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Tom Baxter

The slow, or fast, train to 2014

By Tom Baxter

Stories about the Republican governors’ struggle with accepting the Medicaid expansion often say, as an Associated Press story did this week, that under the Affordable Care Act, “Washington pays the full cost of the expansion for the first three years, gradually phasing down to 90 percent.” This is true, but there is a little more to it, and in political terms that little is large.

To expand the explanation somewhat, from Jan. 1, 2014, to Dec. 31, 2016, the feds will pay the participating states 100 percent of their Medicaid costs. The scale-down begins in 2017 and reaches 90 percent in 2020. (Under the current Medicaid system, the federal share in Georgia is about 66 percent.)

What results from this is somewhat akin to Einstein’s Theory of Relativity. To some GOP governors who have been vocally opposed to Obamacare, the train they’re on appears to be moving slowly enough to get through one more qualifying, one more election, maybe even having their portrait hung in the capitol before they’re compelled to concede. To others, the very same train seems to be moving much faster, as they ponder the costs of delay, both to their state budgets and their re-election prospects.

The train metaphor isn’t accidental. You may think Obamacare and its cornerstone program is as bad an idea as the war in Iraq, but as surely as there was the one, there is going to be the other. Florida Gov. Rick Scott’s announcement last week that he’ll accept the expansion after all was a very loud whistlestop for an engine gathering steam, though there is still much political drama ahead, as evidenced by Gov. Nathan Deal’s insistence that he’s standing firm in refusing the money.

Last week, advocates for expansion released a study by Georgia State’s Bill Custer estimating that it would add 70,000 new jobs to the state’s economy, including 26,000 in the Atlanta region. It’s harder to put a precise value on the cost of delay, although advocates for expansion say it will be high. Tim Sweeney, director of health policy at the Georgia Budget and Policy Institute and a recent guest columnist on this site, said Monday the monthly cost of delay could range anywhere from $240 million to $300 million, with a cost to the state exceeding $3 billion in passed-up federal money by the end of 2014.

But this is only an estimate, and by Sweeney’s admission a wide one, because what will really happen on Jan. 1 of next year is that the feds will pay the 100-percent tab as new enrollees come into the system and start to generate medical bills. No one can say how fast or slow that will happen, although there’s a lot of pent-up demand.

If we think of the costs as U.S. taxpayers, it gets even more complicated. Suppose Georgia waits until, oh let’s just say, November 2014 to accept the money, and someone with hypertension has to wait to see a doctor until then. If they get better in the coming year, the taxpayers saved nearly a year’s worth of blood pressure pills. But if in the interim they have a stroke and the taxpayers inherit a nursing home patient, the costs will be astronomically higher.

On the other hand, maybe that’s not so complicated. Georgia’s chronically underfunded Medicaid system is at a tipping point, with or without the expansion and despite the Bandaid effect of the bed tax extension.  The strongest argument for the inevitability of the expansion may be the state’s inability to come up with a better idea. The legislature has passed some feel-good legislation, like the 2012 law which allows out-of-state insurers to sell stripped-down policies without some of the mandatory coverage that was said to be driving up overall costs. In two years, not one company has taken the state up on that offer.

Going it alone after 2014 is going to require a lot more invention than that.


Tom Baxter

Tom Baxter has written about politics and the South for more than four decades. He was national editor and chief political correspondent at the Atlanta Journal-Constitution, and later edited The Southern Political Report, an online publication, for four years. Tom was the consultant for the 2008 election night coverage sponsored jointly by Current TV, Digg and Twitter, and a 2011 fellow at the Robert J. Dole Institute of Politics at the University of Kansas. He has written about the impact of Georgia’s and Alabama's immigration laws in reports for the Center for American Progress. Tom and his wife, Lili, have three adult children and seven grandchildren.



  1. ScottNAtlanta February 26, 2013 8:22 pm

    This is such a nobrainer. You get 3 years of 100% funding…all the jobs created by that funding in the medical services field which are higher paying jobs and people are healthier…sounds just horrible doesn’t it.  Deal is incompetent and it is showing more every day.  Listening to tea party boosters like Debbie Dooley and Jenny Beth Martin who have no clue about any of the policy they advocate is just plain dumb.  Nathan Deal needs to learn to count as well…600,000 is a lot of votes to energize against you and your partyReport

    1. The Last Democrat in Georgia February 27, 2013 6:50 am

       I wouldn’t say that Governor Deal is incompetent and I also wouldn’t say that Deal is merely just “listening” to Tea Party boosters like Debbie Dooley and Jenny Beth Martin.
      With Deal running for re-election next year and the Tea Party drawing a red line in the sand on the Medicaid funding expansion, it is probably very wise politically for Deal to accept Debbie Dooley’s and the Tea Party’s terms of the Tea Party not challenging him in the 2014 GOP Primary as long as he continues to turn down the expansion of Medicaid funding.
      With those terms being set by the increasingly very politically dominant Tea Party wing of the ruling Georgia GOP, Deal is not just merely “listening” to the Tea Party, he is being dictated a set of non-negotiable political terms by what is currently the state’s most-unquestionably powerful individual political constituency that will decide his re-election prospects…
      …A set of non-negotiable political terms that Governor Deal has no choice but to agree to if he does not want to face a potentially very-stiff and highly-animated challenge in the upcoming GOP primary from a very-irate and very-powerful far-right political flank that is basically claiming responsibility for scaring off from running for another term a conservative U.S. Senator whom the Tea Party deemed to be too moderate and/or liberal in Saxby Chambliss. 
      You are correct that 600,000 votes is a lot of potential votes to energize against oneself and one’s political party for Governor Deal, but just WHO is going to energize them.
      The Georgia Democratic Party is in such a severe state of organizational and financial disarray at the moment that, with little more than $500,000 on-hand to run the entire statewide organization according to some recent reports, the party is having extreme difficulty just simply finding candidates to field in the statewide elections for the U.S. Senate and the Governor’s office in 2014.
      If the reports of Georgia Democrats having only $500,000 on hand are true, that would mean that there are many individual Republican candidates who have more money on hand individually than the entire Georgia Democratic Party organization has as a whole.
      Heck, just the disgraced former Georgia State Senate Rules Committee Chairman Don Balfour of Snellville alone had over $700,000 on hand before his re-election run in his Gwinnett County state senate district last year.
      It is Deal’s politically-wise acknowledgement of the Tea Party’s current overwhelming power and unquestionable dominance in Georgia politics and the Georgia Democratic Party’s state of complete and total organizational and financial disarray that are the reasons that he is surprisingly likely at this point not to be seriously-challenged (if challenged at all) in both the 2014 GOP Primary and the 2014 General Election.
      I don’t know the last time when a Georgia governor may have run for re-election without being challenged by either his own party or the opposition party, or if that type of thing has ever occurred before in the history of Georgia politics, but at this very moment, it certainly looks to be a possibility in 2014.
      What is even more shocking is that the far-from-robust (VERY-FAR-from-robust) Georgia GOP could potentially also be unchallenged in the 2014 U.S. Senate race, meaning that there could possibly be TWO very-major statewide races in the same year in which Georgia Democrats are not represented if the Dems fail to find any candidates to run.Report

  2. The Last Democrat in Georgia February 27, 2013 7:10 am

    If (and that is a very big IF, at this point) Governor Deal were to accept the Medicaid expansion, the earliest that he would likely do it politically would be late 2014 after he had safely secured re-election to a second-term as Mr. Baxter alluded to in the article.
    Though, even if Governor Deal were re-elected to a second term with little or no opposition, there would not necessarily be any guarantee that Deal would accept the Medicaid expansion that the increasingly-powerful Tea Party faction of the dominant Georgia GOP is stridently against.
    Governor Deal could likely not ever accept the Federal expansion of Medicaid because right now, it is the Tea Party that is currently driving the bus in Georgia politics.
    Right now, the Tea Party is probably the most major force in Georgia politics.
    And the virtual complete and total lack of a viable Georgia Democratic Party organization at the state level makes the Tea Party even that much more powerful and dominant politically than in most states outside of the Deep South.
    Though, even with that political calculus, Governor Deal’s unchallenged and unabated path to re-election is still likely the best and only chance that those that are in favor of the Medicaid expansion in Georgia will have at seeing it accepted and enacted in the near future.Report


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