Lifting the lid on the debate over Medicaid expansion

Early this week, a small panel assigned the task of saving rural health care in Georgia gathered to take a first crack at the problem.

Four rural hospitals have closed since 2012, eight since 2000. The finances of another dozen or so balance on a razor’s edge, the panel was told.

A bit of Malthusian arithmetic for you: Jimmy Lewis, CEO of HomeTown Health, a Georgia collection of health care facilities, says a community of 40,000 is required for the independent operation of a hospital.

Rural Georgia has 1.8 million people – enough for 45 hospitals. “We’re down to 55,” Lewis said afterwards. Only ten to go.

The solutions discussed were notable for what wasn’t considered – an expansion of Medicaid coverage offered under the Affordable Care Act, as many hospitals would like to see.

One reason: The panel was appointed by Gov. Nathan Deal, who views an extension of federally subsidized health coverage for the uninsured as a fiscal trap that state governments ultimately won’t be able afford.

Another reason: HB 990, passed this spring by the Republican-dominated Legislature and signed by the governor, gives state lawmakers final approval when it comes to Medicaid expansion. “The Legislature took it off the table,’’ said a somber state Sen. David Lucas, D-Macon, a panel member.

But did it? As the panel deliberated on Monday, Deal’s Democratic challenger, state Sen. Jason Carter of Atlanta, stalked the health care halls of Montezuma, Ga., site of a recently closed hospital.

There, Carter not only declared Medicaid expansion to be very much on the table, but a fiscal necessity. “It’s our money and Nathan Deal wants Washington to keep it. That doesn’t make sense to anyone, certainly not here,” the state senator said.

The Democrat has an uphill argument. Republicans, as their 30-second ads attest, think it is enough simply to link Carter’s name to “Obamacare” – antipathy toward the president is presumed to be that strong in Georgia. Carter, on the other hand, requires his audiences to do the math.

“Every single day, our governor takes $9 million in our taxpayer money, our tax dollars that we pay to the federal government, $9 million a day, that he sends off to other states, to give health care to those people – and denies it to 600,000 people in Georgia,” Carter recently argued to a group of supporters in Savannah.

But if Medicaid expansion remains in the grips of a Legislature in which Republicans outnumber Democrats by 2-to-1, or close to it, then Carter’s calculations become moot. Right?

Which brings us to the loophole. As signed into law, HB 990 requires the General Assembly to approve any expansion of Medicaid “through an increase in the income threshold.”

Other states have cut different deals with the federal government. Arkansas, for instance, uses the federal subsidy to purchase private health care insurance – not Medicaid coverage — for those who can’t afford it.

At this writer’s request, state Senate Democratic Leader Steve Henson of Tucker consulted with one of the many lawyers who draw up bills for passage in the Capitol. “She did think there are ways you could expand Medicaid through an Arkansas-type plan without legislative approval,” Henson said.

So a go-it-alone strategy for a Democratic governor might be feasible when it comes to expanding health care in Georgia. But “could” and “should” aren’t always the same thing.

“The letter of the law gives the General Assembly a say over expanding Medicaid,” said Brian Robinson, a spokesman for the governor. But he, too, appeared to acknowledge the possibility that HB 990 may not be the airtight lid that many have said it is.

“Any workaround that would expand an entitlement connected to the Affordable Care Act without legislative approval would violate, at the very least, the spirit of the law,” Robinson said.

Carter himself walked the same delicate ground in this statement issued by his campaign on Wednesday: “Jason will work with the General Assembly and anyone else who wants to stop sending $9 million a day of Georgia taxpayer dollars to Washington.”

Alan Essig is the executive director of the Georgia Budget & Policy Institute, which provides much of the data used by Democrats in their debates.

Expanding health care through the ACA, regardless of how it’s done, would amount to such a major policy shift that the General Assembly would have to give its approval in some fashion, Essig theorized.

Any governor would have certain tools. “The governor can veto other things. The governor can hold things hostage,” Essig said. “There’s a political aspect to this that will have to play out. It’s not going to be easy, that’s for damn sure. But it’s not impossible.”

Even should Carter break the Democratic drought and win the Governor’s Mansion, the expansion of Medicaid would become one of several issues subject to the same dynamic, Essig said.

“The state of Georgia has never had a governor from one party, and a united General Assembly from another,” he said. “They’ve never had to do that kind of negotiation before. But other states have to deal with that in an on-going basis, and things get done.”

In other words, Essig concluded that when it comes to health care, “HB 990 is not the end-all, be-all of the discussion. It’s the beginning of the discussion.”

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