Georgia: GOP legislators may actually consider full Medicaid expansion...with a string attached (no, not that one)

For ten years, Georgia has remained one of the states which, frustratingly, has refused to expand Medicaid to all adults earning up to 138% of the Federal Poverty Level (FPL)...a bit over $20,000/year for a single adult; roughly $41,000/yr for a family of four.

If the state were to join most of the country, an estimated 434,000 Peach State residents would finally be able to enroll in comprehensive, nominal-cost healthcare coverage: Around 252,000 who earn less than 100% of FPL and another ~182,000 who earn between 100 - 138% FPL (the second batch 

After years of pressure, a few years back GOP Governor Brian Kemp kind of, sort of agreed to a partial expansion of Medicaid...with a pretty big caveat:

...Once implemented, Georgia’s waiver will expand eligibility to 100% of the federal poverty level (FPL), with initial and continued enrollment conditioned on meeting work and premium requirements. These and other provisions of the Georgia Pathways waiver, including additional eligibility and benefit restrictions, are summarized in more detail in Table 1. The work requirement would apply to enrollees below age 65, with “good cause exceptions” (for those who cannot fulfill the requirement in a given month due to a circumstance such as a family emergency) and “reasonable accommodations” (to enable individuals with disabilities to meet the requirement) available.

(sigh) Yeah, that's right: Work requirements, as well as modest premiums ($7 - $11/month) and a tobacco surcharge.

Instead of applying to all 434,000 Georgians, Kemp's so-called "Georgia Pathways" program would only result in a maximum of ~250,000 people...except that state Medicaid officials later admitted that in practice, the odds are that only around 64,000 would likely end up enrolling.

Still, 64,000 people is 64,000 people, right? Well, yeah...except not so much:

Georgia’s partial Medicaid expansion program has enrolled 265 people since it began July 1, doing little to counter advocates’ complaints that work requirements are barriers to coverage and, as a Center for Budget and Policy Priorities report found last month, create a confusing, onerous system that’s only effective at kicking people off Medicaid. The CBPP report specifically calls out House Republicans for proposing to add a national Medicaid work requirement during the debt ceiling negotiations.

...just 265 Georgians were enrolled in the new program as of Aug. 17, Georgia’s Department of Community Health told Inside Health Policy.

Imagine that. And why is this the case? The article offers up several possibilities:

Beneficiary advocates say the surprisingly low number of enrollees is due to a combination of factors: poor advertising for the program mixed with proof of work that must be provided at signup while applications are submitted through an often-counterintuitive online portal and processed by staff who are also preoccupied with redetermining hundreds of post-pandemic renewals.

OK, but that was as of mid-August. What about since then?

Georgia’s Department of Community Health has revealed that it has enrolled about 1,300 Georgians in Pathways to Coverage, the new Medicaid option for adults with lower incomes who do not qualify for traditional Medicaid and who report 80 hours per month of work or other qualifying activities. Since the program launched in July, the state has enrolled only about 1% of the 100,000 Georgians it estimated would enroll in the first year of implementation. In contrast, South Dakota, which launched full Medicaid expansion for low-income adults without monthly reporting or work requirements, has successfully enrolled about 10,000 people since its July start date.


The good news is that it looks like Georgia's Republican-controlled legislature may finally be warming up to the idea of embracing full expansion of the program. As reported by Ariel Hart at the Atlanta Journal-Constitution:

For the first time in a decade, high-ranking Georgia GOP legislators on Thursday convened a meeting to hear testimony on full Medicaid expansion to all the state’s poor people.

At the hearing Thursday, the idea was floated over whether to expand Medicaid in exchange for a political deal to roll back regulations that restrict who can open a new health care business. Those regulations are called Certificate of Need, or CON.

Unfortunately the bulk of the article is behind a paywall so I can't read the details about the "Certificate of Need" issue, but Arkansas healthcare reporter David Ramsey gave me the basics:

...seems to be fight over whether rural hospitals can stop new entrants within 35 miles--so Medicaid expansion cash would help the rural hospitals stay afloat if those regulations are eased.

I don't know quite enough to weigh in on the merits, but at first glance, I find myself sympathetic with the woman who got denied the ability to open a birth center in Augusta.

Of course, the logic here involves Republicans admitting that Medicaid expansion brings a huge funding boost to rural hospitals in need, which would be a bit of an about-face, so we'll see...

Ramsey provided a link to a different article from August in the Georgia Recorder by Jill Nolin which provides more details about the "CON" situation:

Both chambers have set up study committees to examine Georgia’s certificate of need program during the legislative off-season after Lt. Gov. Burt Jones came up short in his push to ease restrictions during his first session presiding over the state Senate. 

A bill that would have exempted most rural hospitals from the certificate of need process cleared the Senate earlier this year with a 42-13 vote but stalled in the House. It remains alive for next session, which begins in January.

The obscure sounding regulatory program controls the number of health care services in a geographic area by requiring health care providers that want to open or expand to show there is a demand for more services. A rival provider can challenge an application if they are within 35 miles of the proposed project.  

Supporters of the program argue the rules help protect fragile rural hospitals from start-ups that might pop up and poach patients seeking profitable services. Critics say it’s an antiquated system that limits access to care and hasn’t stopped rural hospitals from closing their doors.

Anyway, this is in the very early stage so I wouldn't expect any dramatic developments for awhile, but it's definitely something to keep an eye on. One promising tidbit: According to Medicaid advocate Lucy Dagneau, the CON deal, if successful, would be similar to the arrangement made in North Carolina which got Medicaid expansion approved there earlier this year.