Opinion: In Georgia, health care just became the make-or-break issue of 2020

11/04/2019 -- Atlanta, Georgia -- Gov. Brian Kemp answers questions from the media following a press conference to announce a proposed limited expansion of Medicaid in Georgia while at the State Capitol building in Atlanta, Monday, November 4, 2019.  (Alyssa Pointer/Atlanta Journal Constitution)

Credit: Alyssa Pointer

Credit: Alyssa Pointer

11/04/2019 -- Atlanta, Georgia -- Gov. Brian Kemp answers questions from the media following a press conference to announce a proposed limited expansion of Medicaid in Georgia while at the State Capitol building in Atlanta, Monday, November 4, 2019. (Alyssa Pointer/Atlanta Journal Constitution)

Two gauntlets were thrown down this week – one here, another in Kentucky.

Together, they tell us that health care will be the Georgia hill that both Republicans and Democrats are willing to die on in 2020.

At the state Capitol, members of a joint House-Senate committee got their first look at Gov. Brian Kemp’s plan to address Georgia’s health care crisis – by separating the state as much as possible from Obamacare, while adding a modest 50,000 working poor to the rolls of the insured.

“This is something that’s never been tried before,” said one member of Kemp’s staff.

“He does not want to follow a model that another state has already pursued. We have put before you a uniquely Georgia approach,” said the other.

Kemp’s plan places more emphasis on helping those who have coverage to keep it, rather than directly addressing the 408,000 who might be newly covered by full Medicaid expansion under the Affordable Care Act.

Subsidies doled out by the state and federal governments would attempt to lower policy premiums that can run as high as $1,000 a month and more – particularly in the 100 Georgia counties that have only one insurance provider. Georgians of all incomes would be eligible for these policies, and by far the largest savings would go to those with higher incomes.

Kemp administration officials estimate putting $104 million into this reinsurance program, and $36 million into Medicaid expansion the first year.

Employees of small businesses, who also earn less than 400% of the federal poverty level, would be able to accept small subsidies from their employers that would only partially cover premium costs – something that is currently discouraged under the ACA.

Among those disappointed by the Kemp plan is the Georgia Hospital Association. “Our initial impression is that the ‘Georgia Pathways to Coverage’ Medical waiver does not significantly move the needle for rural and safety net hospitals who care for the state’s uninsured patients,” said Earl Rogers, CEO and president of the GHA.

This is not a surprise. Even as more and more rural hospitals have closed in Georgia, Republicans in the Legislature have grown more Darwinian – insisting that access to health care be governed by local market forces.

Undergirding this attitude is the hardcore GOP belief that some poor people are deserving of help, while others are not. It is the subtext of our governor’s promise “to put hardworking Georgians first.”

Those 50,000 of 408,000 Georgians who could be covered under Kemp’s expanded Medicaid program must earn $12,000 a year or less to be eligible, but also must be engaged in “work or work-related activity” for at least 80 hours each month. Caring for an invalid spouse, child or elder would not count.

Those 50,000 would be expected to get control of their health issues, then move to private insurance – allowing others without insurance to take their place.

But that is policy. To be worth anything, political dividends must be observable. By 2022, when a certain governor will be up for re-election, something momentous would happen under the Kemp plan.

HealthCare.gov, the health insurance exchange website operated by the federal government under Affordable Care Act, would be phased out in Georgia. A state-operated website, operated with the help of private insurance companies, will take its place.

Though it wouldn’t be wholly true, “We killed Obamacare” bumper stickers would be snapped up by the GOP base.

Even so, the entire package is a significant gamble on Kemp’s part. Granted, a January poll of registered Georgia voters commissioned by The Atlanta Journal-Constitution showed 49% of Republicans opposed to Medicaid expansion.

And in a radio interview on Wednesday, House Speaker David Ralston indicated that GOP opposition in the Legislature remains firm.

“If we went to a full Medicaid expansion and the federal government chose to walk away from the portion they’re funding, that falls on the taxpayers of Georgia. The implications on our budget would be catastrophic,” Ralston said.

But in that same AJC poll, 71% of all voters said they would like to see Medicaid expansion. Among Democrats, support rose to 97 percent.

And on Tuesday, the issue was among those that drove voters to the polls – particularly in Kentucky, but in Virginia, too.

Specifically, work requirements were a hot topic in both states.

In Virginia, Democratic Gov. Ralph Northam had succeeded in expanding Medicaid in his state two years ago, but a Republican-controlled legislature forced him to accede to some work requirements. With Democrats now in complete control of Virginia state government, those will likely be rolled back.

In Kentucky, Gov. Steve Beshear pushed Medicaid expansion through in 2015. Barred by term limits, he was succeded by Republican Matt Bevin, who implemented work requirements – blocked in court – that would have removed 90,000 from Medicaid rolls in Kentucky.

Tuesday’s apparent gubernatorial victory by Andy Beshear, son of Steve, is all but certain to end that effort. Preservation of Obamacare was a focus of his campaign – and Georgia Democrats are taking heed of the fact that this likely helped Beshear among blue-collar coal miners in eastern Kentucky.

The most important political battle in 2020 Georgia will be for control of the state House. Democrats will need a 16-seat pick-up to wrest control of the chamber from Ralston and his fellow Republicans.

Medicaid expansion will be at the forefront of that effort, said House Minority Leader Bob Trammell, D-Luthersville.

“Voters want and understand Medicaid expansion. When you try to make it more complicated or try to frustrate and work to undermine it, there’s a political price to be paid for it,” Trammell said.

He and his fellow Democrats will argue that the Kemp plan would cost more but cover several hundred thousand fewer people. “This is thinking small. Health care is an issue that requires us to think big and broadly. This is just the opposite,” Trammell said.

Republicans will attempt to paint Trammell & Co. as going too big. “Socialism” and “Medicaid for all” will be among the accusations – although the results in Kentucky are likely to encourage Georgia Democrats to focus, as Andy Beshear did, on “preserving Obamacare.”

Two waivers sought by Kemp will be presented to the Trump administration by the end of the year. They will be the two negotiating parties.

While the governor’s plans will likely require a few expensive lines in the state budget, the Capitol is unlikely to be the venue for any broad policy debate on his venture. And that’s okay with Trammell.

“If legislative inaction is the strategy on the part of the majority party, we will campaign all over Georgia on the issue,” he said.