by Jill Nolin, Georgia Recorder [This article first appeared in the Georgia Recorder, republished with permission]
August 29, 2022

Sharp disagreement over whether to expand Medicaid in Georgia – a state with one of the highest uninsured rates in the country – was one of the defining issues in the governor’s race in 2018.

Four years later, the long-simmering debate over whether the state should expand the public insurance program is still sizzling. But with record-high inflation and the U.S. Supreme Court’s recent decision to end the federal protection of abortion rights, other issues are competing for voters’ attentions.

With the Nov. 8 election still about two months away, it remains to be seen what will ultimately prove the decisive issues in the rematch between Gov. Brian Kemp and Democrat Stacey Abrams. Much can still happen between now and November, says Amy Steigerwalt, a political science professor at Georgia State University.

“What that means is it’s a little bit about starting to lay out some policy parameters but it’s even more so just about reminding people there’s an election and trying to get them interested and trying to say, ‘OK, what matters to you and how do I connect this to your life such that you will actually turn out and vote?’” Steigerwalt said. 

“Because at the end of the day, that’s the only thing that actually matters is people turning out to vote. You can have the best ads in the world. You can have the pithiest comments. You can have the best policies. But if people don’t turn out and vote, it doesn’t matter.”

Abrams has still placed Medicaid at the center of her 2022 bid, holding her first campaign stop outside the shuttered doors of Southwest Georgia Regional Medical Center in rural Cuthbert two hours south of Atlanta – one of two Georgia hospitals to close during the pandemic.

And the former House minority leader is still making the case for Medicaid expansion at every opportunity, weaving the message throughout her broader campaign platform and tying the proposal to both her economic solutions and post-Roe v. Wade health care policies.

Kemp, meanwhile, has largely focused his reelection bid on his record as governor, touting Georgia’s economic strength coming out of the COVID-19 pandemic while pinning the blame for higher prices at the gas pump and in the grocery store squarely on the Biden administration.

But as the Republican governor hones his economic message on the campaign trail, his administration is vigorously defending a health care plan he unveiled in his first year in office – including a modest expansion of Medicaid – that has so far only been partially implemented. Stacey Abrams and Brian Kemp sparred over Medicaid expansion in 2018. Four years later, it’s still a hotly debated issue as the two rivals face each other again.

What became of Kemp’s health care plans?

In the fall of 2019 – about a year after Kemp edged out Abrams by about 55,000 votes and the same year he signed off on Georgia’s new abortion restrictions – the governor held a pair of highly anticipated press conferences at the state Capitol to map out the details of what was seen as his signature health care proposal.

Kemp unveiled plans that he argued would rein in health care costs and increase coverage across the state. His proposal relied on waivers, which allow states to forgo certain requirements of the Affordable Care Act and have appealed to conservative state leaders across the country.

Nearly three years later, only one component of his plan – a reinsurance program – has so far taken effect. The rest of it has been blocked by the Biden administration after being previously approved late in former President Donald Trump’s term, although a federal judge recently found fault with the federal government’s rationale for stopping the governor’s partial Medicaid expansion plans.

Kemp celebrated the ruling, but critics of the plan say there is still no guarantee the program will move forward. The governor’s spokeswoman said last week that his office is still reviewing its options after the ruling.

Voters may get lost in the prolonged back-and-forth, but advocates for full expansion say they still believe the issue holds potency for Abrams. Polling shows a majority of Georgians back expansion. 

“Do I think that the nitty gritty of the waiver is going to be a central focus?” said Liz Ernst, state director for Protect Our Care Georgia, a coalition of groups pushing for full expansion. “Probably not. But the end result is there’s a refusal to cover more Georgians and help our health care industry here in Georgia, and that I think is ripe for Stacey to call Kemp out on. And I think that’s something people understand.”

About 14.5% of Georgians have no health insurance, with the state tied for second place with Oklahoma for the worst rate in the country. And a recent Georgetown University report found that one in five women of reproductive age in Georgia – or 19.3% – has no health insurance, leaving the state with one of the highest rates in the country at a time when the state’s six-week abortion ban has upended the reproductive care landscape.  

Kemp’s campaign has blamed the Biden administration for the impasse. 

“Unfortunately, the Biden Administration is playing politics with people’s healthcare and halting the full implementation of those waivers,” said Kemp’s press secretary, Tate Mitchell. “Governor Kemp and Georgia Republicans are not backing down, and will continue fighting to implement these waivers and develop innovative solutions to make healthcare more accessible and more affordable.”

Under review

The governor’s partial Medicaid expansion plan would increase coverage to as many as 50,000 more people – but only for those who complete 80 hours of work, job training or other qualifying activity for 80 hours a month. When announced, the projected cost was $120 million, with the state’s share at $36 million. The federal government’s match would be 67%.

By contrast, about a half million Georgians could gain coverage through full Medicaid expansion at an estimated cost of $336 million for two years with the feds picking up 90% of the tab, according to analysis from the left-leaning Georgia Budget and Policy Institute. Proponents argue the governor’s plan makes less economic sense than full expansion and forgoes billions of dollars of federal funding. 

An Abrams campaign spokesman, Alex Floyd, accused the governor of trying to “force through expensive halfway measures that cover fewer Georgians at a higher price” after the judge’s recent ruling. 

The governor argues his plan would increase access but encourage participants to ultimately transition from government-run health care to a private sector plan. He also promotes the impact of the reinsurance program as well as a recent move to expand postpartum Medicaid coverage for new moms to one year after a pregnancy ends and efforts to address the provider shortage in rural Georgia.

“We have taken a holistic approach to health care versus a one-size-fits-all government approach that the Democrats and the liberals want – that they’re not being truthful with how much that’s going to cost Georgians and how much your taxes are going to be raised to pay for it,” Kemp said at a July press conference.

The Biden administration clawed back approval for major elements of the governor’s Medicaid plan late last year over concerns the work requirement “significantly compromises” Medicaid’s mission to promote coverage for those who are eligible. A federal judge rejected the federal government’s action this month, but the program’s future remains uncertain.

The status of the governor’s other program is more complicated. The Biden administration did not challenge the reinsurance program, but federal officials this month followed through on their threat to block the state’s plan to bypass healthcare.gov and divert consumers looking for insurance to a privately run process. That decision stalled the state’s program just months before its planned launch.

But in this case, the federal government has given the state more time to provide information that has been requested for months and to revise the plan to avoid a federally projected loss in enrollment. 

The state has not yet responded or indicated whether it will continue to challenge the federal government’s decision. As with the Medicaid standoff, the governor’s spokeswoman said last week that his office is still reviewing the state’s options based on the Centers for Medicare and Medicaid Services’ decision. 

As of July, the state had spent $31 million implementing the program, according to a letter sent to CMS.  Seema Verma, who was the CMS administrator during the Trump administration, came to Georgia in October 2020 to announce federal approval of the governor’s health care waivers. John McCosh/Georgia Recorder (2020 file photo)

‘Safe to say yes’

The state’s Republican leadership has long resisted Medicaid expansion, making Georgia one of 12 states that have not expanded coverage to include poor adults without children as the more than a decade-old Affordable Care Act envisioned.

The state’s GOP-led General Assembly stripped the governor of the ability to expand coverage with a stroke of a pen in 2014.

That means, if elected, Abrams would now have to work with Republican leadership in the Legislature to expand Medicaid, which she pitches as a job-creating move that would also ease Georgia hospitals’ uncompensated care costs and help grow the health care industry here.

“I think when you finally have a governor who makes it safe to say ‘yes’, we will have the votes we need on both sides of the aisle to pass Medicaid expansion as our first mission in the state of Georgia,” Abrams said early in her campaign at the Cuthbert stop.

Abrams says the state can afford to expand Medicaid without raising taxes, pointing to a $5 billion budget surplus and growing revenues – something else the two rivals have competing visions for what should be done. 

Abrams called the governor’s waivers “nonsensical and economically inefficient,” referring to the amount of people covered and the corresponding cost. 

“I believe that if (lawmakers) have the question put before them, they would absolutely vote to expand Medicaid because it creates jobs, especially in those communities that are represented by Republicans but have lost access to hospitals,” Abrams said in an interview. 

In addition to Cuthbert, Commerce also lost its local hospital when Northridge Medical Center closed its doors in 2020. Both areas, Abrams noted, are represented by Republicans at the state Capitol.

Abrams said it was state lawmakers who included money in the budget to expand Medicaid coverage for people living with HIV. Kemp vetoed the spending, partly because the accompanying bill did not make it to his desk.

“We have an opportunity, especially given the dire and extreme situation we find ourselves in with the health care shortage. But I believe that when presented with the information and presented with a pathway to funding that does not require a tax increase, I do believe I can get the majority in the House and the Senate to expand Medicaid in Georgia,” Abrams said. Abrams has put Medicaid expansion at the center of her 2022 campaign. Here she is seen talking to reporters in March.

Reinsurance program has found broad support – including from Abrams

Kemp’s reinsurance program – the one piece that has taken effect – launched in January and has been credited with helping to lower premiums and attract more insurers to the market.

The state included $124 million in this year’s budget for the program, which subsidizes the costs of health insurers by targeting the most expensive claims and lowering the costs for everyone. The program was designed to give extra weight to rural areas of the state, where health care costs are usually higher.

Statewide, premiums have decreased by an average of 11.8% with the highest-cost counties seeing declines as deep as 30%, according to a state Department of Insurance presentation given this summer. Five new carriers also entered the market this year, bringing the total up to 11.

The reinsurance program does deserve some credit for the increased number of carriers and lower premiums, but there are also other factors at play, says Laura Colbert, executive director of Georgians for a Healthy Future, which is a nonprofit consumer advocacy organization.

For example, the program probably did help attract more insurers to the market and provide Georgians greater choice across the state, especially in rural areas. But it also helps that the Affordable Care Act has survived legal challenges and a full-court press in Congress to repeal it, signaling to insurers that the federal law is likely here to stay.

“The reinsurance program certainly helps bring down premiums. I don’t think they can take full credit for it,” Colbert said.

The reinsurance program has found broad support. Even Abrams says she would keep the program intact if elected governor.

“The reinsurance provision isn’t problematic,” Abrams said. “But what is deeply problematic is that it is a distraction from the larger issue of half a million Georgians who are needlessly suffering, not because we can’t afford to expand Medicaid but because Brian Kemp refuses to expand Medicaid.” 

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