The Gold Dome was aflutter during the first week of the legislative session over whether Georgia Republicans might move to fully expand Medicaid this year.

A high-ranking Republican leader elevated the issue further when he uttered the words “Medicaid expansion” during a prominent speech to Georgia’s business community Wednesday. House Speaker Jon Burns said House lawmakers “will continue to gather facts” about a “private option” for expanding Medicaid.  

In particular, several GOP lawmakers have voiced interest in an Arkansas-style model, which purchases private insurance for individuals on the marketplace instead of adding more people to the state-run Medicaid program.

In a statement Friday, Republican Lt. Gov. Burt Jones sounded receptive to the concept. Jones has pressed for changes to the state’s business regulations for medical providers, and discussions about Medicaid expansion are happening alongside the debate over to what extent Georgia should remake its certificate of need rules.

“I have never wavered on my position that expanding access to health care, especially in rural parts of the state, should be a priority for all Georgians,” Jones said.

“The legislative process allows for different options to be presented on a variety of issues. I look forward to addressing this critical issue this upcoming session to help make access to quality health care a reality, regardless of someone’s zip code.”

This all represents what appears to be a softening of the decade-long resistance in Georgia to Medicaid expansion, which is a central piece of former President Barack Obama’s legacy. But one of the big questions of the session will be this: Does that shift in thinking extend to the governor’s mansion? 

Georgia Pathways to Coverage has enrolled about 2,300 people since launching in July. About 345,000 are thought to be eligible for the Medicaid program, according to the state’s estimate.

The governor did not mention Pathways in his State of the State address Thursday even as he touted other elements of his signature health care plans, like a reinsurance program that has helped lower premiums.

Spokesman Garrison Douglas said Wednesday that the governor “has championed and continues to support” Pathways and Georgia Access, which also includes a state-run exchange set to launch later this year. 

Pathways has attracted national attention because it made Georgia the only state to have a work requirement as part of its Medicaid program, with it only applying to those who are newly eligible.

‘We say a rose by any other name is still a rose’

The low enrollment in Pathways has ratcheted up the pressure on Georgia Republicans to change course.

Georgia – which has one of the highest uninsured rates in the country – is now one of 10 states that have not expanded Medicaid under the Affordable Care Act, with neighboring North Carolina recently expanding the health insurance program for the poor.

“This isn’t just a policy oversight, it is a moral failing,” state Sen. Nabilah Islam Parkes, a Lawrenceville Democrat, said at a press conference Thursday. “Hundreds of thousands of our people are left without adequate health care.”

But other Democrats and long-time health care advocates have expressed optimism over the recent chatter, even if the conversation is not centered on traditional Medicaid expansion.

“I’m hearing the same thing that others are hearing – that this is the year that we’re going to have some sort of Medicaid expansion,” Rep. Billy Mitchell, a Stone Mountain Democrat who chairs House minority caucus, told a reporter Thursday. “It may not be called Medicaid expansion because it’s not politically palatable to certain groups. We say a rose by any other name is still a rose.”

Rep. Michelle Au, a Johns Creek Democrat who is an anesthesiologist, said she was encouraged that talk of any kind of Medicaid expansion is now happening in Georgia.

“Even having this conversation at all, and considering something in a serious way, is already way better than anything that we’ve seen for a decade,” Au said in an interview.

Au led an unofficial “hearing” on Medicaid expansion that filled a meeting room and had people standing in the hallways to hear health care experts, hospital representatives and others talk about the impact of Medicaid expansion on the state’s economy and the health of Georgians.

Au, who is a leading Democratic voice on health care issues in Georgia, has regularly held educational forums on Medicaid expansion. But this year’s event was different.

“There’s a feeling in the air: something has changed, and it’s like, we’re really talking about this. This might happen,” Au said. “And many of our holdout-state neighbors have recently changed – states that we have a lot in common with. So, it’s not unreasonable to go down this path to think that there is a chance this could happen.”

Scott Raynes was among the speakers at Au’s meeting. Raynes is president and CEO of Brunswick-based Southeast Georgia Health System and was a member of the House committee that looked at ways to modernize the state’s certificate of need regulations.

“Let’s not get hung up on the fact that we are one of the last 10 or 11 to even explore this,” Raynes said. “Let’s take advantage of the learnings of those states before us and make a good decision. A good economic decision, a decision that is really apolitical if you will, and do what’s right on behalf of the citizens of the state of Georgia, and frankly, help the industry of health care within it.” 

Laura Colbert, executive director of Georgians for a Healthy Future, which advocates for Medicaid expansion, had this message for those who attended the organization’s Health Care Unscrambled event held Thursday: “I’m not going to count our chickens before they hatch – we don’t have expansion yet – but it’s coming.”

Georgia Pathways

The governor has proposed spending $1.7 million in this year’s budget to integrate Pathways into the state’s eligibility system for Medicaid and other public aid services, which is a move that is intended to increase enrollment in the program and improve the effectiveness of caseworkers who are processing applications, according to the governor’s Office of Budget and Planning.

The funding would also connect the state’s system to Georgia Access as Georgia moves toward a state-based exchange for health insurance under the Affordable Care Act.

Pathways slightly expanded eligibility for Medicaid coverage in Georgia but also requires participants to complete 80 hours each month of work, school or other qualifying activity, and critics have long warned that the reporting requirements to show the hours were completed would create a paperwork burden.  

The program was approved under the Trump administration and then delayed by the Biden administration. Georgia moved forward with launching the program in July after successfully challenging the federal government in court.

The federally approved waiver that allowed Georgia to move forward with the program expires in the fall of 2025.

During a conversation about Medicaid expansion at the Health Care Unscrambled event Thursday, Savannah Republican Sen. Ben Watson praised the state’s reinsurance program and urged health care advocates to help enroll people in Pathways.

“The one that’s been a bit of a challenge, and I would challenge you to help our patients to get enrolled, is that 100% on down,” said Watson, who chairs the Senate Health and Human Services Committee. 

As Pathways is being rolled out, an army of state workers is also in the process of checking the eligibility of all 2.8 million people covered by Medicaid after the end of a pandemic-era federal rule that protected coverage during the public health crisis. Hundreds of thousands of Georgians are expected to lose coverage as part of what’s known as the unwinding.