How Obamacare Went South In Mississippi, Part 3

Kudzu vines encroach on everything in their path in rural Mississippi

In the country's unhealthiest state, the failure of Obamacare is a group effort. Click here to read Part 2.

Shortly after the disastrous Cato luncheon, Bryant called and asked Chaney to delay the plans for the exchange.

"I said, 'Phil, I can't do that,'" Chaney recalled. He told the governor the state was contractually obligated to its vendors. The pressure continued. In August, one of the governor's attorneys asked Chaney to withdraw the plan's blueprint from federal consideration. That same month, a confidant of Chaney's who sat on the state government's Personnel Board called to say Bryant had requested the board delay approval of a $3.5 million, federally funded ACA outreach contract meant to make residents aware of their coverage options. It would never be authorized. In a letter to Chaney, Bryant acknowledged the board had blocked the contract. "I simply do not consider it a wise use of taxpayer dollars," he wrote.

As Barbour's second in command, Bryant had publicly supported the then-governor's push for a free-market exchange in Mississippi, but now Bryant wrote to Chaney, "I have never supported exchanges as they will operate under Obamacare," which "will not be market-based in any significant sense" and would depend on "massive and unaffordable federal subsidies."

Still, Chaney fought on, and in October 2012, a full year before the federal government's website opened, his OneMississippi.com went live. The passageways to various federal databases had yet to be built and consumers could not yet qualify for subsidies, but health plans were on sale. The site still needed approval from The Center for Consumer Information and Insurance Oversight, the federal body that oversees the health care exchanges, before it could be an official ACA-sanctioned marketplace, and Chaney's staff had been in weekly contact with CCIIO's director, Gary Cohen, to make sure OneMississippi.com would eventually comply.

But after Obama's reelection in November 2012 made clear his health law was headed toward implementation, Bryant decided to fight. Chaney wrote to CCIIO's Cohen saying it was "our intent to implement and operate a state-based exchange for the citizens of Mississippi that is tailored to the unique needs of our state." He continued: "As an elected official and the chief officer of the Department of Insurance, I am authorized by state law to submit this Exchange Declaration Letter on behalf of the State of Mississippi." Bryant fired off his own letter to Sebelius, declaring that he was in "complete disagreement" with Chaney. By this time, Chaney and Bryant's relationship had deteriorated to the point that Chaney had to get a copy of the letter from federal regulators. "I am disappointed with the submission of that letter, and I am exploring my options," the governor wrote, adding that the health care exchange was a "gateway" for a law he opposed.

As the pitched political drama escalated, the objections among Tea Party activists piled up. An Obamacare-sanctioned exchange, with its generous subsidies, "would just invite more and more people on welfare and public assistance to flock to our state," Laura VanOverschelde, chairwoman of the Mississippi Tea Party, told me. What's more, she added, the types of plans for sale on the exchange "mimicked an old premise – that is health maintenance organizations in the 80s." Those plans "dismally failed," VanOverschelde said, "because people will simply not do what they need to, to take care of themselves. And Mississippi is a prime example."

CCIIO remained quiet about Mississippi's application all fall and into early winter. But by January, Chaney had lost his patience with Cohen. "I asked him point blank, 'Damn it, Cohen, are you going to approve this or not?'" Later that week, Cohen called to say that Sebelius was rejecting Mississippi's exchange, citing Bryant's lack of support. "As a practical matter, it wasn't going to work," Cohen told me. Chaney's exchange would have needed cooperation from the state Medicaid agency led by a Bryant appointee, and the governor could easily stymie funding and hiring decisions. "We'd didn't feel that we should get involved in a battle between two elected state officials," Cohen said.

Mississippi, ever the collector of unenviable distinctions, became the only state to have its exchange application rejected by the federal government. On Valentine's Day, after four months of operation, OneMississippi.com went dark.

The Fall Out

In the weeks following the shutdown of the state exchange, the community organizers, physicians, employers and insurance brokers who had been the architects of the plan fell into disarray. "It was infuriating to see the governor gut all that work," said Felicia Brown-Williams, director of public policy at Planned Parenthood in Jackson. "We were so far ahead of the curve." Many African Americans blamed Obama for the failure. "I've heard leaders in the community, black leaders, blame Obama. That he should have planned it better," Dr. Alice Graham, an ordained minister in Gulfport, told me.

The question now became: In an insular state led by a governor committed to thwarting Obamacare, who was eager to embark on a mission to lead sign ups in Mississippi? It was a short list with a delicate calculus: Those with something to lose didn't want to make the governor look bad by making the ACA look good.

The University of Mississippi Medical Center in Jackson, the state's only academic medical center, raised its hand. Some 220 uninsured patients from around the state passed through the hospital's doors every day making it the perfect place to catch potential customers. Financial counselors who already worked with the hospital's uninsured patients would become certified as "navigators" to enroll Obamacare shoppers, and the hospital would set up a satellite office at the Jackson Medical Mall, a former shopping center repurposed to offer health services to the poor. Still, the decision to apply for a federal navigator grant was politically sensitive; the hospital sought Gov. Bryant's blessing before moving forward.

Community groups in Jackson—some of whom were now competing for the same federal grants—were wary of UMMC's strategy; they doubted the hospital could man the ground war necessary to span the state's rural landscape.

But when the grants to lead signups in Mississippi were announced in August 2013, UMMC trounced the other contenders. Of the $1.1 million awarded to Mississippi, UMMC nabbed the biggest share—$832,000. The only other recipient—Oak Hill Baptist Church, a tiny black congregation in the town of Hernando, near the Tennessee border—was something of a mystery to Mississippi's tight-knit health advocacy network, but its pastor, Michael Minor, and his wife, had been lauded at the White House for the church's health ministry.

Roy Mitchell, named to Chaney's advisory board as the lead member with "experience in enrollment," had been passed over. Mitchell suspects the contracts went to the politically connected UMMC, the largest single recipient of Medicaid funds in Mississippi, and the charismatic pastor with ties to the White House. He feared neither would deliver. Even Commissioner Chaney weighed in, "Your navigator program is so horrible, you outta let me operate it for you," Chaney told Cohen. "They wouldn't let us do it."

To Michael Minor, the strategy made perfect sense. Mississippi consistently ranked as the most religious state in the country, and as part of the National Baptist Convention, which played a vital role in black Mississippi life, Minor—and the White House—viewed the churches as key to getting the word out about the much-maligned new law.

UMMC and Oak Hill had just six weeks before open enrollment began, on Oct. 1, to train and certify their navigators, open call centers and drop-in locations, print publicity materials, schedule public events and deploy their plans with little more than $1 million.

Finite money for advertising and outreach and local political hostilities meant federal administrators focused, by necessity, on their "return on investment," one longtime Republican health policy staffer in the Senate told me. "In states that decided, for political reasons, to oppose Obamacare, there was the sense, 'So be it. Let 'em go.'"

Meanwhile, Cover Mississippi, a coalition that had risen out of Chaney's exchange wreckage, led by Roy Mitchell, was penniless. Enroll America, a nonprofit group that had formed to connect uninsured people with enrollment help, had decided not to send its vast door-knocking army of volunteers. It would concentrate instead on the more populous states of Florida and Texas. Public awareness was dismal; uninsured Mississippians were either indifferent or hostile.

Return next week for Part 4 in the series.

By Sarah Varney

Jeffrey Hess of Mississippi Public Broadcasting contributed to this story.

This article was reprinted from Kaiser Health News with permission from the Henry J. Kaiser
Family Foundation. Kaiser Health News, an editorially independent news service,
is a program of the Kaiser Family Foundation, a nonpartisan health care policy
research organization unaffiliated with Kaiser Permanente.