In spite of support, Medicaid expansion in Georgia remains unlikely

About 20 “Moral Monday” protesters were arrested at the state Capitol in March 2014 after disrupting the Senate by shouting and holding signs calling for Medicaid expansion. Georgia is one of 19 states that has refused to expand Medicaid under the Affordable Care Act. BRANT SANDERLIN /BSANDERLIN@AJC.COM

About 20 “Moral Monday” protesters were arrested at the state Capitol in March 2014 after disrupting the Senate by shouting and holding signs calling for Medicaid expansion. Georgia is one of 19 states that has refused to expand Medicaid under the Affordable Care Act. BRANT SANDERLIN /BSANDERLIN@AJC.COM

Georgians overwhelmingly support an expansion of Medicaid to cover hundreds of thousands of uninsured people, but expansion appears to be even less likely now than at any time since the Affordable Care Act passed in 2010.

That’s in large part because the new Congress is preparing to dismantle the law known as Obamacare, and state officials — the ones who would have to approve a Medicaid expansion — are waiting to see what happens in Washington.

Meanwhile, The Atlanta Journal-Constitution poll this week found that 75 percent of Georgia voters, including 57 percent of Republicans, favor Medicaid expansion. That's up substantially from the AJC's poll in 2014, which found that 57 percent of all Georgians supported expansion.

» Results of the AJC's 2017 political poll

Georgia won’t be entirely on the sidelines as the Obamacare debate unfolds in D.C. That’s partly because of Tom Price, the Georgia Republican who was selected by President-elect Donald Trump to be secretary of Health and Human Services.

“I think it’s going to be critically important … to have a person like him to help shape what the Affordable Care Act in terms of repeal and replace looks like going forward,” said Lt. Gov. Casey Cagle.

Cagle is heading a Senate task force aimed at making recommendations to Congress and Price to help Georgia.

The task force is one among a number of priorities Georgia lawmakers intend to address as the 2017 legislative session convenes on Monday. Issues to watch will include the renewal of a hospital fee to help plug a Medicaid funding shortage, a battle over the state’s approval process to expand medical facilities and unexpected doctor bills hitting patients’ wallets.

Episcopal Bishop Rob Wright joined with approximately 75 protesters, including several Atlanta clergy members and officials, in a Medicaid expansion protest outside the Governor’s Mansion in April 2014. KENT D. JOHNSON / KDJOHNSON@AJC.COM

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Medicaid expansion a no-go

For now, the General Assembly won’t take any significant action to extend health coverage to Georgia’s nearly 1.4 million uninsured residents. Georgia has the third-highest uninsured rate in the country at 13.9 percent, behind only Texas (17.1 percent) and Alaska (14.9 percent), the latest Census Bureau data shows.

“It doesn’t mean that the problem of the uninsured has gone away in Georgia,” said Ethan James, senior vice president of government relations for the Georgia Hospital Association. “We’re facing the same challenges, if not worse.”

Conservative state leaders have long opposed expanding Medicaid under Obamacare, saying Georgia couldn’t afford to grow a program that was already too expensive and unwieldy. (Thirty-one states have expanded Medicaid; Georgia is one of 19 that have not.) That has caused Georgia to lose out on billions of dollars in additional federal funding for the past three years.

But a growing number of Republicans have joined Democrats, doctors, hospitals and consumer advocates in pushing for some form of expansion. Doing so, they say, would not just extend health coverage to an estimated 600,000 Georgians but also bolster the state’s ailing network of rural hospitals.

Legislative leaders, however, say that moving forward with any sweeping expansion plan doesn’t make sense with so much uncertainty in Washington, following the Nov. 8 election. Congressional Republicans have vowed to repeal Obamacare but have not yet outlined any definitive plan, or timetable, for replacing it.

Even making temporary fixes to Georgia’s Medicaid program while Congress works on a possible replacement over the next year or more, isn’t on the front burner.

“Until we get this sort of obstacle out of the way, I think it’s premature to talk about stopgaps,” House Speaker David Ralston told reporters at the Capitol on Thursday.

Still, lawmakers appreciate the extent of Georgia’s uninsured problem, said Brian Robinson, spokesman for a Georgia Chamber of Commerce task force that unveiled three conservative-friendly expansion options last year. It’s now key to strongly communicate Georgia’s needs at the federal level, he said.

Plugging the Medicaid gap

Lawmakers are expected in the early weeks of the legislative session to debate whether to extend a fee on hospitals, known as the “bed tax,” aimed at helping to close a more than $600 million gap in Medicaid funding.

“I think it’s important that we pass it,” Ralston said. “I hope that we can take that up fairly quickly and get it behind us. Because frankly, it’s a real cornerstone of our health care system here in Georgia.”

Instituted in 2010 when Georgia was in the throes of the recession, the bed tax was supposed to last three years. It was renewed by the Legislature in 2010, however, and Gov. Nathan Deal has made keeping the fee in place a priority this year.

The hospital fee is based on a percentage of patient revenue. Those funds are then used to draw down hundreds of millions of additional federal dollars to help fund Medicaid and support hospitals that provide care to large numbers of uninsured patients.

Hospital showdown

The upcoming legislative session is also likely to see a heated debate involving the state’s certificate of need, or CON, process for hospitals and other health care providers.

Cancer Treatment Centers of America wants to admit more Georgia patients at its hospital in Newnan. As part of an initial compromise, CTCA was allowed to circumvent the lengthy and expensive CON process by agreeing to limit the hospital to 50 beds and cap the number of in-state patients it would treat at 35 percent.

The idea was to protect the customer base of the state’s regular hospitals, since cancer treatment is one of the few medical services that is reliably profitable. The company tried but failed to get the 35 percent cap lifted in 2015.

The CON process, which requires health care providers to prove there is a genuine need in a community for the services they want to offer, has long been a contentious issue at the Legislature. Proponents of standalone surgery centers have called for changes but have faced staunch opposition from the hospital industry.

Access to mental health care

Senate leaders plan a push on mental health care access and addiction issues, particularly tackling rampant opioid and heroin abuse. When the recession hit, addiction programs were some of the first state services to get cut, said Senate Health and Human Services Chairwoman Renee Unterman, R-Buford, and she hopes to get them restored.

In addition, she said, the state database that tracks physician prescriptions for Schedule I narcotics should be mandatory for all 20,000 prescribers, not just the 5,000 who are currently members of it.

“Beefing up that (database) is one of our main initiatives,” she said. “It’s also one of the most controversial.”

Other initiatives may improve access to psychotherapy.

Doctors and sex abuse

An AJC investigation found that two-thirds of Georgia doctors it reviewed who were disciplined for sexually violating patients were allowed to get their licenses back, or never lost them.

Some of those doctors then were accused of more violations; but no law prevents them from practicing again, and patients are almost never notified of the doctors’ disciplinary histories.

Unterman said she plans to take up the issue this year. Speaker Ralston has said he thinks the issue is a concern for “every Georgian” but would have to know more about it before backing legislation.

‘Surprise’ billing

The state’s largest doctors’ group plans to focus this legislative session on out-of-network, or so-called “surprise,” billing.

For example, a patient plans a medical procedure at a facility within his or her insurance network. But too late, they learn that one of the doctors brought in to collaborate was not in-network and they get a big unexpected bill for the doctor’s services.

Especially with many patients now having higher deductibles, people can’t afford those higher bills, said Donald Palmisano, executive director of the Medical Association of Georgia. That means doctors sometimes aren’t able to collect payment for services they’ve provided.