Georgia's business-driven shift on Medicaid

Wayne Memorial Hospital in Jesup, Ga. HYOSUB SHIN / HSHIN@AJC.COM

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Wayne Memorial Hospital in Jesup, Ga. HYOSUB SHIN / HSHIN@AJC.COM

If you're looking for the point at which Republicans in Georgia began their slow turn toward Obamacare and the expansion of health care coverage it offers, 2015 is one of several places to start.

That’s when the state’s business leaders were presented with evidence that the U.S. could quickly end up with two economies: One for states with adequate health care, and another for states without.

Georgia was on the wrong side of that formula.

The Affordable Care Act had gone into effect a year earlier, but only after the U.S. Supreme Court ruled that states would not be required to expand their Medicaid rolls to include much of the working poor.

Given that Obamacare was a radioactive topic within GOP ranks, Georgia decided not to indulge. Gov. Nathan Deal said he didn’t trust the federal government to maintain its share of the financial burden — a position many Republicans still embrace.

After 12 months, the Georgia Chamber brought in Deloitte, the consulting firm, and two former Deal staffers: political consultant Brian Robinson and Blake Fulenwider, the state’s former Medicaid chief. A first assignment: Determine what Georgia would look like 10 years hence, without any expansion of Medicaid coverage.

“They spent all of 2015 looking at projections – what the numbers were today, and looking at what the projections would be in 2026. Those numbers were startling. And scary,” said Chris Clark, president and CEO of the Georgia Chamber. “You had a little over a million Georgians without health care insurance.”

That translated to a quarter of Georgia’s anticipated adult population in 2026. “That gets your attention,” Clark said.

Economies do not thrive on numbers like that.

Sometime this week, a bill backed by Gov. Brian Kemp is expected to be introduced. Very probably, it will lead to the expansion of Medicaid-based health care coverage in Georgia.

At least, Democrats will call it Medicaid expansion. Republicans will use the term “waiver.” Details are scarce. The Indiana program pushed through by Vice President Mike Pence when he was governor is likely to be a model. It requires monthly payments from participants — from $1 to $27— into a health savings account. Enrollees who miss payments face a reduction in benefits.

Estimates are that anywhere from 300,000 to 600,000 Georgians could be covered by the — um, Medicaid augmentation.

During the race for governor, the Kemp campaign said the candidate would tolerate no increased drawdown in federal dollars for healthcare in Georgia.

Pence’s explanation for tapping more Medicaid dollars in Indiana could be of some help to the new Georgia governor when the time comes to explain his shift. “I believe Medicaid is not a program we should expand. It’s a program that we should reform — and that’s exactly what we’re accomplishing,” Pence said.

There are many reasons for a Republican change of heart in Georgia. Only a handful endorsed Medicaid expansion from the start. “I am concerned that my party is going to lose thousands of health care workers and independent voters over this,” state Sen. Chuck Hufstetler, R-Rome, an anesthetist, warned in 2014.

But in last year’s race for governor, Democrat Stacey Abrams’ daily mantra that Georgia was giving up $8 million in federal health care dollars every day was clearly effective.

Kemp’s 50.22 percent victory in November is reason enough for Georgia Republicans to want the issue of health care off the table in 2020, when a U.S. Senate seat and control of the Legislature will be at stake. In a Journal-Constitution poll conducted last month, 73 percent of registered Georgia voters supported Medicaid expansion. Among Republicans, support for expansion was measured at 51 percent.

But at bottom, Medicaid augmentation in Georgia has been a business-driven decision. Even among Democrats.

Back in 2012, after the U.S. Supreme Court ruled that states couldn’t be forced by the Affordable Care Act to expand their Medicaid rolls, then-state senator Vincent Fort of Atlanta identified the issue as the top priority of Democrats in the Legislature.

“Moral Monday” demonstrations at the Capitol were built around Georgia’s refusal to participate. Fort was arrested in the governor’s office during one of those protests.

But his most effective lobbying may have been with the business leaders who made up the governing board of Grady Memorial Hospital, which handles more indigent patients than any institution in the state. This was during a war over the hospital’s finances and services. Privatization was a hot topic.

“This was one area where everyone agreed on. I remember pushing some of those doing the privatization — some of the businessmen, urging them to talk to the governor and lieutenant governor to do Medicaid expansion,” said Fort, who resigned from the Senate to run for mayor of Atlanta in 2017.

Hospitals were an entry point for the Georgia Chamber as well — but in rural Georgia, where those health care centers were toppling like dominos.

“One of the things that became very clear as we traveled the state is that those communities that did not have access to quality health care – there was no way that an existing industry was going to expand, or a new industry was going to move there,” said Clark, the chamber president.

“We literally started the conversation from a business and economic development standpoint, not so much from the health care access standpoint,” he said.

The Chamber ordered its Medicaid team to produce three alternatives to the state Legislature in 2017. The unspoken expectation was that Hillary Clinton would take the White House in 2016, ending the debate over Obamacare.

That didn’t happen. Rather, President Donald Trump pressed for a repeal of the Affordable Care Act, only to be denied by the single vote cast by U.S. Sen. John McCain, R-Ariz.

Then came Nov. 6, 2018, and the Democratic takeover of the U.S. House.

“What we heard consistently after the election last year was that the administration in D.C. was open to conservative state waivers. They were open to innovation,” Clark said.

Last summer, in the midst of the general election campaign, the Georgia Chamber presented both Abrams and Kemp to its membership at a huge gathering in Macon.

Abrams spoke a great deal of the need to expand Medicaid in Georgia. Kemp hardly addressed the issue at all. I asked the Georgia Chamber president if that bothered him at the time.

“We had no concerns. Governor Kemp never shut the door. He talked all through that campaign about innovation and health care. When he came into office — here we are, and it’s his proposal to put the dollars in there. He never shut the door,” Clark said.

Looking backward, there’s another, obvious sign of the inevitable nature of the Republican shift on Medicaid in Georgia. We told you about Blake Fulenwider, the former state Medicaid chief who helped the Chamber analyze the economic impact of doing without Medicaid expansion.

The Republican effort to kill the Affordable Care Act died on July 28, 2017, when McCain gave his famous thumbs-down on the U.S. Senate floor.

Four weeks later, Gov. Nathan Deal announced the return of Fulenwider as deputy commissioner of the state Department of Community health, in charge of all things having to do with Medicaid.

The man who helped write the book on how Georgia could go about drawing down more federal Medicaid dollars is still in that position today.