Forty-seven-year-old Selinda Walker had to move back in with her elderly mother after an untreated and severe case of Graves’ disease left her unable to work and live independently.

As a single, low-income individual with no children, Walker has no path toward health care in the state of Mississippi, which remains one of 10 states in the country not to expand Medicaid. And as lawmakers advocate for work requirements in Medicaid expansion bills, Walker faces a Catch-22: she needs health insurance first to get healthy enough to be able to return to work.

The progression of her disease made it impossible for her to continue working at her jobs in retail and car sales. The worst of her symptoms cause her to suffer dizzy spells and temporarily-paralyzing falls throughout the day, among a slew of other problems.

“I feel like I’m a burden to my mother,” Walker, who lives in Columbus, said. “She has to do so much because I can do so little. There are days where I am just useless, the pain is so bad.”

Since she inherited the gene from both her parents, Walker has a textbook case of the autoimmune disease with all of its worst symptoms. The condition, which causes the immune system to mistakenly attack healthy tissue, gets progressively worse if left untreated.

Without health insurance, Walker’s only recourse is a free clinic in Tupelo, about an hour and a half away from where she lives in Columbus. The clinic is able to prescribe her thyroid medications to varying degrees of success, but it’s nothing compared to the quality of life improvement she might experience if she were able to get the proper tests done and potentially undergo a more permanent solution like thyroid surgery.

One of the 10 medications she’s currently on helps treat the insomnia associated with Graves’ disease, but it sometimes causes her to sleep through the day. None of the medications help alleviate her back pain or the gut issues, chills or tremors she lives with.

“It’s very scary to think I don’t have anybody to check me out every month … every day I’m wondering if I’ll wake up,” she mused.

As a childless adult, Walker doesn’t qualify for Medicaid – period. She says the last two times she applied for disability Medicaid, case workers told her they could only help her if she got pregnant.

“I was shocked,” Walker said. “I couldn’t believe what I was hearing. Mississippi is one of the strangest states ever. The only way to help me is if I have children?”

Even if she had children, or if that rule didn’t exist, Walker was at that time making more than 28% of the federal poverty level, a mere $7,000 annually for a family of three – the maximum salary a Mississippi family can make and still qualify for Medicaid – working full-time at her jobs in retail and car sales.

And she’s far from the only one. Anyone making at least minimum wage working full-time makes more than 28% of the federal poverty level, which then counts against them and disqualifies them from Medicaid.

Walker is one of tens of thousands of Mississippians who fall into the “coverage gap.” These individuals don’t qualify for Medicaid under the state’s current restrictions but make less than the 100% of the federal poverty level, about $15,000 a year for an individual, that would qualify them for subsidies that make marketplace insurance affordable.

The coverage gap exists in states that have not expanded Medicaid under the Affordable Care Act, which presumed all states would automatically expand Medicaid. However, a 2012 Supreme Court ruling made expansion optional for states.

New proposals in the Mississippi Legislature would expand Medicaid, as 40 other states have done, covering families and adults with a household income of up to 138% of the federal poverty level, under the House plan, or 99%, under the Senate plan.

Both plans would cover more Mississippians than are currently covered. But under both plans, the threat of a work requirement could leave individuals like Walker behind.

Policing and enforcing the work requirement costs more than it would cost to insure the population of unemployed people who would become eligible for Medicaid under expansion. Experts say developing new administrative systems would burden an already precarious system and could cost up to tens of millions of dollars. What’s more is the paperwork can be confusing to enrollees, causing legitimately employed and income-eligible individuals to be denied coverage.

The House plan would expand Medicaid regardless of whether the federal government approved a special waiver necessary to implement a work requirement. But the Senate plan is entirely contingent on the approval of the work requirement – unlikely to happen under the Biden administration, which has rescinded work requirements previously granted under the Trump administration and not approved new ones.

Dr. Dustin Gentry, a family physician at Winston Medical Center in Louisville, is a self-described Republican who says he can’t abide by his party’s long-standing belief that Medicaid expansion isn’t the most financially responsible decision for Mississippi.

“I want Mississippi to have coverage for uninsured patients in the coverage gap, and I want us to do it in a way that makes most sense financially, which is the House plan,” Gentry said. “It doesn’t make sense for us to not take the (federal) money, when everybody else is taking it. It puts us further behind.”

A plan like the Senate’s would leave $1 billion federal dollars on the table. An expansion plan that doesn’t cover people making up to 138% of the federal poverty level, about $20,000 annually for an individual, isn’t considered “expansion” under the Affordable Care Act, and therefore doesn’t qualify for the increased federal match rate, nor the additional two-year financial incentive the ACA gives to newly-expanded states.

Mississippians are already paying for Medicaid to cover hundreds of thousands of poor, working people – in other states.

“It’s important to note that the residents of Mississippi and the other holdout states have not been spared from paying for Medicaid expansion,” Dr. Joe Thompson, the Arkansas surgeon general under Republican Gov. Mike Huckabee and Democratic Gov. Mike Beebe told Mississippi Today. “They have been helping to fund it for over a decade through their federal tax dollars, but the money has been flowing into states like Arkansas and Louisiana instead of benefiting the working poor, hospitals, and economies of their home states.”

And hospitals are dying because uninsured individuals’ only recourse for medical care is the emergency room – the most expensive place to receive care. One report estimates that nearly half of all Mississippi’s rural hospitals are at risk of closure due to uncompensated care costs hospitals must front to cover these individuals each year.

“Everybody’s got heartburn over people ‘getting something they don’t deserve,’” Gentry said. “But these people get free care anyways. They’re getting it from the emergency room, and it’s uncompensated care, and it’s the most expensive way to get care possible. So they’re getting it for free, we’re just bickering over who is going to pay for it.”

And while emergency rooms cannot turn down individuals who require immediate life-saving care, they do nothing to provide the necessary preventative care to improve the quality of life for people like Walker.

Walker believes if she could get the proper tests and treatment plan, she could go back to work and live independently. But with Gov. Tate Reeves promising to veto any expansion bill and the Senate hung up on a stringer work requirement, the chances Walker will get the care she needs look slim.

The six lawmakers tasked with hammering out a conference report on Medicaid expansion currently have until April 27 to file the bill and until April 29 to adopt it.

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