Medicaid, not Medicare, pays for Dorothy Mae Harbin’s nursing home room in Cumming.
Medicaid also pays for Aaron Hartman’s medications, job coach and home aide in Toco Hill.
Without Medicaid, Savannah pediatrician Dr. Ben Spitalnick doesn’t know how he would serve a quarter of the children in his practice, or if he’d even have a chance to: Many of their parents would probably put off doctor visits, pray, then end up at the ER.
In Georgia, Medicaid serves nearly 2 million people with a surprising array of needs. But the sprawling federal entitlement program has grown beyond what its creators envisioned when President Lyndon B. Johnson signed it into law in 1965. It now forms one of the largest pieces of the pie of government spending — thanks in part to the sheer cost of medical care — and Republican leaders in Washington are determined to rein it in.
Shrinking Medicaid is an integral part of both House and Senate plans to repeal and replace the Affordable Care Act. Senate GOP leaders left Washington for the July 4 holiday week pledging to return with a renewed drive to revise U.S. health care law. It’s a vow that has sparked fear among many of those who rely on the program.
Behind the cuts
The Congressional Budget Office estimated that $772 billion of the Senate plan’s $1 trillion in spending reductions would come from curbing Medicaid spending.
Many Republicans say the program was never designed to grow as large as it did, expanding greatly after the Affordable Care Act, or Obamacare, folded in more working-age people. Some worry program costs are ballooning to untenable levels and that otherwise able-bodied adults are cheating the system rather than joining the private sector.
Rep. Buddy Carter, R-Pooler, supports the efforts of his fellow Republicans in the Senate.
“I believe that once we let the states have control of it, either through block grants or per capita spending, that it’ll be a much more efficient and effective program,” Carter said. “I think it’ll be even better for those that it’s serving.”
Some state leaders, including several Republican governors, aren’t so sure. Some have come out forcefully against the Senate bill. Georgia Gov. Nathan Deal has expressed reservations, but has not opposed it.
For half a century, the federal government has joined with the states in paying for any eligible medical care that a Medicaid patient submitted. Republicans want to cap the amount of money the federal government will send to a state, leaving the final ball — and decisions on what to fund — in states’ courts.
Patient advocates are terrified.
“We’re stressed out of our minds,” said Arletta Brinson, 65, whose mother depends on Medicaid for her nursing room in Atlanta.
Several patients and advocates interviewed by the AJC said that if the plan passes, they foresee a lobbying war between poor children, poor adults, disabled adults and the elderly for diminished resources.
“It would pit segments of populations, it would pit providers against each other,” said Tony Marshall, president of a Georgia association of nursing homes. “Obviously, we all believe the right provider is us.”
The senate plan would cut the deficit by $321 billion over 10 years, but other savings would go to tax breaks for the wealthy and insurance companies, a fact that opponents have seized on.
“It is wrong,” U.S. Rep. John Lewis told the AJC this week as he descended the Capitol steps with fellow Democrats, dressed in funeral black to take part in a “mourn Medicaid” protest against the Republican plan. “It is wrong to give tax cuts to millionaires and billionaires to take away from the most vulnerable among us. It is wrong. And if we do, history will not look kindly upon us.”
For its beneficiaries, Medicaid isn’t about money.
Aaron Hartman might be institutionalized if not for Medicaid. Hartman, 46, has Williams Syndrome, a physical and mental disability. Medicaid has helped pay for surgeries and medications. But it also has a rare deal with Hartman’s family. Medicaid will fund all kinds of services to keep him functioning in his community, as long as they add up to less than it would cost to institutionalize him. It’s a special arrangement the family secured after eight years on a waiting list.
So an aide works at his side eight hours a day making sure he eats well, dresses appropriately, makes it to doctor’s appointments and otherwise functions from day to day. The aide makes sure he’s shaven properly, so that he is presentable for work. A job coach helped train Hartman to do basic tasks like bagging in a grocery store, and he now earns a paycheck on two-hour shifts as a greeter at Publix.
Because of all that, he can live among his synagogue community, and go to visit friends on his down time. “I like wearing my uniform and I really like going to work when I work,” Hartman said.
Aaron’s father, Sandy Hartman, said when he hears about the Medicaid changes being considered in Washington, “My heart sinks. It really does. This has been his lifeline.”
Sandy Hartman is concerned that if cuts come, services like Aaron’s will be the first on the chopping block.
Jerry Patton feels the same way — but about the nursing home patients he houses. He’s afraid they’re a less attractive political constituency than children or the disabled.
And don’t go thinking that a 5 percent cut, much less a 35 percent cut, in available funding is going to be OK, he said. “As it is, Medicaid’s already break-even at best,” he said. “If they cut it it’s really going to affect our ability to get adequate staff. ”
As a businessman, he said he appreciated the message that less regulation would improve things. But sometimes it is just a matter of money, he said. “We’re already stretched pretty thin on how much money we have to spend on resident care as it is,” he added.
One of his residents, Dorothy Mae Harbin, 88, said the nursing home’s social environment was as important to her health as the medicines and medical services. “You’d like to be home,” of course, she said.
But it feels good, she said, when she makes someone a piece of embroidery and they smile.
“I’m the only one on my hall that can walk with my walker,” she said. “I try to take care of them.”
She’s lost her siblings and all her five children but one, who is overloaded caring for other family members of his own. Without Medicaid paying for her and her neighbors’ nursing home beds, she said, “we’d have nowhere to go.”
Over on the coast in Savannah, Dr. Ben Spitalnick is an advocate the children he treats and others across the state. He, in turn, worries the children he treats won’t be able to stand up for themselves.
“That’s the hard part,” Spitalnick said. “While pediatricians do a good job standing up for children, children themselves don’t vote. And parents with children on Medicaid are less likely to be politically active.” They often are stretched thin already working and getting to minimum-wage jobs, he said, and also aren’t sophisticated with the political system.
Spitalnick says pediatricians are stretched, too.
“You don’t realize,” he said. “If your practice is significantly Medicaid and you cut rates 10 percent, some people think, ‘OK that means the doctor makes 10 percent less money.’ No, sometimes that means the doctor makes 100 percent less money. Because he has overhead. It could put a doctor in a rural county out of business.”
Nearly half of Georgia children get Medicaid or another supplementary medical aid program; in rural counties, Spitalnick said, that can be 80 percent or 90 percent of children. More than half of Georgia births are funded by Medicaid.
And families use Medicaid for preventive care, he said, coming in for checkups and immunizations.
“For them, things will build up before they get much sicker and show up at the emergency room,” Spitalnick said.
Senate Republican leaders have been working furiously behind closed doors in recent days to rework their proposal, the Better Care Reconciliation Act, to win support from fellow Republican senators. They can only afford to lose two Republican votes, and reports this week showed them lacking as many as nine or ten.
Issues on the table have included a tax break for the wealthy and funding for opioid addiction treatment. But one of the biggest sticking points has been the 31 states that expanded Medicaid under the Affordable Care Act in order to aid poor adults.
Georgia leaders chose not to expand, saying they feared it would become too costly in the long run.
The state’s two Republican senators and Deal have pushed the Senate authors of the health care bill to ensure that non-expansion states such as Georgia would not be “punished” for their earlier decision to leave Medicaid as-is.
“As I have said before, we want to make sure we are not punished because we did not expand our Medicaid population,” Deal said in an interview Thursday. “We did not add to the federal deficit because we did not put that extra burden on the taxpayers of this country. So we want to be treated fairly.”
Lt. Gov. Casey Cagle convened a task force on how Georgia can try to shape and respond to the federal health care law, and its next meeting is a week from Monday. Georgia would lose less money than other states, but would still lose, according to an anaysis by the firm Avalere.
Sen. Renee Unterman, a Buford Republican who sits on the task force, said there should be more screening for who gets Medicaid, but she’s “very concerned” about what might happen with the state’s funding because the ball will be dropped in the state’s court.
She mentioned opioid funding, which she’s working on in the Legislature. “You have to take care of these people,” she said. “When they come to the ER with an overdose you can’t turn them away. You can’t just turn the ventilator off.”
Both of Georgia’s senators, Johnny Isakson and David Perdue, back the Senate GOP leaders’ efforts, and said that doing right by the people of Georgia is job one.
Their hope is that whatever passes now will be a step in the right direction.
The proposal now is just part of a much longer term plan, said Sen. David Perdue. “I want something that’s better than the ACA,” he said. “It doesn’t have to be perfect, it’s not going to be perfect. But this is step one.”
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Staff writer Greg Bluestein contributed to this article.