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In rural Clay County, Georgia, access to health care is not always easy to obtain. So when a hospital in the area that had long been on the brink of financial collapse closed in October due to the pandemic, Dr. Karen Kinsell, the county’s only doctor, found itself with even fewer resources to treat. his neighbors.
Rarely do Kinsell’s patients have insurance or even coverage under Medicaid, the federal and state program aimed at helping the country’s poorest receive medical care. In this southwest corner of Georgia, one of dozens of states that still have not extended Medicaid, its patients are typical of no health care coverage.
So Kinsell charges $ 10 for a visit to the doctor, less if patients can’t afford it.
“Everyone is born, everyone dies and most people get sick in between,” Kinsell said. “For one of the richest countries in the world, one of the most medically advanced, not leaving out 10 to 20 percent of its population in this service is simply wrong. It is immoral and unsustainable. It harms the whole system. “
This especially hurts in Georgia, which has the third highest rate of uninsured people in the country, according to the Census Bureau. It is also a state where lawmakers gave up billions of federal dollars that would have helped provide hundreds of thousands of Georgians with health care coverage by expanding Medicaid enrollments.
The Biden administration hopes to quickly help uninsured people in Georgia, as well as 11 other states, by offering them incentives to develop Medicaid. The efforts won’t be easy, however: Some state leaders, like Governor Brain Kemp last year, have pursued a variant of the Medicaid expansion pushed by the Trump administration – a version that undermines the insurance program. federal government, implements job requirements and leaves hundreds of thousands of people without access to coverage.
Republican lawmakers argue that the expansion is too much of a financial burden for states to shoulder, even though the federal government will pay 90% of it. There is ideological opposition to the program as well, especially since it was formed under the aegis of Obamacare.
The governor’s office did not respond to a request for comment.
So far, 38 states have extended Medicaid; Georgia, Mississippi, Tennessee, Alabama, Florida, North Carolina, South Carolina, Texas, Wyoming, Kansas, South Dakota, and Wisconsin have not. This left millions of people without coverage more than a decade after states were able to sign up for the expansion of Medicaid through the Affordable Care Act.
Hours after Joe Biden was sworn in as president, the White House devoted itself last Thursday to signing an executive order to take action to “strengthen Medicaid and initiate an open enrollment period under the ACA “, also known as the Affordable Care Act. or Obamacare.
The White House has declined several requests to provide more details on the order and how it would strengthen Medicaid, but many policy experts say it will address the many waivers provided by the Trump administration.
Under the Trump administration, the Centers for Medicare & Medicaid Services, or CMS, provided a series of waivers – essentially agreements between states and federal governments on the implementation of Medicaid – for states to pursue their own goals. with the program.
Most notably, Trump’s White House pushed for providing waivers to allow states to enact work requirements to receive state Medicaid benefits, which no administration had done before and which Congress had rejected in 2017.
Now many are wondering what it will take for the Biden administration to unravel some of these policies and expand access to health care as he has promised.
“Each administration has some discretion and flexibility, but given all the litigation we’ve seen, that discretion is not unlimited,” said Robin Rudowitz, the Kaiser Family Foundation’s vice president of the program on Medicaid and uninsured. “It is certainly still being tested in the courts, but I think it is not in dispute that the new administration has the opportunity to rescind and issue new guidelines on the waivers it would like to promote and encourage. . For all that is pending, it is negotiations between the administration and the State ”.
This has, in essence, left a political bombshell for Biden and the new administration to defuse, most likely to the detriment of political capital, while increasing tensions between the states and the federal government.
Some criticize the Trump administration’s oversight of health care coverage, especially during the pandemic.
“The fact that during a pandemic, when Medicaid is a first responder, they spent so much time trying to trick the program and handcuff the Biden administration when they walked through the door is abhorrent,” said Joan Alker, executive director from Georgetown University Center for Children and Families.
Nineteen states have approved or pending work-requirement waivers, which critics say has hampered Americans’ access to a vital safety net program and could cause a lot of trouble for the Biden administration to be dismantled.
Arkansas, New Hampshire, Kentucky, and Michigan have Trump administration-approved waivers that are being delayed by litigation; Utah, Nebraska, Arizona, Wisconsin, Indiana, Ohio, South Carolina, and Georgia have waivers approved by the Trump administration; and Idaho, Montana, South Dakota, Oklahoma, Mississippi, Alabama and Tennessee are awaiting approval.
In October, Georgia was one of the most recent states to adopt an expansion variant with the approval of the Trump administration’s Department of Health and Human Services.
Georgia got a waiver from the ministry, essentially allowing it to bypass the policy and only cover Georgians up to 100% of the federal poverty line, provided they work 80 hours a month or go to school. Most would also have to pay monthly premiums and would lose coverage if they couldn’t afford to pay.
The policy would only allow about 64,300 people to get coverage, according to state estimates – rather than the state’s estimate of 480,000 to 600,000 that would have access through the full expansion of Medicaid.
Critics say that forcing people to work for health care coverage during a pandemic that sparked the worst jobs crisis since the Great Depression is completely missed.
“As we have seen with so many big policy changes, this is far more politics than actual data and policies, which the vast majority of Georgians and Americans agree with,” said Laura Colbert, Executive Director of Georgians for a Healthy Future.
Kemp criticized the initiative from Democrats and policy experts, but the Trump administration had already provided the waiver, which creates a particularly difficult path forward.
The Trump administration has also gone further in trying to strengthen the agreements by establishing new procedural rights for any future waiver withdrawals by the Centers for Medicare & Medicaid Services.
“At the very end of the Trump administration, CMS Director Seema Verma was pushing states to sign letters of understanding, essentially trying to make it more difficult for the next administration to reverse some of these approved waivers.” , said Rudowitz. “I think we’ll see this tested.”
The Biden administration must also figure out how to deal with lawsuits that blocked four of the waivers.
The Supreme Court has reviewed the Arkansas and New Hampshire cases, and Trump’s Health and Human Services Secretary Alex Azar filed a brief in support of the cases the day before he left.
“Basically, we are in unprecedented territory here,” Alker said, noting that Biden’s Justice Department will have to determine his position in the litigation. “We’ve never had an administration that basically tried to rewrite Medicaid status through the waiver process and allowed things that Congress explicitly didn’t allow, like work requirements.”
All of this is likely to create a political and political headache for the Biden administration, as well as for states that hope to maintain the job demands.
But on the ground in Georgia, Kinsell and others must navigate the realities of these political choices. For her, the choice is simple and she does not understand why the state leaders would not pursue a program that would cover up to 600,000 Georgians instead of 64,400.
Every day in her office, Kinsell said, she sees unmet health care needs that lead to disability and unemployment. A patient who could not afford to treat her diabetes lost both of her legs, and cases like this weigh heavily on her mind.
“It can’t be financially responsible or a good idea,” she said. “It really isn’t moral, Christian, or intelligent where I’m sitting either.”
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