For the next few minutes, ignore that federal judge in Texas, the one who declared Obamacare to be unconstitutional — lock, stock and barrel. From pre-existing conditions to the 26-year-old offspring who still lingers on your health insurance plan.
Depending on the appeal process, that’s a future that could be more than two years away. Something more immediate, and closer to home, is afoot. Even as President Donald Trump celebrates that lower-court ruling in Texas, we’re seeing something different in Georgia.
We‘ve come across hard-to-ignore signs that, for the first time since the Affordable Care Act was passed in 2010, Republicans in the state Capitol are interested in pursuing a customized version of the program that would — in some fashion — pump more federal dollars into health care for the working poor throughout the state.
Given recent Republican losses in Congress, and Brian Kemp’s close call in Georgia, the move makes political sense — especially given the emphasis that Democrat Stacey Abrams placed on health care during the gubernatorial campaign.
Some clues are easier to read than others. For instance, a governor-elect does not bring Tom Price, the former congressman and ex-secretary of health and human services, onto his transition team to formulate a sales tax holiday on guns and ammunition.
Price may have failed to strike a personal rapport with Trump — since he was booted from the president’s Cabinet in 2017, many others have similarly fallen short. But no one doubts that Price knows his way around federal health care law.
Then there was last week’s conference call with a knot of Georgia conservatives interested in finding alternatives to Obamacare and the Medicaid expansion that it encourages. A Trump administration official was on the line, we’re told, openly advertising for pilot programs that could be attempted in five or six Republican-controlled states.
“What we understand from the administration, in numerous ways, numerous conversations, is that they’re open to just about any kind of waiver proposals from states that would help address that working poor category,” said state Rep. Terry England, R-Auburn, the chairman of the House Appropriations Committee.
Obtain the Trump administration’s seal of approval, allow the president to brag that he’s fixed Obamacare in Georgia, and years of Republican political angst over the ACA immediately fade away.
England and his House colleagues are the source of even more clues about a coming debate over health care in Georgia. But those hints take us deep into the weeds, so your undivided attention is required.
Early this month, the House Rural Economic Development Council finished a two-year effort and rolled out a list of cures for what ails rural Georgia, to be taken up when the Legislature comes to town next month.
Many of the usual suspects were named. A need for greater access to broadband and the internet. More incentives for job creation. The shocker in the council’s report was this line: “The state should revolutionize the (health care) industry by shifting from the current restrictive, regulatory ‘certificate of need’ model to an accreditation and licensing process for hospitals.”
I told you this was about to get weedy.
The certificate of need process has been Georgia’s way of regulating hospitals and their services since the mid-1970s. The original idea was that a community’s substantial investment in a hospital shouldn’t be undercut by a for-profit operation that sets up shop across the street.
Today, a certificate of need, issued by the state, often becomes a battleground on which for-profit health care institutions attempt to peel insured patients away from nonprofit hospitals. The latter need the insured to pad out the added expense of indigent patients they’re required to care for.
Such disputes, heavily litigated and often refereed by the Legislature, are usually seen in metro Atlanta. Not in rural Georgia.
“In many of the areas where small, rural hospitals are, there’s not a danger of another entity coming in to pull off any business — because there’s just not enough demand for those services,” England, one of the council’s two co-chairmen, told his fellow legislators last week at a pre-session gathering in Athens.
Including a recommendation to “revolutionize” the state’s entire system of hospital regulation in a package to salvage rural Georgia, on the theory that it won’t hurt Hahira, makes little sense.
What does make sense is the fact that Georgia hospitals have long resisted the Legislature’s efforts to update — or do away with — the state’s certificate of need program. At the same time, hospitals and the Georgia business community are also clamoring for the state’s Republican leadership to tap the millions of federal dollars that Georgia forfeits by refusing to expand its Medicaid rolls and offer health insurance coverage to the working poor.
I talked with England on Monday, shortly after he had met with representatives of the Georgia Hospital Association at the Capitol. I asked the House appropriations chairman whether a trade is on the table.
“Are they connected? I don’t know,” England said. “I know that we’re not going to go for full-fledged Medicaid expansion. I don’t think the new administration wants to do it. But I think there is an appetite to find a happy spot there.”
England spoke specifically about preserving a safety net for the working poor, to help the individual who suffers because he or she gets a 50-cent-an-hour raise. “They get a thousand extra in their pockets but lose $15,000 in benefits,” England said.
And if, in return, Georgia’s hospitals are willing to accept some changes to how they’re regulated, that would be a good thing, he added.
(When informed of England’s remarks, Earl Rogers, the president and CEO of the Georgia Hospital Association, responded with this: “As policymakers discuss competition and free-market solutions, it’s important to remember that no one competes for the uninsured. That responsibility falls to the hospital community, which provides care to all patients, regardless of ability to pay.”)
But there may be yet another reason that hospital regulation has jumped up as an issue. Again, it has nothing to do with Hahira.
The playbook for creating a customized, Georgia-only waiver under the Affordable Care Act is a 114-page guide published this year by the U.S. Department of Health and Human Services. On Page 50, the topic of certificate of need regulation is addressed.
“The evidence to date … suggests that (certificate of need) laws are frequently costly barriers to entry for healthcare providers rather than successful tools for controlling costs or improving healthcare quality,” the handbook says.
So upending Georgia’s system of hospital regulation wouldn’t just be the Legislature’s price for bringing more federal health care dollars into the state. It might also be the Trump administration’s price for allowing Georgia Republicans to customize Obamacare, and so make it something they can live with.
Like I said — it’s a weedy issue. But an important one.