Georgia Republicans considering Medicaid expansion risk backlash from primary voters

The prospect — albeit still dim — that Georgia could fully expand Medicaid has prompted Democrats and patient advocates to turn up the pressure on Republicans in the state legislature to act.

But political experts, advocates and policy analysts say GOP lawmakers face significant headwinds to approving a plan they have long derided as wasteful, and that could ultimately doom the effort.

"There’s reason to be a little more optimistic than one year or two years ago, but there’s not a groundswell of support and willingness to change the status quo on the part of the Republican members of the legislature," said Harry Heiman, a health policy professor at Georgia State University.

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The biggest obstacle is Georgia Pathways, the state's limited Medicaid expansion that includes the nation's only work requirement for Medicaid recipients, said Laura Colbert, executive director of the advocacy group Georgians for a Healthy Future.

Republican Georgia Gov. Brian Kemp has championed the program, which launched in July. Though it is off to a rocky start, with just under 2,350 people enrolled as of mid-December, the Kemp administration has sought to extend it past its September 2025 expiration date.

"Governor Kemp has put a lot of political capital into Pathways," Colbert said.

Colbert said she was optimistic that Georgia lawmakers would eventually approve a fuller expansion of coverage for low-income adults, but not necessarily this year.

Kyle Wingfield, president of the conservative Georgia Public Policy Foundation, said he, too, was skeptical Kemp would be willing to retreat from Pathways.

He also warned that Republican lawmakers could face backlash for any Medicaid deal from Republican primary voters.

Expanding Medicaid to low-income adults who make up to 138% of the federal poverty level, with the federal government picking up 90% of the cost, was a key part of the Affordable Care Act. Georgia is among 10 states that have not done it.

Wingfield said he thinks Republicans in Washington, and to a lesser extent in Georgia, have accepted that the Affordable Care Act is here to stay, but that acceptance may not be shared by rank-and-file GOP primary voters.

"When it comes to the voters in a Republican primary, I don’t think I’d want to be the one finding that out," he said.

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But Brian Robinson, a Republican political consultant who counts the Georgia Alliance of Community Hospitals and House GOP caucus among his clients, says he thinks Republicans face little risk from primary opponents if they vote for Medicaid.

"The political issue of the danger has faded over the time," Robinson said. "We’ve had some mini-expansions in Georgia and there’s been no blowback on Republicans. In fact they’ve proudly touted it for groups like new mothers."

Republicans in Georgia also risk alienating the conservative organization Americans for Prosperity with a vote to expand Medicaid coverage.

The group is opposed to expansion, even as part of a deal that would repeal permitting requirements for hospitals and health services, said Tony West, the group's Georgia State Director. That sort of deal has emerged as a possible compromise between Republicans and Democrats.

West wants lawmakers to focus solely on repealing the permitting requirements and leave Medicaid expansion by the wayside.

"I think we’re taking our eye off the ball," he said.

Conversely, Wingfield raised the possibility that some Democrats could balk at a deal, noting that Medicaid expansion has been a key political issue for the party in Georgia.

"What do they gain from taking one of their signature issues off the table and letting the Republicans claim a large share of the credit for it?" he asked.

At least for now, Democrats in the General Assembly don't appear concerned about losing their ability to hammer the GOP on Medicaid. The Democratic caucus organized a lengthy hearing Wednesday focused on the economic and health benefits of expansion that featured health care providers, advocates and policy experts.

In opening remarks, Democratic state Rep. Michelle Au, a doctor, noted Georgia had one of the highest rates of uninsured residents in the country and some of its worst health outcomes.

"As we start this 2024 legislative session, it is my hope that all options are on the table," she said.