The COVID-19 pandemic has focused a new bright light on a set of old and familiar realities for Mississippi.

First is Mississippi’s persistent, endemic poverty. That poverty begets poor healthcare access and ultimately poor healthcare outcomes. According to the Census Bureau’s American Community Survey, 43 percent of Mississippians had employer-provided health insurance and an additional five percent had other group health insurance.

Medicaid covered another 23 percent while Medicare covered 14 percent and military benefits covered an additional two percent. Some 12.1 percent of Mississippians have no health insurance of any kind.

Remember, those were the percentages before COVID-19 was part of the daily lexicon. Those were the numbers before Mississippi, like the rest of the country, saw tens of thousands in our state lose their jobs and the healthcare benefits that were attached to them.

Without question, Mississippi has a significant number of citizens who have transitioned from insured to uninsured as part of the pandemic. And with that transition comes the rest of the story on how health care is delivered to the poor in Mississippi.

Second is the structure of health care finance in Mississippi. When it comes to the provision of health care for Mississippi’s poor, elderly, disabled, and children, the undeniable and unchanging fact is that taxpayers at the federal, state and local levels will continue to pick up the lion’s share of the tab with those three groups bearing varied and at the same time intertwined percentages of responsibility.

How? Medicaid covers over one in five. The uninsured primarily receive uncompensated care. Nationally, uncompensated care in the U.S. is estimated to comprise over 55 percent of all emergency care delivered. In Mississippi’s state-owned rural hospitals, that percentage is believed to be significantly higher. Mississippi hospitals estimate they delivered $600 million in uncompensated care in 2018.

Two federal laws virtually dictate that unreimbursed spending. First, there’s the fact that many of the local government-owned community hospitals in Mississippi were funded through the federal Hill-Burton Act, which originally gave hospitals built with federal dollars a 20-year post-construction mandate to provide free or subsidized care to a portion of their indigent patients.

In 1975, Congress enacted an amendment to the Hill-Burton Program, Title XVI of the Public Health Service Act. Facilities assisted under Title XVI were required to provide uncompensated services in perpetuity.

Second, there is the 1986 Emergency Medical Treatment Act (EMTALA) that was enacted by Congress. This act requires any hospital that accepts Medicare payments to provide care to any patient who arrives in its emergency department for treatment, regardless of the patient’s citizenship, legal status in the United States or ability to pay for the services – including medical transport and hospital care.

Also applicable under EMTALA is the requirement that every U.S. hospital with an emergency room has a legal duty to treat patients who arrive in labor, caring for them at least until the delivery of the placenta after a baby is born. The law allows hospitals to bill patients and sue them for unpaid bills, but the odds of making recoveries from indigent patients are extremely low.

Third, there is the matter of the state’s political reality. Mississippi voters have had multiple opportunities to decide about the straightforward question of Medicaid expansion or “expanding Obamacare” as it is called in the public debate. Candidates who opposed Medicaid expansion have won elections while candidates who favored it have lost elections.

That’s been true at the state level and in federal elections as well. The 2019 statewide elections are a case in point. Eventual gubernatorial race winner Republican Tate Reeves defeated fellow GOP candidate Justice Bill Waller in the GOP primaries and Democrat Jim Hood in the general election. Both Waller and Hood expressly supported Medicaid expansion and had the tailwind of a strong statewide push from the Mississippi Hospital Association for an alternative Medicaid expansion plan that featured a provider-run insurance plan.

Will the jarring impacts of the COVID-19 pandemic change the minds of state voters about public health care finance and how Mississippi deals with indigent care moving forward? Not likely, but the depth and duration of COVID-19’s accompanying economic disaster will weigh on that decision.

Sid Salter is a syndicated columnist. Contact him at sidsalter@sidsalter.com.