Now that President Barack Obama’s re-election has secured the survival of his health care law, Georgia’s Republican leaders must decide whether to help shape how the law will work here or cede control to the federal government.
Two major decisions loom for Gov. Nathan Deal and other Republican governors who have put off key decisions tied to the law, hoping it would be repealed if Mitt Romney won election.
One is whether they to accept billions of federal dollars to expand Medicaid, the government health program for the poor. Deal’s decision will determine whether hundreds of thousands of low-income Georgians get access to health coverage.
To date Deal has said the state can’t afford the expansion longterm.
More immediately, state leaders must declare by Nov. 16 whether they will build and operate new online exchanges where consumers and small businesses can shop for affordable insurance or leave it to the federal government. Experts say even if Georgia opts to create its own exchange, there isn’t enough time to get one up and running by the Jan. 1, 2014 deadline.
“States have to start moving fast,” said William Custer, a health care expert at Georgia State University. “This is a freight train and not all the cars are loaded.”
A Deal spokeswoman said the governor was not prepared Wednesday to speak about the implications of the election on Georgia health care but would comment later in the week.
The election result, which appears to prevent any Republican move to repeal Obamacare for the forseeable future, was a big step in giving state governments and businesses clarity on how to move forward with health care plans, Custer said. But there are still a host of details to hammer out, he said.
2013 will be a big year for education about the law — ensuring business owners understand how it applies to them and their workers, said Kyle Jackson, state director of the National Federation of Independent Business’ Georgia chapter. Federal health officials have released thousands of new regulations with more to come, Jackson said.
“It’s a very convoluted process,” he said. “(Small business owners) don’t have the time to follow the thousands of rules and regulations.”
For the state, the challenge will be figuring out how to integrate with the federal government’s phased rollout of different aspects of the law — including the new insurance exchange, Custer said.
Custer estimates roughly 900,000 Georgians will shop on the exchange — an online marketplace where individual consumers can shop for health plans and get federal subsidies to make coverage affordable. Exchanges are part of Obamacare’s plan to assure that people who don’t have employer policies can find coverage.
An exchange alone, however, won’t be enough to ensure most of Georgia’s nearly 2 million uninsured citizens, about 19 percent, get coverage.
With just the exchange but no Medicaid expansion only about 300,000 uninsured Georgians would gain coverage, and the state’s uninsured rate still would be about 18 percent, Custer said.
In June, the U.S. Supreme Court ruled that states could not be forced to expand Medicaid — a pillar of the health law critical to its aim of extending coverage to millions of uninsured people. The law calls for states to expand their Medicaid programs in 2014 to people with incomes of up to 133 percent of the federal poverty level, or roughly $31,000 for a family of four.
The state estimates an expansion would add 650,000 new enrollees to the program at a cost to the state of $4 billion over 10 years.
Gov. Deal has said he will not expand Medicaid — which already faces a shortfall of hundreds of millions of dollars — as it is currently structured. At least five other Republican governors, including in Texas and Florida, have also rebuffed an expansion.
Others hope the federal government may allow them to expand the program, but not as broadly as the law calls for.
If Georgia partially expanded its program to include people with incomes up to 100 percent of the poverty level, it would be able to provide coverage to a tremendous number of people, Custer said. He estimates Georgia’s uninsured rate would fall to 9 percent under that scenario, or to 7 percent under a full expansion.
Proponents of an expansion argue turning down billions in federal dollars will put Georgia at a big disadvantage compared with states moving forward with expansions. When states invest in health care, it can boost economies and improve quality of life, said Cindy Zeldin, executive director of the nonprofit advocacy group Georgians for a Healthy Future.
Georgia risks becoming a less attractive state for people looking for a place to live and work, Zeldin said.
“It’s all eyes on the Medicaid expansion now,” she said. “That’s really the big question.”
Obamacare opponents note that the federal funding declines after the first few years and worry the expansion will saddle the state with massive costs down the road.
State Sen. Renee Unterman, (R-Buford), who heads the Health and Human Services Committee, questions whether the state should add more people onto Medicaid at a time when the program is already overburdened and facing a huge deficit.
She said the federal government would allow Georgia to turn Medicaid into a block grant program, with the state getting one set amount of federal government for Medicaid, along with fewer rules on how it must be spent.
Romney favored Medicaid reform based on block grants, but such a plan seems unlikely with Obama’s reelection and a split Congress, Unterman said.
“It’s just a huge issue,” she said. “I don’t know how the state of Georgia is going to answer it.”
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