Republican lawmakers reluctant to commit to Medicaid expansion

After years of opposition, GOP state legislators take a cautious approach to change
Gov. Brian Kemp, shown shaking hands with Lt. Gov. Burt Jones following the State of the State address, has not made clear his stance on expanding Medicaid. (Arvin Temkar/

Credit: Arvin Temkar/AJC

Credit: Arvin Temkar/AJC

Gov. Brian Kemp, shown shaking hands with Lt. Gov. Burt Jones following the State of the State address, has not made clear his stance on expanding Medicaid. (Arvin Temkar/

Some Republican state lawmakers are softly signaling an openness to enrolling more people in government-funded health care plans — just don’t call it “Medicaid expansion.”

The politics behind extending government-funded health care to the state’s uninsured poor means the GOP-dominated General Assembly is not rushing to commit to a vote — either for or against — despite more than a decade of groundwork from advocates since the passage of the Affordable Care Act.

However, in interviews with more than a dozen Republican leaders and rank-and-file members across the state Senate and state House, two points are evident.

First, most would favor a waiver program that has been tested in Arkansas, where the state used federal expansion dollars to buy plans for people with lower incomes on the Health Insurance Marketplace.

Second, some are interested in trading a vote for expansion in exchange for easing rules that govern the establishment of new hospitals, called certificate of need or CON.

Georgia is one of just 10 states that have not accepted federal funding to expand Medicaid. Whether that changes may depend on who is willing to spend the political capital to lead Republicans to vote for something they have long opposed.

Several lawmakers interviewed said they were looking for signals from Gov. Brian Kemp, who has opposed Medicaid expansion and campaigned on an alternative called Georgia Pathways to Coverage, which has so far attracted fewer than 3,000 people out of an estimated 370,000 eligible for the program. Pathways offers Medicaid to working-age adults who work at least 80 hours a month, attend a technical college, or comply with another state-approved activity.

State Rep. Sharon Cooper, chair of the House Public Health Committee, said she would not support traditional Medicaid expansion. However, she said she would be open to extending access to private health care plans “if the governor was willing to champion a change to a different program.”

The governor has not made clear his stance on expanding Medicaid, through either the typical method, which provides Medicaid through private managed care plans or an Arkansas-style approach, and the issue was left unmentioned in his State of the State address earlier this month.

However, other top leaders shared sentiments that keep the discussion on the table, even if they are not stepping out as the issue’s torchbearer.

In a statement to The Atlanta Journal-Constitution, Lt. Gov Burt Jones said he “will prioritize expanding access to quality health care and removing barriers like the antiquated CON laws currently in place.”

Similarly, Senate Majority Whip Randy Robertson added that, “once I digest it and how it relates to CON, I’ll figure out what the best situation is.”

Jones did not directly address whether he would support Medicaid expansion without getting CON rules eased in exchange, saying he would “look at whatever the House puts forward.”

But there is no consensus on such a swap. Cooper said extending health care coverage “should be considered on merit, not linked as bait.”

At the annual Faith and Freedom Coalition luncheon Tuesday in Atlanta, where legislative priorities are laid out for a Christian conservative audience, state House Speaker Jon Burns said he wanted to “ensure all Georgians get the care they need and stay healthy.” Burns did not specifically say that meant he supports expanding Medicaid, but he has previously said he supports studying the issue.

The revived conversation around Medicaid expansion follows polling from the AJC that found 69% approval from Georgia voters toward expansion, including 47% of Republicans.

For many Republican lawmakers, it’s too soon to stake out a position on such a politically fraught issue, and their answers reflect that.

State Senate Majority Leader Steve Gooch said “people are asking questions,” and he’s “looking at options closely.”

Republicans have been friendlier toward the method from Arkansas, which was developed by a Republican-led Statehouse, partly because they view it as easier to sell to conservative constituents.

State Sen. Ben Watson, who chairs the Health and Human Services Committee, said he would favor the Arkansas method because more providers accept private insurance plans, giving patients more options for care.

Practically speaking, there is little difference in the health outcomes achieved by traditional expansion compared with Arkansas’ method, said Robin Rudowitz, vice president and director for program on Medicaid and the uninsured at KFF, a nonprofit health policy organization. Studies have found that in both approaches, more people in the state are enrolled in health insurance and benefit from preventive care, Rudowitz said.

The main difference between implementation plans is that in traditional expansion, most states administer Medicaid through private managed care plans while the Arkansas method uses the money received from the federal government to buy private plans in the health care marketplace. Often there is more politics than substance in how states have chosen to address expanding health care access.

“Sometimes states have called things different names and operate their programs a little bit differently for public outreach and to get support politically,” Rudowitz said.

If Georgia were to seek a waiver to implement its version of Medicaid expansion, the state would still need the private plans in the ACA exchanges to meet the requirements of Medicaid. For example, enrollees would still be entitled to lower out-of-pocket costs and non-emergency medical transportation access.

The details of a waiver plan, which typically spans five years, would also need to be negotiated with the Centers for Medicare and Medicaid Services because “the waivers are asking to do something that is not otherwise allowed under current law,” Rudowitz said.

Expanding Medicaid is mostly a good trade for states, she said, because the federal government would cover 90% of the cost of additional beneficiaries. States would also qualify for an added incentive for two years that would create a financial surplus, and hospitals often receive access to money for additional services, such as mental health care. Republican lawmakers have opposed expansion, in part out of a fear that federal dollars could disappear under future administrations, leaving the state to foot the bill.

Only two lawmakers were willing to endorse a health insurance expansion plan. Senate Finance Committee Chair Chuck Hufstetler, a Republican whose support dates to 2014, said the state should look at Medicaid expansion.

“It takes federal dollars and gets people preventative care that will keep them from much more expensive care,” he said.

A measure would also have a vote of confidence from Sen. Billy Hickman, who said that “in rural Georgia, we have people that need health care support.”

Election-year politics could throw a wrench into the lawmakers’ decisions to support or oppose expansion.

Some lawmakers privately worry their support could hurt them in primaries, but others have inched toward the measure following pressure from Democrats, who have long supported Medicaid expansion, during general elections in vulnerable districts.

Only one lawmaker — Senate Appropriations Chair Blake Tillery — flatly said “no.”

“I have not been convinced by the arguments I’ve heard so far,” the Vidalia Republican said.

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