ATLANTA — Gov. Brian Kemp sent his partial health care waiver plan to Washington for federal review, despite calls for full Medicaid expansion.
Kemp unveiled his health care waiver proposal and opened it for public comment from Nov. 4 to Dec. 3.
The state received a total of 946 public comments on the first part of the plan, known as the 1332 waiver, including 907 written comments and 39 testimonies across six public hearings.
There were 869 public comments on the second portion, the 1115 Medicaid waiver, including 827 written comments and 42 testimonies across the public hearings.
A call for full Medicaid expansion was the overwhelming plea, from health care groups and the general public alike. But with proposals already OK’d by the Georgia Board of Community Health and sent to Washington, D.C., for federal approval, Georgians can only wait and see if there will be any modifications.
Supporters said waivers are a good first step in the right direction in addressing what some are calling the state's "health care crisis." But critics condemned the proposals as a "piecemeal approach" to the state's problems.
Web comments — with personal information redacted — expressed concern from Georgia residents. For this article, CNHI reviewed the public comments submitted through the state's online submission form and letters mailed in that were made available on Dec. 23.
According to the governor’s policy staff, the state made two clarification changes to the 1115 Medicaid Waiver, no changes to the first phase of the 1132 waiver and added additional marketplace requirements to the second phase of the 1132 waiver, calling the changes an effort to maintain consumer protections while still allowing plan flexibility.
The state now awaits federal approvals, rejection or modifications to Kemp's partial health care waiver plans that for the most part are the same as what was first proposed.
Barriers serving Georgia's uninsured
The administration has consistently argued the partial Medicaid waiver is meant to be a pathway out of poverty for low-income Georgians by “incentivizing and promoting employment and employment-related activities.”
Grady Health System, the Georgia Society of Clinical Oncology, the Georgia Hospitals Association and the United Way of Greater Atlanta were among the health care industry leaders that wrote to the governor’s office.
A letter signed by John Haupert, the CEO of Grady Health Systems, said the state is stopping short in covering all Georgians below the federal poverty level and adding obstacles to quality health. The state’s largest public hospital, the letter said, serves 700,000 patients annually — 30% of which are uninsured.
Kemp’s partial Medicaid expansion waiver and Georgia Access waiver would cost the state about $215 million to cover, by the state's estimates, upward of 80,000 Georgians by 2022.
The Medicaid waiver proposal has the capacity to cover 408,000 or so adult Georgians who make less than the federal poverty level but do not qualify for Medicaid. However, the governor's office estimates only about 50,000 will be enrolled after five years — residents must also meet an 80-hour-a-month work requirement.
A Georgia Budget and Policy Institute report indicated that full Medicaid expansion would cost $2 million less and have the potential to cover more than 486,000 Georgians by 2022.
Georgia is among the 17 states that have not taken steps to fully expand Medicaid under the Affordable Care Act due to a bill that passed last session that limited any expansion at 100% of the federal poverty line.
Kemp has called full Medicaid expansion a "risky, one-size-fits-all approach."
United Way of Greater Atlanta said in its letter it recommends the state give “serious consideration to simply expanding Medicaid.”
Haupert said Georgia would be the first in the nation to “precondition” Medicaid eligibility with a work or qualifying-activity requirement, resulting in low estimates of the number of individuals who would participate in the program.
“We believe that Georgia is in an ideal position to take a more comprehensive approach to the challenges of caring for the uninsured,” he wrote on behalf of the hospital. “Otherwise our patients will continue to suffer the consequences of a piecemeal approach that costs more and is less efficient and effective.”
In addition, activists raised concerns the work requirement baked into the proposals would limit participation and fail to address the state’s high rates of uninsured.
Mental health care advocates were also worried about the implementation of the work requirement through the Medicaid waiver. Similar concerns were listed for individuals with disabilities or suffering from preexisting conditions, comments outlining scenarios that would prevent individuals from working.
Stan Jones, an Atlanta-based health care attorney, wrote to Kemp suggesting an alternative “qualifying activity” requirement for individuals suffering from mental illness. Jones suggested that individuals struggling with a mental illness should be able to count group therapy sessions, family intervention programs, participation in drug abuse programs or even proof of refills on their medication as a “qualifying activity” for the 80-hour-a-month work requirement.
“What I was trying to urge was that those requirements be widened,” Jones told CNHI, “so that participation in a rehabilitation program or recovery program, or mental health services to some level, could qualify you for benefits ... the activity requirements are going to prohibit eligibility for a large number of people who suffer from mental illness or substance abuse disabilities, because they cannot work, or go to school.”
Democrats held a press conference on the last day for public comment submissions, urging residents to write in. House Minority Leader Bob Trammell, D-Luthersville, told CNHI that full Medicaid expansion has been and will continue to be the top priority during the upcoming session.
In a final clarification of the Medicaid waiver, the state said part-time students would be able to satisfy the work requirement through work and school, but no other qualifying activities were added for individuals facing other obstacles.
Federal protections waived for preexisting conditions, mental health
The American Cancer Society penned a letter in support of the first phase of the 1332 reinsurance waiver, but expressed concern federal requirements waived for private insurers will affect individuals with cancer and other preexisting conditions. Allowing private plans without essential health benefits harm people with preexisting conditions, the society said, by causing prices for more comprehensive plans to increase.
"For patients with cancer and cancer survivors, it is crucial to choose a health insurance plan that provides coverage for their unique needs ..." the letter said. "We are concerned that the proposal will inhibit an individual from finding a plan that best meets his/her needs."
Mental health advocates and patients expressed concern for Georgians suffering from mental illness because federal mental health protections are also waived under the proposals.
According to a 2019 report compiled by Mental Health America, about 1,341,000 adults in Georgia struggle with mental illness — the rate on par with the national average. The state has higher than average rates of youth mental illness.
“I am concerned about the elimination of the requirement that insurers cover mental health services such as for physical health services,” one commenter wrote. “I know far too many families with teenagers and young adults who are in need of these services to help their children out of despair and/or substance abuse. It seems almost epidemic now and requires more support, not less.”
A number of parents wrote into Kemp’s office offering stories of the obstacles they face caring for children with mental illnesses.
“My 38-year-old son suffers from severe schizophrenia and his quality of life is very poor. He is currently incarcerated in a county jail because of untreated mental illness,” another commenter wrote. “People living with severe and persistent mental illness need and deserve proper mental health treatment and care. Both physical and mental health care is a human right and should be treated as such.”
Under the Affordable Care Act, private insurers are required to maintain consumer protections including mental health and substance abuse parity, meaning they must treat mental health benefits equal to physical health benefits.
Kemp’s reinsurance waiver program meant to stabilize the market by reducing premiums does away with the federal requirement for individual insurance markets in Georgia, allowing subsidies to go toward plans with fewer essential health benefits.
After public comments expressed concern that coverage for individuals with preexisting conditions or mental health needs will lapse or rise drastically in cost, the state added requirements for eligible plans that qualify for subsidies. To be eligible for state subsidies, the final report says, “Eligible non-QHPs will not be required to meet the full requirements of QHPs; however, they will be required to maintain basic consumer protections and regulatory requirements.”
Some commenters expressed concern that the new online marketplace will breed misleading and discriminatory packages, causing confusion for individuals looking for coverage.
As a result, the final waiver proposals added requirements for “web-broker participation,” according to the governor's policy staff. The new requirements include: display all qualifying plans in the market available to consumers; provide clear and transparent language to differentiate between qualifying and private plans; and a ban on rebates and giveaways.
The state argues the reinsurance waiver will promote a more competitive private insurance marketplace.
Riley Bunch covers the Georgia Statehouse for CNHI’s newspapers and websites.