Weighing impact on Medicaid expansion, exchange

Gov. Nathan Deal  said Thursday that it’s too early for the state to make a decision on whether to expand Medicaid or create its own health insurance exchange, if the Affordable Care Act (ACA) survives a renewed Republican effort to repeal it.

Deal, expressing dismay over the Supreme Court ruling that largely upheld the health law, called for its repeal by Congress.

He said at a press conference that he did welcome the part of the court ruling that left it up to the states whether they would expand their Medicaid programs to cover more low-income residents.

The Medicaid expansion under the law would increase the Georgia rolls by more than 600,000 people, and cost the state $76 million in 2014, and much more in costs in later years. The court decision, though, could lead to many fewer people covered, if a state rejects the Medicaid expansion, experts said.

Deal called the Medicaid decision “a door that was left open” and told reporters that “there are a lot of unanswered questions.”

One of the biggest questions after the ruling is the effect on the uninsured in states that reject a Medicaid expansion.

Health care experts tried to determine Thursday whether the people who would have been covered by an expansion – non-elderly individuals living under 133 percent of the federal poverty level, about $31,000 for a family of four  – would be eligible to enter the health insurance exchange, or whether they would get subsidies to afford coverage.

The Georgia Hospital Association said it’s not clear what happens to these uninsured people if a state rejects a Medicaid expansion.

GHA noted  that if the federal government decides to provide subsidies to these individuals, it would actually end up as an incentive for states not to do the Medicaid expansion. That’s because that population would be covered in the exchange with 100 percent federal dollars, without states sharing in the costs, the hospital organization said.

States that don’t expand Medicaid will leave most of the people who would have qualified without coverage, Kaiser Health News reported. That’s because people making under the  poverty level are not eligible for federal subsidies provided by the law, KHN said.

Tim Sweeney, health policy expert at the Georgia Budget and Policy Institute, agreed that many poor Georgians could be left without coverage if the state does not expand Medicaid. As the law is written, he said, “the people under 100 percent of the federal poverty level would not be eligible for subsidies” in the exchange.

The Medicaid portion of the ruling, thus, could lead to vastly different health care systems in different states.

Deal said he was surprised by the court’s decision to uphold the law’s requirement for individuals to buy insurance.

He also said at his press conference that Georgia will wait until after the November election to decide whether to create its own health insurance exchange.

“The elections in November will determine a lot,” Deal said.

An exchange is envisioned as an online marketplace where insurers would compete for consumers based on price and quality of care.

If a state declines to set up its own exchange, the federal government would implement one in that state.

The Obama administration has set a Nov. 16 deadline for state governments to submit proposals showing how they intend to operate health insurance exchanges in 2014.

Deal acknowledged that “it is a short window” between the election and the exchange deadline.

He said he supports the idea of small businesses to be able to band together to buy health insurance, which was a recommendation of the study commission on exchanges that he created.

Graham Thompson of the Georgia Association of Health Plans told GHN that his membership ‘’would much rather have a Georgia-centric solution.”

Meanwhile, Rep. Pat Gardner (D-Atlanta) led a press conference of supporters of the legislation, calling the court ruling ‘’a very historic step forward.’’

“What a great day to be an American,” said Gardner, who introduced legislation this year in the General Assembly to create a health insurance exchange in the state.

Gardner said her daughter was denied coverage by a health insurer decades ago because of a pre-existing condition.

She said she supports Georgia expanding its Medicaid population. She noted that if the state decides against this move, Georgia taxpayers would be paying for those expansions in other states.

Dr. Harry Heiman of Morehouse School of Medicine said that the court ruling helps give new access to services for uninsured people with health conditions. It also will help address health disparities, Heiman said.