Georgia, North Carolina part ways on Medicaid expansion

Next month, North Carolina will become the 40th state to enter the Affordable Care Act’s Medicaid expansion program. The way it got there has been long and tortuous and not without its costs.

Another way of writing this would be, “Next month, Georgia will become one of ten remaining states that have held out against Medicaid expansion.” But that would require an asterisk since the state has begun a limited version of expansion: Georgia Pathways to Coverage, the only Medicaid program in the country that has a work requirement for recipients.

The neighboring states have chosen very different healthcare strategies, and in the years ahead, the outcomes of these strategies are sure to be compared.

The General Assembly passed the legislation establishing the Pathways program in 2020, but the Biden administration rejected the plan for the federal-state program because of the work requirement. The state sued, and last year, a federal judge allowed the program to go forward. It was finally launched in July of this year.

The Georgia Department of Public Health has projected that some 100,000 people could eventually be helped by the Pathways program, and in the early weeks of the program, only a few hundred signed up. In North Carolina, officials estimate the full-fledged expansion will cover 600,000 people who earned too much to qualify for traditional Medicaid but too little to afford private insurance, plus an additional 300,000 people already on Medicaid who will receive expanded coverage.

Georgia has a Republican governor, and North Carolina has a Democrat, Gov. Roy Cooper. That is a critical reason why the states took different directions, but it’s not the only reason. A number of advocacy groups in North Carolina worked for years to lay the groundwork for the expansion, building a grassroots movement that ultimately won over Republican legislators. A generous federal incentive didn’t hurt, either.

In an analysis for the Georgetown University McCourt School of Public Policy Center for Children and Families, Dr. Adam Searing said years of attempting to “fix” the existing Medicaid system with more managed care eventually caused Republican legislators to embrace the expansion.

“With their stamp on Medicaid system’ improvement,’ they felt more comfortable expanding the program,” Searing wrote.

That suggests a direction Georgia might take in the future if its do-it-yourself plan doesn’t work out.

The North Carolina legislature, which has a Republican supermajority, approved the expansion last March, with the provision that it could not go into effect until the legislature passed its next two-year budget.

That was the final rub. The budget put forth by Republicans increased the legislature’s power over judicial appointments, governmental transparency and community colleges, expanded private school vouchers and spent less on education than Democrats wanted. Its passage last month was three months late and mostly along party lines.

Cooper called it a “bad budget that seriously shortchanges our schools, prioritizes power grabs, keeps shady backroom deals secret and blatantly violates the constitution,” but unlike previous years in which he used the veto pen, he let the budget pass without his signature. “I will not allow people who are crying for help to wait any longer,” he wrote. The expansion is scheduled to begin Dec. 1.

With Republicans solidly in control of the legislature, a veto would, for the most part, have been only a delaying tactic. The passage of what amounted to a Republican wish list is still stuck in the craw of Democrats, but expansion has been the centerpiece goal of Cooper, who is term-limited and nearing the end of his second term.

Even when they’ve started with the same plan, states can have much different experiences. Voters in Oklahoma and Missouri adopted the expansion in 2020, but after a year, Oklahoma had enrolled 200,000 people and Missouri only 20,000. Oklahoma funded a vigorous enrollment, while in Missouri, the legislature refused to fund the expansion until a judge ordered it to do so.

A year from now, we’ll be able to compare North Carolina’s progress with Georgia’s by a number of measures. Another important factor that led our neighbor to adopt the full expansion was the crisis in that state’s rural hospitals, which looks a lot like the crisis in Georgia’s rural hospitals. Will an enormous injection of federal funds result in a different outcome for North Carolina than Georgia? We’ll know next year.