If the feds revoke the Medicaid waiver plan, “Georgia will challenge the decision,’' Commissioner of Community Health Frank Berry wrote in the conclusion of his letter to officials with the Centers for Medicare and Medicaid Services. He called the work and other eligibility requirements “core to the waiver.’'

State Republican lawmakers have defended the waiver plan promoted by Gov. Brian Kemp.

The Berry letter comes as the federal government dangles new incentives for states to pursue a much larger enrollment increase in Medicaid through a regular expansion of the program under the Affordable Care Act, something most states have done already.

Medicaid provides health coverage to low-income and disabled residents, including about 2 million in Georgia.

Georgia’s waiver says that to get Medicaid coverage, a person is required to put 80 hours a month into a job, an education program, a volunteer organization or another qualifying activity.

A February letter from the CMS, though, criticized Georgia’s policies ’'that condition health care coverage on meeting work or other community engagement requirements.’'

The letter from the feds pointed to uncertainties related to the COVID-19 pandemic, including job training and other activities used to satisfy work and other requirements, along with access to transportation and affordable child care.

Twelve states received federal approval under the Trump administration to impose Medicaid work requirements. But federal courts have blocked work requirements in Arkansas, Kentucky and elsewhere, and the U.S. Supreme Court is expected to take up a related case this month.

Berry, in his letter, said state officials “worked with CMS in good faith to adopt an innovative program to deliver coverage to a new category of individuals while helping them build important skills and become more independent and self-reliant.’'

The Berry letter said Georgia officials had agreed to allow virus-related exceptions to the requirements for coverage, and that the COVID-19 pandemic has now eased.

CMS officials could not be reached Wednesday for comment on the Georgia letter.

The Trump administration opposed the ACA, supporting lawsuits against it and congressional efforts to repeal it. CMS officials under Trump approved the Georgia waiver as an alternative to a standard Medicaid expansion.

President Joe Biden, however, is a staunch supporter of the ACA, which became law while he was vice president.

Sweetening the offer

Georgia is one of 12 states that so far have chosen not to expand their Medicaid programs as outlined by the ACA. But the newly approved COVID-19 relief legislation gives those states enhanced financial incentives to adopt expansion.

States that expand the program at this point would receive an additional 5-percentage-point increase in their regular federal Medicaid matching rate for two years. So over that time, even factoring in the costs of implementing expansion, Georgia would net $700 million under the new incentives, according to the Kaiser Family Foundation.

The Kemp waiver plan, as outlined now, is much less ambitious. It would cost $75 million for the first year and cover just 31,000 low-income adults, according to the consumer advocacy group Georgians for a Healthy Future. The federal match under the Kemp waiver plan would be the regular 67% of the cost.

A standard expansion would give Medicaid eligibility to 480,000 to 600,000 people in the state, said Laura Colbert, the group’s executive director.

“Medicaid expansion has always been the moral and cost-effective choice for Georgia,’' she said recently. The new incentive package, she said, “just amplifies that choice.’'

Democrats, including Georgia’s newly elected U.S. Sens. Jon Ossoff and Raphael Warnock, have pointed to the state’s potential gains under Medicaid expansion, including helping hospitals and other medical providers.

“If Georgia does not expand Medicaid,” Warnock recently told The Atlanta Journal-Constitution, “then we are literally leaving money on the table that could save the lives of Georgians.”

Andy Miller is editor and CEO of Georgia Health News.