Rural hospitals are closing at an alarming rate across the Southeast. The pandemic may have exacerbated the problem, but the region was losing thousands of hospital beds even before Covid-19.

The South is also a region where few states have expanded Medicaid,  a decision driven in part by the politics of expanding a program tied to the Affordable Care Act, also known as Obamacare. But Medicaid expansion may offer a lifeline to the South’s rural hospitals.

This week, on the Reckon Interview, we’re examining the South’s broken health care system and the work being done to improve it. Dr. Andrea Patterson is an expert on the history of health care in the South. She explains how academics in the 18th and 19th centuries created a biological justification for denying health care to Black Southerners that still haunts us today. And Olivia Paschal, a reporter with Facing South, describes what the fight to expand health coverage looks like today.

Here are a few excerpts from our conversation with Olivia Paschal. You can find the conversation with Dr. Andrea Patterson here. And you can listen to the whole episode here.

And go ahead and subscribe on Apple Podcasts, Spotify, Acast or wherever else you get your podcasts to stay informed about the South this election season.

Olivia Paschal on how high uninsured rates affect Southern hospitals

One of the things that I’ve spent a lot of reporting energy on –  especially at the beginning of the pandemic –  was that in states that haven’t expanded Medicaid, particularly rural hospitals have been closing at a very, very high rate, especially in the South. The rural South has lost thousands of hospital beds in just the last five years. I’ve seen, you know, dozens of closures, and especially in the Southeast, it impacts, poor Black rural populations most. Those are also the populations that have been hit particularly hard by this pandemic.

The reason that you know Medicaid expansion is such a big deal when you’re talking about rural hospitals is that when people come to an emergency room, the hospital’s gonna treat them. They have to treat them. That’s their code of ethics. If the patient is uninsured, the hospital isn’t going to get reimbursed for that care. Medicaid expansion expands insurance rates and means that if a patient shows up to an ER or to a doctor with symptoms of some serious illness, the hospital isn’t gonna be responsible for floating the cost of their care.

When hospitals go in the red, they’re not necessarily going to close but a lot of them do and it’s a pretty strong predictor of which ones will close. So the pandemic has really exacerbated a lot of these health disparities that had already existed for a long time and just really made them much more pronounced and made a lot of rural health care advocates really concerned about the access for care in vulnerable populations in the Black Belt, but also in other rural areas and Appalachia.

There’s really well documented research on this. There is a glaring disparity between states that expanded Medicaid and how many hospital closures they’ve had versus states have not. I have a map that I put together back in March or April, looking at this, and it is like just far, far, far, far fewer rural hospitals have closed. And when you talk to rural health advocates and rural hospital advocates, the number one thing that they will tell you, the data bears out that Medicaid expansion is like the one thing that can really help a rural hospital stay afloat, because, you know, rural uninsured rates are so high in the South.

Olivia Paschal on the ongoing efforts to expand Medicaid in the South

Arkansas is interesting because we were actually one of the first states to expand Medicaid, right when the [Affordable Care Act] happened. and we did it under the private option. So basically, it allows people on Medicaid to buy in the private marketplace for insurance. And when that happened it was sort of seen as a way that Medicaid expansion could be palatable in the South.

At the time that the private option passed in Arkansas, we, I believe, still had a democratic governor, a very popular moderate Democratic governor and had a newly red state legislature, newly Republican. But at the time it was much less polarized than it is now. The incoming governor was also a pretty moderate Republican, like two sides of the same coin. And so they got it through Arkansas. And that was supposed to be the way that it would be packaged in other Southern states.

What has happened is that you have some states that have done similar things. So Louisiana and Kentucky more recently have done it. Virginia recently expanded Medicaid.

But it’s become – because it’s connected in part to the ACA, to Obamacare – it’s like a bit of a scary thing for Republicans to touch, especially as these state houses get more polarized.

Some of the most active folks in the fight for Medicaid expansion, in terms of on the ground, grassroots efforts, a lot of organizing is happening in North Carolina. A lot is happening in Alabama. And we’ve had a few states on the sort of border of the South expand Medicaid, they recently voted to expand Medicaid in Missouri and Oklahoma.

But in North Carolina and Alabama, folks in both of those states have sort of hit the ground. Tennessee is a state that has been trying for state legislature has been trying for several years to get Medicaid expanded but has had a lot of industry pushback. And essentially, during the pandemic, it’s been all but tabled, because they’re just sort of trying to put a band aid on the crisis that exists now.

For more from Olivia Paschal about efforts to expand Medicaid, listen to the whole conversation here.  

Episode One: The fight for the vote and how to ensure your vote counts

Episode Two: How the South created modern politics and what’s at stake in 2020

Episode Three: How the South nearly blocked women’s suffrage

Episode Four: To live here, you have to fight: Coalition building in the South