For the 15 years since President Barack Obama signed the Affordable Care Act into law, Georgia Democrats have been pushing to expand Medicaid and cover more of the state’s low-income uninsured.
The ACA gives additional federal funding to states that offer the government insurance program to people earning up to 138% of the Federal Poverty Level — about $21,000 for an individual in 2025.
But Congressional Republicans are looking to cut health care funding as part of President Donald Trump’s budget reconciliation bill. Those cuts include enhanced subsidies for expansion made during the pandemic, making expanding coverage in Georgia less likely than ever.
“It would be kind of hard to do it because you’ve got to have the money,” said state Sen. David Lucas, a Democrat from Macon who has pushed for expansion for a decade. But there is a path, he said, if Congress avoids deep cuts to health care.
Gov. Brian Kemp has long opposed expanding Medicaid, saying that federal support could vanish and leave the state on the hook financially to care for thousands more people. His predecessor, Nathan Deal, also questioned whether the federal incentives were sustainable.
Instead, Kemp enacted a more limited expansion that makes low-income people eligible for Medicaid if they work at least 80 hours per month or meet academic or other requirements. Though the program has low enrollment compared to initial projections, the House GOP’s proposal mirrors Georgia by making work requirements a condition for qualifying.
“The very nature of proposals is that they are always subject to change and lack certainty of implementation. Therefore, it is our practice not to speculate or comment on proposed legislation,” said Garrison Douglas, a spokesperson for Kemp.
Credit: Miguel Martinez-Jimenez
Credit: Miguel Martinez-Jimenez
The fiscal argument
Democrats, along with a small number of Republicans, argue that expanding Medicaid is a good business deal for Georgia.
Currently, the federal government covers about two-thirds of the cost of Medicaid, with the state making up the remaining third. If Georgia had expanded the program — as 40 other states have done — the federal government would cover 90% of the costs.
In a statement to the AJC, U.S. Sen. Raphael Warnock said he “will not stop fighting to protect this vital program and close the health care coverage gap. The people of Georgia need quality, affordable health care, and I will keep working to deliver it.”
To some advocates’ surprise, the Republican-controlled U.S. House has so far kept the 90% match rate for expansion intact, though negotiations are ongoing. That match rate is the baseline in the Affordable Care Act, so Republicans would have to repeal the ACA to change it.
“This bill, if passed with (the federal match) in place, really enshrines Medicaid and Medicaid expansion. With the inclusion of work requirements that mirrors Georgia’s own, it makes it a lot harder for Georgia to keep saying no to expansion and leaving federal dollars on the table,” said Natalie Crawford, the executive director of Georgia First, which supports Medicaid expansion.
Republican interest
As the years have gone on, it’s not only Democrats who bought into the bright side of Medicaid expansion.
Last year, the Georgia Senate came within an inch of allowing a bill that would have expanded Medicaid to pass out of a committee for a full Senate vote. Two Republicans joined with Democrats to vote in favor of the measure, but the committee’s chair broke the tie and voted against it.
And this year, four Republican senators signed onto a bill to expand Medicaid. But the politics of Republican support for Medicaid are tricky, and one of the original four ended up taking his name off.
State Sen. Carden Summers, a Republican from Cordele who supports exploring Medicaid expansion, said growing the program’s rolls would be good for rural hospitals.
“I’m very concerned about rural Georgia hospitals and rural Georgia health care,” he said. But, he said, “there’s no doubt that our hands are tied until the feds give us some insight.”
The state’s lieutenant governor and a likely candidate for governor, Burt Jones, said he backs Kemp’s Pathways program, which, in January, sought to add parents and legal guardians of children 6 years and younger to the state’s Medicaid rolls.
“I am proud to stand with Gov. Kemp today and to support his new initiatives to ensure that more Georgians have access to quality health care across the state,” Jones said at the time.
Most Republicans are against expansion.
Georgia House Speaker Jon Burns said he’s watching for the final version of the federal budget before considering any state-level budget decisions, including those related to health care.
“When the budget is passed, the House will continue to do what we always do — deal with the facts, and make strategic, fiscally responsible policy decisions that ensure the well-being of our state and citizens,” he said in a statement.
Last year, as part of legislation easing regulations for new hospitals to open, the House added a provision to create a commission to study health care access and quality across the state. However, the commission has not met since November.
State Rep. Butch Parrish, a Republican from Swainsboro who sponsored the hospital bill, said he’s also waiting on Congress before determining his position on the issue.
New territory
Given the political realities, Democrats are trying to chart a new path forward.
State Sen. Jason Esteves, a Democratic candidate for governor, said he is “open to doing whatever works and whatever provides hardworking Georgians with the coverage that they need to stay healthy.”
He cosponsored legislation this year allowing the state Department of Community Health to pilot a program that would provide subsidies to Georgia’s Medicaid program, but because it was a Democrat-only bill in the Republican-controlled General Assembly, it never received a committee hearing.
Democrats have not completely abandoned the idea.
Former Atlanta Mayor Keisha Lance Bottoms, who announced she is running for the Democratic nomination for Georgia governor, said expanding Medicaid would be a key part of her platform.
Former DeKalb County CEO Michael Thurmond, another probable candidate for governor, said expansion would be the “dominant” issue in his campaign.
“Our mandate is to protect and expand Medicaid. I believe that it can be done,” he said.
Stacey Abrams made Medicaid expansion the forefront of both of her campaigns, but the issue failed to translate to election success. Still, almost 70% of Georgians support expansion, including nearly half of Republicans, according to a 2024 AJC poll.
Credit: Miguel Martinez
Credit: Miguel Martinez
But under a Trump administration that has been less favorable to Medicaid expansion, political realities may alter the approach.
Heath Garrett, the chief strategist for Attorney General Chris Carr’s campaign for governor, said the Republican has “real concerns” about the long-term costs of full expansion and wants a Georgia-based solution that “delivers better outcomes for patients and taxpayers alike.”
He added, “That is more achievable under the Trump administration, who we believe will work with us on that.”
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