would have resulted in the state spending upwards of $30 million extra each year, almost doubling OSFA's roughly $50 million budget.
The increase derived from two aspects of the proposal: An estimated 37,000 Mississippians who have never been eligible for college financial aid would have become eligible to receive it, and the scholarship amounts would have increased.
While college students from millionaire families can get MTAG, the state's poorest students are not eligible, Mississippi Today previously reported.
Rep. Kent McCarty, R-Hattiesburg, said he supports efforts to help low-income Mississippians afford college, but that HB 765 was not an appropriate vehicle to do so because it was not an appropriations bill. Attempting to expand MTAG through that legislation would have put the original subject of HB 765, the Mississippi Critical Teachers Shortage Act, at risk.
“We didn't feel it was appropriate to include an appropriation in a bill that had not been through the appropriations process,” he said.
McCarty, a member of the House Universities and Colleges Committee, added that he is in favor of changing MTAG and doesn't understand the logic behind excluding from state financial aid Mississippi college students who receive a full federal Pell Grant, meaning they come from the state's poorest families.
“What is the purpose of financial aid? To aid those who need financial aid,” he said. “Excluding a group of students because they're eligible for other financial aid doesn't make a lot of sense to me.”
Ultimately, the Mississippi House deemed the proposal too expensive. It never passed out of that chamber's Appropriations Committee.
READ MORE: ‘A thing called money:' Bill to expand financial aid stalled after House lawmakers balk at price tag
Rogers said she plans to work with lawmakers to convince them that it is a good use of state dollars to invest in financial aid. She added that the support of the business community helped keep the bill alive as long as it did this session. The Mississippi Economic Council supported the legislation.
“I don't understand why there is such a hesitancy to invest more in the future workforce of the state,” she said. “I don't understand why there isn't a willingness to invest in student financial aid as a way to help more Mississippians complete meaningful certificates or degrees, valuable certificates or degrees and improve the quality of the workforce.”
Senate Education Committee Chairman Dennis DeBar, R-Leakesville, told Mississippi Today that he hopes to take a closer look at MTAG this summer, noting that the Senate's version of the proposal, which also included a last-dollar tuition scholarship, was a priority of the lieutenant governor on last year's campaign trail.
“We had so many issues last session,” DeBar said. “Hopefully there won't be as many next year so we can just focus this year and get it across the finish line.”
This article first appeared on Mississippi Today and is republished here under a Creative Commons license.
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