“Certainly the speaker (of the House) is having those conversations, and it’s an issue that he’s looking at,” Stephen Lawson, an aide to House Speaker Jon Burns, told Atlanta Journal-Constitution journalists this week.

Gov. Brian Kemp, who has an alternative Medicaid program of his own construction to defend, remained mum when asked about Medicaid expansion in exchange for CON rollbacks. “Out of respect of the legislative process, it is our practice not to comment on proposed legislation,” Kemp spokesman Garrison Douglas said.

Lt. Gov. Burt Jones wouldn’t rule it out.

“I have never wavered on my position that expanding access to health care, especially in rural parts of the state, should be a priority for all Georgians,” Jones, who oversees the Senate, said in a statement.

Much has changed over the years, including widespread acceptance that the ACA is here to stay, and polls show strong support for Medicaid expansion among Georgia voters, even Republicans. Perhaps the most important new development was that Kemp’s signature alternative to Medicaid expansion finally launched July 1, and its results so far have been weak.

Out of perhaps 370,000 Georgians that the Kemp administration thinks could sign up, only 2,344 had done so as of Dec. 15, according to data released by the Georgia Department of Community Health.

“Something has definitely changed in the last several months, especially,” said Danny Kanso, a former Republican lieutenant governor’s aide who is now director of legislative strategy and a senior fiscal analyst at the Georgia Budget and Policy Institute, a left-leaning think tank that favors Medicaid expansion.

“As somebody who’s been observing this issue in recent years, I do think this session stands out uniquely, as a real opportunity for consensus,” Kanso said.

Not blanket Medicaid expansion

Medicaid is the federal-state program that insures poor children and some of a state’s poor adults. Georgia has the third-highest rate of uninsured people in the nation, according to the nonprofit health research organization KFF.

It is also one of 10 states that reserve Medicaid for only certain classes of poor adults. Poor adults who qualify for Medicaid in Georgia include those who gave birth within the past year, many elderly residents of nursing homes, some who are federally declared disabled, and others who perform certain state specified activities for 80 hours a month.

That does not include, for example, someone who works 80 hours a month caring for a disabled relative or someone who is disabled but has been denied government disability status.

Reporting by the AJC has found that the Medicaid enrollment system is broken when it comes to helping Georgians navigate the complexities of dozens of possible eligibility categories. Each category requires submitting documentation for proof the person is qualified. The computers and phone answering machines often give unhelpful or conflicting answers, and the caseworkers who should help in person are understaffed. The Kemp administration is working to staff up the agency that handles eligibility.

Georgia Democrats have long pushed for a simple expansion of Medicaid to all the state’s uninsured poor adults.

No one interviewed for this story thought the GOP-led Legislature was open to that. Rather, anything viable for Republicans would be a “waiver” plan that accomplishes the same goal of widespread coverage for the poor but is tailored for the state.

Several states have done that, and at a committee meeting in November, Georgia House leaders showed they were interested in Arkansas’ version.

For its waiver plan, Arkansas agreed to cover the uninsured adult poor population earning up to 138% of the federal poverty level, or about $41,400 a year for a family of four. That’s standard and what the ACA calls for.

But what makes it unique is how Arkansas uses the Medicaid money. Arkansas took funds that would normally go to paying doctor and hospitals bills, and instead used them to pay private insurance premiums. The money is buying a traditional insurance policy on the ACA marketplace.

Private insurance is often better than Medicaid insurance because many doctors refuse to take Medicaid, so those patient experience a worse shortage of medical care.

That addresses a key worry of Kemp and his allies: that a slice of Georgians who already receive private ACA insurance under the governor’s plans not be shifted into weaker Medicaid coverage.

Whether it will improve health outcomes is not certain.

What was undisputed, though, was the health care funding pouring into Arkansas, especially in rural communities, which has helped sustain rural hospitals.

Resistance still remains

Not everyone in Georgia is thrilled at the idea of expanding Medicaid.

Some Republicans still believe it is too expensive. The federal government pays at least 90% of the cost of care for Medicaid expansion patients, but the state would still have to pay its sliver. If hundreds of thousands of patients take part, that could exceed $100 million.

That said, more than $1 billion in federal funding each year would start coming to Georgia health care providers.

In November, when the House leaders publicly opened discussion on Medicaid expansion, Americans for Prosperity, a libertarian-leaning group, issued a press release expressing “disappointment” with the committee’s discussion.

Libertarian-leaning groups such as Americans for Prosperity wanted lawmakers to instead repeal CON.

CON protects hospitals from competition by requiring anyone who wants to open a new hospital or some other health facilities to get the state’s permission, certifying that the new service is needed. Hospitals have traditionally said that without CON, new businesses would open up to cherry-pick their most lucrative customers, such as patients seeking treatment for cancer or bone surgery, and leave them with the money-losers, such as uninsured emergency room patients.

Opponents of CON call it government squelching a health care free market.

One of them is Jones. The lieutenant governor has made CON repeal a signature issue. He has also supported types of CON repeal that could benefit his family’s business. Jones’ father, Bill Jones, has pressed for a new hospital in Butts County in an area where his business owns nearby land. The lieutenant governor said he is focused on improving health care access for Georgians, not his family’s business.

He has an ally in Americans for Prosperity. But the group’s Georgia state director, Tony West, said in his written statement that Medicaid expansion would be “a poison pill.”

“AFP-GA opposes Medicaid expansion because it is bad for patients and taxpayers,” he said.

Some Democrats, on the other hand, are glumly watching Republicans get credit for even considering what Democrats have worked to achieve for a decade.

Sen. Michelle Au, D-Johns Creek, said she is not one of them. She chairs a committee of Democrats examining Medicaid expansion and is a physician.

“As a health care provider, I would say: Awesome,” Au said. “Whatever makes it as easy as possible to get them to ‘yes’ is what I would do and I will help them do it.

“They’re the reason we don’t have it, and they’re the reason we would have it, because they have the numbers. ... I would applaud them finally looking at the facts, and looking at the history, after more than a decade, to make the right choice.”

EDITOR’S NOTE: This story has been corrected to note that the state’s Medicaid program for poor adults includes those who perform certain state-specified activities at least 80 hours per month.