The reporting and writing of this article were part of a collaboration with Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.
LITTLE ROCK — A growing number of red states are intensely debating — and some actively pursuing — Republican-friendly ways to extend health insurance to their poorest citizens under the Affordable Care Act, a law they've long reviled.
Georgia isn’t one of those states.
Indeed, the issue remains so politically toxic here that many Georgia Republicans are loath even to utter the phrase “Medicaid expansion” under the Gold Dome.
But experts say it’s just a matter of time before all states expand the health care program for the poor. They point to history: as now, many states were reluctant to embrace Medicaid when it was created in 1965, but all eventually did (Arizona was last to sign on, in 1982). And they cite economics, which they say turns the unpalatable into the inevitable. (Arizona, under a Republican governor, has already joined the states expanding Medicaid under Obamacare.)
“It makes too much sense from a state economic impact standpoint,” said Carter Price, a senior mathematician who studies health policy issues at the nonprofit Washington Center for Equitable Growth. “I don’t think I’ve (heard) a convincing argument against it.”
Every year Georgia passes on expansion, it turns away an infusion of roughly $3 billion in new federal money. Hospitals continue to lose about $1.7 billion a year in free care to the uninsured.
Often lost in the political and economic calculations is this harsh and simple fact: hundreds of thousands of poor Georgians continue to go without health care, and some of them are dying from conditions for which treatment is now available in other states.
For that reason alone, supporters say, rejecting expansion is morally unconscionable. But for those who are unmoved by that argument, refusing to expand Medicaid is also financially reckless for the state, supporters say.
Even Georgians who do have insurance are bearing the burden of the state’s refusal to address its uninsured problem. They pay roughly $1,500 more on average in higher hospital and doctor bills, highter insurance premiums and higher taxes each year. Expansion could help solve that dilemma.
That is, of course, if Obamacare stays intact.
Key court ruling due in June
The U.S. Supreme Court is poised to rule in June on whether millions of Americans should be allowed to receive federal tax credits that make buying health insurance affordable. The decision could preserve or potentially destroy the Affordable Care Act.
It’s that uncertainty, in part, that Gov. Nathan Deal and other Obamacare critics say makes it wise to wait on making a decision on whether to expand Medicaid.
The health care landscape could radically change based on the court ruling, said state Rep. Butch Parrish, R-Swainsboro, who co-chaired a study committee on Medicaid reform in 2013.
Parrish and other conservatives have also raised concerns over whether the federal government will fulfill its promise to pay at least 90 percent of the cost of expansion.
And, Deal says, the state can’t afford to expand a program that’s already bloated and inefficient.
“There are so many unknowns out there,” Parrish said. “We really don’t need to jump off this cliff before we know what we’re doing.”
'The right political combination'
Two Southern states — Arkansas and Kentucky — have expanded Medicaid so far. (This article is the third in a three-part series that began this week with an in-depth report on Arkansas’ expansion.)
And those decisions are already paying big dividends.
The states experienced the biggest drops in uninsured rates in the country, the latest Gallup survey shows. (Georgia, meanwhile, now has the second-highest uninsured rate, second only to Texas.)
Under expansion in Arkansas, more than 233,000 low-income residents have received health insurance. The state stands to save nearly $1 billion over a decade thanks to expansion. Admissions of uninsured patients to hospitals fell by nearly half in the first six months of expansion.
Those benefits haven’t come easy.
To achieve expansion in this small red state, a group of Republican lawmakers teamed up with then-Gov. Mike Beebe, a Democrat, to develop a conservative twist on expansion known as the “private option.” The private option uses government money to buy private insurance on the state’s online insurance exchange set up under the health care law. (The state had to get special permission from the federal government to pursue a nontraditional expansion.)
“It’s a matter of finding the right path and the right political combination to get to a yes,” said Joe Thompson, head of the nonpartisan Arkansas Center for Health Improvement and former state surgeon general. Thompson played a key role in creating the private option.
The private option is working, and Arkansas will end up with a healthier workforce and a competitive advantage over its neighboring states when it comes to economic development, he said.
‘They’re our friends, our relatives’
Even Arkansans not on Medicaid have benefited. The addition of tens of thousands of generally younger, healthier Medicaid recipients on the insurance exchange has helped to lower overall premiums by 2 percent on average in 2015.
In Kentucky, which also has a Democratic governor, leaders went a more traditional route and expanded its Medicaid program as is.
Expansion in the Bluegrass State will add an estimated 40,000 new jobs and $30 billion to the state’s economy through 2021, according to a study released earlier this year by Deloitte Consulting and the University of Louisville.
Most importantly, expansion is already having a collective impact on the health of Kentucky, a historically unhealthy state, said Gov. Steve Beshear in a recent speech. Some 46,000 people have been screened for diabetes; more than 80,000 have had preventive dental visits. The list goes on.
Better access to care for all Kentuckians was the whole purpose of this effort, Beshear said.
“These are not aliens from some distant planet,” he said. “They’re our friends, they’re our relatives, they’re our neighbors.”
‘Time to quit trying to be obstructionist’
Georgia Rep. Pat Gardner, D-Atlanta, sometimes feels like telling the poor in her community to move to Kentucky.
Georgia taxpayers are funding the expansions in Kentucky and other states anyway, Gardner said.
A spate of pro-expansion bills proposed by Georgia Democrats over the past two years have been largely ignored by the Republican-controlled General Assembly.
Currently, Georgia’s Medicaid program provides health coverage to about 1.8 million low-income children, pregnant mothers, the elderly and disabled. Expansion could extend coverage to another roughly 600,000 people, mostly adults without children.
Gardner said that while the governor may have been right to wait a bit, it’s far overdue for Georgia to begin looking at what it can learn from states that have successfully expanded Medicaid.
“Is it not time to quit trying to be obstructionists and make it work for the people of our state?” she said. “It’s baffling to me.”
‘Too good of a deal to pass up’
Gov. Deal has said everyone needs to wait until the Supreme Court hands down its ruling this summer before making any decisions, spokesman Brian Robinson said in a statement to The Atlanta Journal-Constitution.
Arkansas is one of six states to get permission from federal health officials to experiment with nontraditional Medicaid expansions. Iowa has adopted a variation on the private option. Indiana’s plan requires some Medicaid recipients to pay co-pays and contribute to health savings accounts. In Michigan, people can lower their out-of-pocket costs by changing unhealthy behaviors.
There are a variety of expansion alternatives for Georgia to look at, said Bill Custer, a health policy expert at Georgia State University.
“It seems a waste not to take one of those options,” Custer said. “The amount of money Georgia is passing up, the amount of jobs, it’s just too good of a deal to pass up.”
States that haven’t yet expanded will likely end up doing so using the nontraditional route, said Joan Alker, head of the Center for Children and Families at Georgetown University. Expansion has been a point of discussion — and contention — in recent months in Tennessee, Missouri, Utah, Florida, Wyoming and other states.
Gardner remains hopeful there will be some movement toward expansion in Georgia within the next year.
“(Deal) can do the math,” she said. “He does care about these families that don’t have insurance.”
‘We’re going to do something great’
Arkansas’ Republican leaders say they have only just begun transforming the state’s health care system.
The private option’s three-year trial phase concludes at the end of 2016. In the meantime, a group of lawmakers will be exploring pro-free market ways to overhaul the entire health care system, not just Medicaid.
Starting in 2017, states can apply for permission to make larger changes to some parts of the Affordable Care Act within certain limits. They could, for example, do away with the individual mandate or penalties for employers with more than 50 full-time workers. They cannot eliminate other elements, such as the requirement that insurers cover anyone regardless of whether an individual has a pre-existing condition.
“We’re going to do something great for those in need of health care,” said recently elected Arkansas Gov. Asa Hutchinson, a Republican. “I’m an optimist.”
For now, individuals and health care providers across the state continue to reap the benefits of the private option. Once losing money, the safety net hospital at the University of Arkansas for Medical Sciences in Little Rock is now in the black and able to invest in technology and begin to grant raises again, said Dr. Dan Rahn, the university’s chancellor.
If Georgia expanded, there would be less pressure on Grady Memorial Hospital, the safety net facility in Atlanta, Rahn said. States have to have a strategy to foster better health and economic development in the future, he said.
“You’ve got to have some kind of plan,” he said. “’Let’s just repeal the Affordable Care Act’ is not a plan. Then what?”