ATLANTA – Medicaid expansion was long politically impossible in Georgia.
Now it's just unlikely.
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Georgia House Speaker Jon Burns says he wants lawmakers to consider more health coverage in the state as their session begins Monday. But he’s careful not to label it Medicaid expansion, and certainly not “Obamacare.”
“The speaker is committed to lowering costs and increasing access to healthcare across the state, and will be working closely with members over the coming weeks to develop sound policy to do just that,” Stephen Lawson, a spokesperson for the Newington Republican, said Thursday.
After North Carolina began offering Medicaid to uninsured adults on Dec. 1, there are 10 remaining states that don't cover people with incomes up to 138% of the federal poverty line. That's what was envisioned in President Barack Obama’s 2010 health care overhaul.
Like in Georgia, there's a thaw in Mississippi, where GOP legislative leaders say they're open to extending coverage, even if newly reelected Republican Gov. Tate Reeves remains vocally opposed.
“We’re fixing to look at every facet of Medicaid expansion, and if it makes sense, we’re going to do it,” Rep. Jason White, newly elected as Mississippi's House speaker, said last week.
But Robin Rudowitz, a KFF vice president who directs the nonprofit group's program on Medicaid and the uninsured, said there's little movement in other states. In Kansas for example, Republican lawmakers are spurning Democratic Gov. Laura Kelly's pro-expansion campaign of events with business leaders, hospital administrators and health advocates.
Kelly argued in a recent interview that she’s addressed every Republican argument opposing expansion and “there really, truly is no good reason" not to act.
Like other holdouts, Georgia Republicans long resisted participating. Lawmakers in 2014 even passed a law saying the governor couldn't expand Medicaid without their approval.
In July, Republican Gov. Brian Kemp launched a limited expansion offering coverage to able-bodied adults earning up to the poverty line — $14,580 for an individual or $24,860 for a family of three. But people must document 80 monthly hours of work, study, rehabilitation or volunteering to be eligible for Georgia's Pathways program, and enrollment has plodded, with fewer than 1,100 people signed up through October.
Opposition to broader expansion in Georgia began publicly wavering in November, when state House members held a hearing on how Arkansas uses Medicaid money to buy private coverage for residents. Like traditional Medicaid, the plan requires copayments of $5 or less for most services while paying medical providers more than Arkansas' traditional Medicaid program.
Republican Arkansas State Sen. Missy Irvin told Georgia lawmakers that Arkansas cut uninsured visits to hospitals and clinics by half, calling it “the best outcome for Arkansas.”
Advocates of extending health coverage feel hopeful.
“In the past it has been the Republicans that have said ‘no’ to Medicaid expansion. Now we see more coming around,” said Monte Veazey, CEO of the Georgia Alliance of Community Hospitals.
KFF projects more than 430,000 uninsured Georgia adults could gain coverage if Medicaid is broadened. Of those, 250,000 don't qualify for subsidies to buy individual policies, leaving them ineligible for both Medicaid and subsidized marketplace policies. Others are eligible for marketplace policies, but haven't enrolled.
Nationwide, KFF estimates 3.5 million uninsured adults would become eligible if all states expanded Medicaid.
Any expansion would come as Georgia and other states are purging millions off the Medicaid rolls who had been retained during the pandemic without proving continuing eligibility. Georgia thus far has removed almost 450,000 people.
Democratic state Sen. Nan Orrock of Atlanta calls Kemp’s refusal to expand while so many are being purged a “failure of governance."
Any Georgia deal could also reduce or eliminate permitting requirements for hospitals and health services. That's been a top priority for Lt. Gov. Burt Jones, the Republican who presides over Georgia's Senate, while the House has balked at loosening certificate of need rules. A similar deal to reduce permitting requirements helped clinch expansion votes last year in North Carolina.
Georgia Senate Majority Leader Steve Gooch says his more ideologically conservative chamber isn't interested in “full-blown expansion of Medicaid." But he suggests an Arkansas-style plan could succeed.
“I believe there’s an appetite there to make some changes to our certificate of need requirements that could include better access for all Georgians to health care facilities and services," the Dahlonega Republican said.
Even then, Kemp could veto any plan. He invested years to win a legal fight with President Joe Biden’s administration over the Pathways work requirement. In a 2022 letter to Georgia’s Democratic members of Congress, Kemp called full Medicaid expansion a “failed one-size-fit-none” policy.
But Kemp could face a difficult renegotiation on Pathways if Biden wins reelection. Georgia sought to extend the program past its September 2025 expiration, saying the legal fight delayed its start. Last month, the federal Centers for Medicare and Medicaid Services said it couldn't consider Georgia's request because the state hadn't met extension requirements, including a public notice and comment period.
Kemp spokesperson Garrison Douglas said Thursday that the governor “has championed and continues to support” Pathways and a linked program that has subsidized private health insurance premiums. He declined to comment on the prospect of a broader expansion.
Kemp wouldn’t necessarily have to sign any proposal. In Georgia, bills not signed or vetoed by the governor can automatically become law.
But without vocal support, Veazey said the inertia of entrenched opposition could defeat expansion. That's especially true because all of Georgia's 236 legislators face 2024 elections.
“We’ve got to have the leadership to come out with a plan," Veazey said. "They have to have buy-in.”
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Associated Press writers Sudhin Thanawala in Atlanta, John Hanna in Topeka, Kansas, and Emily Wagster Pettus in Jackson, Mississippi, contributed.