Democratic wins revive Medicaid expansion push in Georgia, but new hurdles await

Three days after Keisha Lance Bottoms won the governor’s seat, Ryan Loke faced a crowd of Georgia health advocates, some giddy at the possibility of the state finally expanding Medicaid. Loke understood. In 2019, as health policy adviser to newly elected Gov. Brian Kemp, Loke had helped form the Georgia Pathways to Coverage program and knew its struggles well. He has long been a convert to full expansion.

“I’m fully confident that the General Assembly is going to expand Medicaid in the 2027 session. Like, 100% confident,” Loke told the crowd. “No matter the Senate makeup, House makeup” – his words then drowned out by applause.

But he was actually delivering a warning.

“Medicaid expansion in this state under the provisions of H.R. 1 as it’s in effect right now – versus as if H.R. 1 were not in effect?” he said. “Massively different scenarios.”

Loke was referring to President Donald Trump’s One Big, Beautiful Bill law passed last summer that is packed with nearly $1 trillion in Medicaid cuts in the coming years. And knowing the issue intimately, now from inside the system as a senior vice president and chief health policy officer at Grady Health System, Loke wanted the people in the audience to know there was still more to do to make Medicaid expansion work. The coverage of large numbers of Georgians could depend on it.

A system ‘built on Windows 97′

If nothing changes to simplify eligibility on the federal level, Georgians who are eligible for Medicaid expansion will continue to fall through cracks in the state’s bureaucracy, said Jen Wagner, director of Medicaid eligibility and enrollment at the Washington-based Center on Budget and Policy Priorities.  

Wagner’s organization this year released a study using 2024 data, and it suggested that 347,000 uninsured Georgians might be eligible for insurance under full Medicaid expansion – but that doesn’t include those who would be culled by the work requirements, much less those who could meet them but can’t make it through the state’s rickety, glitch-prone, understaffed Medicaid enrollment system.

“To get closer to that number of eligible people, there’s a number of changes that Georgia would need to make, in making their application more friendly, their online system more accessible, their verification processes – and all of those things,” Wagner said.

“The Medicaid eligibility system in this state is built on Windows 97,” Loke said. “It takes 45 to 60 clicks to get somebody enrolled. I can buy a Tesla in the next five minutes and have it delivered to my house tomorrow quicker than I can get somebody enrolled in Medicaid. 

“We have to address that,” he added.

At this point, changing the work requirements – and the accompanying twice-a-year paperwork reporting that will be required by federal law – would take a change in the law and rules from Congress and the Trump administration. And fixing Georgia’s computer system would take an investment of state money.  

Moreover, the One Big, Beautiful Bill Act cuts Medicaid in yet another way that discourages Medicaid expansion, reducing a particular funding stream for hospitals in states that expand.

In Washington, where Democrats now are set to control both the U.S. House and Senate, Sen. Raphael Warnock, a Georgia Democrat, has joined others in pushing for a two-year delay of the work reporting requirements.

“No state that has attempted work reporting requirements in Medicaid has ever meaningfully increased workforce participation. Instead, every state that has done so has either seen or predicted significant coverage loss for people who continue to be eligible for Medicaid but lose coverage because they can’t navigate all the red tape,” their letter read.

The politics

Last week’s Democratic wins are driving the conversation. Democrats such as Bottoms have long held full insurance for the poor and low-income as a goal. They now will take the governor’s seat and the Georgia House of Representatives too. But Republicans still hold the state Senate, so they hold some cards.

Patient advocacy groups like some of those that were in the room where Loke spoke Friday are working, researching and talking in a frenzy to put together a coherent recommendation to Democratic leaders on what will have the most impact.

There’s still a big reward for states that expand Medicaid under the Affordable Care Act: The federal government pays 90% of the cost. That’s a big carrot worth billions of dollars to Georgia, which normally has to pay one-third of the cost. And when more people are covered, struggling hospitals are more likely to stay afloat.

But there are now sticks for hospitals alongside that carrot. 

There’s that Medicaid funding stream for hospitals that will decrease after a state expands Medicaid. It will decrease for all states, but it will decrease slightly more for states that expand.

In addition, hospitals will have to take a lower fee for treating patients who got Medicaid through the expansion than if those patients were on Affordable Care Act plans. And there’s a huge group of patients – perhaps 500,000, hospital advocates say – who are currently insured on the ACA exchange but could have to switch to Medicaid if the state expanded Medicaid.

For those patients, getting Medicaid may be an improvement, studies show. But for the hospitals that treat them and lose the private insurance money, it may not be.

The Georgia Hospital Association has a powerpoint on the new complexities of Medicaid expansion. It doesn’t take a position on expansion; it says there would be “gains” and “losses.”  It also says there may be a third option. Or more.

“I’m very much looking forward to hearing what our hospital community and advocates are coming up with,” said Sandy Springs Democratic state Sen. Josh McLaurin, the incoming lieutenant governor.

Those calculations can shake out differently for different hospitals. If a hospital will lose more money through those federal funding cuts than it will gain for newly insured patients, is it worth it for them? In fact, does the new federal law pit patients against hospitals in that situation?

Georgia Hospital Association CEO Caylee Noggle acknowledged the issue but hopes to help negotiate changes. 

“My goal is to remain a partner at the table to find a solution where that’s not even an issue,” she said.

When it comes down to the Senate, the Georgia Recorder reached out to a handful of Georgia senators. None of them wrote off the idea of the Senate passing Medicaid expansion. 

“My answer is, ‘I don’t know,’” said Sen. Kay Kirkpatrick, a Marietta Republican and a physician who serves among Senate majority leaders as the Republican caucus secretary.

Senate President Pro Tem Larry Walker referred questions to his press team, but didn’t say no.

Sen. Russ Goodman, a Cogdell Republican who is one of the senators who has signed on to support Medicaid expansion before, said he was listening. “You can’t commit to anything until you see it,” Goodman said. “I’d be a fool to do that. But I mean, I’ve been open to the idea all along.”

The Georgia Republican Party’s new post-election playbook, however, says part of their strategy going forward will be to focus on two sticking points: “negotiate any wider coverage on Georgia terms: work requirements and private plans.”

The patient

Michael Cortes, a lobbyist in Georgia for the American Cancer Society Cancer Action Network, said to remember what’s at stake. 

“Having access to quality health insurance is a top predictor of whether or not someone will survive their cancer,” Cortes said. 

That applies, he said, to not just through fancy treatments but through regular screenings that find cancers early.  

“We want everyone to be able to have access to those colonoscopies or breast cancer screenings and what have you,” Cortes said. 

He’s not a fan of work requirements but will take what he can get.

“The overriding emotion from Tuesday is hope,” Cortes said, referring to the midterm election results. “We’re feeling hopeful that over 300,000 Georgians are going to have a real chance for their concerns to be heard in the Legislature this upcoming year. 

“We’ve been working on this for years with both parties, and I think we’re looking forward to having those serious discussions again now with new leaders in the state.”