Now that President Barack Obama’s landmark health care law has twice been upheld by the nation’s highest court, Georgia’s state and federal leaders are coming to the begrudging recognition that the legislation won’t be changed any time soon.
But the well-dug trenches remain unmoved: Most Democrats insist on a Medicaid expansion in the state as the only path forward. Most Republicans are determined to repeal the law.
Meanwhile, a small cadre of lawmakers hope that Georgia’s involvement in a controversial waiver program could provide a new, and less contentious, path forward to bring in more federal funding for health care.
In the wake of Thursday's U.S. Supreme Court ruling to maintain health insurance tax credits in states such as Georgia that did not create their own exchanges, the political and policy status quo remained unmoved.
Gov. Nathan Deal and House Speaker David Ralston both signaled they don’t intend to step into what they see as a federal matter, and they called on Congress to give states more flexibility to use federal funding.
Republicans in Washington, meanwhile, pledged to maintain a path to repeal the law and replace it with a more conservative version, even while conceding that any significant changes would have to wait until at least 2017, when Obamacare’s namesake is no longer in office.
And Democrats implored critics of the Affordable Care Act to admit defeat and move on.
“The ACA is now the law of the land,” Atlanta Mayor Kasim Reed said. “And millions of Americans are healthier and more financially secure as a result.”
Medicaid expansion unlikely
Thursday's decision was the second landmark ruling upholding a key tenet of the law. The Supreme Court in 2012 voted 5-4 to validate the law's requirement mandating that most Americans buy health insurance or face a penalty. Both decisions were devastating to the law's GOP critics, who have sought to undo Obamacare since it was enacted in 2010.
“I’m disappointed because we really hoped we’d have the opportunity to correct, replace and otherwise fix an awful lot of problems caused by the Affordable Care Act,” Georgia Republican U.S. Sen. Johnny Isakson said. He said it means Republicans will have to “continue to do what we’ve been trying to do, which is amend where necessary, repeal where necessary.”
Georgia Democrats tried to pivot the conversation to their long-held dream of expanding Medicaid, the health care program for the poor and disabled. Part of the Supreme Court’s 2012 ruling allowed states to choose not to take part in the Affordable Care Act’s expansion of the health insurance program for the poor.
DuBose Porter, who heads the Democratic Party of Georgia, accused Deal of playing politics by refusing to expand the program. And state Sen. Vincent Fort, the chamber’s No. 2 Democrat, said his party would make it an election-year priority.
“The wait is over,” Fort said.
The federal government would pick up at least 90 percent of the costs of an expansion, but Deal and other GOP leaders have long said that Georgia can’t afford its long-term share of growing the program.
Reversing course would require more than just changing the governor’s mind. A law enacted last year would also require a vote from the Republican-controlled state Legislature to expand Medicaid. Ralston, the House speaker, adamantly opposes such a move, and he called on Congress to take “decisive action” to keep insurance costs in check.
“American health care was once the envy of the world,” Ralston said. “Now the world watches as Obamacare drags our health care system down into ruin.”
Boosters of expanding Medicaid predict that hard line will soften over time. Millions more Americans will likely be enrolled in Obamacare’s programs by 2017, making it increasingly difficult for Republicans to gut the law even if the GOP wins the White House.
U.S. Rep. David Scott, an Atlanta Democrat, pointed to the plight of Georgia’s rural hospitals. Dozens of those facilities face funding shortfalls so acute that they threaten access to care for tens of thousands of Georgians across the state, and eight have shuttered since 2001.
“People are not going to move, businesses are not going to move where there’s not a hospital,” Scott said. “And we need solid economic development and growth in rural Georgia. And who are the representatives that represent most of rural Georgia? Our Republican friends.”
A third path?
A third path, however narrow, has emerged in recent weeks.
The spending plan Deal signed into law in May empowers the state to apply for a Section 1115 waiver to the Medicaid program, which could be used to secure more federal funding for health care. Deal insisted in a recent interview it won’t be used to expand Medicaid, but it would “explore the possibilities of covering people who are uninsured.”
The request is led by Grady Memorial Hospital, which is working with struggling rural hospitals to craft a plan to cover some of the estimated 650,000 people who would be covered if Georgia expanded Medicaid. Deal said the request aims to “give us some flexibility” in using federal funds for health care.
“That’s the main ingredient that governors like me have been saying all along,” he said. “If you give us some flexibility, then we could provide greater coverage and more coverage.”
Some fiscal conservatives have questioned the legality of the move, including Republican state Rep. Scot Turner of Holly Springs, who called it an attempt to "back-door an expansion of Medicaid."
Others, though, hold out hope it could break the stalemate in Georgia. State Sen. Chuck Hufstetler, a Dalton Republican who is one of the few GOP elected officials who publicly supports expansion, said the waiver could emerge as a politically palatable compromise.
“I am hopeful that the federal government will allow us to use these dollars in a responsible manner that brings better health to our citizens and allows our health facilities to continue to be there to provide for them,” Hufstetler said.
On to the campaign trail
Many Republicans publicly bemoaned the ruling, while some quietly acknowledged their party had dodged a bullet.
The GOP-held House and Senate leaders were coalescing behind strikingly different plans on how to step in if the Supreme Court stripped health insurance tax credits from millions of Americans, as hard-line conservatives refused any plan that would prop up the law.
Instead, they have a black-and-white campaign issue. All the major Republicans running for president have said they want to repeal the law.
“Every GOP candidate for the Republican nomination should know that this decision makes the 2016 election a referendum on the full repeal of Obamacare,” said U.S. Sen. Ted Cruz, R-Texas, who is running for president.
Hillary Clinton, the Democratic front-runner for president, has embraced the law and urged Republicans to “move on.”
“The Affordable Care Act isn’t perfect, but the evidence is clear: It’s working,” she said, adding: “Republicans should stop trying to tear down the law and start working across party lines to build on these successes.”
Public opinion remains split, though there are some signs the law is becoming more popular: A CBS/New York Times poll Monday showed that 47 percent of Americans approve of Obamacare — the highest number in that poll since the law was signed — compared with 44 percent who disapprove. Still, only 9 percent wanted to keep the law as is, while 55 percent said it has good aspects but needs changes, and 31 percent want a total repeal.
Republicans have held more than 50 votes in the U.S. Senate seeking to repeal or strip parts of the law, mostly without success. The next question is whether they'll try again this year using a procedural maneuver known as "budget reconciliation" that only requires 51 votes in the Senate to pass.
That move would surely face an Obama veto, as the president declared Thursday that the law is “here to stay.”
Georgia’s GOP delegation is quick to add a caveat to that.
“Well, it’s probably here to stay until he’s not president anymore,” Isakson replied when told of the remark.
“Nothing in Washington is forever, and nothing is for certain. And we’re going to continue to work to try and see to it the American people have access to affordable, competitive, quality health care.”
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