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Ten states in the United States have refused to expand Medicaid under the federal government's Affordable Care Act, also known as Obamacare. If they did, it could provide care to more than a million people on low incomes. Reporter Drew Hawkins of the Gulf States Newsroom looks at why Alabama isn't going for it and how that's affecting access to medical care in the state.
BRITTNEY ANDERSON: Let's set up, get rooms ready to go.
DREW HAWKINS, BYLINE: On a bright and clear Thursday morning, Dr. Brittney Anderson sets up shop at her small rural health clinic.
ANDERSON: Coffee's on the pot. All right.
HAWKINS: The Anderson Family Care clinic is a one-story, white brick building in downtown Demopolis, Ala. The clinic treats about 1,700 patients.
ANDERSON: We see a lot of schoolteachers, a lot of folks who work here within the city, some who work outside of the city.
HAWKINS: She says one of the biggest challenges her patients face is transportation. It's not covered under Medicaid.
ANDERSON: Very often, it breaks my heart, folks who have to, you know, pay someone to bring them into clinic, and then we get here and we're talking about, you know, what medicines we would do and things like that, and you're then including a trip to the pharmacy on the way home.
HAWKINS: It also makes it hard to get to specialists, who may be more than 2 1/2 hours away. That sometimes puts Anderson in a pickle. Does she refer them to a specialist they can't get to or try to treat them herself as best she can?
ANDERSON: We're not out here to be cowboys practicing, you know, medicine that we're not comfortable with.
HAWKINS: These aren't new problems, but they're getting worse, and part of the reason is what's known as the coverage gap, people who don't qualify for Medicaid but can't afford private insurance. If Alabama adopted Medicaid expansion under the federal Affordable Care Act, at least 174,000 residents would be covered, according to KFF, the health policy research group. So why not cover more people, especially since most of the money would come from the federal government?
JUSTIN BOGIE: You're giving up a lot of your sovereignty as a state to set health policy, and so I think that's a concern.
HAWKINS: Justin Bogie is senior director of fiscal policy at the Alabama Policy Institute, a research group that says it's committed to limited government and strong families.
BOGIE: So we think, if you expand Medicaid and you open up this federal subsidized program for hundreds of thousands of people, then it could actually hurt that labor participation rate, give them another reason not to go to work, to stay at home.
HAWKINS: Supporters of Medicaid expansion say many in the coverage gap do work. They just don't have insurance. Bogie and groups like the Alabama Hospital Association say they want to close the coverage gap, just not with Medicaid expansion. They want a state-run plan that would use federal dollars to subsidize private health care, but that hasn't been put in place yet, and federal Medicaid expansion is a nonstarter in the Republican-dominated state legislature because of its connection to the Affordable Care Act or Obamacare.
REGINA WAGNER: Just the partisan nature of this is definitely a problem.
HAWKINS: Regina Wagner is a professor of political science at the University of Alabama. She says for years, Republican legislators ran on repealing the Affordable Care Act, but she says now most Alabama voters support it, and many other red states have adopted expansion.
WAGNER: A lot of rural voters are Republicans - right? - and so your own constituents are being hit by this, and you're not addressing it.
HAWKINS: There was an attempt this year to fund more rural health. It was tucked into a casino gambling bill that would increase state revenues, but ultimately, it didn't happen. Dr. Anderson, back at her health clinic, says she was disappointed, but she'll keep pushing legislators.
ANDERSON: I'd simply say, look at where we are now. It's unfortunate when we as a state have folks who can't have access to care simply because we don't make this expansion.
HAWKINS: Both supporters and opponents of Medicaid expansion say the state has to close the coverage gap somehow, but until that happens, it means even less access to health care for Alabama's poorest patients.
For NPR News, I'm Drew Hawkins. Transcript provided by NPR, Copyright NPR.
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