Imagine that you own a business with a partner. Your product costs a dollar to make. You invest 33 cents on the dollar to make your product; your partner invests the rest. What if your partner said they see so much potential in your product, that you must only pay 10 cents and they will invest the rest? We’re doctors, not business leaders, but to us this sounds like a great deal! Except here we aren’t making products, we’re helping Georgians achieve better health through Medicaid expansion.
Expanding Medicaid means Georgia only pays 10 cents on the dollar for new enrollees in Medicaid through expansion. Currently, our state contributes about 33 cents on the dollar for Medicaid enrollees.
As physicians caring for adults at the largest safety-net hospital in Georgia, we see firsthand the gaps that exist in healthcare delivery among the uninsured in rural and urban communities alike. Our patients come not only from counties our health system serves, but also from “out of county,” paying out-of-pocket for the care they receive. This is often because of rural hospital closures, lack of access to specialty care centers, scarce access to primary care in rural areas, all downstream effects of uninsurance which limits practices from opening in affected areas.
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Take for example the patient who’s a widower and visits her doctor to get a note for work. She works as a greeter in a retail store, a position which requires her to be on her feet for long stretches. Her knee arthritis is getting worse, and she can no longer stand for long. She wants to continue working and needs her doctor to attest to her need to occasionally sit in a chair. She can’t work a full-time job because she is also a part-time caregiver to her elderly mother, whose own health is failing. Medicaid makes sense as her part-time employment does not provide insurance.
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Many more are now uninsured as a result of layoffs; fortunately Medicaid is not linked to jobs. Through Medicaid expansion, we now have a deal where the state only pays 10% of such persons’ care!
In Georgia, we have not yet expanded Medicaid. This decision was partly due to concern that Georgia’s budget would hurt too much if we expanded Medicaid. However, the newly passed American Rescue Plan of 2021 includes a deal too good to pass up: the share of current Medicaid enrollees’ costs would be boosted by the federal government by 5 percentage points over the first two years after expansion. This boost to a large pool of current enrollees would more than make up for the costs of expansion to a much-smaller group of newly eligible enrollees, meaning Georgia would, in effect, get paid over the next 2 years to provide coverage to additional Georgians!
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While the 5 percentage-point increase in federal funding to current Medicaid enrollees ends after 2 years of expansion, federal funding to new enrollees through the expansion will remain at 90% moving forward, meaning health spending by the state will occur at 10 cents on the dollar for new enrollees via the expansion. However, this cost is offset by the fact that states save money in other areas, such as mental health, education, and public health spending.
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Could the increase in Medicaid enrollees through expansion overwhelm the primary care workforce, making access to care worse? Studies do not suggest this. In Michigan, for example, a large surge in Medicaid enrollees occurred after the state chose to expand. Interestingly, appointment availability for new Medicaid patients increased from 49% to 55% after the implementation of Medicaid expansion in Michigan, and wait times for new Medicaid and new privately insured did not significantly change. Increases in the Medicaid reimbursement rate to primary care doctors under the ACA in 2013-2014 could have played a role in physicians and other healthcare providers accepting additional patients. Clinicians and health systems in Michigan may have considered Medicaid expansion an opportunity to serve a larger share of new patients, allowing them to expand practices in financially viable ways.
Are there other ways Georgia might benefit form Medicaid expansion? Yes -- through more jobs! Job growth has been observed in multiple expansion states, which means not only enhanced quality of life within communities -- but also increased tax revenues for participating states. Further, Medicaid expansion improves the health disparities that we see in minority and other vulnerable populations, which in part results from lack of health insurance and access to care.
Health starts where we work, live, and play. Too many Georgians live in communities suffering from extremely costly housing, diminished public transportation, underemployment, and lack of access to medical care. Expanding Medicaid will improve access to care and employment among these communities, allowing them to thrive, not just survive. Georgia made the mistake of not expanding Medicaid in 2010. Many hospitals in rural areas closed as a result, leaving individuals like the above-described patient struggling. Second chances don’t come often; let’s make this commonsense decision that will be a “win” for all.
Stacie Schmidt, M.D. is a primary care internist in Georgia and an associate professor of medicine. Tracey L. Henry, M.D., M.P.H., M.S., is an assistant professor of medicine at Emory University and assistant health director in the Grady Primary Care Center. Erica Heiman, M.D., MSc, is a primary care internist at Grady Memorial Hospital and assistant professor of medicine at Emory University. Marshall Fleurant, M.D., M.P.H., is an internist at Grady Memorial Hospital and an assistant professor of Medicine at Emory University. The views expressed here are their own and do not represent Emory University or Grady Health System.
