Louisiana Gov. John Bel Edwards: Medicaid expansion 'easiest big decision I ever made'

As the Mississippi hospital crisis worsens and 2023 gubernatorial candidates debate a proposed solution to it — Medicaid expansion — Louisiana Gov. John Bel Edwards spoke with Mississippi Today about his successful push for expansion and what it's done for his state since it went into effect.

Two-term Louisiana Gov. John Bel Edwards calls expanding Medicaid as he took office in 2016 "the easiest big decision I have ever made" — and one that has had clear and convincing positive results for Louisianans.

"To me it was an obvious no-brainer, and maybe it's easier for me to say that than others because I believe in making government work," Edwards said in a recent interview with Mississippi Today. "I don't believe in just saying, 'Well, we just don't want to expand government.' Quite frankly, I don't expect St. Peter to ask that question one day: Did you expand government? But I do expect him to ask what I did for the least fortunate among us."

Louisiana, like other states nationwide, was at the time facing a health care crisis. It led the nation in rates of uninsured people — 22%-23%, mostly the "working poor."

"We had many hospitals, especially rural hospitals, that were in danger of closing when I became governor," Edwards said. "But because we have expanded Medicaid, we have not lost a single one.

"I'm not going to try to tell you that it fixed all of our problems and that all of a sudden we have the best health outcomes in the country," Edwards continued. "What I can tell you is it addressed our most pressing problems, and it has created an environment where we can more easily produce better health outcomes because you just have more people with the ability to go to a doctor."

Edwards said that when he became governor of Louisiana in 2016, the politics of Medicaid expansion "were probably about the same" as they are now in neighboring Mississippi, and so was the dire health care situation. He would unequivocally recommend Mississippi leaders take advantage of the federal program designed to help poor states with health care.

Edwards notes the politics on expansion have changed in Louisiana.

"In Louisiana we have a gubernatorial campaign underway, and I don't believe there is a single major candidate of either party who says anything other than they will leave the Medicaid expansion in place."

Mississippi Today interviewed the term-limited Gov. Edwards on Medicaid expansion as the end of his term nears, on a policy he says "ranks at the very top" of his accomplishments. The interview is below, edited for brevity.

Mississippi Today: Could you give a brief/broad overview of the situation when you took office, and of the impact Medicaid expansion has had in Louisiana since 2016.

Gov. John Bel Edwards: First, I'll talk about the impact it's had on our overall state budget. Secondly, individuals and families — many for the first time — have health insurance. And thirdly, we saw positive impact on the financial bottom line of hospitals across our state.

When I became governor, we had the largest general fund budget deficit in our state's history. It exceeded $2 billion for the first full fiscal year that started July 1, 2016, and that was a little more than 20% of all our state general fund. And that deficit occurred after several years of leading the nation in cuts to higher education, and cuts to basic health care delivery systems in our state.

And the cuts were just horrible with respect to Medicaid ... You have optional programs, but the optional programs were like hospice, end-stage renal disease care — things that most people would never consider optional, like things that would impact a person's ability to stay in a nursing home.

The people who were caught uninsured were working poor people. The poorest of the poor qualified for Medicaid. Those who worked and made enough money had private insurance or employer sponsored insurance. Working poor people were left out of that equation, and our uninsured rate among working aged adults was the highest in the country, around 22%-23%.

If someone is uninsured and they have access to any health care, it's likely to be an emergency room, which is the most costly way to receive health care. It's also the least effective way to manage disease ... That care either went totally uncompensated by the health care provider, meaning they had to pay for its themselves, or it might have been compensated in part by the (federal-state Disproportionate Share Hospitals) program.

But the DiSH program costs the state about 40 cents on the dollar. Medicaid expansion has never cost more than 10 cents on the dollar, and in Louisiana, the 10 cents is actually borne by the health care providers themselves because the hospitals realized their bottom lines would benefit so much that they assessed themselves.

This has produced an awful lot of compensation for these hospitals. Their bottom line is so much better — and this is all hospitals, our community hospitals, our very large hospitals like Ochsner, like Franciscan Missionaries of Our Lady, like Children's Hospitals of New Orleans. But also, and I suspect most importantly, rural hospitals, because they were the ones struggling the most just to keep their doors open and routinely cutting programs and reducing staff to stay afloat.

We were able to address all of that through the Medicaid expansion, and it helped our state budget tremendously. My predecessor said he refused to expand Medicaid because we couldn't afford it. The truth is we couldn't afford not to do it. It actually helped our bottom line and allowed us to shore up the financing of our hospitals.

But it also helped these working poor people because many of them for the first time in their lives had an insurance card in their pockets ... As the medical community here has told me many times, it saved a lot of lives here in Louisiana ... I believe that Medicaid expansion is a pro-life position.

MT: Did Louisiana see an increase in gross domestic product from Medicaid expansion?

Edwards: We had GDP gains. I can't say it's because of Medicaid expansion or that it's responsible for X percentage of that, but I can tell you we have had the highest personal income ever. We have had the lowest unemployment rates ever and we have had the most people working ever. We have had tremendous growth in our GDP, and I just intuitively know it helped.

... By getting away from all that uncompensated care and the matching payments we had to put up, and because hospitals assessed themselves to cover the 10% costs, we were then able to use the budget savings and the money we had to address other pressing concerns that we inherited after a long period of disinvestment in our state. It allowed us to invest in other critical priorities.

MT: How has expansion affected Louisiana's workforce?

Edwards: So, you have a relationship with a primary care physician. You have routine appointments and diagnostic evaluations, breast cancer screenings, prostate cancer screenings ... Your disease gets diagnosed earlier. Your treatment starts sooner, and it comes with a prescription benefit, so you have a way to be healthier. You're a more productive worker. You're less likely to be laid off. You're more likely to be able to support your family. That business has a healthier employee who shows up to work more often and is more productive — and the business didn't have to pay for it.

I've had employers tell me they had good employees, but they weren't necessarily healthy. They had a disease. They didn't have health insurance, so they had to miss work to go and wait around an emergency room. They would have to call in sick more often. These employers benefit from having a healthier, more productive workforce that doesn't come at their expense.

When you expand Medicaid for the working poor, you also work with the health care providers so that they don't just have appointments 9-5 Monday through Friday, but you work with them so they have appointments after hours during the week, have places they can go on the weekends so that they don't have to miss work in order to access basic care.

Now we have the advent of telehealth, which can be covered through the Medicaid program and allow them to see doctors and even specialists without having to travel. That is particularly onerous for poor people in rural areas that lack the resources and also are furthest away from the nearest physicians that they need to see.

MT: Has expansion had an impact on mental health and-or substance abuse?

Edwards: It comes with behavioral health benefits for mental health, and it also comes with benefits for those people who have addiction disorders, and those benefits both in patient and outpatient. That's clearly something we still don't have enough of, but we have a lot more services available now than we ever did before.

MT: What is your take on Mississippi's battle over expanding Medicaid and its ongoing hospital/health care crisis? What advice would you give to Mississippi – particularly its politicians and leaders – on Medicaid expansion?

Edwards: I don't think the whole time I have been governor I have addressed comments critical to another state or the leadership of another state. I will say the situation there, the one that I read about and the one that I know a little bit about firsthand — my wife is from Wayne County, Mississippi, and all of her family is still up there — it looks an awful lot like the situation we had here. The politics were probably about the same here.

... Here in Louisiana, we decided that decision was made by the federal government when they passed the Affordable Care Act — otherwise known as Obamacare — a feature of which was Medicaid expansion. So that decision was made by the Obama administration and the Congress at that time. It hasn't been repealed, so it remains available to states, although not mandatory as it was originally intended. I believe that we should try to make government work for those who need it the most. The working poor people certainly need health care.

I believe that you should make available to your state federal programs that not only do that, but provide a benefit to your budget so that you can then have the flexibility to address other pressing concerns as well. We were able to do that here. Obviously the situation as it exists in Mississippi to the extent that I am familiar with it — I'm rather familiar — looks an awful lot like what we had here in Louisiana.

I would certainly recommend Medicaid expansion to the Legislature there, to the governor there, to the people who are running for governor there. I would recommend it to Gov. Reeves, to Brandon Presley and to everyone else.

MT: How is expansion viewed across the aisle now in Louisiana? What level of opposition remains there? Any chance Louisiana voters would go along with undoing expansion?

Edwards: Obviously people might expect me to give a full throated defense of Medicaid expansion. I was a champion of it while Gov. Jindal was in office and refused to do it. I ran for office saying I was going to do it, and I have since done it. I would just invite anybody to come over here and talk to the hospital association, talk to hospital medical directors and CEOs.

Go to the most rural isolated, poorest parts of our state ask them about Medicaid expansion, and then go talk to employers in those areas and see what a difference its made for them.

The opposition has just melted away here. It's virtually nonexistent. I think that's borne out by the campaign that's underway where not a single candidate says they would undo the Medicaid expansion, and it would be a perilous position for them to take in the campaign if they said that.

-- Article credit to Geoff Pender of Mississippi Today