We are about to get down to the nitty-gritty of the presidential contest in Georgia.
But we’re not talking about Donald Trump or Hillary Clinton. Not exactly.
This more hidden facet of the presidential contest is about expanding the number of people who receive government-assisted health insurance coverage in the state. And about the survival of Grady Memorial Hospital in Atlanta and Memorial University Medical Center in Savannah — never mind the dozens of smaller hospitals already winking out in rural Georgia.
Within the next few days, a task force deputized by the Georgia Chamber is expected to unveil a cafeteria-style plate of choices for expanding Medicaid rolls in this state under the auspices of the Affordable Care Act.
“So far, what we’ve heard is that the plan will be as conservative as possible — but that could include premiums, that could include co-pays,” said Laura Harker, a health policy analyst for the center-left Georgia Budget and Policy Institute.
A few members of the state Legislature, at whom the work is aimed, have already seen portions of this attempt by business leaders to revive a Georgia debate that was quickly shut down after Obamacare received congressional passage in 2010.
Other lawmakers have preferred being kept in the dark. “I purposely have kept an arm’s length from the Chamber. I know all those people. I could have called them, but I purposely have not done that because I want them to be independent and come up with some new ideas,” said Renee Unterman, R-Buford, chairwoman of the state Senate Health and Human Services Committee.
She did put one demand on the Chamber. “I said, ‘Don’t show up on Jan. 1 and tell us what we’re going to do.’ That’s very prudent that they’re coming out now, so we can think over and digest what they’re suggesting,” Unterman said.
Once out, the Georgia Chamber initiative will require several months of marinating — and not just because the repeal of Obamacare has been a rote line in every GOP campaign speech for the past six years.
Important bridges must be crossed before the real debate can begin here.
If Trump is victorious on Nov. 8, Republicans would presumably keep control of both the U.S. House and Senate — and the Georgia Chamber venture would likely be stillborn, replaced by a Washington-based effort to do away with Barack Obama’s signature domestic accomplishment.
Should Clinton win the White House and Republicans maintain control of Congress, the six-year status quo on health care in Georgia would extend at least four more years — putting more strain on efforts to bring economic development to areas of the state outside major urban areas.
If Democrats win both the presidency and the Senate, well within the bounds of possibility, then a President Hillary Clinton would be positioned to put extreme pressure on red states such as Georgia that have been reluctant to cooperate with Obamacare — by ending millions of dollars in federal subsidies for hospitals that provide indigent care.
The subsidies have been long scheduled to be dropped under the new system. Grady Memorial in Atlanta and Memorial University in Savannah would be hard put to maintain their current levels of service. And Georgia could be forced into Obamacare negotiations.
Even as restrictions on coverage are maintained in Georgia, Medicaid rolls are already expanding. In January, the Department of Community Health will ask the General Assembly for an additional $300 million.
Loosening coverage requirements to cover more of the working poor would be largely paid for with federal dollars, but state officials — Gov. Nathan Deal included — have expressed concern that the financial burden could shift in the future.
Expansion of Medicaid could be a larger challenge for Georgia’s political middle than the 2015 passage of a nearly $1 billion tax increase to repair the state’s crumbling system of roads and bridges. But it would probably require a similar alliance of Republicans and Democrats for passage.
The balancing act would be a delicate one.
“I would hope that the solution could come from the Republican caucus,” said state Rep. Buzz Brockway, R-Lawrenceville. “I’d hate to see the (House) speaker put in the position where the only way it passes is he has to go get Democratic votes. ‘Cause then it’s probably a solution I won’t like.”
On the other side are Democrats such as state Sen. Vincent Fort of Atlanta. “We want Medicaid expansion, but we want it to be done the right way to help as many people as possible,” Fort said. “Which means we need to be included upfront.”
If walking that tightrope weren’t difficult enough, several complicating issues are likely to be wrapped into any Medicaid expansion debate. For instance, a “bed tax” on hospitals, first passed in 2010 and used to draw down $750 million in federal money, is set to expire again next year.
Then there’s the fierce state Capitol fight over state-issued “certificates of need” that restrict where and how hospitals and clinics can compete throughout the state.
“They’re all intrinsically tied together. It’s a wave of a tsunami splashing up against the state,” Unterman said. But the health committee chairwoman hinted at some of the gears that might already be turning, especially on the Medicaid expansion issue. Instead of a separate piece of legislation that would put lawmakers on the spot, the initiative could be lumped in with billions of dollars of other choices.
“It really doesn’t have to be a bill. It could be written into the budget,” she said. “And you vote on the budget.”