Yesterday, the Trump administration approved one of Georgia Governor Brian Kemp’s two waiver applications and is on track to approve the other in the coming days. Both are likely to present challenges to the way Georgians access their health care.
Section 1115 Waiver: a small-scale Medicaid expansion for Georgia adults who can prove employment status (at least 80 hours per month) and who earn no more than 100 percent of the federal poverty level (FPL) – $12,760 a year for an individual.
Section 1332 Waiver: a two-part waiver, including reinsurance and the Georgia Access Model. The Georgia Access Model poses problems for Georgians purchasing insurance as it dismantles the ACA’s Marketplace, a single market where consumers can compare plans, and makes it harder for people to learn whether they are eligible for Medicaid. Instead, consumers will be forced to compare coverage via various private insurer and broker websites.
How do these waivers threaten health care access for Georgians?
Through his Section 1115 waiver, Gov. Kemp’s plan falls far short of full Medicaid expansion. This waiver is projected to provide Medicaid coverage to 65,000 people whereas full Medicaid expansion under the Affordable Care Act (ACA) could provide coverage to roughly 500,000 Georgians. This 1115 waiver extends coverage to adults whose household income is at or below 100 percent FPL, contrasted with full Medicaid expansion that extends coverage to adults whose household income is at or below 133 percent FPL.
Not only is Gov. Kemp’s 1115 waiver a limited expansion, it also contains harmful and legally suspect barriers to coverage. Work requirements have been struck down in court on the basis that 1) work requirements do not necessarily lead to transitions to private insurance, 2) work requirements will likely result in massive coverage losses, 3) the objective of the Medicaid program is not to promote financial independence but to increase health care coverage, and 4) coverage should not be conditioned on someone’s employment status or ability to work.
Low-income adults can fail to meet work requirements for a number of reasons, including a disability, serious illness or substance use disorder. The administrative and bureaucratic obstacles associated with proving employment or exemption qualifications could make obtaining and maintaining coverage a consistent struggle for Georgians. These concerns are of utmost urgency as we continue to battle the COVID-19 pandemic. Georgia, as a state, faces a crippling budget crisis, with significant cuts to multiple areas of their state budget, due to the pandemic. Adopting full Medicaid expansion could alleviate some financial strain with the influx of additional federal dollars. Instead, Georgia will forgo the enhanced federal match rate of 90 percent (attained with full Medicaid expansion adoption) and maintain its current level of Medicaid federal match at 67 percent with this waiver.
Whereas the 1115 waiver could benefit a marginal number of Georgians, the Section 1332 waiver will likely not benefit any Georgia consumers shopping for coverage. In 2020, 79 percent of Georgia marketplace enrollees used HealthCare.gov to sign up for coverage, even though they already had the option of using a private broker or insurer website. A consequential benefit of HealthCare.gov is that through the website, consumers can easily learn whether they are eligible for Medicaid and if so, how to enroll in Medicaid. Medicaid enrollment trends show that one-stop government-run marketplaces (whether state-based or federal) have led to growth in Medicaid enrollment.
Another major consequence of moving away from HealthCare.gov is that consumers will be confronted with offers of subpar insurance products, such as short-term, limited-duration insurance, alongside offers of comprehensive coverage without the tools to differentiate between the two. If more consumers end up in subpar plans, either knowingly or unknowingly, they’re at greater risk for exposure to high out-of-pocket costs. Georgia’s 1332 waiver, in effect, increases the likelihood that consumers will become underinsured and see cost as a barrier to care.
These waivers are especially harmful during the COVID-19 pandemic.
The COVID-19 pandemic is an unprecedented public health crisis that calls for a strong public health response and bold action. Neither of Governor Kemp’s proposed plans meet these criteria – and in fact would be harmful to Georgians’ ability to get and maintain consistent health care coverage. These plans are steps backward in providing Georgians greater access to health care during this pandemic, and now more than ever, we must seek ways to expand health care coverage, not take it away.