Key Republicans say they’re open to legislation that would add hundreds of thousands of poor Georgians to the state’s Medicaid rolls — and bring in billions of federal dollars to subsidize it — as part of a compromise to roll back hospital regulations.

Some are giving a fresh look to a program adopted in Republican-led Arkansas, where 250,000 additional residents are eligible for Medicaid coverage under a long-running initiative that health care analysts have dubbed the “private option.”

And senior officials say a tradeoff could involve changes to certificate of need rules sought by Lt. Gov. Burt Jones and his allies that could clear the way for new hospitals, particularly in rural parts of the state, and for-profit medical offices.

That was the subtext earlier this month when a hearing on Georgia hospital regulations led by state Rep. Butch Parrish, one of the Legislature’s health policy experts, shifted suddenly to a discussion of plans to boost Medicaid enrollment.

“We just got a lot of good information,” the Swainsboro Republican told The Atlanta Journal-Constitution, “and now we’ll have to sort it all out.”

Talk of a GOP embrace of broader Medicaid changes has become such a perennial issue in Georgia it often prompts eye rolls at the Capitol. But there’s a sense it has gained new traction.

“This year, I do think it’s possible — if the right factors come into place,” said state Sen. Chuck Hufstetler, long an outspoken GOP supporter of the idea.

Gov. Brian Kemp’s plan to extend Medicaid coverage to Georgians who meet work or activity requirements has drawn tepid interest, with just 1,343 uninsured adults enrolled in its first three months. Kemp aides estimate that’s out of about 370,000 uninsured Georgians who could apply.

That waiver is set to expire in 2025 — and Republicans acknowledge it’s unlikely to win an extension if President Joe Biden is elected to a second term.

Add to that the all-out push by the lieutenant governor and his allies to roll back hospital regulations, an initiative that could require Democratic support as part of a comprehensive health care overhaul.

With the 2024 election looming, some Republicans hope to neuter Democratic criticism of Georgia’s health care policy by joining 40 other states that have already expanded Medicaid or are set to do so this year.

That political clash could intensify as former President Donald Trump threatened to resurrect the fight over the Affordable Care Act, saying he is “seriously looking at alternatives” if he wins a second term after failing to repeal it during his first stint in the White House.

Credit: Arvin Temkar/AJC

Credit: Arvin Temkar/AJC

Democrats see an opportunity, particularly if their votes are needed to adopt a compromise.

“We have a lot of leverage,” said House Minority Leader James Beverly, who added that any proposal must address two issues: “We have to negotiate to lower the high maternal mortality rates, and Medicaid expansion has to be front and center.”

‘Private option’

There’s good reason to be skeptical of any new Medicaid breakthrough.

Democrats and a handful of Republicans have pressed to expand the Medicaid program since then-Gov. Nathan Deal closed the door on a full-scale expansion about a decade ago.

And each year, they’ve been blocked by GOP leaders who remain opposed to a broader expansion, which they see as too costly and inflexible in the long term.

Instead, Kemp and his allies have backed a limited expansion for poor adults who meet requirements such as working or volunteering for at least 80 hours a month.

But that still means hundreds of thousands of Georgians remain uncovered at a time when other GOP-led states have abandoned their opposition.

Georgia is one of only 10 states that haven’t fully expanded Medicaid eligibility when North Carolina joins the roster in December, though state polls routinely indicate a broad majority of voters support expanding the rolls.

Some Republicans worry the opposition could come back to haunt the GOP. A small group began gathering about a year ago with a handful of lawmakers to seek out ways to redefine the debate.

Among the advocates is Chris Riley, a former top aide to Deal who now lobbies on behalf of the Grady Memorial Health System. He said Georgia can craft a “tailored Medicaid waiver” in 2025 that provides commercial insurance reimbursement rates while staying budget-neutral.

Credit: Alyssa Pointer

He and others often refer to the program as a “1115 Medicaid waiver” rather than “expansion,” a politically freighted term for many conservatives. A waiver allows a state to add to its Medicaid rolls, but with federal permission to waive some of the Affordable Care Act’s requirements.

Riley called Arkansas’ program a prime “blueprint” for Georgia.

“Georgia’s rapidly growing workforce requires healthy workers,” Riley said. “This program is about meeting the needs of hardworking Georgians who get up and go to a job every day to provide for themselves but aren’t yet able to afford coverage.”

A ‘workable’ win?

The Arkansas plan quickly gained converts among the small group of Republicans, who recently brought in GOP state Sen. Missy Irvin to discuss how she helped lead the Medicaid expansion in that state.

When Arkansas expanded Medicaid in 2014, it took a novel approach. Unlike states that enrolled new residents into existing Medicaid programs, the state used expansion dollars to buy private insurance for uninsured residents.

Credit: TNS

In Georgia, a 2014 law took the power to expand Medicaid away from the governor and gave it to the General Assembly. Georgia House leaders are seen as more receptive to an expansion, while the state Senate might be the most significant stumbling block.

State Sen. Ben Watson, who chairs the Health and Human Services Committee, was noncommittal in a recent interview.

“I’d have to learn more about it,” said Watson, a physician who has pressed to weaken the state’s certificate of need requirements. “I really would have to study that more and evaluate it a little bit better.”

Kemp is not openly taking sides, either, at least for now, though his allies remind lawmakers that he won his 2022 reelection victory on a campaign that featured his health care policy even as Democrat Stacey Abrams made expanding Medicaid a focal point of her agenda.

Credit: Miguel Martinez

A prime target of any health care overhaul is the certificate of need, which requires medical providers to undergo a state approval process before they can build a new hospital or expand health care facilities.

Supporters say it prevents private practices from cherry-picking the most lucrative patients and leaving hospitals with the money losers, such as rural emergency and primary care patients. Critics say it’s outdated and helps powerful hospitals maintain their dominance.

The lieutenant governor led a push in the Senate earlier this year that would have freed rural parts of the state from certificate of need requirements, allowing new hospitals and for-profit medical offices to be built in counties with fewer than 50,000 residents. That would have paved the way for construction of a medical center in Butts County, possibly on land owned by Jones’ father.

It didn’t pass then but remains a priority for Jones and his allies in the Senate. On Tuesday, a Senate committee approved recommendations that include a full repeal of the certificate of need rules.

“The Senate analyzed this issue and provided strong recommendations to consider once the legislative session begins in January,” Jones said. “We will take a look at those in the coming weeks and will work with the House to find real, innovative solutions.”

Longtime advocates of Medicaid expansion are cautiously optimistic. Monty Veazey is president of the Georgia Alliance of Community Hospitals, which has sought to both safeguard current hospital regulations while pressing to expand Medicaid.

“Everything right now seems pretty positive from our standpoint,” Veazey said, “we’ll just see how it all unrolls.”

Hufstetler, who chairs the Senate Finance Committee, has seen this debate play out plenty of times before over the past decade. But he also acknowledged that federal funding tied to any expansion serves as an enticing sweetener.

“I see a win that’s workable for everybody — combined with a Medicaid expansion,” he said.