For seven years, Georgia’s GOP leadership has opposed expanding Medicaid to cover the state’s poorest residents, citing worries about the long-term cost. That may be about to change.
Gov. Brian Kemp has proposed the state spend $1 million to investigate how the state could get a “waiver” to give the state more flexibility to use federal dollars and may let Georgia add more people to the Medicaid rolls.
He’s guided by former U.S. Health and Human Services Secretary Tom Price, who has urged Georgia to “lead in a big way” on such programs. And now the Georgia Senate’s new health and human services chairman is out front on the effort, advocating for a conservative way to cover hundreds of thousands of additional Georgians.
Whatever comes of the effort won’t be the wholesale expansion that Democrats say is essential to help rural hospitals, spur the economy and provide the neediest with medical coverage. But it would be a more limited way to expand the rolls that borrows ideas from other Republican-led states.
Advocates of the idea sense some momentum in Kemp’s first year, but they also urge caution.
“I feel it,” said Monty Veazey, who lobbies for rural hospitals. “I gotta see it.”
Medicaid expansion has broad public support in Georgia. The Atlanta Journal-Constitution's most recent poll, conducted in January, showed 71 percent of registered voters want the state to expand the program. Previous polls have showed a similar level of support.
State GOP leaders say they can make a conservative case to do it. That would entail obtaining a Medicaid “waiver” to allow Georgia to tailor the expansion in a more conservative way.
State Sen. Ben Watson, the new chairman of the state Senate Health and Human Services Committee, joined a small but growing group of elected Republican officials seeking a conservative way to give more Georgians coverage.
Watson’s vision involves mirroring a program adopted by Indiana when Mike Pence was governor, including mandatory health savings accounts and work requirements for Medicaid recipients. He called it a palatable way Georgia could join the other 36 states that have expanded the program. It comes with a bonus: According to the AJC’s January poll, 65 percent of registered voters also support a work requirement.
“It’s a compromise. It’s a way to get hundreds of thousands more people on the rolls, but to do it in a conservative way,” Watson, a Savannah physician, said in an interview. “We need to get them covered, but this is the Georgia way to do that.”
In doing so, he echoed the former chairwoman of the influential health committee, state Sen. Renee Unterman, and several other Republican officials who have called for the GOP to retreat from its opposition to expansion.
It sharpens a divide in the Georgia GOP over one of the biggest perennial debates in the statehouse, pitting Republicans who have long opposed any sort of expansion under the Affordable Care Act, also known as Obamacare, against others who say Georgia should try to leverage the program to help rural communities and spur the economy.
“At the end of the day, any expansion is good for rural hospitals,” Veazey said. Not having coverage for the poorest has been devastating for hospitals, he said, helping lead to several closures. “I talked to one last week, they had five days’ operating cash,” he said. “That’s how dire it is.”
The waiver is by no means a done deal. House Speaker David Ralston, R-Blue Ridge, in an interview this week said he wasn't ready to discuss the idea. "I haven't looked at it, so I'm not ruling anything out," he said.
But the statements by Watson are the best sign of a Republican shift in attitude since Kemp used his State of the State address to float the idea earlier this month. In that speech, Kemp said he’d devote $1 million to developing a waiver proposal but offered few other details.
“It’s going to give us the ability to innovate and change the system. The problem that we have now is the current system is not working,” Kemp said in a recent Georgia Public Broadcasting interview, speaking broadly of the waiver idea. “This will give us new initiative, new innovation to change the model — which is what we need.”
The Indiana waiver that Watson referenced was used to add hundreds of thousands of people to the Medicaid rolls — and was often cited by Democrat Stacey Abrams during the governor’s race as an example of how Republicans support a version of Medicaid expansion.
Laura Colbert, who leads Georgians for a Healthy Future, has long advocated for full-on Medicaid expansion. She said she was cautiously optimistic. Work requirements don’t have to be a deal-breaker, she said, but she likes to call them “work reporting requirements,” leaving room for coverage for people who can’t be employed to report why and still get covered.
“Most people who are in the coverage gap who can work already work,” she said. “Those who don’t tend to be doing things society values, such as going to school or caring for loved ones. The reporting requirements can be burdensome bureaucratic processes that get in the way of people getting coverage.”
However, she said, “I am pleased that Georgia’s decision-makers are taking steps forward to ensure low-income Georgians have health insurance coverage.”
Indiana’s program requires adult enrollees to work an average of 20 hours a month, and it doesn’t apply to people who are over 60. It offers a list of exemptions, which include job training, volunteering, and caring for a child or disabled parent.
Georgia is one of 14 states that have not expanded the Medicaid program, and Democrats generally insist it’s the only sensible option. Aside from the health care issue, by not expanding Georgia is turning down billions of dollars in federal matching money.
A fiscal note released last week shows the net cost of expansion for the state is about $200 million a year.
In an eight-page fiscal note delivered to House leaders, the state auditor estimated the net cost of the expansion would be about $150 million in 2020 and range between $188 million and $213 million by 2022.
Democrats seized on the estimates to build a case for expansion. House Minority Leader Bob Trammell called it the "best investment Georgia can make in health care spending."
“Putting an insurance card in the pocket of nearly 500,000 Georgians for a net cost to the state of $150 million in 2020 should be the first priority for this General Assembly,” Trammell said. “The fiscal note shows what 36 other states have already figured out: It’s time to expand Medicaid.”
The audit projected that as many as 535,000 newly eligible Georgians would join the program by fiscal year 2022, once it reaches full enrollment. It also foresees at least 40,000 people who are already eligible for the program will sign up after expansion.
State auditors say total state spending on the new recipients will range between $273 million and $340 million by 2022 — about $560 per new enrollee. That will partly be offset by a spate of health care spending that brings in more tax revenue and cost savings associated with the program.
Republicans, including Kemp and former Gov. Nathan Deal, have said funding Medicaid expansion would be too costly in the long run, particularly if the federal government ends a matching program. They also say expansion would take state dollars from priorities such as public safety or education.
"We're not going to put our state at risk by relying on Nancy Pelosi and Chuck Schumer to fund one of Barack Obama's policies," Republican state Rep. Trey Kelley said. "We want to find ways to lessen Georgia's dependency on the federal government and find a Georgia-grown solution."
Any debate over expanding Medicaid in Georgia is complicated by a 2014 law that gives legislators the final say over expanding the program. Watson said using Indiana as a template could be key to earning legislative approval, in part because it’s more likely to be approved by the White House.
“If we model it after that plan, the feds will likely approve it,” he said. “I’m not saying it’s the only one we can do it, but it sounds like it’s more easily done.”
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