Gov. Nathan Deal and other state GOP leaders could soon be forced to consider what was once unthinkable: an expansion of the Medicaid program while there’s a Republican in the White House.
The governor and Republican allies for years slammed the expansion of the Medicaid rolls under the Affordable Care Act as too costly in the long run, and Deal’s opposition was a cornerstone of his re-election campaign against a Democrat who embraced the program.
But the House GOP health care proposal swiftly moving through Congress could force Deal and lawmakers to revive a debate that once seemed moot after Hillary Clinton’s defeat, thanks to a formula in the proposal that benefits states with more generous Medicaid funding.
That’s led Deal to lash out, warning that Congress shouldn’t “punish” Georgia and other Republican-led states that refused to expand the program because of long-term fiscal fears. Complicating the timeline is a late push by the White House that could wind up banning the states that haven’t yet enlarged the program from doing so now.
But if approved without substantive changes, Georgia Republicans are quietly bracing for an embarrassing new debate over Medicaid expansion while publicly lobbying Congress to help them avoid that painful decision.
“My concern is that states like ours that did not expand Medicaid coverage not be punished,” Deal said, “that we be treated fairly in the process of the reform.”
It gives gleeful Democrats who long slammed Deal and other Republicans for refusing to expand the program under the Affordable Care Act a gaping opening to say: “I told you so.”
"Your bad decisions oftentimes follow you," said state Sen. Vincent Fort, the chamber's No. 2 Democrat and one of Deal's most outspoken critics. "And not expanding Medicaid may be the home run of all bad decisions. Now we're going to have to pay the piper."
A GOP ‘dilemma’
The governor has long said Georgia can’t afford to grow a Medicaid program that is already broken and too costly by adding at least 650,000 people, mostly adults without kids, to Georgia Medicaid rolls that already cover about 2 million people.
His office had projected it would cost the state $2.5 billion over a decade because the state would be responsible for picking up 10 percent of the tab after three years, while expansion supporters said the actual cost would have been far less.
Democrat Jason Carter, Deal's challenger for the governorship in 2014, visited struggling rural hospitals that year to sharpen his call for Medicaid expansion. Worried about Carter's campaign, Republicans approved legislation that took expansion powers away from the governor and gave it to the GOP-dominated General Assembly.
Amid pressure from business groups, Georgia conservatives were begrudgingly preparing for some sort of expansion in a Clinton White House before Donald Trump's stunning victory seemed to have rendered that moot.
Yet the Trump-endorsed plan to repeal Obamacare has brought the discussion roaring back to life.
The measure, under fire from conservatives and liberals, would allow the more than two dozen states that have expanded the Medicaid program to continue receiving the generous federal funding before it freezes in 2020.
Right now, the feds pay states a certain percentage of any Medicaid costs they incur. But the GOP plan would shift to providing states a flat rate for each Medicaid enrollee, which doesn’t account for changing demographics. And the amount Georgia spends per person on Medicaid is one of the least generous in the nation.
Georgia and other states that didn’t expand their Medicaid rolls under Obamacare could recoup some of those costs over five years through a $10 billion account in the proposal for “safety net funding.” But frustrated state leaders worry they’ll still end up getting the short shrift for refusing the Obama program.
Lt. Gov. Casey Cagle was blunt in an appearance last week on GPB’s “Lawmakers” when he said Georgia came out on the losing end of the proposal.
“We’re working with our congressional delegation and others to obviously try to find some resolution where Georgia can become a winner going forward,” he said.
Changes aimed at appeasing conservatives unveiled Friday could let states transform their Medicaid programs into lump-sum block grants. And there was talk of a new provision that would deny Georgia and the 18 other states that didn’t expand their Medicaid programs additional funding if they did so now, although officials said the proposal was still in flux.
U.S. Rep. Buddy Carter, a Pooler Republican who is one of the state’s leading supporters of the plan, said he would strive to “make it as even as we can between the expansion states and the non-expansion states.” But he made no promises.
“I can certainly appreciate that, and I certainly understand that. It does create a dilemma,” he said of state leaders’ concerns, before pivoting toward an attack on the existing law. “To me, this is one of the worst things that Obamacare did. It puts able-bodied adults on Medicaid.”
‘Take advantage’
The plan could still be significantly changed before it reaches a final vote under pressure from the conservative wing of the GOP. Two Republican members of Georgia’s congressional delegation have expressed concern about the measure, in part because of the expansion dilemma it creates.
And the nonpartisan Congressional Budget Office's estimate that up to 24 million fewer Americans would be covered under the GOP plan by 2026 has spurred some Republicans in the U.S. Senate to call for more deliberation. A Georgia State University analysis concluded that 750,000 Georgians could lose their health coverage under the plan.
Meanwhile, scattered reports out of Washington signal there could be more changes that block states that haven’t expanded Medicaid from reversing course, which would please fiscal conservatives who don’t want to further grow the entitlement program.
U.S. Rep. David Scott said Republicans should seize the opportunity — and quick — to “immediately get a flush of money” for the state’s coffers.
“Take advantage of that now. Nathan Deal should have done it,” the Atlanta Democrat said. “They don’t have anything to lose, everything to gain to get this. It’s good for Georgia. We need an influx of money.”
Deal, for his part, has insisted Georgia made the right decision in refusing the expansion.
“When you give somebody something for nothing, it’s going to be very difficult to take it away,” Deal said, adding: “They’re going to have to find some other alternative. That’s perfectly fine with me, as long as they don’t punish Georgia in the process.”
Lawmakers are left preparing for what could be a gut-check moment. State Sen. Butch Miller, a likely candidate for lieutenant governor, said Republicans are well aware there's "wiggle room to come back and expand and adjust" in the law.
“The proof will be in the pudding. When the sun sets I think we’ll be in the right position,” said the Gainesville Republican, one of Deal’s top allies in the Senate.
“If we have to make changes, I’m sure the governor and the Legislature will make changes. But right now we’re sitting exactly where we need to be,” he added. “Let’s wait and see what the federal government does and then we take action.”
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