Tens of thousands of poor Georgians could receive Medicaid or subsidized employer health insurance under the second part of a wide-ranging proposal Gov. Brian Kemp unveiled Monday seeking to revamp health care in Georgia.
The governor’s long-awaited waiver plan would impose requirements that recipients of a limited Medicaid expansion be employed or involved in other activities, an idea that pleases conservatives but is meeting stiff resistance in federal courts.
The potential impact of his “Georgia Pathways” proposal falls far short of what a full-scale expansion of the Medicaid program under the Affordable Care Act would achieve. That prospect is a nonstarter under Kemp, who campaigned against it.
Kemp’s alternative, known as an 1115 waiver, takes aim at some of the state’s poorest residents: the 408,000 or so adult Georgians who make less than the federal poverty level — about $12,000 a year for an individual — but do not qualify for Medicaid.
Kemp’s aides estimate a fraction of those — about 50,000 people — will be enrolled under this plan.
“They need coverage but have run out of realistic options,” Kemp said. “We will shake up the status quo and give 408,000 Georgians the opportunity to purchase affordable health insurance. We will bring hope to what many think is a hopeless situation.”
The governor and his aides say that extending Medicaid eligibility to those who have jobs, are enrolled in school or are engaged in specific types of community service will encourage more of the state’s poor to lift themselves out of poverty through job training and education.
Kemp, who called a full-scale expansion a “risky one-size-fits-all that costs too much,” declined to answer a question Monday about how the plan would address the more than 300,000 people who would be left uninsured under his plan’s projections.
Federal challenges
The policy he outlined Monday is designed to package with a separate set of proposals he introduced last week.
One part seeks to lower insurance premiums by setting aside more than $300 million in public money that the government could pay to insurance firms to cover high-cost claims. The second piece would also shift $2.7 billion in subsidies from federal to state control to reduce costs to lower-income policyholders.
Each of the waiver proposals must be approved by the federal government before it is implemented — no certainty despite Kemp’s ties to President Donald Trump. Kemp’s advisers, however, express confidence the proposals will pass muster and note they’re in frequent contact with White House officials.
The proposals must also withstand court scrutiny, no simple task in light of a spate of federal lawsuits that have forced states to overhaul how they handle health plans that link benefits with employment.
Federal judges have blocked or stalled work requirements in Arkansas, Kentucky and New Hampshire. And officials in Arizona and Indiana voluntarily moved away from compelling poor people to work in order to qualify for their Medicaid programs.
The revamp will face stiff criticism from Democrats and health care advocacy groups who say nothing short of a full Medicaid expansion will cover hundreds of thousands of uninsured Georgians, boost the state’s economy and shore up the flagging network of rural hospitals. It also met criticism from advocates of waivers that do more than Kemp’s would, as Grady Memorial Hospital released a statement Monday saying it was “deeply disappointed.”
The governor intends to move quickly. Following his announcement Monday the Department of Community Health held a specially called meeting and voted to approve the proposal. His administration set up a six-stop “listening tour” starting Thursday in Savannah.
The public commenting period closes on Dec. 3, and Kemp aims to submit the waiver to Washington by year’s end.
How it works
Work and community engagement requirements in other states have been blocked or tied up in courts. Kemp’s aides say Georgia is different because those other states first tried full Medicaid expansion, then decreased the number of people in the program by implementing the engagement requirements. Georgia is doing both at once. The plan also has added a couple of unique engagement options.
To qualify, recipients must show 80 hours of activity a month. That could be through a job, volunteering, community service, vocational training, full-time post-secondary education or a limited set of other activities.
The time would have to be documented and qualify under state guidelines. Under the plan’s guidelines, community service wouldn’t qualify unless it was at a registered nonprofit or public organization. And those taking care of a sick relative also wouldn’t be eligible.
“This is not a free handout. Hardworking Georgians who qualify will have skin in the game,” the governor said. “It is a path forward toward higher earnings, better opportunities and healthier behaviors.”
Kemp’s aides project that the 50,000 or so residents that the waiver would cover would change from year to year, as they cycle up out of Medicaid and into private insurance available through Obamacare to working-class earners.
His administration pegs the cost for the first year of the program at $128 million, with the state on the hook for roughly $36 million and the federal government footing the rest. That’s less than half of what the governor expects to put toward his initiative for higher-income insurance customers, which is expected to cost $104 million in its first year.
The point is not to throw money at the problem of the uninsured poor, supporters say, but to push recipients toward full-time employment.
"There's going to be no excuse for people not to be covered," said state Sen. Ben Watson, R-Savannah, the chairman of the Senate Health Committee, who has been briefed on the plan.
‘Something wrong’
Proponents of full Medicaid expansion to all of Georgia’s poor criticized the logic behind the plan.
They say it’s turned around: That people need health coverage first in order to be healthy enough to find work. They ticked off the list of people who would likely remain untouched, including those with mental illness, the homeless and the many who are disabled but don’t meet the narrow federal designation of disabled.
The idea reminded Laura Colbert, the director of Georgians for a Healthy Future, of the same activity requirements that were stymied by federal judges in other states.
“Those plans don’t work for the people that need coverage,” Colbert said. “If there are really 408,000 people who could qualify for coverage and in five years the majority of those people are not expected to be covered, then there’s something wrong with the plan.”
Grady’s administration said that the plan “continues to place the burden of caring for hundreds of thousands of Georgia’s medically underserved on rural and safety-net hospitals across the state.”
Still, Kemp’s advisers point to unique incentives embedded into Georgia’s waiver designed to win court approval and the White House’s sign-off.
The plan offers premium assistance to some people whose employers offer health insurance at unaffordable levels. And it would require beneficiaries to pay a premium, starting at $7 per month for those with almost no income, that caps at $11.
The U.S. Supreme Court could soon weigh in on the matter, potentially complicating Kemp’s waiver efforts. But supporters say they can amend their proposal if needed.
The backers include state Sen. Chuck Hufstetler, an anesthetist from Rome who is among a small group of Republicans who bucked party lines to call for an expansion.
“It’s got a great opportunity to help people get training and to get out of poverty,” said Hufstetler, the chairman of the Senate Finance Committee. “As well as getting them insurance.”
