I asked Garrett what she made of her governor’s plan to create jobs with health benefits that uninsured workers like her could move into. “No offense,” said, Garrett, who is black, “but we got a little racial issue here in Mississippi.” As if that explained everything to me, the pool’s only white visitor.

Many of Lewis’ friends and customers didn’t earn enough to buy insurance on the federal exchange as he did – they fell into the Medicaid gap. “I know guys who wash cars every day, and it’s hot,” he explained. “They fall down and have a stroke or somethin’, they don’t have any health insurance. And where’s the money gonna come from? His family is depending on him.” Lewis had followed the news about Bryant’s opposition to the Medicaid expansion. To him, it made sense that white conservatives wouldn’t want people like him—blacks—to have Medicaid; people in Mississippi have learned to deal with bigotry. But it surprised him that Republicans in the state were leaving white people in the Medicaid gap, too. “As long as you don’t step on my shoes, and I don’t step on yours, man, we can live and coincide,” he said. “But when you’re white and do that to other white people? Man, that’s mean-spirited.”

* * *

With the sophomore year of open enrollment for the health law quickly approaching, Mississippi remains hostile territory as Gov. Bryant continues to steadfastly oppose the law. “Prior to Obamacare, the individual insurance market was a more viable option for people who did not have access to group health insurance,” he said in a statement. “By design, the law gutted the market and replaced it with the heavily regulated, astronomically expensive but often heavily publicly subsidized individual policies.”

Bryant, and his Tea Party compatriots, continue to push “economic development” and “personal responsibility” as the appropriate remedies for Mississippi’s health care woes. When I asked VanOverschelde, the Tea-Party chairwoman, if her group had more specific health policy proposals to move her state out of last place in the nation’s health rankings, she told me: “Our premise is: We believe in free markets, constitutionally limited government and fiscal responsibility. So given those, we’re not taking a position.” Her personal conviction, however, was that “people ought to be taking better care of themselves.”

The lengthy war over Obamacare has surprised even the most seasoned political appointees: “I’ve really never seen anything like this in my life,” Sebelius, the former health secretary, said at a conference in June. Those states that broadened Medicaid and encouraged residents to buy subsidized insurance are seeing sharp declines in their uninsured populations; that’s not the case in Mississippi. “I think over time we’ll see tangible differences from state to state in health outcomes,” Gary Cohen, the former CCIIO director, told me. Indeed, Massachusetts, health reform’s forerunner, has seen its death rate fall since its 2006 expansion of health insurance.

In Mississippi, the second year of Obamacare will look much like the first: Tens of thousands of poor working adults remain locked out of public insurance and government subsidies; the University Mississippi Medical Center and Oak Hill Baptist Church have again been selected to spearhead enrollment, with $1 million in federal grants; and the insurance offered to Mississippians, with its spotty networks and out-of-town hospitals, will remain essentially the same.

There is a sign, however, that at least one of the health law’s tenets—competition—has made it to Mississippi: United Healthcare intends to sell insurance on Healthcare.gov in the state. Fourteen counties will have three companies competing to insure Mississippians and every county will have at least two choices.

Still, for the health advocates who have kept the law alive here, expectations are low. The Medicaid gap crippled enrollment efforts, so advocates have made expanded public insurance their top priority. The Cover Mississippi coalition is debuting an online video campaign called “Mississippi Left Me Out,” which features teary testimonials from uninsured residents. They hope lawmakers will be unable to turn away, although Republicans remain opposed to the ACA and firmly in control of the state legislature.

When I met him this summer, Roy Mitchell, of the Mississippi Health Advocacy Program, was decidedly pessimistic. “Ideology put a man on the moon,” he said. “Ideology can certainly kill health care.”

The organization that sponsors his group laid off hundreds of people in June, and he felt he was barely holding onto his job. “By the grace of God, I’m sitting here,” he said, wearing a worried look.

Optimism trades on innocence, a sense that anything is possible; here in Mississippi, where poverty and sickness seem affixed to the landscape and an ambisonic elegy hums overhead, the long odds are well-known. Mitchell wondered aloud whether he and others could press ahead with little money in a state feverish with anti-Obamacare hatred.

“Can we continue to do this?” Mitchell asked rhetorically. “No.”

This article appears courtesy of Kaiser Health News.

We want to hear what you think about this article. Submit a letter to the editor or write to letters@theatlantic.com.