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

March 15, 2024

A proposal to loosen up Georgia’s health care business regulations cleared the Senate Thursday with some bipartisan support, but Democrats say they will withhold support next time unless the bill includes full Medicaid expansion.

Republicans in the GOP-controlled chamber may not need Democrats to send the measure to the governor’s desk, but the final form of the bill is destined to be hashed out in a conference committee and there were already some signs of unease among GOP lawmakers.

Sen. Billy Hickman, a Statesboro Republican, said he was voting for the measure because it would set aside more state funds for a rural hospital tax credit program. The cap would go from $75 million to $100 million.

Hickman, though, said he was concerned about proposed changes that would make it easier for some ambulatory-surgery centers to open, which is a change opposed by hospital representatives.

“I have prayed over this bill probably more than any bill in my four years up here. I prayed over this more than I did the horse racing bill,” Hickman said.

The more than hourlong debate featured a string of Senate Democrats calling for full Medicaid expansion. The proposal would instead create a commission focused on comprehensive health care coverage that would meet after lawmakers go home for the year.

Sen. Jason Esteves, an Atlanta Democrat, argued that changes to the state’s certificate-of-need rules alone will not be enough to improve access to health care in Georgia.

“I am voting ‘no’ today as a call to action,” Esteves said. “While I agree with the principles in this legislation, I also firmly believe that we have to expand Medicaid now. We can take the lead in this chamber by signaling our desire to expand Medicaid with an easy vote right here on this floor.

“We don’t have to wait on the House. We don’t have to wait on the governor to make a statement that we want to make progress on health care in this great state,” he said.

The bill’s Senate sponsor, Sen. Bill Cowsert, an Athens Republican, said backing the bill would keep the debate over Medicaid expansion alive – just maybe not for this year.

“It sets up a commission that will consider that,” Cowsert said. “And we will continue that discussion until we find a solution. You can’t get everything you want in one bill.”

The decades-old certificate-of-need rules were designed to control costs by limiting the number of health care services allowed in a community. But the regulations have long been the source of debate under the Gold Dome, with critics saying the limits do not help but hospitals arguing they protect fragile hospitals from standalone centers that would poach the more profitable services.

This year’s proposal would keep the program in place but loosen some of the rules, making it easier, for example, to open or expand a psychiatric and substance abuse inpatient facility, a rural hospital if certain conditions are met, and freestanding birth centers.

The bill cleared the Senate with a 43-to-11 vote Thursday and will now go back to the House for consideration. An earlier version passed overwhelmingly in the House last month with a 166-to-1 vote. But it is expected to land in a conference committee made of lawmakers from both chambers who meet to hash out a deal. 

Minority Leader Gloria Butler, a Stone Mountain Democrat, and other Senate Democrats who supported the bill Thursday said after the vote that they will not do so again if the bill comes back from the House this session without full Medicaid expansion.

“If we pass Medicaid expansion, Democrats will support the certificate-of-need reform, just like we saw last year in North Carolina,” Butler said during a press conference Thursday afternoon. “Let me be clear: CON and Medicaid expansion must be done together.”

North Carolina became the most recent Southern state to expand Medicaid last year when lawmakers tied it to changes to the state’s hospital business regulations. And Medicaid expansion is currently being debated in Mississippi.  

Georgia is one of 10 states that have not expanded Medicaid under the Affordable Care Act. About a half million people could gain insurance, and the state’s coffers would benefit from federal incentives.

Instead, Georgia partially expanded Medicaid through a program called Georgia Pathways to Coverage, which requires participants to complete 80 hours of work, school or other qualifying activity each month to gain and keep coverage. Less than 3,000 people enrolled in the first six months.

This year’s session started with chatter about Medicaid after high-level Republicans signaled an openness to talking about an Arkansas-style model that uses federal dollars to purchase private insurance for low-income participants.

But House leaders seemed to signal that this would not be the year that Georgia would change course when they proposed a measure last month that instead called for the commission. In early February, the state sued the federal government over delays to the implementation of Georgia pathways, which launched in July.

Kemp, though, dismissed the idea that he put the kibosh on the Medicaid expansion talks this session.

“It was never even my idea to discuss that,” the governor told reporters Tuesday. “That was a legislative priority, mainly of the House, to put that out there and have some conversations.”

Kemp said he has been focused on his health care waivers since first taking office in 2019, including one that sets up what Kemp called “a limited Medicaid expansion in a conservative way.” 

Advocacy groups, though, continue to hold out hope that full expansion could still happen this session.

“We urge legislators to act before this session ends and close the healthcare coverage gap now rather than kicking the can down the road,” Natalie Crawford, executive director of Georgia First, said in a statement Thursday. 

Georgia Recorder is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Georgia Recorder maintains editorial independence. Contact Editor John McCosh for questions: info@georgiarecorder.com. Follow Georgia Recorder on Facebook and Twitter.