Citizens in Kentucky and Mississippi voted in their gubernatorial elections November 5, in two contests that were pivotal to the future of healthcare access for millions in both states. Both elections pitted a Republican, opposed to Affordable Care Act state-Medicaid expansion, against a Democrat seeking to protect or expand their state’s Medicaid program. The results have a huge impact on people who use drugs in the states, both of which have historically high rates of drug-related fatalities.
In Kentucky, voters elected Democratic Attorney General Andy Beshear as their new Governor with 49.2 percent of the vote. Incumbent Republican Governor Matt Bevin has not conceded yet.
In Mississippi, voters elected Republican Lieutenant Governor Tate Reeves as their new Governor with 52.2 percent of the vote.
The results are significant for their effects on whether or not upwards of a million people in either state will have access to a state Medicaid program implemented through the Affordable Care Act (ACA). As part of the ACA signed by President Barack Obama in 2010, adults with incomes up to 138 percent of the federal poverty level are eligible for Medicaid health insurance.
But due to a 2012 US Supreme Court ruling, states have to opt in to what’s called the Medicaid expansion. The federal government pays for the bulk of the program’s cost for each state, covering 90 percent as of 2020 and in the future. State governments pay for the remaining 10 percent. Because now 31 states and the District of Columbia have expanded Medicaid, over 13 million Americans have become enrolled in those states between 2013 and 2019.
In other important election news, Democrats are projected to flip both chambers of the state legislature in Virginia, giving them complete control of Virginia for the first time in over 20 years. These results will also have significant consequences for healthcare access in Virginia, allowing the state to strengthen gains it has made after enrolling over 325,000 people through its Medicaid expansion.
Kentucky and Mississippi are in different places on Medicaid expansion. Former Kentucky Governor Steve Beshear (Governor-Elect Andy’s father) successfully implemented Medicaid expansion in 2013, bringing nearly a half million Kentuckians into the program. That number represented an increase in enrollment of over 99 percent.
But former Governor Beshear’s successor Governor Bevin has tried to undermine the program by implementing controversial work requirements that may remove hundreds of thousands from the Medicaid program. A US District Court judge for the District of Columbia blocked this policy, prompting Bevin and even President Trump to appeal the decision.
Governor-Elect Beshear ran on protecting the state’s Medicaid program, as well as other healthcare issues like fighting the federal court ruling that jeopardizes health care coverage for people with pre-existing conditions.
But the fight in Mississippi was fought over different lines. Mississippi is one of 14 states that have refused to expand Medicaid to their citizens. Both candidates sparred on this issue during the election.
“I am opposed to Obamacare expansion in Mississippi. I am opposed to Obamacare expansion in Mississippi. I am opposed to Obamacare expansion in Mississippi,” said Lt. Governor Reeves in January. Meanwhile, AG Hood’s campaign stated, “In Mississippi, around 300,000 adults would benefit from reforming Medicaid—nearly 100,000 of those individuals live in poverty without health insurance.”
This whole issue has significant impact for Kentuckians and Mississippians who use drugs or have substance use disorders. Lack of healthcare access often prevents, for example, people with opioid use disorder receiving a medication like buprenorphine. But it also means they lack simple primary care and treatment for physical and mental illnesses, including for infectious diseases like HIV/AIDS and hepatitis C caused by injection drug use.
The Kaiser Family Foundation found in 2019 that 18 percent of American adults under age 65 with an opioid use disorder are uninsured. This population is more likely to have low incomes, report being in fair or poor health, have a mental illness, and have an unmet need for drug treatment. Not insignificant proportions of this population also suffer a disability and a chronic condition or cancer.
Kentucky has a particularly severe fatal overdose crisis. According to the CDC, Kentucky has among the highest overdose death rates in the US at 37.2 per 100,000 residents. This is well above the national average of 21.7 per 100,000.
And its overdose deaths involving opioids, at 27.9 per 100,000 in 2017, are nearly double the national average of 14.6 per 100,000, NIDA numbers show. It also has among the highest rates of opioid prescriptions in the US. In addition, over 6,600 people live with HIV diagnoses, and 43,000 people live with hepatitis C.
As for Mississippi, it has a drug overdose death rate of 12.2 per 100,000 (2017), below the national average. But that has more than doubled from its drug death rate in 1999, and roughly doubled compared to the national drug death rate in 1999. In a state of less than 3 million people, over 9,200 people live with an HIV diagnosis, and 23,300 people live with hepatitis C.
For Kentucky Governor-Elect Beshear, he will likely still face challenges in implementing progressive healthcare policy given Republican control of both state legislative chambers. And Mississippi Governor-Elect Reeves will likely face little pressure to do the same, as his party now controls all of the state government.
Any reform in these states, for better or worse, will have significant consequences for people who use drugs and experience difficult healthcare barriers. But if the new governors wish to substantially reduce their historically high rates of drug overdose deaths, they should be thinking about expanding healthcare access to their most marginalized constituents.
Image of Kentucky Governor-elect Andy Beshear, from Andy Beshear via Facebook.