The measure, Senate Bill 106, now heads to the House, where it is likely to face stronger opposition.
SB 106 would allow the governor to request waivers from the federal government to design a Medicaid program for the poor and a health insurance support program for the Affordable Care Act exchange market.
The 32-20 vote in the Senate broke cleanly along party lines, with Democrats opposed to the latitude it would give the governor and the limits it would impose. Kemp said he thought they were being “just stubborn in some regards.”
He continued: “It’s OK to disagree on one part of a bill, but it’s still worth going through the exercise even if you don’t agree with our position. I personally do, obviously. I mean I staked my political career on that.”
Relieving one piece of the curiosity about how he would use such a law, Kemp confirmed that he would attempt to use the ACA waiver to form a “reinsurance” program. His idea is to help private insurance companies on the exchange market pay for the high cost of patients with pre-existing conditions, which would save them money and hopefully pass the savings on to their consumers. That would include people of all income levels who buy individual plans on the exchange.
“I want to help give better health care for all Georgians, more accessible, more affordable,” Kemp told The Atlanta Journal-Constitution.
The part of the bill directed at the poor, the Medicaid waiver provision, spurred the most angst. The bill initially raised hopes, especially among liberals and moderates who would like to see Medicaid expanded to the hundreds of thousands of poor childless working-age adults in Georgia who have no health insurance.
Critics are now concerned, however, by the amount of power it would give the governor to shape the programs if the bill becomes law. Republicans in the House have expressed concern about expanding the number of people covered by Medicaid. Democrats in both chambers are concerned the governor may get the power and then do too little with it. They also oppose a cap within the bill that would limit the poor population to be covered by a Medicaid waiver.
"This bill doesn't have safeguards," said Senate Minority Leader Steve Henson, D-Stone Mountain. "It doesn't have a backup plan."
Senate Republicans began the day by voting to engross the bill, meaning that no one would be allowed to suggest amendments to it or debate them. Democrats objected.
"We should be debating this bill, which is the most important bill we're going to see," said state Sen. Zahra Karinshak, D-Duluth. "We should be ashamed. This is not Republican or Democrat, this is life or death."
Senate Health Committee Chairman Ben Watson, R-Savannah, bridled at the notion the bill had not been debated, citing a dozen witnesses who testified before his committee. He gave the bill one hearing last week in which 14 witnesses were each given three minutes or less, and then the debate and vote were held, all in the space of an hour.
“To say that we did not debate that is not factually accurate,” Watson said. “It’s not right to say things that are misleading.”
SB 106 needed to get through the Senate quickly in order to deal with what is likely to be a more complicated reception in the state House. House Speaker Pro Tem Jan Jones, R-Milton, earlier this month warned to "look very carefully until we add an entirely new entitlement program that doesn't really look at the long-term financial implications."
On the Democratic side, two primary concerns about the bill both centered on the possibility it would exclude too many people from coverage, and cost the state money it doesn’t need to forgo. Full Medicaid expansion under the Affordable Care Act could bring billions of federal dollars into the state health care industry to help cover Georgia’s poor under a 9-to-1 federal match to dollars the state puts in.
Full Medicaid expansion covers those up to 138 percent of the poverty level, such as individuals with an income of about $16,000 per year. But SB 106 would only allow the governor’s waiver to deal with those who make up to 100 percent of the poverty level, or about $12,000 per year for an individual.
That has a couple of consequences. One is, it’s possible Georgia wouldn’t receive the full 90 percent federal match promised for full Medicaid expansion. So far, opposition in the Obama administration and internal disagreements in the Trump administration have stalled applications for that 9-to-1 federal match by states that only wanted to expand Medicaid up to 100 percent of the poverty level.
The other is the hiccup for the poor who fall between 100 percent and 138 percent of the poverty level. They would still be allowed to obtain coverage on the ACA exchange with big subsidies as they are now. But they have small co-pays and would have only six weeks a year to enroll.
“Premiums and co-pays are great barriers to care for low-income people,” said Joan Alker, the executive director of Georgetown University’s Center for Children and Families.
State Sen. Blake Tillery, R-Vidalia, the bill's sponsor, called SB 106 "a simple bill that can do miraculous things for health care in Georgia."
“This bill doesn’t just address the rich, it doesn’t just address the poor,” Tillery said. “It covers the gamut of Georgians.”
THE MEDICAID GAP IN GEORGIA
The poor in Georgia are covered my Medicaid only under specific circumstances, including if they are children, mothers with minor children, or declared disabled by the state. Most childless adult Georgians below age 65 are not covered by Medicaid no matter how poor they are. Full Medicaid expansion under federal rules would cover all people who make up to 138 percent of the federal poverty level, or about $16,000 per year for an individual. Georgia’s Medicaid waiver, however, intends only to deal with the population up to 100 percent of the poverty level, or about $12,000 per year for an individual. Here are the pluses and minuses for those groups:
Income $0 to 100 percent of poverty level:
In Georgia, they’re currently not eligible for Medicaid or the Affordable Care Act insurance exchange. Senate Bill 106 proposes to develop a Medicaid waiver to possibly cover some of this population. That would be more than they’ve got now, but possibly with restrictions they wouldn’t have under full Medicaid expansion. One possible restriction, should it be approved, is a work requirement.
Income 100 percent of poverty level to 138 percent of poverty level:
In Georgia, they’re currently not eligible for Medicaid but they are eligible for ACA exchange plans with big subsidies. These are very cheap or even free private health plans with some $5 co-pays and a small out-of-pocket cost cap. And they can go to in-network doctors who don’t take Medicaid. The downside: $5 co-pays for an individual who makes $13,000 a year is a big problem, according to researchers. And having to marshal transportation and scheduling to register only during the annual six-week open enrollment period is also a roadblock. If these people had Medicaid instead, they could enroll any time of the year and would have no co-pays.
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