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Georgia is poised to make a dent in its large uninsured population after the Legislature passed a law that could quickly add thousands of children to the Medicaid program.

The new law helps to shore up health care coverage for children at a time when the possibility of Medicaid coverage for low-income adults is more uncertain than ever. The federal government put a hold on Governor Brian Kemp’s partial Medicaid expansion program, which had been approved by the Trump administration, and now questions loom over health care for thousands of Georgia’s poorest adults.

Georgia has the third highest rate of uninsured individuals in the country, which includes a 7% rate for children and a 15% rate for adults. Now, after two key developments concerning the Medicaid program, the number of uninsured children will likely drop while the number of uninsured adults holds steady at well over 1 million people.

The Express Lane

The improved outlook for uninsured children comes from a new law allowing the implementation of express lane eligibility for Medicaid. The Department of Human Services can now automatically enroll children into the program if they already receive assistance from other federal programs, such as the Supplemental Nutrition Assistance Program.

These children are already eligible for the Medicaid program, but something keeps them from actually being enrolled. Their parents may be unaware their child is Medicaid eligible, or they are unable or unsure about how to complete the application. The express lane program uses data from federal programs that struggling families enroll in with more urgency, like food assistance programs, to get children signed up for Medicaid without a separate application.

In a committee meeting, bill author Rep. Sharon Cooper, R-Marietta, emphasized that the measure did not expand any Medicaid eligibility but simply streamlined the enrollment process and improved government efficiency.

Medicaid expansion: Rep. Sharon Cooper headshot - Woman with short blonde hair and light-framed glasses wearing red suit jacket with white cllared blouse smiling in front of navy background
Rep. Sharon Cooper (Courtesy of Georga General Assembly)

“We’re paying money for programs to try to reach these kids that are very expensive, when having the dual system would be much more efficient than what we’re paying for to go out and enroll them, which isn’t always doing a really good job,” Cooper said.

While eligibility for Medicaid is not expanding, the number of children set to join the rolls certainly is. Director of the Georgia Division of Family and Children Services Tom Rollins said in the committee hearing that about 120,000 children receiving federal food assistance were not enrolled in the program, despite being eligible. Some of these children have private insurance, so the state expects to see an additional 60,000 enrollees through the express lane program, which Rollins said will be a great improvement.

“If we can get these children on Medicaid or on PeachCare, think about how that will improve their ability to get preventive care, their ability to get early care, to really prevent longer term issues that cost us, as the taxpayers, more money and that cost them, as individuals and children, more health care problems,” Rollins said.

If the estimates are accurate, a 60,000 person increase would reduce  the uninsured population of children by more than 2.5%, at a cost of roughly $40 million, putting Georgia in the middle of the pack in the country instead of in the bottom 10.

These statistics, and the fact that the measure concerns children, combined to create a bipartisan moment for health care and Medicaid. The law passed unanimously in both chambers and drew praise from many lawmakers and advocacy groups as a smart government maneuver that will positively impact thousands of lives.

Laura Colbert, executive director of the advocacy group Georgians for a Healthy Future, called it a game changer for Georgia’s children. She said Georgia is finally trending in the right direction on health care, something the Legislature avoided for many years following the passage of the Affordable Care Act.

“The return of legislators toward these issues gives me a lot of hope,” Colbert said.

Before the bill passed, Georgia was one of only seven states to pass up all of the following policy moves: expand Medicaid to all low-income adults, enable express lane eligibility, or enact presumptive eligibility, another enrollment mechanism allowing children to access Medicaid services before their applications finish processing. Six of these seven states made up the most uninsured states in the country, and the seventh, North Carolina, was not much better at 41st overall.

Medicaid expansion: Rep. Mesha Mainor headshot - Black womain with short brown hair wearing ourple suit kacket with lighter purple blouse smiling in front of a navy background
Rep. Mesha Mainor (Courtesy of Georgia General Assembly)

Now, by becoming the 14th state to enact express lane eligibility, Georgia will secure coverage for thousands of children and begin chipping away at the high uninsured rate. Co-sponsor of the bill, Rep. Mesha Mainor, D-Atlanta, said the boost to children’s health coverage was an opportunity to encourage bipartisanship on other health care issues.

“A lot of times our hands are tied,” Mainor said. “In general, I wish that we were more bipartisan when it comes to trying to figure out how to help Georgians.”

Mainor said she hopes that reaching across the aisle on measures like express lane eligibility, which cover thousands with little controversy or debate, can increase the odds of her party advancing a long-sought after and much more controversial policy goal – full Medicaid expansion. This conversation is revving up in Georgia once again after the Biden administration put the brakes on the governor’s partial expansion.

Medicaid Expansion

No help equivalent to the children’s express lane eligibility is on the horizon for Georgia’s uninsured adults.

Prior to the passage of the Affordable Care Act, Medicaid existed primarily for children and selected groups of low-income adults, including pregnant women and individuals with disabilities. A cornerstone of the ACA was the expansion of Medicaid eligibility to all adults earning up to 138% of the federal poverty level, but the Supreme Court ultimately put it up to the states to voluntarily opt-in to this expanded coverage. As a result, Georgia is one of 12 states, all under Republican legislative control, not to have expanded Medicaid to all low-income adults.

Last year, Governor Kemp submitted what is known as a waiver program to partially expand Medicaid in Georgia with modifications that don’t exist in states with traditional expansion. These Section 1115 waivers are designed to let states experiment with the Medicaid program, and in the case of Medicaid expansion, they have often been used by Republican states to add restrictions.

Gov. Brian Kemp (Andrew-van-Tilborgh/Shutterstock)

Kemp’s plan, known as Georgia Pathways to Coverage, would enable adults making up to 100% of the federal poverty level to enroll in Medicaid with certain requirements, including 80 hours a month of work or community engagement and the payment of small premiums and copays. The Trump administration approved the waiver last year, but the Centers for Medicare and Medicaid Services paused this approval in March, citing concerns with the work requirements.

In a lengthy response to that decision, Commissioner of the Georgia Department of Public Health Frank Berry accused the federal government of reversing its decision in bad-faith and promised to challenge any decision to officially revoke the waiver’s approval.

“Any attempt to change the terms of the waiver at this late stage would be arbitrary and unlawful, and CMS must allow the Georgia Pathways program to proceed as initially designed,” Berry wrote.

Cooper, the sponsor of the express lane bill, said in an interview the pause was a political move that will hurt Georgians who would have been covered by the program beginning this summer. She said the unique approach could have served as a stepping stone toward covering more people in the future, and she expects that the governor will continue fighting on this issue.

“He was committed to trying to get health care, just a Georgia way instead of a federal way,” Cooper said. “And I would think maybe he would be looking at another route.”

But the possibility of a legal battle over Georgia Pathways provides no relief for the massive population of uninsured adults in Georgia, which sits at over 1.5 million people. Many see a Medicaid expansion as a key way to begin addressing the problem, but now that possibility, in either full or partial form, seems more uncertain than ever.

Rep. Donna McLeod (Courtesy of Georgia General Assembly)

Kemp’s waiver-program was set to cover about 50,000 low-income individuals in Georgia, which would slightly decrease the state’s 15% uninsured rate among adults, the third highest in the country. But Democrats like Rep. Donna McLeod, D-Lawrenceville, have criticized the program for not going far enough.  

“It would be better than nothing, but it wouldn’t reach the 500,000 that we know could be reached,” McLeod said.

Democrats cite a fiscal note prepared in 2019 that estimated over 500,000 Georgians could be covered by the full expansion offered by the Affordable Care Act. That same fiscal note also estimated that Georgia would be on the hook for somewhere between $250 million and $350 million a year to continue operating the program. While the total costs of the program would be much more than that, the federal government offers to cover 90% of the costs of the expanded Medicaid population, as opposed to the usual 67% match offered for standard Medicaid coverage.

However, the federal government did not offer that enhanced funding match to Kemp’s waiver program because it did not cover the full expansion eligible population of up to 138% of the federal poverty level. Instead, those enrolled in Kemp’s plan would receive the traditional 67% funding match from the U.S. government. This means that Georgia Pathways could cost the state over $200 million to cover about 50,000 people, and Democrats are quick to point out that for a bit more spending, the state could cover 10 times as many people.

“To be in service of people, and to know that you can do better for the people and you don’t, you are failing from the oath you took,” McLeod said.

While Kemp’s plan would cover fewer people than a traditional expansion, it would still close the “coverage gap” in Georgia. This gap exists because those making below 100% of the federal poverty level do not receive premium subsidies on insurance plans offered under the Affordable Care Act, and in states without Medicaid expansion, there is no realistically affordable coverage option for low-income adults. Kemp’s plan would therefore close the gap by offering Medicaid to low-income adults ineligible for discounted health plans.

Still, Democrats in Georgia are banking that the delay of Kemp’s plan will give them time to highlight the differences between Georgia Pathways and a traditional expansion. But the reaction by the Kemp administration so far has been to double-down on the original proposal, saying that the unique approach and work requirements incentivize Georgians to work toward “self-sufficiency”.

Laura Colbert of Georgians for Healthy Future takes issue with the work provisions, saying they are illogical and a mechanism for getting less people covered on Medicaid.

Medicaid expansion: Laura Colbert headshot - Woman with shoulder-length blonde hair wearing navy top smiling into camera on gray background
Laura Colbert (Courtesy of Georgians for a Healthy Future)

“What people need first is health, and therefore access to health care, before they can work,” Colbert said.

Colbert said she worries that if the debate rages on and a lengthy legal battle emerges between Georgia and the federal government, important time will be lost and the human and economic costs of having a large uninsured population will get worse.

“The more folks that we have uninsured, the more our health system is going to struggle,” Colbert said. “When our health system fails, so do local communities and our state as a whole.”

Colbert said she doubts any waiver program could fulfill the needs of the state like a full expansion could, but such an expansion remains incredibly unlikely anytime soon. Under current state law, the governor is only permitted to expand Medicaid up to 100% of the federal poverty level, so even a Democratic win in next year’s gubernatorial election would not necessarily mean a traditional expansion could be enacted.

Still, other deeply Republican states have expanded Medicaid through waiver programs to success. In Arkansas, a waiver program expansion that incorporated the private market added hundreds of thousands to the Medicaid rolls. Craig Wilson, director of health policy at the Arkansas Center for Health Improvement, said this cut the uninsured population in half and prevented rural hospitals from shutting down in the state, which has been an ongoing issue in Georgia.

Medicaid Expansion: Craig Wilson headshot - Man with linde hair and beard wearing dark-framed glasses in blue suit with white shirt and blue stripes ties smiling in front of greenery background
Craig Wilson (Courtesy of Arkansas Center for Health Improvement)

Wilson said states like Arkansas prove there are options out there for the conservative hold-out states. He said aversion to the program stems from a rejection of former President Barack Obama’s health care legislation, but noted that added funding incentives for states to expand the program packed into the recently passed American Rescue Plan will test just how long states like Georgia are willing to pass up on expansion.

“With the enhanced match, the little sweetener that Congress put in the American Rescue Plan, I can’t really see from a fiscal standpoint that it’s a bad deal for any state that’s holding out,” Wilson said.

In accordance with the American Rescue Plan, Georgia would receive billions in additional funding if they expanded Medicaid now, but given the response from Kemp’s office to the halting of Georgia Pathways, this is unlikely.

More likely, Kemp and his allies will continue to push for Georgia Pathways or some variant thereof, and in the interim hundreds of thousands of Georgia’s poorest citizens will remain uninsured. But while the battle wages on over Medicaid expansion, Georgia will likely see the biggest drop in its uninsured population in some time as express lane eligibility comes to fruition for thousands of children across the state. And in the complicated issue of insuring Georgians, Medicaid will continue to play a central role.

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