LAMAR – Kimberly Todd sat in a brown and gold upholstered chair on her front porch at the end of a long dirt driveway on a cloudy September afternoon. Wearing jeans and a crimson blouse, it’s the most dressed up she’s been in months, she says. 

Tight clothing, socks and shoes make her skin feel like it’s on fire – a symptom of fibromyalgia she has lived with for four years without health insurance. A single mother of five, Todd also has endured numbness in her abdomen, pain in her uterus and two periods a month as a result of complications from a C-section in 2021. 

Todd qualifies for Medicaid, but the difficulty she has faced getting on the program over the last few months reveals the cracks poor people fall through when trying to get assistance from the social programs that purportedly exist to help them. Mississippi has among the strictest Medicaid income eligibility requirements in the nation. People must meet the income threshold, which amounts to less than $500 per month for a family of three and is a fraction of the federal poverty level. They also face bureaucratic red tape and punitive measures for missteps that often force them into deeper holes. 

Her most recent barrier to getting health care? The state has asked Todd to file for child support from her ex-boyfriend. This little-known Medicaid requirement has translated to four months of back-and-forth with caseworkers, miscommunication among state agencies, delayed medical care and the possibility of sending the father of her two youngest children to jail. 

“I want to take care of my family – that’s it,” Todd said. “Something I never had growing up.”

Whether or not it’s intentional, social safety net programs end up shutting out eligible people through “unnecessary complexity,” explained Daniel Dawes, an attorney and founding dean of Meharry Medical College in Nashville who helped write the Affordable Care Act, widely considered the most progressive health care legislation since the formation of Medicaid and Medicare in 1965. 

“Many of these programs are designed as if they’re intended to keep people in perpetual poverty,” Dawes said. “Instead of making allowances and helping people to maneuver out of that.”

By all accounts, people in circumstances like Todd motivated lawmakers to create the Medicaid program. Todd has worked multiple jobs, from cleaning houses and hotels and working in convenience stores to fixing cars and broken phones. She has worked in grueling conditions so that she can care for the three children ages 4 to 18 in her custody – two of whom have autism. 

She has no family in the state and lives in what she calls “a shack” on an acre of wooded land without the resources to put her kids in afterschool activities like art classes or programs for autistic children. Todd and her children lack the community safety net most people take for granted. 

“Most people have family, friends – I don’t even have a friend,” Todd said. “I don’t have one friend.”

Medicaid would be her safety net, at least in theory. But the system has been failing her. 

“I will work myself literally to death and not have any health care coverage,” Todd said. “Who’s going to take care of my autistic child when I pass away? Where is she going to go? She can’t talk. Who’s going to hurt her while I’m not here?”

‘I didn’t want that for my kids’

The child support requirement aims to help single parents. In practice, research suggests it can be harmful for families – yet it pervades most social safety net programs. 

“It may be that a family already has informal arrangements for all the parents to financially contribute to the child’s wellbeing, and complying with this requirement through the state can disrupt those informal arrangements that are working better for families in many cases,” explained Matt Williams, director of research with the Mississippi Low-Income Child Care Initiative. 

That’s the case with Todd. She said she is on good terms with her ex-boyfriend and often gives him a place to stay. She said she is hoping to help him get back on his feet so he can start working again after his own mental health conditions and lack of insurance made working impossible. He doesn’t qualify for Medicaid because his biological children are not in his custody. Mississippi’s version of Medicaid does not insure childless adults. 

In other cases, being forced to file for child support with the non-custodial parent could have dangerous repercussions. 

“For any one of a number of reasons, including concern for their own physical wellbeing, they might be reluctant to identify someone,” said Sen. Hob Bryan, a Democrat from Amory, who previously told Mississippi Today “the child support system in Mississippi is f-cked up, and no one knows how to unf-ck it.”

Exemptions to the rule technically exist for those who are concerned for their own or their children’s safety. In practice they are very difficult to obtain, explained Williams. 

“It’s not always the case that they are granted that exemption if they don’t have the right kind of legal paper trail, court documents or restraining orders,” Bryan said. “If they’re unable to prove through documentation that they are experiencing domestic violence or fleeing domestic violence, they may not get that exemption.”

In Todd’s case, filing for child support from her former partner in August was an impossible decision. She worries the missed payments that she knows he will incur will put him in jail. 

“How is he going to help me from jail?” Todd asked. “What sense does that make?”

She knows this situation all too well. Her own driver’s license was revoked twice in the last year after she fell behind on child support payments to the father of her two children who are not in her custody. She has not been able to pay off the most recent fine since she is out of work, making it harder for her to find work and to take her non-verbal autistic daughter to therapy. 

What makes the child support requirement even more harmful in Todd’s case is that evidence suggests it was implemented incorrectly. States are only allowed to ask applicants to agree to comply with requirements at the time of application, according to several national Medicaid experts who spoke to Mississippi Today. States cannot force applicants to file for child support before they are approved for Medicaid. But according to Todd, they did. 

“Part of that’s just practicality,” said Jennifer Wagner, director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities. “In the application timeframe, filing for child support is not something that can always be completed before the state’s deadline and it’s counter to the concept of Medicaid and providing timely care.”

Mississippi Division of Medicaid Spokesperson Matt Westerfield confirmed applicants cannot be required to file for child support until after their Medicaid application is approved. He did not respond to a request for comment on Todd’s case.

Once Mississippi Today informed her of state and federal law, Todd went back to her case worker in mid-October with the information, at which point they told her she should expect an approval letter in the mail in a week.

According to Todd, the caseworker alleged over the phone that Todd had been approved for Medicaid in August, failed to comply with the child support requirement, and had her coverage rescinded. But Todd says the application in her online portal went from “processing” to “denied,” and she never got an approval letter in the mail. 

Her online portal finally said “eligible” on Wednesday – nearly four months after her initial application. But Todd has yet to receive her official approval letter and insurance card in the mail  – and she can’t start using her coverage until then, according to the Mississippi Division of Medicaid site.  

It’s not uncommon for Medicaid requirements to be implemented incorrectly at the local level, according to Tricia Brooks, a research professor at the Center for Children and Families at Georgetown University. 

“Although we don’t have hard data, we consistently hear about errors made by eligibility workers or misinformation provided by call center staff,” Brooks said. “Unfortunately, applicants and enrollees are often unaware of their right to a fair hearing and hit roadblocks in getting accurate information.”

Before Todd got sick, life wasn’t much easier. 

The last time Todd and her former partner were working full-time, they were told they made too much money to qualify for Medicaid. Together, they struggled to cover rent and utilities and had no money left over for food – much less health insurance. They got by on provisions from a nearby church, but they only ever ate “peanut butter and jelly and noodles,” Todd said. 

Since then, her health has deteriorated to the point that she can no longer work. As a result, Todd qualifies for Medicaid. Advocates for Medicaid expansion in Mississippi have long sounded the alarms on this paradox. In one of 10 states that has not expanded Medicaid, Mississippi could have covered tens of thousands more working people who do not earn enough to pay for their own insurance – people like Todd. 

Nearly a quarter of people in Marshall County, where Todd lives in the northern part of the state, are living below the poverty line, according to the Mississippi Department of Employment Security. That’s more than double the national average. Todd grew up in poverty, but she always thought it was an escapable fate. She has since lost all faith in the system.

“I grew up in nasty houses with roaches and rats and holes in the floor and no money and starving – I grew up like that,” Todd reflected. “I didn’t want that for my kids. But there’s nothing I can do. I see how hard it is now.”

Widening gaps

Government programs are not universally difficult to apply for. Those serving poor people tend to be far more wrapped up in red tape, unequally levying what’s called “the time tax.” A 2021 Atlantic article written by Annie Lowrey sums it up: The time tax is regressive. 

“Programs for the wealthy tend to be easy, automatic, and guaranteed. You do not need to prostrate yourself before a caseworker to get the benefits of a 529 college-savings plan. You do not need to urinate in a cup to get a tax write-off for your home, boat, or plane. You do not need to find a former partner to get a child-support determination as a prerequisite for profiting from a 401(k).”

Application processes for government programs aimed at the wealthy are so much easier that many affluent people don’t even realize they’re benefiting from them, according to a survey conducted by political scientist Suzanne Mettler at Cornell University. 

In Mettler’s survey, the majority of high-income participants initially said they had never used a government safety net program. When told what counted as a government program, 96% reported they had. 

The wealth gap will widen and the time tax inequality will increase under President Donald Trump’s so-called One Big Beautiful Bill Act, experts warn. The new law contains the largest cuts to Medicaid and SNAP, or food stamps, in history. 

“We know that programs like SNAP and Medicaid reduce poverty, and so if they’re less available, we can expect poverty and hardships to rise,” said Elaine Waxman, a senior fellow in the Tax and Income Supports Division at the Urban Institute. “And we also know that the tax cuts for higher income groups are designed to boost those incomes, so you can just do the math without even having to do the math.”

Strict policies and cuts to Medicaid and food aid disproportionately harm women – a fact Todd knows firsthand. In her community, she says many mothers she knows are dropping dead because of heart attacks, too sick to take care of their kids, or committing suicide – a fate she almost fell prey to except that she didn’t want to repeat the generational trauma with which she grew up. 

“I know how it is to live without a parent because my mom mentally and emotionally wasn’t there, and I would never do that to my kids,” Todd said. “That’s the only reason why I’m here. I promise you, if it wasn’t for them, I would not be here. This world is too much for me, trying to just survive with nobody.”