The more significant drag on sign-ups, though, was Mississippi’s decision not to expand Medicaid. The state’s low standard of living means many people earn less than the federal poverty limit but too much for Medicaid; under the health law, they can’t buy insurance on the exchange, leaving 138,000 Mississippians who fall into what has come to be known as the Medicaid gap. For Minnie Wilkinson, it brought a sense of desperation to her church office. She recalls a man who returned there four or five times hoping to get a different answer about his coverage options—his wife had cancer. Surely, there was some help in the law? She could offer little more than prayer. Wilkinson dutifully referred people to a community clinic, where they could pay a sliding-scale fee to see a doctor. But the clinics aren’t equipped to treat serious maladies. “It was heartbreaking for us and for them,” she said. The Medicaid gap also fueled a negative feedback loop about the law. As Wilkinson describes it, people felt deceived: “They were under the impression that the less money you made, you get insurance for free.” It killed momentum even for those who could have bought heavily subsidized coverage on the exchange. Word spread quickly: This Obamacare is a waste of time, and Obama was to blame.

But the administration had few options. And the law was, after all, a federal-state partnership. If the state didn’t play, the feds were stuck. “When we were designing the legislation, we were very aware that the states that, in many cases, benefited the most were poor and generally anti-Obama,” Bob Kocher, a special assistant to Obama in 2009 and 2010 who helped draft the ACA, told me. But “you needed a state that at a minimum level is cooperative for this to work,” he said, which became more difficult after the Supreme Court’s Medicaid ruling in 2012. That meant even idealistic liberals had to turn their efforts away from needy states like Mississippi to more receptive regions. “It broke the heart of some folks at HHS,” Kocher said. “But I’m not sure they had another choice.”

The Medicaid gap hit hospitals hard, too. Without the cash infusion that a Medicaid expansion would have brought, Mississippi hospitals are being strained to a near breaking point, with a number of them shuttering entire departments and laying off staff. Poor people often flocked to the emergency room at Montfort Jones Memorial Hospital in Kosciusko, for instance. The central Mississippi town is best known as Oprah Winfrey’s birthplace, but that distinction has done little to change its fate. Earlier this year, the hospital shut down its intensive care unit and laid off 38 employees. Next, the psychiatric unit for seniors closed. One in five people who come to the hospital can’t pay their medical bills, and Montfort Jones had relied on supplemental Medicaid payments to defray the costs. But under the health law, federal aid for uncompensated care trails off. Without those payments, and with no softening in the demand for uncompensated care, Montfort Jones had been losing up to $3 million a year, and couldn’t meet payroll.

Triage In Kosciusko, Dr. Tim Alford now has to send patients with pneumonia, blood clots and infections 70 miles away to Jackson for treatment. | Jon Lowenstein/NOOR

Tim Alford is a country physician who likes to say rural doctors in Mississippi practice “real medicine.” At Montfort’s emergency room, across the street from his family medicine practice in Kosciusko, he attends to stroke patients, heart attack victims and, the week I met him in June, an energetic 3-year-old boy who had somehow managed to bite a hole through his tongue. Montfort was one of the original hospitals built under the Hill-Burton Act, a post-World War II, government-financed hospital construction program. The hospital, along with its intensive care unit, was rebuilt just a few years ago into a modern rural gem.

Alford led me down a darkened hallway and pushed open the doors to the ICU. It looked as though the nurses, doctors and janitors had just gotten up and left. Scanning the bay of ghostly patient rooms, Alford said mordantly, “This is a state-of-the-art ICU.” Now, patients with pneumonia, blood clots or infections are sent 70 miles away to Jackson. Nationally, two of the five hospital systems with the largest financial margin declines are located in Mississippi.

During state budget negotiations in the fall of 2013, Bryant proposed giving the state’s struggling hospitals $4.4 million to offset their losses. The association’s new chief executive officer, Tim Moore, responded politely to the gesture, but Democrats viewed the earmark as hush money. “I’ve asked the [hospital association] a number of times what they got in exchange for their deciding to become mute on this issue,” state Senator Hob Bryan, the Democratic vice chairman of the health committee, told me. “They said they got a seat at the table. I said, ‘So, in other words, you sold your birthright. You didn’t even get a bowl of porridge. You just get to sit at the table and watch other people eat porridge?’”

Besides, Mississippi couldn’t come close to making hospitals whole. The state was facing eviscerating cuts in federal subsidies of $8.7 million in 2015 and 2016; $26 million in 2017; $72.3 million in 2018; $81 million in 2019, and $57.8 million in 2020, according to the Center for Mississippi Health Policy. Over breakfast one morning in Jackson, Ronnie Musgrove, a Democratic former governor of Mississippi, told me, “It just defies logic.”

***

The failure of Obamacare in Mississippi has many authors. Political infighting, an overwhelmed federal agency and a surprise decision from the Supreme Court—all of these filled Minnie Wilkinson’s church office, shuttered Tim Alford’s ICU. And there’s no clear way out for the people of Mississippi.

Jon Lowenstein/NOOR

The second year of Obamacare in Mississippi, in fact, will look much like the first: Yes, United Healthcare, the nation’s largest insurer, will now be selling insurance on HealthCare.gov in nearly every county of the state, and every Mississippi county will now have at least two choices.

Still, tens of thousands of poor working adults will remain in the Medicaid gap. There’s little political movement on that issue to speak of, and Bryant, the governor who remains adamantly opposed to Obamacare, is headed toward reelection in 2015. Nobody, not even the former optimists, thinks Mississippi is on track to get out of its perpetual last place, on health care and most other things.

I kept thinking of my conversation with Roy Mitchell, the embattled head of the Mississippi Health Advocacy Program, this summer. I had asked whether Jackson—or Washington, for that matter—would ever find a way to actually help the sick and the poor in Mississippi. “Ideology put a man on the moon,” he said. “Ideology can certainly kill health care.”