Everywhere Stacey Abrams campaigns for governor, she brings up Medicaid expansion.
The question — of whether to expand Medicaid to Georgia’s poorest adults — is now 6 years old and no more advanced than it was when the state’s GOP leaders first shot it down. But, pitched as “a moral and economic imperative” by Democrat Abrams’ campaign and “a failed government program” by Republican Brian Kemp’s, Medicaid expansion has become a central issue of the 2018 race for governor.
And no matter who wins, it’s hard to say for sure some version of expansion won’t happen.
The state’s health care problems are manifest to anyone looking for votes: rural hospitals closing, rural counties without doctors, doctors and hospitals everywhere that patients can’t afford. Each side sees that and declares Medicaid is either the solution or part of the problem.
“I do think health care’s going to be one of the big issues,” said Alan Abramowitz, a professor of political science at Emory University.
He said Abrams will continue hammering the economic advantages of Medicaid expansion while Kemp pans its cost to taxpayers.
“I don’t know whether, or how much he wants to talk about that (in the general election) to be honest,” Abramowitz said. “It polls pretty well. It’s a popular idea.”
Big idea, big roadblock
That much is true.
The Atlanta Journal-Constitution has polled Georgians for years about Medicaid expansion, and solid majorities have always favored it. As years passed, majorities of Republicans did, too. In a poll this January, 73 percent of Georgians supported Medicaid expansion and 51 percent of Republicans did.
But many conservatives within the GOP have slammed it as an egregious expansion of government by the Obama administration.
The authors of the Affordable Care Act, also known as Obamacare, never intended to be in this position. They wrote the law to give insurance help to everyone who earned about the average U.S. income or below. For most people, it created the well-known private market for insurance with public subsidies, the ACA exchange market.
But for the poorest, including those just above the poverty level, the law simply mandated that Medicaid would expand to cover all of them, even childless adults.
When conservatives challenged the Obamacare law, they lost the war, but they won a battle. The U.S. Supreme Court ruled that forcing states to expand Medicaid wasn’t legal. They could choose, and conservative states mostly set down stakes against it.
Since then, popular movements or political shifts in some of those states have led them to approve expansion after all, as Virginia did this year.
Would it help?
Georgia is one of the nation’s most populous states, with some of its most advanced industry and yet some of its worst health care metrics. At least seven rural hospitals have closed since 2010. Nine Georgia counties have no doctor. Only Alabama, Delaware, Mississippi and the District of Columbia have worse rates of infant mortality.
Even for the well off, insurance prices are exorbitant.For Abrams, access to health care is “the fundamental, expensive problem the state of Georgia faces today,” as she told an audience last week in Columbus, and the first answer she offers is Medicaid expansion. She paints it as an economic boon, an investment of state dollars that would be more than matched by the payoff to workers and boost to Georgia’s economy, especially when the influx of federal dollars is considered. The ACA promised states that the federal government would match the states’ contribution 9-to-1 at least until 2020.
Abrams spokeswoman Priyanka Mantha said that “expanding Medicaid actually makes our state money, bringing our tax dollars home from Washington, D.C., to keep our rural hospitals open, bring health care to nearly 500,000 Georgians, drive down health care costs for everyone, and create over 50,000 jobs.”
She and other advocates of Medicaid expansion play down the price tag, which even the most optimistic count as well over $100 million a year from the state. An analysis from the Urban Institute found that it would cost Georgia taxpayers $246 million a year and cover an additional 473,000 Georgians. Critics have disputed those numbers.
Georgians for a Healthy Future is a patient advocacy group that supports Medicaid expansion. “Georgia’s really leaving money on the table,” said Laura Colbert, the group’s president. Just raising the state’s tobacco tax to the regional average would cover it, she said.
Kemp’s campaign is just as aware of the state’s health care woes. He makes a point of telling rural Georgians he will work with the private sector to use “incentives” and the internet to improve access to care. Just not Medicaid expansion.
“Medicaid costs too much and fails to deliver for hardworking Georgians,” Kemp spokesman Ryan Mahoney said in a statement to the AJC. “Taking money away from public safety and education to expand a failed government program will only make things worse.”
A third way
There is another solution that has always had the ear of moderate Republicans and is getting a louder hearing now. A Medicaid “waiver,” if approved by the federal government and cleared of legal controversy, could expand Medicaid coverage in a more tailored way.
An option that often comes up in interviews with GOP leaders is a work requirement. That’s something the Trump administration supports, although the courts have struck down at least one state’s attempt at a work requirement because it didn’t show it advanced the goals of the Medicaid law.
Colbert acknowledges that a waiver might do the same thing as outright expansion, depending on how it’s set up. She doesn’t want it to screen out those who don’t draw a salary. “Health insurance is a tool that allows people to go to work rather than vice versa,” she said.
Kyle Wingfield, the president of the Georgia Public Policy Foundation, is keenly interested in a waiver for the state. He’d like to see more flexibility in state insurance plans, freeing them from covering everything that plans currently do. While Democrats have called that “junk insurance,” he says there’s little difference when patients can’t afford a deductible.
“What we believe about Medicaid expansion is that it’s more expensive than the solution needs to be,” he said.
Mahoney, asked about Kemp’s position on a waiver, didn’t directly answer but mentioned other ideas such as high-risk insurance pools and association plans. “As governor,” he said, “Kemp will champion health care solutions that lower premiums and costs while improving access for hardworking Georgians.”And if Abrams won, for all her promises, she’d still have to get the Legislature to vote with her. “It’s unimaginable she’d have a Democratic majority there,” said Charles Bullock, a political scientist at the University of Georgia. “So she’d face a major selling job, she’d have to tap the skills she had as minority leader to reach across the aisle.”
If so, her spokeswoman said, it wouldn’t be because of the polling. “Expanding Medicaid …,” Mantha wrote, is “not a political issue.”
Medicaid expansion: some facts
- The Affordable Care Act covers people with medium-to-lower income via the exchange, a market of private plans subsidized with public help. This income range was 138 percent to 400 percent of the federal poverty level.
- Originally, it mandated that for people at 138 percent of the federal poverty level and below — those making zero to about $16,000 a year for a single person — would be covered by expanding Medicaid in every state to cover not just children or their mothers but working and nonworking adults.
- The U.S. Supreme Court decided that the ACA was legal, but not with the mandate for Medicaid expansion. That would be a choice for each state to make.
- Many Republican-dominated states refused to make the expansion, leaving a coverage gap for the consumers with the least means to pay. Some states have since changed their minds. Georgia is now one of 14 states with no Medicaid expansion or expansion waiver in place or in play.
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