Exterior of the vacant Charlton Memorial Hospital in Folkston, Ga., in February. HYOSUB SHIN / HSHIN@AJC.COM
Photo: HYOSUB SHIN / AJC
Photo: HYOSUB SHIN / AJC

Rural health care and the coming GOP collision with reality

Georgia Republicans with November ambitions have just escaped one come-to-Jesus moment. Another is riding close on its heels — and the two situations have much in common.

The “red-state” revolts over teacher pay in West Virginia and Oklahoma make it hard to overstate the importance of Gov. Nathan Deal’s recent decision to restore state spending on education to a pre-Great Recession level.

Broad backing for rebellious educators in both states has underlined a gap between many GOP purists, who caricature public education as a bureaucracy that needs to be starved into submission, and popular support for local schools.

Deal isn’t the only Georgia Republican to spot this chasm, though his access to the $167 million that will help repair it in Georgia does make him rather special. We caught a glimpse of the same worry from Lindsey Tippins, R-Marietta, who last week resigned his chairmanship of the state Senate Education Committee.

Tippins attempted to block a bill that would treat charter schools more generously with state funds than many public schools that must take all comers. His Senate Republican colleagues would have none of that thinking, and passed the bill anyway.

“If that bill is reflective of their vision for education in the state of Georgia, they got the wrong person being the committee chairman,” Tippins was quoted as saying.

Yet another choice between reality and ideological purity looms this election year. Everyone agrees that a working health care system is foundational to bringing back the economy of rural Georgia. No business is going to re-locate in a region with a sick or dying hospital.

The question is whether the situation in rural Georgia is considered dire enough to embrace, in some fashion, what’s left of the Affordable Care Act. Obamacare, in other words.

In the just-completed session, our GOP-controlled Legislature passed a number of measures that work the edges of the problem. One bill permits “micro-hospitals,” another allows prescriptions to be filled via the internet, where the internet is available.

Just before legislators adjourned, Chris Clark, president and CEO of the Georgia Chamber, was on GPB’s “Lawmakers.” So was I.

Clark called the above measures “a great start.” But he also said this: “The sad thing is, we’ve had seven rural hospitals close in the last few years. They’re several more that are right on the bubble.

“At the end of the day, if we don’t act now, if we don’t address Medicaid and Medicare in Georgia, if the federal government doesn’t address it, you could have 26 percent of the rural population in Georgia without health care access over the next few years. There’s a huge need to act,” Clark said.

As we’ve reported before, Democrats and Republicans have developed different vocabularies for using Medicaid dollars to extend health care to those who aren’t poor enough to qualify for outright coverage, but can’t afford market-based health insurance, either.

Democrats speak of Medicaid expansion. Republicans talk in terms of Medicaid waivers, singular deals with the federal government that offer states more control over how such money is spent.

Clark was speaking Republican, and I prompted him to elaborate.

“I think we have to continue to have the conversation about a Medicaid waiver. It needs to be a Georgia solution,” he said. “There are new waivers coming online every day from the federal government. We’ve just got to make a decision to go after that, and try to get some of those billions of dollars that we’ve been sending to other states to take care of their people.”

In essence, the chairman of the Georgia Chamber was asking Republicans to bow to two realities: First, that the ACA is here to stay, at least for some time to come. Secondly, that the situation in rural Georgia is bad enough to warrant a break with a decade of GOP orthodoxy.

Over the weekend, I transcribed Clark’s GPB remarks and sent them to the five major Republican candidates for governor, with this question: “If elected, will you seek a Medicaid waiver to draw down more federal dollars and offer more health insurance coverage for more Georgians?”

A spokeswoman for businessman Clay Tippins said her candidate wasn’t ready to answer that question yet.

State Sen. Michael Williams of Cumming said no. “Medicaid expansion only comes with strings attached from the federal government,” he wrote. “Far too often, states have sold their sovereignty for federal funds. That will not happen in my administration.”

Former state Sen. Hunter Hill of Buckhead said much the same thing. “Big government created the health care crisis in our country, so more government is not the answer,” Hill wrote. “My administration would address access to care and health outcomes for Georgians by returning to free-market solutions and personal responsibility.”

Secretary of State Brian Kemp, who has sought to position himself as a champion of rural Georgia, said he would not pursue additional federal dollars for health care coverage through Medicaid, whether under the name of waivers or expansion. However, he would “work with the Trump administration to implement a Georgia-focused, free-market solution that enhances health care coverage and reduces costs.”

Which leaves Lt. Gov. Casey Cagle as the only Republican candidate who appears ready to accept Clark’s challenge.

“If we can get more flexibility from the federal government to lower the costs of our Medicaid program, and increase personal responsibility by putting able-bodied recipients on the path to a job and private health insurance, then we should consider it,” he wrote. “This all comes down to a question of how creative and flexible [the federal government] is willing to let us be in terms of comprehensive Medicaid reform.”

But this question of Medicaid waivers/expansion shouldn’t be the sole property of gubernatorial candidates. In that GPB interview, Clark noted that the next governor will need to obtain the permission of the Legislature to pursue any attempt to extend coverage through Medicaid.

This is debate season. Let them frame it how they want, whether a Medicaid expansion or a Medicaid waiver. But every candidate for the state House and Senate needs to tell us which is more valuable — rural Georgia, or principled opposition to a health care system that’s likely to remain the law of the land for some time to come.

Because the time is rapidly approaching when we won’t be able to afford both.

***

For the curious, I add below the full remarks sent in by the candidates to this question: “If elected governor, will you seek a Medicaid waiver to draw down more federal dollars and offer more health insurance coverage for more Georgians? And if so, what would your waiver look like?”

Clay Tippins: (Updated: After the above article was published, Erinn Robinson, spokeswoman for the Tippins campaign, offered this response from her candidate: 

"Clay would decline to expand Medicaid. Even when Medicaid funds come from the federal government, those are still Georgia taxpayers' dollars. It’s a false narrative that Georgia gets this free money from the federal government that will create these magical results. It doesn’t."

Michael Williams: "I do not support any Medicaid expansion that puts Georgia taxpayers on the line in future periods. Medicaid expansion only comes with strings attached from the federal government. Far too often, states have sold their sovereignty for federal funds. That will not happen in my administration."

Hunter Hill: “I would not expand Obamacare. Big government created the healthcare crisis in our country, so more government is not the answer. ‘Federal dollars’ - that liberals wish to use in drastically increasing government - are taxpayer funds leveraged from a nearly bankrupt federal government.

“My administration would address access to care and health outcomes for Georgians by returning to free market solutions and personal responsibility. In the state Senate, I sponsored Direct Primary Care to do just that.”

Brian Kemp: "I am against the expansion of Medicaid in Georgia. As governor, I will work with the Trump administration to implement a Georgia-focused, free-market solution that enhances healthcare coverage and reduces costs for hard-working Georgians.

“We will require able-bodied Medicaid recipients to work and move away from unsustainable, big government programs that cost too much and fail to deliver."

Casey Cagle: “If we can get more flexibility from the federal government to lower the costs of our Medicaid program and increase personal responsibility by putting able-bodied recipients on the path to a job and private health insurance, then we should consider it.

“That said, I will not support any approach to Medicaid reform that saddles hard-working Georgia taxpayers with additional net costs. This all comes down to a question of how creative and flexible CMS is willing to let us be in terms of comprehensive Medicaid reform.”

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About the Author

Jim Galloway
Jim Galloway
Jim Galloway is a three-decade veteran of The Atlanta Journal-Constitution who writes the Political Insider blog and column.
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