LAKE PROVIDENCE, La. — East Carroll Parish sits in the northeastern corner of Louisiana, along the winding Mississippi River. Its seat, Lake Providence, was once a thriving agricultural hub of the region. Now, charred and dilapidated buildings dot the small city center. There are a few gas stations, a handful of restaurants — and little to no industry.
Mayor Bobby Amacker, 79, remembers a time when "you couldn't even walk down the street" in Lake Providence's main business district because "there were so many people."
"It's gone down tremendously in the last 50 years," said Amacker, a Democrat. "The town, it looks like it's drying up."
Now, East Carroll residents stand to lose even more with the pending cutbacks to Medicaid, which covers many low-income people in the region.
Like many people in Louisiana, they received a lifeline when the state expanded Medicaid in 2016. Expansion drove Louisiana's uninsured rate to the lowest in the Deep South, at 8% in 2023 for working-age adults, according to state data, despite it having the highest poverty rate in the U.S. that year.
State health data show the number of people on Medicaid in East Carroll Parish increased from about 53% in 2015 to about 64% in 2023, according to state health data.
Many now worry those gains in coverage could disappear. The tax and spending bill President Donald Trump signed into law this summer includes nearly $1 trillion in cuts over the next decade to Medicaid, the joint state-federal health insurance program for poor families and individuals.
Researchers from Princeton University estimate that 317,000 low-income Louisianans could lose health coverage because of the new law. More than 30,000 Mississippians too; that state has refused to expand Medicaid.
The tax and spending law now imposes new work reporting requirements on Medicaid expansion enrollees and will make them verify eligibility every six months, instead of yearly. This requirement, among others, won't kick in until 2027, after the midterm elections. It also limits a key financing strategy — known as a provider tax — that states rely on to give more money to health providers.
Nationwide, about 10 million people are expected to become uninsured over ten years because of the law, according to the Congressional Budget Office. Across the deep South, Louisiana was the only state that expanded Medicaid.
"The way I've described this [law] right now is we know there's a hurricane out in the Gulf," said Richard Roberson, president and CEO of the Mississippi Hospital Association. "We don't know exactly what the category of the storm is going to be at landfall. But we know we need to be prepared for it."
Struggling rural communities brace for impact
In the Delta region, which includes communities in both Louisiana and Mississippi, the impacts are expected to be damaging.
Louisiana, where almost half of the state depended on Medicaid in 2023, could lose up to $34 billion in federal Medicaid dollars in the next decade, according to KFF, a health policy research group. Mississippi could lose up to $4 billion.
"The physician community spoke out pretty heavily against this," said Dr. Brent Smith, a physician at Delta Health System in Greenville, Mississippi, about 50 miles northeast of Lake Providence, across the river. "The fact that it still went though…was a real sense of disconnect with what our legislators are doing and what we as a health care community feel like is the reality on the ground."
Residents of the Delta say they feel similarly distraught and are wondering how Congress could be so blind to how much they are struggling.
"Why do you wanna knock someone who doesn't have anything and you already got everything," said Sherila Ervin, who lives 20 minutes up the road from Lake Providence in Oak Grove and has Medicaid coverage. "It's gonna be real difficult when [the law] goes into effect."
Ervin, 58, has been working at Oak Grove High School in the cafeteria, serving hot plates to children for 25 years. She says it's one of the good, steady jobs available in this area, but her income is only around $1,500 per month.
Her job offers health benefits, but she can't afford the premiums on her salary. She relies on Medicaid for care, including medications for her high blood pressure. She said the new work reporting requirements are completely unfair, and she's worried she will accidentally lose her Medicaid.
"My coworkers are talking about it every day," Ervin said. "A lot of people probably won't even know until they go to the doctor and they don't have any coverage."
In East Carroll Parish, finding a job — let alone a good-paying one with health benefits — is difficult, says Rosie Brown, executive director at the East Carroll Community Action Agency, a nonprofit that helps low-income people with their utility bills. Many of the jobs available in town pay minimum wage, just $7.25 an hour.
"We have one bank. We have one supermarket," Brown said. "Transportation isn't easy either."
Even a full-time job doesn't guarantee health care coverage. Nevada Qualls, 25, earns $12 an hour, working as a cashier at city hall in Lake Providence. She qualifies for Medicaid expansion coverage, which is good because she can't afford the premiums for private insurance.
Because of the new Medicaid law, the mom-of-two will have to work extra hard to keep her coverage. Qualls will face regular work reporting requirements, more frequent eligibility checks, as well as the quarterly wage checks that Louisiana Medicaid already conducts.
"It's going to be stressful," Qualls said. "It's another thing to add to my load that is already heavy."
A massive burden for states
States will be required to implement work requirements by Jan. 1, 2027, giving them less than a year-and-a-half to build a reporting system and raise awareness among enrollees. Depending on how Louisiana's work reporting system functions, researchers estimate up to 357,000 people could lose coverage.
The law will now require adults who get Medicaid through expansion to prove they are working or volunteering for 80 hours a month or going to school part-time to keep their coverage, unless they qualify for an exemption.
But, data show most Medicaid enrollees are already working, KFF reports. When Arkansas implemented Medicaid work requirements in 2018 — the first state to do so before a court struck it down — about 18,000 people were disenrolled in less than a year, many for 'paperwork' reasons, says Benjamin Sommers, a health economist at Harvard T.H. Chan School of Public Health.
And there was no evidence that work requirements had a positive impact on employment, he said.
"We are leveling this bureaucratic red tape on people, the vast majority of whom are already doing the things that we supposedly want them to do," Sommers said.
Courtney Foster, senior policy adviser for Medicaid with the nonprofit Invest in Louisiana, said it will be a "really big lift" for states to administer the new Medicaid work reporting systems.
"The hope is that [Louisiana] really engages with people on the ground, as well as with community-based organizations that work with people who are covered by Medicaid to create a system that actually works," Foster said. "Let's make sure that we can mitigate as much harm as possible."
Mississippi is also getting ready, said Roberson at the Mississippi Hospital Association. Without Medicaid expansion, the state's enrollees won't be subject to work requirements, but the law's financing changes to the Medicaid program could strip hundreds of millions of dollars away from hospitals, said Roberson.
'Why are we going back?'
The law did create a $50 billion rural health fund, meant to offset spending cuts and help keep rural hospitals open. Roberson said Mississippi is applying and believes the state will be awarded at least $500 million over five years.
But if those funds don't make it to struggling hospitals, they could either close or significantly cut back services, he said.
From her small, sunny office in East Carroll Parish, nurse Jennifer Newton, who oversees The Family Medical Clinic in Lake Providence, doesn't understand the attacks on Medicaid.
The community health center is one of the few providers in town, and half of its patients are on Medicaid.
Newton, who has worked in health care in the area for decades, saw first-hand how Medicaid expansion made it possible for more patients to afford the care they desperately needed.
"It's absolutely helped," she said. "Absolutely."
In 2015, the year before Louisiana expanded Medicaid, the uninsured rate among working-age adults in East Carroll Parish was nearly 35%. By 2021, that number was 12.7%.
"Why are we going back?" Newton asked. "We've made so much progress."
This story was produced as part of a collaboration between Public Health Watch and Stateline, which is part of States Newsroom. It is part of "Uninsured in America," a project that focuses on life in America's health coverage gap and the 10 states that haven't expanded Medicaid under the Affordable Care Act.
Stateline reporter Shalina Chatlani can be reached at schatlani@stateline.org. Public Health Watch reporter Kim Krisberg can be reached at kkrisberg@publichealthwatch.org.
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