Biden, Georgia clash over Medicaid and the future of Obamacare

The Affordable Care Act was once a powerful election issue that could have swayed campaigns under its more familiar name, Obamacare. But the 2010 health care law was not included in last week’s Republican National Convention.

The Republican National Committee platform included only vague references to Trump’s health plan, stating that the party would “raise transparency, promote choice and competition, and expand access to recent, affordable health care.” Former President Donald J. Trump, who he said last year “seriously considering alternatives” to Obamacare, he made little mention of health care policy in his Republican nomination acceptance speech on Thursday.

Instead, the fight over Obamacare has moved more to state capitals, in part because a provision of the law allows states — which share funding for Medicaid with the federal government — to expand their programs to cover more adults.

No state reflects the ongoing divisions over the Affordable Care Act’s place in Social Security more than Georgia, one of the last 10 states to decline to adopt Medicaid expansion.

Last July, Georgia officials implemented a more tough alternative to Medicaid expansion, known as Georgia Pathways to Coverage. The recent program required participants to show they were working, enrolled in college or doing community service for at least 80 hours a month — activities that Republican state lawmakers hoped would encourage a spirit of responsibility among recipients of publicly subsidized health care.

Officials have estimated the program could reach up to 100,000 residents within a year. Fewer than 4,500 Georgia residents had signed up in July, the program’s one-year anniversary, according to state data.

For critics, the Georgia experiment serves as a cautionary tale in a campaign to overhaul the way Medicaid is run, which covers about 75 million people nationwide.

Pathways beneficiaries’ insurance costs are significantly lower than those of a standard Medicaid expansion beneficiary, health policy experts say he saidThe program has already cost state and federal governments more than $32 million to run, mostly in administrative costs, state records show.

“It’s clear that the Pathways to Coverage program is more high-priced and covers fewer people than a program that fully closes the coverage gap,” said Leah Chan, a health policy expert who has tracked Pathways enrollment data at the Georgia Budget and Policy Institute, a nonprofit research firm.

Georgia already has one of the strictest income limits for Medicaid in the country and conducted one of highest uninsured rates in the country in recent years.

The push for a work requirement coincided with the enthusiastic reception of the Affordable Care Act. Georgia saw third fastest growth in any state’s records as of 2020. More than 1 million people saved This year’s plans are record-breaking in terms of condition.

During the first presidential debate in Atlanta, President Biden repeatedly cited the Affordable Care Act, saying 40 million Americans exploit the program. That number appears to include people who signed up for plans on federal and state marketplaces this year and have Medicaid in states that expanded the program.

The federal government is footing 90 percent of the cost of expanding Medicaid, and the 2021 pandemic relief package sweetened the deal even more for states that haven’t yet expanded the program. Those incentives have made the option attractive even to some fiscal conservatives.

The option has transformed America’s safety net, allowing millions of adults to get coverage. The results could come quickly. Half a million people in North Carolina gained coverage after the program expanded last December.

About 175,000 people in Georgia are stuck in the so-called coverage gap, earning too much to qualify for the state Medicaid program but not enough to benefit from heavily subsidized plans in the Affordable Care Act marketplaces. More than 350,000 people in the state could qualify for Medicaid if Georgia officials expanded the program, researchers estimate.

Pathways’ anemic enrollment is the result of a number of factors, state lawmakers, advocates and policy experts say. Applying, enrolling and staying in the program can be confusing and bureaucratic. Many of those who tried to enroll I am still waiting to consider their applications.

After three months of insufficient hours or reporting, a beneficiary can be removed from Pathways altogether. But Georgia officials do not appear to be rigidly enforcing that policy. Fiona Roberts, a spokeswoman for the Georgia Department of Community Health, which oversees Medicaid, said no Pathways beneficiaries have been removed from the program.

It also appears that state actions aimed at lower-income groups have been insufficient.

Ms. Chan, the Georgia health policy expert, said the state’s huge rural uninsured population doesn’t enroll in Pathways in huge numbers. “It’s not necessarily tracking need,” she said of the program.

State officials continued to promote the program at events across the state and promoted Pathways on social media, television and radio, Ms. Roberts said.

Still, many lower-income state residents who would qualify for Pathways would have difficulty accessing the internet or submitting forms to the state health office, said Alysia Cutting, director of rural health equity at SOWEGA Rising, a nonprofit advocacy group in the southwest part of the state. “You have a broadband internet issue that makes it hard for people to submit their paperwork,” she said.

Finding people in rural Georgia who signed up was like “looking for a needle in a haystack,” Ms. Cutting said.

Pathways, which was first approved in 2020, has sparked a bitter legal battle between Gov. Brian Kemp, a Republican, and the Biden administration. The program was set to launch in 2021 after approval from the Trump administration, but its launch was delayed after the Biden administration withdrew that agreement. A federal judge ruled in 2022 that the program could continue, leaving Georgia as the only state to introduce a work requirement for Medicaid eligibility.

Garrison Douglas, a spokesman for Mr Kemp, said Georgia was “still fighting to reclaim the time stolen from us by the Biden administration”.

“The state is redoubling its efforts to educate and enroll as many eligible Georgians as possible in the Pathways program,” he said.

The presidential election could have huge ramifications for states that seek to enact similar work orders. The prospect of a Republican-controlled Congress undermining the Affordable Care Act is reportedly one reason Representative Nancy Pelosi has expressed concerns to Mr. Biden about his reelection chances.

If Mr. Trump wins another term, his health department could once again encourage states to include work requirements in Medicaid programs. During his term, 13 states have been approved for their implementation by so-called waiversthat allow states to test recent strategies in Medicaid. The Biden administration has rolled back those.

“Those who waited more than a decade for Obamacare to be declared unconstitutional or destroyed by former President Trump are now counting on a second Trump administration to grant them waivers from programs like Pathways,” said state Sen. Jason Esteves, a Democrat who represents a suburban Atlanta district, referring to Republican state lawmakers.

Arkansas was the first state to implement work requirements under Medicaid, but its difficult implementation led to thousands of people losing coverage. The program was later invalidated by a court.

That hasn’t stopped other Republican-run states from trying again. This year, lawmakers in Mississippi, South Dakota and Idaho have considered legislation to include them. Kansas Democratic Gov. Laura Kelly included work requirements in a compromise bill to expand Medicaid that failed to pass earlier this year.

Opponents of Medicaid expansion have long argued that the state’s share of funding for the program is a significant drain on an already restricted budget and will only raise over time.

“They designed the Georgia Pathways program to operate within their resource constraints,” said Peter Nelson, a former Medicaid official in the Trump administration who is now at the Center of the American Experiment, a think tank. “They did something very different. But they did something to get people insurance.”

Chris Denson, director of policy and research at the conservative Georgia Public Policy Foundation, said that “the promise of Georgia Pathways is to provide a path for these individuals to transition to private health insurance while they receive Medicaid in the meantime.”

Other health policy experts say the program’s low enrollment after more than a year of operation is a sign of a deeper problem.

“I don’t know how long you can keep saying, ‘We need more time to see how this plays out,’” said Laura Harker, a health policy analyst at the Center on Budget and Policy Priorities, who studied Pathways. “We really just saw that it was a lot of money to invest in a program that doesn’t really put money into health care.”