(This is the fifth installment in The Stakes 2020, a series of interviews with community leaders, organizers, and advocates highlighting what's at stake for Southern communities during this year's election. We're going beyond the candidates on the ballot to dig into how elections influence the policies, budgets, and regulations that affect Southerners' everyday lives. Find the rest of the interviews here.)

When Congress passed the Affordable Care Act (ACA) into law 10 years ago, it gave states the authority to expand their Medicaid programs to people with incomes under 138% of the federal poverty line, which translates to just over $17,600 for an individual and $36,000 for a family of four. The federal government covers 90% of the expansion's cost.

There are now only 12 states that have opted against Medicaid expansion, with eight of those states in the South: Alabama, Florida, Georgia, Mississippi, North Carolina, South Carolina, Tennessee, and Texas.

Since the ACA's passage, Alabama Arise, a nonpartisan coalition of faith groups and nonprofits around the state, has been working to convince Alabama's government to expand the Medicaid program in that state, which has some of the country's most restrictive eligibility limits. One in 10 Alabamians currently lacks health insurance, higher than the national average of 9.4%, and that number is even higher in some parts of the state.

Jim Carnes is the policy director for Alabama Arise, where he has worked for nearly two decades. We spoke with him about what the 2020 elections and the new Supreme Court could mean for the future of Medicaid expansion in Alabama. Our conversation has been edited for length and clarity.

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Tell me about your own background and how you became involved in Alabama Arise.

I grew up in North Mississippi a long time ago, and left there to go to school and then wandered around. I felt the call to come back to the South as I turned 30. I really wanted to come back and see where I might fit into a new project for the South. My first stop in that direction was with the Southern Poverty Law Center (SPLC). I worked there for 10 years, and had an opportunity to volunteer with Alabama Arise, which is a statewide coalition of congregations and community organizations working to improve public policies that affect low-income Alabamians. And I really found it appealing to turn from the national classroom focus of my SPLC work to a more local and policy-oriented advocacy at Arise. I asked the director if there was room for me on the permanent staff, we made a deal, and gosh — that was 17 years ago. I've been here a long time, longer than I've worked anywhere else.

Alabama Arise has been working on the issue of Medicaid expansion for quite a few years. Why is it so important for Alabamians? And what are the major obstacles?

We've been working on Medicaid expansion for 10 years. The importance of Medicaid expansion is enormous for Alabama. We have arguably the most restrictive Medicaid program in the country. We have the lowest adult income limit for Medicaid besides Texas. In Alabama, if you make more than 18% of the federal poverty level [of $26,200 for a family of four] then Alabama cuts that down to 18% [$4,716 for a family of four] as our cutoff for Medicaid. And even among those destitute adults, there's a further restriction: You have to have a dependent child in the home. So a single adult who's destitute cannot get Medicaid in Alabama unless that person has a disability. For ordinary folks who are just down on their luck or entrenched in poverty for whatever reason, there is no Medicaid.

As a consequence, we have hundreds of thousands of adults who can't get any health insurance at all in Alabama. They make too much to qualify for our extremely meager Medicaid, but they don't make quite enough to qualify for the subsidized plans on the marketplace. They are stuck in what we call the “coverage gap.” We estimate that there are about 220,000 Alabamians who are literally caught in the gap, they have no option, and then there are another 120,000 or so who are stretching to pay the co-pays and deductibles for private insurance that they can't really afford. They are what we call under-insured. So all told, about 340,000 people are in the coverage gap and would stand to gain health coverage as soon as we expand Medicaid.

For those people, it's a life and death question. For our economy, it's a matter of bringing literally billions of new federal dollars into the state as a part of the 90% federal match for Medicaid expansion. The federal government pays nine times what the state has to pay for Medicaid expansion. And there simply is no bargain like that available to the states for any other funding, or any other economic development incentive. That 10 cents on the dollar is an investment that we just can't afford to pass up. Unfortunately, our leaders have not seen it that way — and I should say yet, because that is beginning to change.

The opposition to Medicaid expansion has evolved rather dramatically over those 10 years. At the very beginning, we had another governor, and the objection there was pure and simple President Obama. The Affordable Care Act was [Obama's] policy achievement, and our governor and our legislature were damned if they were going to approve it. So they did not embrace expansion for those first several years. As a matter of fact, Alabama was a part of the 26 states that sued to have the act overturned. The lawsuit went to the Supreme Court, and that's when the court decided that Medicaid expansion could not be mandatory, it had to be voluntary for the states. That made it even less likely that Alabama would comply.

In just the last year or two, the governor and key lawmakers — not all of them, but several key lawmakers — have really come around to understanding and even acknowledging that forgoing this federal investment is harmful to our economy, it's harmful to our community, it's putting our rural hospitals especially at further risk of closure, and it is jeopardizing the health of these Alabamians in the coverage gap.

Another issue that has brought the question of Medicaid expansion into a different light is our prison crisis. The federal Department of Justice put Alabama on notice that our overcrowded and unsafe prisons are likely a violation of federal law and have to be addressed as soon as possible. A part of addressing that problem is shoring up our inadequate mental health and substance use disorder services in the community, which is a factor that's playing such a role in our rates of incarceration and, on the other end of the prison cycle, our failure to reintegrate formerly incarcerated people back into the community, particularly people who suffer from mental illness and substance use disorder. We simply don't have the services available to help those people avoid recidivism and reentry into the prisons. So I think all of those things together have opened the curtain on the real issues, and we're hearing much more serious, much more encouraging conversations among our leaders.

How could the results of the elections change the conversation around Medicaid expansion in Alabama, or change what's possible?

It's going to be a turning point. And the only question is, in what direction will we turn?

If the election maintains the status quo in federal leadership — and let's go all the way, let's say if the election brings Republicans into the majority in the House — if that's the case, then all bets are off on health care. We know that this administration is using every tool in its toolbox and then some to try to overturn the Affordable Care Act with no substitute plan in sight, despite all the claims to the contrary. And so we're fully preparing for the dangerous situation of not only losing the option to expand Medicaid and extend coverage to 340,000 more Alabamians, but the real possibility that around 122,000 Alabamians who are currently insured on the marketplace would lose their coverage. We would be looking at a health care crisis. We feel pretty certain that if that comes to pass we would begin to see more rural hospitals close, which creates not only an economic crisis in those communities but a health care crisis as well, all in the midst of a pandemic — which is really hard to get a grip on in your mind, but that's the possibility.

On the other hand, if we go in the other direction and Vice President Biden wins and Democrats retain the House and perhaps even take the Senate, then we think there'll be a clear path toward restoring the initial grace period for Medicaid expansion. For the first three years of the effective period of Medicaid expansion states didn't have to put up any matching funds to get their Medicaid expansion started. Alabama let that grace period expire so that now we would have to pay the 10% share. However, we would expect a Democratic Congress under a new administration to restore that grace period, and our own senator Doug Jones is one of the key sponsors of a bill to do just that. We think that not only would Alabama be likely to say "Well, I guess the writing's on the wall, this thing is going to be around for a while, we might as well do it," but we would have the original incentive to do it. It would be virtually impossible for the state to resist at that point. So we're very hopeful that that's the direction things are going to turn.

Does the upcoming Supreme Court case on the Affordable Care Act affect your calculus at all?

It does. The Supreme Court will hear the case in mid-November, but they aren't likely to rule until mid-summer of next year. So we won't really know much about the decision until we get it. Even if we anticipate the worst —  that the court, with its stronger conservative majority now, struck down the entire law — we would anticipate that a Democratically-controlled legislature and a Democratic administration would put safeguards in place legislatively. They would pass the necessary laws to make the Supreme Court outcome a moot point. They could make changes to the Affordable Care Act, they could pass something altogether new, but anticipating what the Supreme Court is likely to find fault with, they could create new safeguards. So I think the outcome of the election could buffer the Supreme Court decision. Of course, if the Republicans maintain control and particularly in the House, then that would only pave the way for the Supreme Court decision with no safeguards in place.

You mentioned the threat to rural hospitals. We know that rural hospitals in the South are closing, especially in states that haven't expanded Medicaid. We know that the pandemic has posed a serious threat to the budgets of a lot of rural hospitals. Could you talk about the situation in Alabama, and what kind of threat rural hospital closures are to people's ability to access health care?

Alabama is a rural state. We have some well-known metropolitan areas, but the vast majority of our counties are rural. And we have already seen a wave of closures in the last decade. We have lost eight rural hospitals since 2011. In the communities where that has happened, we have seen a hollowing out of the economy. Often in rural communities that have a hospital, the hospital is the largest employer in the county, and it may be the largest employer in the surrounding counties. Each rural hospital has a catchment area that it draws patients from, usually three or four counties around, and when that hospital closes, those patients have to drive further to get their care. The small businesses that surround a hospital suffer and experience closures themselves, so that the two cafes that were across the road from the hospital don't have their customer base anymore so they close, the supply companies that kept cleaning supplies in the hospital lose their biggest customer. It's obvious how that ripple effect works.

It's not just the hospital itself that is a concern. We're also very concerned about a reduction in medical services even in hospitals that have been able to remain open. The most striking service that I could point to is delivery rooms. Let's look at 40 years ago. In many ways when we look backwards in the health care system, we think of a time when treatments were less advanced and patient care was a little less developed and you were more at risk of dying from various illnesses. But when we look at delivery rooms and obstetrical services in Alabama, if you look back 40 years, the availability of a nearby delivery room was significantly higher in Alabama in 1980 than it is in 2020. In that period, Alabama has lost obstetrical services in 29 counties.

The loss of a delivery room is a critical loss to a community, because the farther the expectant mother has to drive to get prenatal care and especially to deliver, the more likely that mother is to experience complications and the more likely there is to be infant death and even maternal death. We have really thinned out our obstetrical services across the state, to the point where that is a major factor in some rural areas for our very high maternal mortality and infant mortality rates. And unfortunately, because of the way poverty intersects with the racial makeup of our state, particularly in rural areas, we see significantly higher infant mortality rates among African Americans. When you look at maternal mortality, the disparity is almost three-fold — African American mothers are three times more likely than their white counterparts to die in childbirth.

That leads into my final question. Alabama, like most Southern states, has massive disparities in terms of the percentage of Black people living under the poverty line versus white people. How does that affect coverage rates across racial groups? And how would Medicaid expansion change that?

The coverage gap shows a clear disparity by race and ethnicity. Remember that the coverage gap is made up of people who are uninsured and have low income. Of those people in the coverage gap, almost half — 49% of low-income uninsured Alabamians — are people of color, while those racial and ethnic groups make up only 34% of the general population. So the rate of uninsurance for people of color is significantly higher.

Expanding Medicaid would promote racial equity very directly. We're also making that appeal to our leaders. Our governor and our lawmakers have recognized that the unrest and the protests that we're seeing around the country are about the law enforcement disparities, but are also about the racial disparities we've seen with COVID — COVID is much more likely to have a severe or a fatal impact on people of color than on white people. Those factors have really caused our lawmakers to recognize the need for doing something to address racial inequities in our state. We're trying to impress upon them that their action, their response to these problems needs to be more than symbolic. They're talking about repealing a law that passed a couple years ago to protect Confederate monuments. That would be fine to do, but symbols aren't enough. We're trying to impress upon them that expanding Medicaid and providing health coverage to these folks in the gap would be one of the biggest, if not the biggest, policy steps they could take to promote racial equity.