New life for Medicaid expansion in Georgia

For a decade, Medicaid expansion has seemed a stubborn partisan issue, with Georgia Republicans reluctant to support a key component of the Affordable Care Act.

• But the tide can turn.

Driving the news: Speaking on condition of anonymity with nearly a dozen lawmakers and lobbyists, Axios has learned that some Georgia Republicans have quietly changed their minds about Medicaid expansion and that behind-the-scenes discussions have been going on about a way forward .

• Sources declined to speak about the recording due to the political sensitivity of the issue.

101: The expansion of Medicaid means increased access to state health insurance coverage for low-income residents in exchange for a 10 percent state adjustment in federal spending.

Why it matters: Georgia is one of 12 states still declining the government’s offer to extend coverage to people living up to 138% of the federal poverty line, or nearly $19,000 in annual income for one person.

• If it gets here, an estimated 500,000 more Georgians could get coverage compared to pre-COVID numbers.
• Polls have consistently shown that a majority of Georgians support the expansion, and most Republicans according to a national poll.

What you say: “There’s a lot of talk going on in many rooms about how Medicaid might be expanded in Georgia regardless of who gets elected governor,” Democratic House Representative Mary Margaret Oliver told Axios. Conversations between Democrats and Republicans are happening in a way that feels new, she said.

• “None of us have a clear path right now, but everyone is crossing their fingers,” she said.

brian robinson was spokesman for former Georgia Gov. Nathan Deal, who first opposed Medicaid expansion a decade ago. But Robinson is one of the few Georgia Republicans to publicly argue that it’s time to make the change because of politics and politics, he told Axios.

• “We wouldn’t do that,” Robinson said of Medicaid’s much-criticized structure. “But Republicans can’t agree on what we would do. This is the policy and the law and it will not go away. It would bring home hundreds of millions from a program we are already contributing to.”
• Robinson said Republicans’ initial fears — that the federal government was withdrawing its 90% matching fund — have not materialized in other states. And the “Repeal and Replace” movement against the Affordable Care Act has died in Congress and in court.

Yes but: Georgia Republican leaders, including Gov. Brian Kemp, who has rejected the idea of ​​full expansion, have so far blocked the policy.

• In a July news conference, Kemp said he hadn’t heard from Republicans who had changed their minds. “It will take a vote at the General Assembly,” he said.
• He said Republicans have opted for “a more holistic approach to health care versus a unified government approach,” including a partial expansion of Medicaid for mothers a year after childbirth, state funding for rural health care providers, and a waiver proposal to expand coverage around 50,000 other Georgians.

Hospital maintenance personnel remove the Southwest Georgia Regional Medical Center sign in Cuthbert, Georgia after the hospital closed in October 2020. Photo: Courtesy of Hyosub Shin/The Atlanta Journal-Constitution

republican some of the 11 other non-enlargement countries have also shifted their positions recently.

Zoom out: North Carolina Republicans shocked many by nearly passing this spring’s expansion.

• A former Alabama governor has publicly urged fellow Republicans to pass it in favor of rural parts of the state.
• Some bipartisan legislative moves to expand this year have given supporters in Wyoming hope.
• Voting initiatives to expand Medicaid by referendum were approved by voters in several Republican states. The issue is on the ballot in South Dakota this year.

“There’s a real dynamic about Medicaid expansion in these conservative states that have held back,” said Melissa Burroughs of Families USA, a health care advocacy group that works with partners in non-expansion states to advance the policy.

• The raid, she told Axios, “is more a matter of overriding political dynamics and leadership.”

What’s happening: Based on Axios’ coverage, there are several reasons why the Georgia talks have shifted.

• closures of hospitals. Eight rural hospitals have been closed in Georgia over the past decade, including the highest number in the country. While not a silver bullet, adding people to Medicaid rosters would mean revenue for hospitals that they don’t otherwise get for uninsured patients.
• COVID-19. As part of the federal public health emergency, Medicaid access has been automatically extended. This state of emergency could soon expire, which could mean an estimated 250,000 to 450,000 Georgians could lose their cover.

• Money. While estimates vary, full expansion could cost Georgia less in the first year than the governor’s proposed waiver program, according to calculations by state budget writers and officials for 2019. Also, the federal Pandemic Relief Act of 2021 sweetened the deal for non-enlargement states.
• Politics. Medicaid expansion continues to be popular in this battleground state.

Note: South Dakota voters will vote on expanding Medicaid in November; Data: KFF; Diagram: Axios Visuals

Game Status: Stacey Abrams, which continues to make Medicaid expansion a central pillar of its campaign platform, told reporters last month that it is confident the votes for expansion are in place to pass the Georgia legislature today.

• “Republican governors gradually moved across the country, realizing that the economic benefits outweighed any political challenges they might inherit,” she said.

Flashback: In 2014, under Gov. Deal brought together nearly all Georgia Republicans to pass legislation preventing the governor from unilaterally expanding Medicaid.

Yes but: In a notable shift for a Republican governor, Kemp lobbied for a partial expansion of Medicaid through two waiver proposals in 2019 that would expand coverage to about 50,000 more Georgians. However, both were rejected by the Biden administration.

• One was rejected because it contains labor requirements that multiple courts have ruled unconstitutional but remain the subject of active litigation. Georgia sued the federal government over it.
• The other waiver would sever the state’s relationship with Healthcare.gov and was rejected last week.

The Intrigue: Robinson, a Republican strategist, claims that Kemp actually has “a better chance of getting this through with a Republican legislature than Abrams would.”

• “Nobody questions Kemp’s conservative credibility, and it fits his message about expanding access to health care and rural development,” he said.
• Kemp, Robinson said, actually “led the Medicaid issue [with the waivers] and the support he received in the General Assembly for his waiver plan shows that the policy has changed.”

while robinson, who supports Kemp’s re-election, understands why some still oppose full expansion, he argued that fears of a backlash from Republican voters are less realistic today.

• Also, “Politically, it would steal an issue where the Democrats have an electoral advantage,” he said.

Majority Leader in the State Senate Mike Dugan Axios said Republicans are “expanding Medicaid,” citing partial expansions like waivers and postpartum coverage. However, he does not know whether the full expansion will pass the state senate.

• “We are rigorously reviewing it and will continue to do so,” he said. “It’s just not as fast as some would like it to be.”