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Medicaid expansion: How it has worked in other Southern states

The University of Arkansas Medical Sciences Medical Center has seen its number of uninsured patients drop since the state expanded Medicaid.

The University of Arkansas for Medical Sciences Medical Center has seen its number of uninsured patients drop since the state expanded Medicaid.

The University of Kentucky’s Chandler Hospital has seen its inpatient numbers rise by 5 percent and its outpatient numbers rise by 10 percent since July. But its number of uninsured patients has dropped, from about 9 percent to 2.5 percent.

Prior to this year, says Chandler’s Dr. Michael Karpf, “we were getting paid 10 cents on the dollar” serving low-income patients. “Now we are getting 40 cents on the dollar, so the cost of care for these people isn’t totally covered, but there is a lot more reimbursement. It means we are having very strong bottom lines in the hospital.”

The financial transformation, he says, has been fueled by the state’s expansion of Medicaid.

Dr. Michael Karpf

Dr. Michael Karpf

Kentucky and Arkansas, unlike other Southern states, adopted the Affordable Care Act’s expansion of Medicaid, adding more people to the program. Although the two states took different approaches, hospital officials in both say it is working better than expected.

Besides extending insurance to millions of Americans, the ACA has brought increased reimbursements to hospitals for patients who were previously uninsured. Gradually, though, the health reform law will cut federal “disproportionate share’’ funds to hospitals that care for many indigent patients.

Georgia Health News contacted health care experts and officials in Arkansas and Kentucky to gauge the impact of Medicaid expansion thus far on hospitals, and found both states are experiencing significant benefits.

Kentucky, with a Democratic governor and Democratic-controlled House, chose to expand its Medicaid program as originally mandated by the ACA. Federal funding covers 100 percent of the expansion for three years and then drops to 95 percent after 2017 and to 90 percent by 2020.

A 2012 decision by the U.S. Supreme Court, while generally upholding the health care law, said states had the right to opt out of expanding Medicaid. That complicated the issue of expansion, which drafters of the new law had envisioned would be nationwide.

The expansion is designed to cover all individuals and families with incomes below 138 percent of the federal poverty level (FPL). Roughly half the states, including Georgia, have refused to expand Medicaid.

Arkansas, with a Democratic governor and Republican-controlled House and Senate, reached a compromise. It did not directly expand its Medicaid program, but received a waiver from the federal government to use expansion funds to create a “private option” alternative. The state is buying commercial health insurance for those low-income citizens on Arkansas’ health care exchange.

The federal funds pay the premiums for the insurance plans. The money also covers co-pays and out-of-pocket expenses for beneficiaries below 100 percent of the poverty level. Between 100 percent and 138 percent FPL, individuals and families are responsible for shared expenses up to 2 percent of their annual income.

“The impact has been remarkable,” said Joseph Thompson, director of the Arkansas Center for Health Improvement, a nonpartisan, independent health policy center. Of the state’s 250,000 uninsured low-income adults, 205,000, or 85 percent, are enrolled in the private option program.

Other data, Thompson said, show overall emergency room visits statewide were down 2 percent for the first four months of 2014, compared with the same time last year. Uninsured ER visits decreased by 24 percent, and uninsured hospital stays dropped 30 percent.

Dr. Roxane Townsend, CEO of the University of Arkansas for Medical Sciences Medical Center in Little Rock, says, “Our monthly uninsured patient rate has been consistently below 4 percent down from nearly 15 percent prior to insurance expansion.”

Roxane Townsend

Roxane Townsend

UAMS is in the process of evaluating the financial impact, but Townsend says the medical center already has seen improvement since the start of its fiscal year this past July 1.

She also notes, “The rates in the private option are nearly the same as our other commercial contracts. This is a higher rate than traditional Medicaid, and this has a positive impact on a hospital’s ability to cover all the costs of care.”

Several rural hospital CEOs reported a positive effect from expansion, according to an article in Arkansas Business this month.

Darren Caldwell, CEO of DeWitt Hospital and Nursing Home, a rural hospital in DeWitt, Ark., told Arkansas Business that the ACA and the private option have led to a decrease in his organization’s uncompensated care, an increase in insured patients and a decline in bad debt.

“We’ve seen really good numbers,” he said. “In talking with my counterparts in other hospitals in this region, they too have seen good numbers.”

The earliest impact for patients, Thompson says, was at pharmacies. People who had prescriptions for medicines but could not afford to purchase them were able to fill their prescriptions with their newly acquired commercial insurance.

Thompson also has heard from front-line providers at community health centers who say they have been able to connect low-income patients to hospital care more readily, including specialist care.


Other states showing interest


The Arkansas alternative to Medicaid expansion has drawn attention from other states such as Iowa, Michigan and Pennsylvania. Thompson notes it represents a hard-fought compromise made palatable to the GOP legislature by Gov. Mike Beebe’s support for a $100 million tax cut.

“From an impact perspective, the program is performing even better than originally expected because of the uptake,” Thompson says. “We didn’t think we could be at 85 percent in the first year. We thought it would take a little longer, but that’s because of the need that’s out there.”

Gov. Steve Beshear

Gov. Steve Beshear

In Kentucky, Democratic Gov. Steve Beshear used his executive authority to expand Medicaid under ACA and had enough support in the Legislature to defeat several Republican bills to stop it.

The state has experienced significantly greater enrollment than expected, according to Jill Midkiff, director of communications for the Cabinet for Health and Family Services (CHFS).

Of 640,000 uninsured Kentuckians, 521,000, or 81 percent, have acquired insurance under the ACA through the state’s health care exchange. Of those, more than 310,000 enrolled through the Medicaid expansion.

CHFS Secretary Audrey Haynes says, “More than 80 percent of those who qualified for the Medicaid expansion have used their benefits at least once this year, clearly demonstrating a need in this population who likely were not receiving the preventive care and treatment they required.”

She says Kentucky hospitals, pharmacies, physicians and dentists have received more than $591 million in Medicaid expansion reimbursements.

Other data reveal a significant decrease in hospitals’ uncompensated care costs. For the first six months of this year, those costs dropped by nearly 60 percent to $218 million from $511 million in the first half of 2013.

Another benefit has been an increase in jobs. The U.S. Bureau of Labor Statistics reported Kentucky added 3,000 health care jobs and 8,000 administrative and support services jobs from July 2013 to July 2014. The job growth, Midkiff says, “is a result of Kentucky fully embracing the ACA, including Medicaid expansion.”


Long-term concerns


Karpf, University of Kentucky executive vice president for health affairs and head of the school’s Chandler Hospital, agrees the Medicaid expansion is having a positive impact.

In the long term, however, Karpf predicts the current strong financial performance of hospitals fueled by the Medicaid expansion won’t last. After 2017, he said, Kentucky will be hard-pressed to pay its amount for the expansion.

University of Kentucky Chandler Hospital

University of Kentucky Chandler Hospital

“Kentucky is an overutilizer,” he explains. “Our hospital utilization is 120 percent or 125 percent of the national average. That is a problem, and that problem will get compounded when the state has to start picking up its share of the Medicaid costs.”

By 2020, he says, the state’s share of the costs for Kentucky’s newly eligible Medicaid patients will be substantial, in the hundreds of millions of dollars annually.

With a fixed budget for Medicaid, Karpf anticipates the state will push “for decreased utilization and for providers to take more risk and more responsibility for utilization.”

That means reducing inpatient care and supporting fewer hospitals, he added. In the long run, he predicted, some small rural hospitals may close as the state’s portion of Medicaid reimbursements fails to keep pace with the higher volume of patients.

Karpf favors Medicaid expansion, but says he would have delayed it until greater efficiencies in hospital utilization were in place.

The eventual state match for Medicaid expansion was a focal point of Gov. Nathan Deal’s refusal to support expanding Medicaid to up to 600,000 uninsured low income adults in Georgia. The state, Deal said, could not afford the expansion, which state officials have calculated at $2.5 billion over 10 years.

Deal is in a tight race for re-election with Democrat Jason Carter, a state senator, who has indicated his support for expansion.


A variety of challenges


Meanwhile, many Georgia hospital officials, especially those in rural areas, report facing financial challenges greater than ever before.

Regardless of who is governor, Medicaid expansion would have to be authorized by Georgia’s General Assembly. The Legislature is currently Republican-dominated and generally to hostile tot he ACA. In fact, it put considerable effort recently into blocking the state government from helping implement the health law.

Joseph Thompson

Joseph Thompson

In Arkansas, Thompson’s Center for Health Improvement is charged with evaluating the state’s private option experiment. The evaluation will determine if the program is cost-effective compared with conventional Medicaid expansion, such as in Kentucky.

In securing its waiver, Arkansas estimated the program would be revenue-neutral for the federal government after 10 years. The U.S. Government Accountability Office has projected the program will cost the federal government considerably more than conventional Medicaid expansion.

Thompson clearly hopes the evaluation supports the state’s experiment.

“There are 50 different Medicaid programs, and each one has been developed in its own unique way,” he says. “You overlay on top of that the political division that is present within our nation now between the two parties, and it becomes difficult for constructive policy to emerge.

“We found a way to craft a constructive and acceptable new way to provide health care to our lowest income individuals.”

The Medicaid pay raise: Doctors finally got it, but soon may lose it

Dr. Evelyn Johnson examines a patient in her Brunswick office.

Dr. Evelyn Johnson examines a patient in her Brunswick office.

Dr. Samuel Church is among Georgia physicians who received their first pay raise in more than a decade this year for treating Medicaid patients.

The extra money gave a financial boost to Church, a family medicine doctor with a solo practice in the mountain town of Hiawassee.

With the increased reimbursement, he says, “I can cover the [office] overhead and a little more. . . . We’re already operating at narrow profit margins as it is.”

That Medicaid pay increase, though, will disappear in January if the budget recommendation from the Georgia Department of Community Health to the governor and Legislature holds up during the state’s budget process.

The proposal approved by the Community Health board last week for this fiscal year and next did not include what experts estimate as $50 million to $70 million in annual state funding to extend the pay hike for primary care doctors treating Medicaid patients.

Currently, the pay raise is being funded entirely by the federal government, as a provision of the Affordable Care Act, bringing doctors’ pay for Medicaid up to the level of Medicare.

The additional reimbursement, which goes to family physicians, pediatricians and internists, is scheduled to run out at the end of December.

Doctors say if that cutoff happens, Georgia’s poor will find it harder to find a physician to treat them. Roughly 60 percent of Georgia physicians currently accept Medicaid patients.

A spokeswoman for Gov. Nathan Deal, Sasha Dlugolenski, said in an email to GHN on Thursday, “The governor will be developing his budget recommendations throughout the fall and is aware of this issue – one of the early, blatantly obvious examples of Obamacare unloading costs onto the states. This was a short-term Band-Aid to a long-term problem, and now the states are left holding the bag.”

Sen. Judson Hill (R-Marietta) told the AJC that he supports compensating doctors fully for treating Medicare and Medicaid patients. But he told the newspaper that he is opposed to the state “being forced’’ to picking up the entire cost of maintaining the pay increase.


Taking new patients


For Church, going back to the former pay rate would be a big setback.

The area around Hiawassee, in the scenic Blue Ridge Mountains near North Carolina, gets its main revenue from tourism. But the population base is small, and many residents have low incomes. The area has a severe physician shortage, Church says, and roughly 30 percent of his patients are Medicaid beneficiaries.

Dr. Samuel Church with a patient in his Hiawassee practice.

Dr. Samuel Church with a patient in his Hiawassee practice.

“It’s really scary,’’ says Church. “You have to be able to pay staff and overhead” to keep a practice going.

Recently, two physicians moved out of the area, he notes. “I’m the only doctor taking new patients in the community.”

Inadequate payment, Church says, “makes it difficult for new providers to choose service to vulnerable groups, even if their heart is there.”

The federal health law required that the raise be paid for two years, 2013 and 2014.

But the money didn’t arrive till this year. Eligible doctors received the pay hike retroactively, back to Jan. 1, 2013. Delays in the payments occurred in many states, including Georgia, that use managed care in their Medicaid programs.

A Kaiser Family Foundation study estimated in 2012 that the increase in Georgia’s Medicaid payment rate for doctors would be 48 percent.

A handful of states have announced they will continue to pay the higher rate in 2015, out of their own budgets. The six states include Alabama and Mississippi, according to a recent Kaiser Health News article.

The Medical Association of Georgia says it’s studying the impact of the loss of the extra pay in terms of physician participation in Medicaid. When fewer doctors participate in Medicaid, fewer patients have access to care.


Hard choices for physicians


Dr. Evelyn Johnson, a Brunswick pediatrician, says losing the pay hike would be devastating for physician practices.

A large majority of her patients in Georgia’s coastal region are on Medicaid. Johnson, president of the Georgia chapter of the American Academy of Pediatrics, says if the pay reverts to the former rate, “I wouldn’t be able to take new Medicaid patients.”

“I’m trained to serve the underserved,’’ Johnson says. But she adds, “There are only so many patients I can see in a day. If kids can’t get into a doctor to be seen, they will wind up in urgent care or the emergency room,” which will run up higher costs for the state.

Many physicians don’t take Medicaid patients, or limit the number they will take, notes Johnson, a solo practitioner.

Extending the pay raise “is the right thing to do,’’ Johnson says. Children, who make up the majority of Georgia’s Medicaid beneficiaries, need the medical foundation that pediatricians provide, she adds.

For Dr. Michael Satchell, an Albany family physician, the pay raise “has been instrumental in accepting more Medicaid patients in my practice.”

It has allowed him to hire a nurse practitioner and a medical assistant. “Before that, what I was paid wasn’t covering my overhead,” Satchell says.

If the state doesn’t act to preserve the current rate, patients will find access to care more difficult, he says, with “fewer providers to choose from.”

A county’s difficult question: How to save its local hospital?

Elbert Memorial Hospital needs funding from the county in order to remain open.

Elbert Memorial Hospital needs funding from the county in order to remain open.

Elbert Memorial Hospital has served its northeast Georgia county for more than 60 years.

But the future of the hospital is now unclear. Its fate will hinge on the coming days and weeks.

Elbert County commissioners are holding public hearings this week and next on a proposed one-mill property tax increase for one year to raise about $500,000 to offset the Elberton hospital’s costs for indigent care.

Without the money, the 52-bed hospital will close, officials warn. That would eliminate more than 200 jobs, and residents would have to travel more than 30 miles to the nearest hospital. A closure would jolt the mostly rural county’s economy.

Elbert Memorial lost $1.5 million in its last fiscal year, CEO Jim Yarborough said Tuesday. “Our concern is that charity care and bad debt are trending upward,” he said. Yarborough calls the financial crunch facing many Georgia hospitals “a silent epidemic.”

The hospital’s predicament demonstrates how counties and hospitals depend on each other financially, and how revenue pressure on each is creating an unprecedented squeeze.

“Counties are in major turmoil deciding whether they want a hospital or pick up the garbage,’’ said Jimmy Lewis, CEO of HomeTown Health, an organization of rural hospitals in the state. Meanwhile, he added, “The general cash position in most rural hospitals is extremely dire.’’

Hospitals are facing lower reimbursements from government programs and private health insurers, along with high levels of uninsured and underinsured patients.

But another key issue is Georgia’s decision not to expand Medicaid, hospital execs say.

Gov. Nathan Deal and Georgia’s legislative leaders, citing costs, have decided not to expand Medicaid as outlined under the Affordable Care Act.

Expansion “would help significantly,’’ Yarborough said. “It would create a paying source” from uninsured low-income patients, he added.

The Elbert County predicament comes in the wake of five hospitals closing in Georgia in the past two years. Four were in rural areas. And several other hospitals around the state are struggling just to stay open.

Debra Nesbit

Debra Nesbit

“If this disturbing trend continues, we’ll have major access-to-care issues for hundreds of thousands of Georgians throughout the state,” Kevin Bloye of the Georgia Hospital Association told GHN recently. “It will also have devastating financial consequences to areas that lose their local hospital which serves as a major economic engine.”

Meanwhile, hospitals’ requests to counties for help are more urgent now, said Debra Nesbit of ACCG, which represents county governments in Georgia. “The counties are really struggling with that.”

“Hospitals are saying, ‘Give us money or we are going to shut the door,’ ’’ Nesbit added. But with property appraisals decreasing, she said, counties have financial problems of their own. “They may not have the resources, particularly in rural areas.”

Most counties are supporting their hospitals financially, Lewis said.

Reimbursement reductions for hospitals “translate into an unfunded mandate onto the county,” Lewis added. “Rural unemployment rates are so high there’s no millage capacity to support the unfunded mandate.”

Some counties are pursuing new avenues to keep their hospitals upright. Recently, Habersham County in the northeast Georgia mountains agreed in a deal with the
local hospital authority to make monthly bond payments on Habersham Medical Center’s $37 million debt. The county will eventually take over the assets of the facility.

Newton Medical Center

Newton Medical Center

In Newton County, east of Atlanta, 97-bed Newton Medical Center recently requested a property tax increase to offset indigent care costs. It would have resulted in about a $600,000 funding increase, said Troy Brooks, assistant administrator of fiscal services for the hospital. But he said the county has already set the budget and did not include the funding that the hospital requested.

The hospital isn’t in danger of closing, Brooks indicated. Last year the hospital posted its first positive margin since fiscal 2008, which Brooks attributed to the nearly $2 million in funds related to the Electronic Health Record initiative in the Affordable Care Act.


Rocky times in the rock hills


Elbert County takes pride in its granite industry, and Elberton calls itself “The Granite Capital of the World.”

But its overall economy is less solid.

About one in four residents has no health insurance, according to the 2014 County Health Rankings, produced by the Robert Wood Johnson Foundation and the University of Wisconsin. The report also shows the Elbert County unemployment rate is higher than the state average, and that about one in three children live in poverty.

Elbert County

Elbert County

As the Elbert County commissioners hold public hearings on the tax increase, Elbert Memorial’s website sums up the situation: “This financial relief is needed to keep our hospital from closing, which would result in a devastating economic loss to the community and leave Elbert County residents without local access to health care services.”

Yarborough said he’s “very hopeful and optimistic” about the financial help. Still, he noted that in the current hard times, “there is a portion of citizens that are not in favor of a property tax increase.”

Elbert Memorial has an affiliation and management agreement with AnMed Health in nearby South Carolina, which has helped the hospital. Nevertheless, the charity care and bad debt for Elbert Memorial Hospital grew to nearly $4 million in its last fiscal year.

The request to the county commissioners is for funding the charity care of Elbert County residents. “They don’t have a mechanism to pay,” Yarborough said. “The ER always has to take care of you.”

The county commissioners will take a final vote on the tax increase after the public hearings. Commission Chairman Tommy Lyon said if the hospital closes, the county will have to add another ambulance and crew to transport patients to hospitals in Athens or in Anderson, S.C. – a step that would cause the budget to be in deficit.

“We’re in a very dire situation,’’ Lyon said, according to an Elberton Star article.

A recent report by the Urban Institute said Georgia’s decision not to expand Medicaid will cost the state’s hospitals $12.8 billion in lost reimbursements over a 10-year period. Medicaid expansion – making more low-income people eligible for the program – would ensure some reimbursement for hospitals that treat these people.

Hospital executives aren’t saying expansion is a complete cure-all. In Georgia, said Yarborough, Medicaid pays only 85 percent of the cost of a covered patient’s medical services. “We lose 15 cents on every dollar,’’ he said.

Still, Yarborough noted that for a hospital, getting “85 cents on the dollar is much better than zero cents on the dollar.”

Brooks of Newton Medical Center said, “I am hearing that hospitals in those states that did expand Medicaid have seen noticeable improvement because of it.”

Nesbit of ACCG recognizes the political realities in Georgia. “Clearly, Medicaid expansion is off the table right now,” she said.

“We don’t have a position on Medicaid expansion,” Nesbit said, though she added, “We want all Georgians to have access to health care.”

“We are continuing to look at the situation, look at creative ways to expand some health care access.”

Elberton Georgia, Granite Capitol

Elberton, in northeast Georgia, takes pride in its famous granite industry.

A health care Q&A with Gov. Deal

Gov. Nathan Deal visits WellStar Cobb Hospital in Austell last year. Photo courtesy of Andrea Briscoe

Gov. Nathan Deal visits WellStar Cobb Hospital last year. Photo courtesy of Andrea Briscoe

Nathan Deal has been involved in many high-profile decisions on health care while serving as Georgia’s governor.

Deal, who is running for re-election this year, has staked out his opposition to the Affordable Care Act (often called Obamacare) and to expanding the state’s Medicaid program. He has also supported changes to the health plan covering state employees and educators, following a wave of criticism that occurred after a new benefits framework debuted Jan. 1.

Georgia Health News recently emailed questions to Deal on a wide range of  major health care issues in the state. We received his reply Monday,  shortly before the scheduled close of the 2014 General Assembly.

In his answers, he discusses pending legislation, the federal law on ER care, the financial struggles of rural hospitals, and what he sees as ways the state can improve its health care system.

Here are GHN’s questions and Gov. Deal’s responses:


Q: What is your biggest accomplishment as governor in the field of health care?

A: When Washington tried to levy the huge taxpayer burden that is the Affordable Care Act on Georgians, I could not allow for billions of dollars of our state budget to be diverted from our schools and our citizens. By mitigating that disastrous impact on our state — an additional 620,000 people on Medicaid rolls and billions of dollars — we are keeping our budget balanced and protecting the people of Georgia.

Q:  As governor, you have blocked Medicaid expansion in Georgia. House Bill 990 would require legislative approval for any such expansion in the state. Do you support this legislation?

A: Yes, just the expansion of Medicaid would cost Georgia an additional $2.5 billion over 10 years. This will have major budgetary impacts so it only makes sense to have our state legislature play a part in the decision making process.

Q:  Do you foresee any circumstances under which you would support an expansion of Medicaid?

Gov. Nathan Deal

Gov. Nathan Deal

A: No, not under current conditions. I am doing everything in my power to rebuild our school funding as we come out of the Great Recession. We simply cannot afford the $2.5 billion in new spending that the expansion would require without a severe impact on public education. The federal administration needs to start acknowledging the Supreme Court ruling and look at other alternatives that don’t force new spending by the state. I have often discussed the advantages of a block grant. States need more flexibility in order to make their program work for their unique population rather than a one-size-fits-all Washington mandate. When I was a congressman, I served as chairman of the health subcommittee of Energy and Commerce. The need for flexibility is not new to me, but serving in my role as governor has only reinforced the notion that states can operate more efficiently with flexibility.
Q: HB 707 would prohibit employees of any state unit from spending state funds to advocate for Medicaid expansion. It would also bar the University of Georgia from operating its current navigator program, which hires and trains people to help consumers use the health care exchange. Do you support this legislation?

A: It is my policy to not comment on pending legislation that is not part of my legislative agenda.

Q: You recently commented that changes to the federal EMTALA law (requiring hospitals to treat arriving ER patients) can help reduce health care costs. Can you expand on those comments?

A: I have always been a supporter of promoting primary care and preventative care as opposed to emergency room visits for non-emergency circumstances. In the case of a true medical emergency, people should always have access to emergency rooms. However, for non-emergency situations, we should encourage those people to seek treatment in a more cost-effective setting, thus opening beds and reserving resources for those in most critical need. Because there is some confusion on this issue, let me be clear: No one’s going to be denied service. None. This isn’t about blocking doors to health services. It’s about opening new doors that yield better health outcomes at a fraction of the price of emergency rooms. The onus is on us to make sure these non-emergency resources are available and convenient to the populations in need of service.
Q: Four rural hospitals have closed in Georgia over the past two years. Can the state of Georgia do anything to prevent more from closing?

A: I recognize the critical need for hospital infrastructure in rural Georgia, as they save lives and maintain our communities. Hospitals large and small have all felt the impact of the recent economic downturn. While support that these hospitals received has diminished, I am hopeful that as the economy improves, so does the flow of funding and contributions that keep our rural areas thriving. We will continue to monitor the situation with the Department of Community Health.

Q: The changes to the State Health Benefit Plan that began in January have sparked a wave of criticism from educators, state employees and retirees. Will the pending switch to a co-pay system alleviate the members’ concerns?

A: The intention of those changes was to lower out-of-pocket health care costs for state employees. The SHBP already covered 100 percent of preventative care visits, and these improvements give employees an additional layer of security so they can do the right things to stay healthy. I believe the changes address the core concerns of our employees, but the Department of Community Health will continue to monitor and evaluate the situation.

Q: Medical marijuana has suddenly become a high-profile topic in the General Assembly. Do you support this legislation that would create a mechanism to help children with seizure disorders?

A: As I said previously, it is my policy to not comment on pending legislation that is not part of my legislative agenda.

Q: What can be done to improve the health care system in Georgia?

A:  Since taking office, I have focused on the need for additional health professionals in Georgia. We have been increasing the number of residency slots in hospitals across the state. Georgia taxpayers help fund a promising young Georgian’s pre-K, K-12, post-secondary and graduate-level medical education only to see them perform their residency outside of our state and not return. That doesn’t provide value for Georgians paying taxes. It doesn’t make sense for Georgians needing care and it isn’t fair to young Georgians looking to begin medical careers. We must ensure that no doctor trained in Georgia is forced to leave the state to complete his or her medical education. There is still work to be done, but we are making strides on this front. Individuals in Georgia can also play a major role in improving their own health by being active in their healthcare decisions. This means taking advantage of all the preventative care opportunities to improve the well-being of themselves and their families.





Carter: ‘Reduce the size of our uninsured population’

State Sen. Jason Carter (D-Decatur) recently announced that he is running to become governor of Georgia, attempting to follow in the footsteps of his grandfather Jimmy Carter, who was governor of the state from 1971 to 1975. 

Carter sat down this week with GHN to discuss a range of health care issues, including the Affordable Care Act, the criticism of the State Health Benefit Plan, and the financial struggles of rural hospitals.

 (GHN is also reaching out to Gov. Nathan Deal for a similar interview on health care topics.)

 Here is the Carter interview:



Q: What are your thoughts about House Bill 990, which would require legislative approval for any expansion of Medicaid in Georgia?

A: I think it’s essentially a political bill. If you examine the bill by looking at the problem that it’s attempting to solve, it’s very difficult to discern what the Legislature believes that problem to be, other than they’re worried that I’m going to get elected governor . . .

The politics are real and I think are at the forefront of it. I think the thing that’s amazing to me is that the governor would agree to give up the ability to respond in an appropriate way to the situation that’s there, to operate the state government as an executive. And I think that’s part of a pattern that this governor’s leadership style has been essentially one of passing the buck on important issues. And I think that’s a problem. This bill is indicative of that pattern.

Q: You’re in favor of Medicaid expansion?

A: What I believe is that we have to look at this problem critically. I think expansion should be on the table … and make sure those folks [eligible for coverage] can get either private insurance on the exchanges or get a Medicaid-like expansion — it all has to be on the table. I think we will do one of those things if I’m elected governor.

Q: Are you going to make expansion and health reform issues in your campaign?

A: There are sort of two sides to this coin. What you’re talking about on some level is, what are the politics of it? And on another level, what’s the moral value, or what’s the correct policy option?

I’m not sure what the politics are, but I’m going to do what I think is right, no matter what.

I think that it makes economic sense for our state to ensure that we draw down our tax dollars and bring them back to Georgia to improve the health options that our citizens have, to improve the economics of our hospitals, to inject a giant amount of money into the economy.

The jobs impact of taking the billions of dollars back and not rejecting our own tax dollars is huge. Plus, it ripples out to having more productive, healthier citizens.

My impression thus far of the governor’s campaign is that they’re going to talk about “Obamacare” a lot. I think [with] the national dialogue on Obamacare, there are going to be books written about it. It has become whatever it has become as this political animal.

The bottom line is the Affordable Care Act [Obamacare] was passed by Congress, signed by the president and affirmed as constitutional by the Supreme Court. It is the law of the land, no matter what.

What has happened in my view is what we’ve seen in Georgia is that all the Washington politics about Obamacare have been imported. It doesn’t matter if I support 100 percent of the Affordable Care Act or not. There are things I would change, there are things the president would change. The question we have to confront as governor, is what’s best for the state, given the federal law.

This governor came from being in Congress for two decades and can’t let go of the Washington politics, and wants to use Georgia’s tax dollars and Georgia’s health and sacrifice it on this Washington politics altar of Obamacare, and say, we are not going to do this because of Washington politics, instead of looking at this, and say, what makes sense? We have to look as governor at what’s best for the citizens of Georgia.

To me, it is examining the best way to do an exchange, rather than just rejecting it. [Georgia, like a number of other states, lets the federal government run its exchange.] And examining the best way to take the health care dollars and reduce the size of our uninsured population.

Q: Can you comment on the argument that expansion will cost the state too much money?

A: What’s interesting to me about this rhetoric about the federal government is that it’s pick-and-choose. We don’t like Obamacare because Obamacare is unpopular. That’s pure politics. We like deepening the Savannah Harbor with federal dollars because, well, that is popular.

Georgia today under the current leadership is one of the most dependent states on the federal government in the country, and yet we sit here and blast the federal government all day, while we grow more and more dependent on it. Half of the time we’re begging for federal dollars.

I think we have to strengthen our state government in ways that make sense. We have to invest in the future. To the extent that we’re going to participate or not participate in federal programs, we need to look at what they are doing for our state. Are we investing in our future? Are we getting stronger? When we build roads, when we invest in our infrastructure, when we deepen the Savannah port, I think those things strengthen our state. I think it strengthens our state by injecting billions of dollars into our health care system to reduce the size of our uninsured population. Those things are investments in our future that don’t make us more dependent on the federal government.

We pay our federal tax dollars in Georgia, yet we’re going to try to pick and choose based on politics when we get the benefits of those tax dollars? That doesn’t make sense.

Q: There was another rural hospital that closed in Georgia last week – Lower Oconee Community Hospital in Wheeler County. That makes four to close in Georgia in two years. What are your thoughts on that issue?

A: It is a major crisis for a community when a hospital closes. Lower Oconee in Glenwood had 100 employees and 25 beds. The problem in a community like that when a hospital closes is not just that you’re losing health care options and not just that you’re losing jobs. The economic impact a hospital has in a community like that is gigantic. It also ripples out beyond that. If it takes 30 or 40 minutes to get to a hospital from that spot, it’s harder to put a factory or mill there. You’ve got someone operating a nail gun, you have someone operating a piece of machinery, and you’re nowhere close to a hospital. It makes it more difficult. Those things about rural Georgia and rural hospitals are incredibly important to me and to those communities.

We have to find a way to make those hospitals economically viable and sustainable. One piece of that, I believe, is to use our federal tax dollars that we’ve already paid that are waiting for us to reduce the size of the uninsured population. That uninsured population is just a giant hole in [hospitals’] budgets.

We have to find ways to have sustainable economic models for those hospitals going forward. It’s not just reducing the uninsured population. It’s also finding an appropriate mix of services that are going to work in those areas. I understand there are ways to approach that issue through the regulatory environment. It doesn’t have to be to open up [the certificate of need rules]. I think we can explore regulatory solutions. We haven’t seen that yet from this administration. This being an election year, as soon as we start talking about things, the administration has acted. Hopefully we’ll see some of that in a short period of time.

Q: The health plan that covers state employees and teachers has come under sharp criticism since changes were launched in January. What’s your view of this situation?

A: First of all, I’m on that same health plan. I not only heard complaints from citizens, but complaints from my wife. A very important constituent (laughs) . . . [Both Carter, as a state legislator, and his wife, a teacher, are eligible for the state health plan.]

I believe that we have to have options — more options than we have now. I think the outcry from teachers and others has been intense and powerful. And you saw, all of sudden it’s an election year, and we’re seeing a huge amount of responsiveness from the governor’s office. The flip-flop on whether we needed to use the reserves from the State Health Benefit Plan is not shocking, it’s just politics as usual.

We’ve spent $100 million out of the reserve fund as an attempt to placate the anger. It doesn’t actually solve the problem. We’re going to continue to hear from a great number of people, led in part by the teachers, that this is not enough. We’re talking about real options that need to be there.

The State Health Benefit Plan is a symptom of a much deeper-seated problem, which is the current leadership of our state doesn’t believe they need to take care of those teachers. They don’t have a respect for the work that gets done, and the desire to recruit and retain and support the best possible workforce that they can.

I think one other aspect of the current leadership’s ideology that is indicated by this decision is they don’t run the state with the belief that it can succeed as an entity. They’re so against “government” as a concept that they don’t believe in its success. If that’s true, you’re running a multi-thousand-employee entity with serious morale problems, with disrespect for the employees. . . . You end up with decisions like this that result in a backlash.

Q: Medical marijuana is an issue that seems to have come out of the blue, yet there’s momentum in the General Assembly to allow its use for children. Do you have a position on that?

A: I agree with you that it was an interesting and surprising development, given the makeup of the Legislature. I think the fact that it was a very conservative Republican from Middle Georgia who has led the charge is interesting.

But I personally tend to be a libertarian on things like this. . . . If you have a carefully crafted piece of legislation that’s going to minimize the unintended consequences, then I wouldn’t have a problem getting on board with it.

When you talk about the health outcomes for the kids that they’ve been discussing, you have to put those facts first, and whatever ideology there is, second, or not at all.

Q: Is health care going to be a big part of your campaign?

A: Part of a campaign is meeting people where they are.

Health care is an undeniably important part of our policymaking. The state government has a huge impact on the health care industry and the health care of its citizens. There are major problems that we’re confronting. There’s no doubt in my mind that it will be an important, crucial part of my governorship.

How the campaign plays out is too hard to know.

Q: Anything you want to add about health care?

A: I think it’s important that people get good information about the health care policy discussions because it’s so opaque.

If I buy a car muffler, I know exactly what it costs. If you go get an MRI, I haven’t found anyone who tells me how much it costs.

Q: The prices could vary by hundreds of dollars.

A: Not only that, but to different patients. Having a good, well-informed discussion about it is really important.

Q: Can the state do anything about making health care prices more transparent?

A: Yes, I think that the state can do that. Part of the problem is that [there is] so much volatility into the system with the staggered rollout of the different parts of the Affordable Care Act, we have to take a minute so see where that’s going to go. We don’t know what it’s going to do to costs.

But once we settle in, and understand what the [impact of] the federal law is going to be, I think there’s a variety of things the state can do, certainly from an informational standpoint. It’s not easy, but I do think transparency is one of the things that almost always helps.



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