Standstill on Medicaid expansion leaves poor Georgians without coverage

Kelly Stewart, 41, at her home in Chatsworth, Georgia, where she lives with family. Stewart has lived for years in the Medicaid gap; she is an adult with no minor children, and Georgia has not expanded Medicaid to include people like her. (PHOTO by Alyssa Pointer / Alyssa.Pointer@ajc.com)
Kelly Stewart, 41, at her home in Chatsworth, Georgia, where she lives with family. Stewart has lived for years in the Medicaid gap; she is an adult with no minor children, and Georgia has not expanded Medicaid to include people like her. (PHOTO by Alyssa Pointer / Alyssa.Pointer@ajc.com)

Credit: Alyssa Pointer/Alyssa.Pointer@ajc.com

Credit: Alyssa Pointer/Alyssa.Pointer@ajc.com

Kelly Stewart hasn’t had health insurance in years. In most states, she would qualify for Medicaid, even with her occasional – and modest – earnings as an in-home caregiver.

But not in Georgia.

Unlike 38 other states and the District of Columbia, Georgia still refuses to expand Medicaid eligibility to most of its poor residents under the Affordable Care Act, despite new financial incentives offered by President Joe Biden’s administration.

As a result, unless things change Georgia will forego an estimated $710 million in federal funding by the time Gov. Brian Kemp’s first term concludes in 2023.

Instead, Kemp continues to seek federal approval of a far more modest expansion of Medicaid, one that would provide benefits to most adults only if they met requirements for work or other approved activities. The Biden administration, however, has so far rejected Kemp’s plan as unconnected to health care.

This stalemate leaves perhaps 400,000 Georgians like Stewart, 41, stuck in the middle. She cannot afford private insurance and does not qualify for government assistance, so she can’t afford visits to an endocrinologist to monitor her abnormal thyroid.

“It’s not fair,” she said.

Kemp’s proposal — technically a requested waiver to existing Medicaid rules — had won the enthusiastic support of former President Donald Trump’s administration and had been scheduled to go into effect next month. State officials estimate it could have ended up providing coverage to more than 20,000 people the first year and perhaps 50,000 by the second year.

An estimated 350,000 other Georgians, such as Stewart, would not have met the plan’s proposals and would have remained uninsured.

But linking work or other activities to health coverage has been repeatedly struck down by federal courts as not consistent with Medicaid’s objective of providing health care. One of the Biden administration’s earliest actions was to rescind the approval of Georgia’s waiver application, marking its status as “pending.”

Ryan Loke, an aide to Kemp who works on Medicaid and other health care issues, said Georgia and the federal government are still discussing the state’s waiver application.

State officials, Loke said, “do expect that Georgians who are caught in that coverage gap will have access to coverage as a result of our innovative approach.”

Hurdles to coverage

For four years, Stewart has not qualified for subsidized health care, either under Georgia’s current system or under Kemp’s waiver proposal. The last time she had coverage was when she qualified for Medicaid as a mother of minors. They are now grown.

Since then, Stewart has often helped relatives who couldn’t care for themselves, but not for an official salary. Under Kemp’s proposed work requirement, that would not be considered “employment.”

To qualify for coverage under another “qualifying activity” provision of the proposed waiver, Stewart would have had to leave her relatives alone in order to do something else, such as taking certain kinds of classes, enrolling in a job-training program or working for an approved nonprofit at least 80 hours a month.

Otherwise, her only option would have been subsidized insurance through the Affordable Care Act. But those subsidies are offered only to people earning at least as much as the federal poverty level, or $12,880. Stewart never made that much in a year.

Stewart lives in Chatsworth, a small town in Murray County, about 85 miles northwest of Atlanta. Over the past year, she tried driving for DoorDash, the meal delivery service, but spent more on gas covering her rural area than she could earn. She has applied online to any job she could find. She applied for unemployment insurance but said she has received no response to more than 20 requests to appeal her denial of account registration by the state Labor Department.

The bureaucratic hurdles to receiving government aid demonstrate why Stewart would like to see Georgia open up Medicaid to anyone who is poor.

When it comes to setting up special eligibility categories, lawyers for the poor — who are trained in getting people qualified as disabled — say it’s a nightmare for those who need care immediately. It takes several months if they qualify. Few qualify. If their disability could be fixed with surgery, for example, that person is usually not registered as disabled, even if they can’t afford the surgery.

$700 million incentive

Even if he wanted to fully expand Medicaid, Kemp’s aides point out, he would need approval from state legislators. But the Republicans who control the state House and Senate have so far not wavered from their opposition to the idea. They say that while bringing in billions of federal dollars to expand Medicaid eligibility sounds good, Congress could end those payments at any time, forcing the state to cover the full cost itself.

But 10 years after the Affordable Care Act’s passage, “there hasn’t been discussion of lowering that matching rate,” said Rachel Garfield, vice president at the Kaiser Family Foundation, a nonprofit research organization that focuses on health care.

Kyle Wingfield, president of the libertarian-leaning Georgia Public Policy Foundation, agreed, to a point.

“They’re doing what they said they would do,” Wingfield said. “But the trajectory of federal spending has also gotten only more unsustainable.”

Last October, Gov. Brian Kemp celebrated with Seema Verma, then the administrator of the federal Centers for Medicare and Medicaid Services, after they agreed to a limited expansion of Medicaid benefits in Georgia. This year, President Joe Biden's administration rescinded the approval. (Hyosub Shin / hyosub.shin@ajc.com)
Last October, Gov. Brian Kemp celebrated with Seema Verma, then the administrator of the federal Centers for Medicare and Medicaid Services, after they agreed to a limited expansion of Medicaid benefits in Georgia. This year, President Joe Biden's administration rescinded the approval. (Hyosub Shin / hyosub.shin@ajc.com)

Credit: HYOSUB SHIN / AJC

Credit: HYOSUB SHIN / AJC

The federal government currently provides about two-thirds of Georgia’s regular Medicaid expenses. Under full Medicaid expansion, the federal match to cover newly added beneficiaries would increase to 90%.

In addition, the Biden administration is offering another incentive: The federal government would increase its contribution for those already on the Medicaid rolls by 5 percentage points for two years. That would result in a net gain for Georgia of more than $700 million by 2023, according to Kaiser.

Full Medicaid expansion also would benefit hospitals and doctors who have been treating many uninsured people for free. At the charity clinic Mercy Care, for instance, as many as 80% of patients have no coverage, and many are homeless, said Tom Andrews, the organization’s CEO.

“If you can’t take care of your health, you can’t get jobs,” said Andrews, who initially supported Kemp’s limited Medicaid expansion proposal. “The basis of access to health care is at the basis of really being able to live a whole life.”

With government solutions stalled, Stewart is trying to take care of her own health care needs, training for a work-from-home call center job that could include insurance benefits.

She expects to need the coverage. In the past 30 days, she has experienced symptoms that her one-time endocrinologist warned her about. Growths in her thyroid are suddenly off kilter. She has gone from wearing a size 4 to a size 10 in one month because of rapid weight gain. Her moods are swinging badly.

She’s afraid it could be cancer. But without insurance coverage, she can’t afford to see the endocrinologist. She is left with a grim outlook.

“There’s people out there putting a price tag on our lives.”

In Other News