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Georgians with Mental Health & Substance Use Conditions Endangered by Gov. Kemp’s Plan to Change Health Insurance

In July 2020, Governor Brian Kemp asked the federal government to approve a plan that would make several changes to private insurance in Georgia. The Governor’s plan is made up of two parts: 1) Reinsurance—which would help to lower premiums for some Georgians; and 2) the Georgia Access model—which would force consumers to enroll in coverage through for-profit insurance companies and web brokers instead of the unbiased and centralized enrollment platform that consumers know and trust (healthcare.gov). Federal health officials are asking Georgians like you to weigh in on the Governor’s plan. The deadline to comment is September 16, 2020. Don’t miss your chance to say how this plan will affect you, your loved ones, and Georgians across the state. After you read this short blog, tell health officials what you think.

What’s in the plan

Reinsurance

Reinsurance is a tool that some other states have used to lower premiums for consumers and attract more insurers to their marketplaces. Georgia’s proposed reinsurance program is designed so that it would lower premiums more in regions that have higher insurance premiums. Southwest Georgia consistently has some of the highest premiums in the U.S. Georgia’s plan predicts that premiums may drop by 10% across the state, with rural areas seeing bigger drops than urban areas.

Georgia Access Model

Woman sitting in front of computer looking confused In the second part of his plan, Gov. Kemp proposes to dismantle the Affordable Care Act’s (ACA) health insurance marketplace (healthcare.gov). Georgians would no longer be able to enroll in health coverage through healthcare.gov. Instead individuals would be forced to enroll through a health insurer, web-broker, or a traditional broker. Healthcare.gov is the most widely used and only unbiased place that consumers can shop for comprehensive health coverage. Consumers know all available plans will cover their health needs and they are offered financial help if they qualify and notified of their eligibility for Medicaid or other public coverage programs. Under the Governor’s plan, Georgia consumers would be the only people in the U.S. forced to go without healthcare.gov, and instead rely on private entities for shopping and enrollment. For-profit insurance companies, online brokers, and even some insurance agents will display comprehensive, ACA-compliant plans alongside short-term plans or plans that do not cover all health services (like mental health and substance use services).

Impacts on Georgians with mental health & substance use conditions (and those in recovery)

Reinsurance: Could help make treatment & recovery services more affordable

The expected drop in premiums from the proposed reinsurance program will help to lower premiums for comprehensive health coverage (which cover mental health (MH) & substance use (SU) services), especially for rural consumers and consumers with incomes too high to qualify for the ACA’s financial help (>400% FPL). For consumers who need their coverage to access treatment services or to support their recovery, lower premiums will make it easier to afford their premiums and to cover their deductibles and other costs.

Georgia Access: Leaves consumers without access to treatment or recovery services

Under this plan, Georgia consumers will lose access to the most widely used enrollment pathway and its attached consumer assistance but will gain no additional enrollment options. Georgians are already permitted to enroll through insurers, web brokers, and agents. Under an existing enrollment program run by the federal government, insurers and web-brokers have developed a track record of steering consumers toward substandard plans that expose them to catastrophic costs if they get sick; failing to alert or assist consumers when they are eligible for Medicaid; and making it difficult to compare plans. Because these companies are allowed to show substandard plans alongside comprehensive plans, the Georgia Access model will encourage Georgia consumers to enroll in substandard plans. Substandard plans are dangerous for Georgians with mental health and substance use needs because most do not cover mental health, and many do not offer substance use or prescription drug benefits. On top of that, substandard plans are allowed to exclude coverage for pre-existing conditions and charge more for people with pre-existing conditions like a history of mental illness or substance use. The Georgia Access model puts Georgians at risk of getting lost in a confusing new enrollment process and becoming uninsured altogether. Georgians with little or no experience buying or using health insurance (e.g. young people), those with limited English proficiency, Georgians with low health literacy skills, and people with intellectual or cognitive disabilities would be at greatest risk of experiencing adverse consequences from the outlined plan.
Governor Kemp’s plan to change private health insurance in Georgia turns back the clock for Georgians with mental health and substance use conditions. Under this plan, Georgians would be at risk of enrolling in plans that do not cover their health needs and leave them to manage their recoveries with no help. As mental health and substance use issues rise as consequences of COVID-19, this plan moves Georgia in the wrong direction. For what is likely the last time, health officials are asking for comments from Georgians about the Governor’s plan. The deadline to comment is September 16, 2020. Don’t miss your chance to say how this plan will affect you, your loved ones, and Georgians across the state! Tell health officials what you think today!  

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Gov. Kemp revises plan to change private insurance

In December 2019, Governor Brian Kemp asked the federal government to approve a plan that would make seismic changes to private health insurance in Georgia. In July 2020, Gov. Kemp revised his plan and released it to the public for comment. The revised plan is made up of two parts: 1) Reinsurance—which would help to lower premiums; and 2) the Georgia Access model—which would force consumers to enroll in coverage through for-profit insurance companies and web brokers instead of the unbiased and centralized enrollment platform that consumers know and trust (healthcare.gov).

Federal law allows states to make changes to the Affordable Care Act (ACA) so long as a comparable number of consumers have coverage that is at least as comprehensive and affordable as they would have under the ACA, and the changes do not increase the federal deficit. Unfortunately, the second part of Gov. Kemp’s plan does not meet this standard and poses real risks to families and individuals in Georgia. Georgians have a limited-time opportunity to raise their voices in opposition to this part of the Governor’s plan and speak up in favor of affordable, comprehensive health coverage for all Georgians. Check out the Georgians can take action to protect our state section of this blog.


Part I: Reinsurance

Reinsurance is a tool that some other states have used to lower premiums for consumers and attract more insurers to their marketplaces. Reinsurance is a system that pays insurance companies for a portion of the costs of consumers who have unusually expensive health needs. When these outlier costs are shared between the state and insurers, insurers are able to lower premiums for everyone.

Georgia’s reinsurance program is designed so that it would lower premiums more in areas of Georgia that have higher insurance premiums. Southwest Georgia has consistently had some of the highest premiums in the U.S. Georgia’s plan predicts that premiums may drop by 10% across the state, with rural areas seeing bigger drops than urban areas.

If approved by the federal government, Georgia’s reinsurance program would go into effect for 2022 insurance plans.


Part II: Georgia Access model—Georgia consumers at a disadvantage

The second part of Gov. Kemp’s plan would make it more difficult for Georgia individuals and families to shop for comprehensive coverage, understand their options, and take advantage of financial help to lower the costs of their plans. It would put insurance companies in the driver’s seat, leaving consumers in the back seat with little control.

Gov. Kemp proposes to dismantle healthcare.gov and instead force Georgians to use profit-driven insurance company websites, e-brokers, or agents to shop for coverage

Woman sitting in front of computer looking confused

More than 450,000 Georgians bought affordable, comprehensive coverage through the ACA marketplace (also called healthcare.gov) in 2020. Nine out of ten Georgians who purchased coverage on healthcare.gov received financial help to lower their premiums and other out-of-pocket costs.

The ACA marketplace is the most widely used and only unbiased place that consumers can shop for comprehensive health coverage. Consumers know all available plans will cover their health needs and they are offered financial help if they qualify and notified of their eligibility for Medicaid or other public coverage programs.

Under the Governor’s plan, Georgia consumers would be the only people in the U.S. forced to go without this resource and instead rely on private entities for shopping and enrollment. For-profit insurance companies, online brokers, and even some insurance agents will display comprehensive, ACA-compliant plans alongside short-term plans or plans that do not cover all services.

Under this system, insurance companies and brokers, who are regularly incentivized to enroll consumers in plans that offer the highest commissions, will push consumers to plans that do not fit their health needs or financial situation. They are not obligated or incentivized to help qualified Georgians enroll in Medicaid or PeachCare, or provide other safety net referrals.

This part of the Governor’s plan does not add any new ways for people to shop for health coverage (consumers can already shop with brokers or insurance companies). Instead, it only serves to shut off the most trusted and widely used path for Georgians purchasing their own coverage.

Likely result: Georgia consumers will struggle to navigate a decentralized enrollment system with numerous websites, translate the sales lingo of insurers, and disentangle conflicting information. For many, it may be harder to find a plan that they feel good about. Others will get lost in the process altogether and unintentionally become uninsured.


Governor Kemp’s plan to change private health insurance in Georgia turns back the clock to a time when consumers were at the mercy of health insurance companies. Under this plan, consumers would have a harder time shopping for comprehensive coverage and run a real risk of enrolling in plans that do not cover the essential health benefits or leave them on the hook for tens of thousands of dollars. It is likely that some Georgians would end up uninsured because of the confusing, decentralized system, increasing Georgia’s 3rd in the nation uninsured rate.


Georgians can take action to protect our state from this flawed plan!

As part of an important legal process, state and federal officials must ask for input from the public about  these kinds of changes to health coverage. More than 500 Georgians weighed in during the state’s public comment period in July! Georgians now have one more opportunity to make their voices heard on this issue during the current federal comment period.

Person writing an email on a laptop

Georgians can write and submit their comments at coverGA.org from August 17 to September 16, 2020.

When the final comment period ends on Wednesday, September 16th, Georgians can still take action against the Governor’s plan in these ways:

          1. Sign up for email updates at CoverGA.org so you know when and how to take action in the upcoming federal comment period and for other advocacy opportunities!
          2. Georgians can share their stories about why it’s important to protect people with pre-existing conditions, maintain comprehensive health coverage and financial protections, and preserve healthcare.gov as a tool for Georgia shoppers. Share your story at coverGA.org.

By working together to protect accessible, unbiased ways to shop and enroll in affordable, comprehensive health coverage, we will ensure hardworking young people, parents, veterans, students, and many other Georgians have access to the health care they need when they need it.


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Explained: Governor Kemp’s Plan to Change Medicaid in Georgia

In December 2019, Georgia’s Governor asked federal officials to approve changes to the state’s Medicaid program. Medicaid is a public health insurance program that currently covers half of Georgia’s children, some low-income seniors and people with disabilities, low- and moderate-income pregnant women, and very low-income parents. 

The Affordable Care Act (ACA) gave states the option to expand Medicaid to cover adults making slightly more than poverty-level wages (about $16,700 for an individual and $35,900 for a family of four). Unfortunately, Georgia is one of only 14 states who have so far refused to extend health insurance to these low-income Georgians. That leaves 408,000 uninsured Georgians ineligible for Medicaid, and at the same time, their incomes remain too low to qualify for financial help to buy coverage through the ACA’s health insurance marketplace.

Governor Kemp’s plan to change Medicaid, called Georgia Pathways, will do little to close this coverage gap. The state estimates the plan will cover only about 50,000 low-income Georgians because of the unwarranted complications that it puts in place. The Governor’s plan ultimately leaves thousands of low-income Georgians uninsured and ignores the most cost-effective solution available: Medicaid expansion.

Some low-income Georgians would be allowed to enroll in Medicaid

The Governor’s plan would allow Georgians with incomes up to the poverty line (or those with incomes of less than $12,700 for an individual or $26,000 for a family of four) to enroll in Medicaid. 

This change, sometimes called a “partial Medicaid expansion,” falls short of the ACA’s Medicaid expansion which envisioned that states would cover adults making slightly more than poverty-level income. Under the Governor’s plan, 408,000 Georgians could qualify for coverage—if they can meet the stringent requirements described below.  Under a full Medicaid expansion, Georgia could cover 567,000 low-income adults. 

Georgians would be subjected to illegal paperwork requirements to enroll in coverage

Under the Governor’s plan, Georgia adults who may qualify for coverage must prove they are working or performing certain activities for at least 80 hours a month. Work and qualifying activities include full or part-time employment, community service, vocational readiness, certain education activities, or job readiness. Qualifying activities do not include caregiving and participating in substance use recovery programs; Georgians who are homeless or have limited access to the internet would not be excused from the reporting requirements.

If the Governor’s plan is approved, Georgians would be required to complete bureaucratic paperwork to prove they are spending 80 hours a month participating in an eligible activity before they can enroll in Medicaid coverage. They must continue to prove their work or other activities to Georgia’s government for at least three months. After that, they would be subject to random requests for proof of continued work. 

Other states have attempted to implement similarly burdensome “work requirements.” In those states, thousands of qualified people lost their health care coverage because they were unable to successfully report their work due to technology barriers, insufficient notice from the state about the requirements, bureaucratic mistakes, and other issues. As a result, work requirements are currently the subject of a federal lawsuit and have been deemed illegal by three federal courts. 

Low-income Georgians must pay premiums and copays to Georgia’s government

The current proposal requires that Georgians making between 50 – 100% of the federal poverty line (between $6300-$12,700 annually for an individual) would be required to pay monthly premiums of $7-$11 per month. If an enrollee misses two months of premium payments, their coverage would be suspended and after three months of missed payments, the person would lose their coverage. When accessing health care services, enrollees would be required to additionally pay copays of up to $30 per visit. 

Traditionally, Medicaid members have not been required to pay premiums or co-pays because their incomes are so low. While the state caps enrollees’ cost-sharing at 5% of a person’s income, that could add up to as much as $600 for an individual and $1300 for a family of four per year, who are surviving on poverty-level wages. 

The plan eliminates the option for low-income Georgians to get transportation to their health appointments 

Under the Governor’s plan, Georgians who enroll in coverage would not have access to some traditional Medicaid benefits like non-emergency medical transportation. Non-emergency medical transportation (NEMT) is a free service that provides transportation to people who are covered by Medicaid who do not have their own way to get to and from health appointments or the pharmacy. The program is especially important for people with disabilities, seniors, rural residents, and people of color. 

Adequate transportation is important to the health of Georgians because in most cases people need to go to a location outside of their homes to receive medical care. Without access to reliable, safe transportation, Georgians may be forced to skip health appointments, go without medication and ultimately, experience worse health outcomes. 

According to the Georgia and Budget Policy Institute, “Cutting out transportation is not likely to significantly reduce state costs but would deeply impact rural Georgians who may live farther away from health facilities. Non-emergency medical transportation is less than two percent of traditional Medicaid spending in Georgia according to GBPI’s budget calculations. A relatively small investment in Medicaid funding could mean a huge difference to Georgians who don’t have reliable access to safe transportation.”

The plan creates a complicated, expensive bureaucracy  

The state’s proposed plan creates complicated restrictions and burdens for low-income Georgians. In addition to the paperwork requirements and required cost-sharing, the Governor’s plan would establish a member rewards account and a point reward system for enrollees. Consumers’ monthly premiums would be deposited into their rewards account, which could be used to pay future copays for health services. The point reward system would “reward” individuals for healthy behaviors and add money to the account based on those behaviors. 

Indiana initially operated a similar reward system as part of their version of Medicaid expansion. The state saw limited participation and no benefits to beneficiaries’ health because of the complexity of the system, which mirrors Georgia’s in many ways. Ultimately, these kinds of systems are expensive and ineffective at keeping Medicaid enrollees enrolled in coverage, facilitating access to comprehensive benefits, or achieving better health outcomes. 

Governor Kemp’s office has not provided an estimate of the costs to the state to operate the rewards systems, track work requirements or collect premiums. The Atlanta Journal-Constitution reported, “Other states that have tried to implement a work requirement reported costs ranging from $6 million to $272 million, according to the federal Government Accountability Office.” The intricacies of Georgia’s plan would require significant spending by the state that is not currently budgeted for in the Governor’s plan.

Georgia would pay three times more per person than needed

The Governor’s plan only expands coverage to Georgians making up to the poverty line, rather than slightly more than the poverty level (138% of the federal poverty level) as intended by the Affordable Care Act (ACA). Because Georgia is not proposing a full Medicaid expansion, the state will have to pay three times more per person to carry out this plan. When states fully expand Medicaid, the federal government covers at least 90% of the costs of the expansion and the state has to pay only 10% of the costs. If Georgia were to full expand Medicaid coverage the state would be eligible for this “enhanced match”. Instead, Georgia will pay 33% of the costs (and the federal government will pay the remaining 67% ) of the Governor’s plan–three times more than needed. 

Conclusion 

Governor Kemp’s plan to change Medicaid in Georgia does not work for Georgians. It would exclude most low-income, uninsured adults and subject those who can enroll to illegal, complicated, and expensive requirements. At the same time, the plan passes up the most cost-effective option to provide coverage to low-income adults in Georgia. 

Our elected officials have the power to ensure that every Georgian, regardless of income, have access to affordable, comprehensive coverage. Leaders of 34 other states have made the choice to expand Medicaid and their states are reaping the benefits. Georgia can join them, but elected officials need to hear from you. Ask Governor Kemp and your state legislators to expand Medicaid. 

 


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Explained: Gov. Kemp’s Plan to Change Private Health Insurance in Georgia

In December 2019, Governor Brian Kemp asked the federal government to approve a plan that would make seismic changes to private health insurance in Georgia. Gov. Kemp’s plan is made up of two parts: 1) Reinsurance—which would help to lower premiums; and 2) the Georgia Access model—which would undermine comprehensive coverage for the 417,000 Georgians who now have comprehensive coverage through the marketplace and put future enrollees at risk.

Federal law allows states to make changes to the Affordable Care Act (ACA) so long as a comparable number of consumers have coverage that is at least as comprehensive and affordable as they would have under the ACA, and the changes do not increase the federal deficit. Unfortunately, the second part of Gov. Kemp’s plan does not meet this standard and poses real risks to families and individuals in Georgia.


Phase I: Reinsurance

Reinsurance is a tool that some other states have used to lower premiums for consumers and attract more insurers to their marketplaces. Reinsurance is a system that pays insurance companies for a portion of the costs of consumers who have unusually expensive health needs. When these outlier costs are shared between the state and insurers, insurers are able to lower premiums for everyone.

Georgia’s reinsurance program is designed so that it would lower premiums more in areas of Georgia that have higher insurance premiums. Southwest Georgia has consistently had some of the highest premiums in the U.S. Georgia’s plan predicts that premiums may drop by 10% across the state, with rural areas seeing bigger drops than urban areas.

If approved by the federal government, Georgia’s reinsurance program would go into effect for 2021 insurance plans.


Phase II: Georgia Access model—a bad deal for Georgia consumers  

The second part of Gov. Kemp’s plan would undermine the benefits of reinsurance while also endangering the health and finances of Georgia consumers. Georgia is the first state to propose these complicated changes, putting Georgians at great risk of being guinea pigs in an unwise policy experiment. The second phase of the plan would make three major changes:

Limits the amount of financial help available to moderate and middle-income consumers and families when they purchase comprehensive health coverage. Nine out of ten Georgia consumers who purchase coverage on healthcare.gov get financial help that lowers their monthly premiums or reduces their deductibles and co-pays. Under the current system, every Georgian who qualifies gets financial help. The financial assistance helps people who make between 100-400% of the federal poverty level (an individual, $12,760-$51,040 or a family of 4 making $26,200-$104,800) by limiting their health spending to a small percentage of the household’s budget.[i]

Under Gov. Kemp’s plan the state would offer the same financial assistance to consumers but would limit the total amount of help available. The state’s budget for financial help could easily be exhausted if more people enroll in coverage than the state predicts or if premiums rise faster than expected. People who shop for coverage after the financial assistance limit is reached would be put on a waiting list and would not get any help in the meantime.

Likely impact: Some moderate- and middle-income Georgians would be forced to choose between going uninsured or paying the full price for coverage (which could be as much as their yearly income).

Erodes the requirement that insurance plans cover all essential health services and the financial protection that limits yearly health spending for individuals and families. The Governor’s plan introduces two new kinds of health plans: copper plans and disease management plans. Copper plans would feature cheaper premiums than current bronze level plans but would balance that with higher deductibles and co-pays. The disease management plans would be tailored to meet the needs of people with certain chronic diseases (like diabetes or HIV) and would have unspecified flexibility about how they cover the ten essential health benefits, like mental health or prescription drugs.[ii]

In order to offer these new kinds of plans, the Governor’s plan asks to “waive” (or set aside) two key ACA requirements: 1) the requirement that all plans sold on the ACA marketplace (healthcare.gov) cover the ten essential health benefits; and 2) the protective limit on annual out of pocket health spending for consumers.

Under the current system, the ACA limits a consumer’s out-of-pocket spending each year based on their income. Gov. Kemp’s plan would eliminate that spending ceiling, which is already too high for most Georgians to afford. Georgians are struggling with the difficult combination of premiums, deductibles, and other out of pocket costs, and copper plans with even higher (or even unlimited) spending caps would only exacerbate this problem.

Maximum Annual Limitation on Cost-Sharing
Income

(% Federal Poverty Line)

OOP Max for Individual/Family under the ACA, 2020 OOP Max for Individual/Family under Gov. Kemp’s plan
100-200% $2,700 / $5,400 Unknown or unlimited cap
200-250% $6,500 / $13,000 Unknown or unlimited cap
Over 250% $8,150 / $16,300 Unknown or unlimited cap
Source: Kaiser Family Foundation. See Endnote 1.

The Governor’s plan would also eliminate the requirement that insurance plans cover the ten essential health benefits. The proposal states that for the first year Georgia will ensure all plans cover those services but makes no commitment about later plan years. The proposal says that disease management plans will have “flexibility” around how thy cover the ten essential health benefits (EHBs) with little detail about how Georgia would ensure that these plans offer comprehensive coverage for consumers who may enroll in them.

Likely impacts: Consumers could be on the hook for drastically unaffordable out of pocket costs and they could be left with insurance plans that do not meet their needs because they are not required to cover the essential health benefits.  

Dismantles healthcare.gov and instead forces Georgians to use profit-driven insurance company websites, e-brokers, or agents to shop for coverage.gov (also called “the marketplace”) is the most widely used and only unbiased place that consumers can shop for comprehensive health coverage. Consumers know all available plans will cover their health needs and they are offered financial help if they qualify and notified of their eligibility for Medicaid or other public coverage programs.

Under the Governor’s plan, Georgia consumers would be the only people in the U.S. forced to go without this resource and instead rely on private entities for shopping and enrollment. For-profit insurance companies, online brokers, and even some insurance agents will display comprehensive, ACA-compliant plans alongside short-term plans or plans that do not cover all services.

Under this system, insurance companies and brokers, who are regularly incentivized to enroll consumers in plans that offer the highest commissions, will push consumers to plans that do not fit their health needs or financial situation. They are not obligated or incentivized to help qualified Georgians enroll in Medicaid or PeachCare, or provide other safety net referrals.

This part of the Governor’s plan does not add any new ways for people to shop for health coverage (consumers can already shop with brokers or insurance companies). Instead, it only serves to shut off the most trusted and widely used path for Georgians purchasing their own coverage.

Likely result: Georgia consumers will struggle to navigate a decentralized enrollment system with numerous websites, translate the sales lingo of insurers, and disentangle conflicting information. For many, it may be harder to find a plan that they feel good about. Others will get lost in the process altogether and unintentionally become uninsured.

 Governor Kemp’s plan to change private health insurance in Georgia turns back the clock to a time when consumers were at the mercy of health insurance companies. Under this plan, consumers would have a harder time shopping for comprehensive coverage, run a real risk of receiving no financial help to purchase coverage, and may find that the only available plans in their area do not cover the essential health benefits or leave them on the hook for tens of thousands of dollars.


Want to know the latest on Gov. Kemp’s private health insurance plan? Check out this timeline and sign up for email updates here. We will let you know where things stand and how you can help protect affordable, comprehensive coverage for all Georgians.


 

[i] Kaiser Family Foundation, January 16, 2020. Explaining Health Care Reform: Questions about Health Insurance Subsidies. https://www.kff.org/health-reform/issue-brief/explaining-health-care-reform-questions-about-health/

[ii] The ten essential health benefits are ambulatory services (also called outpatient care); emergency services; hospitalization; pregnancy, maternity, and newborn care; mental health and substance use disorder services (like counseling and therapy); prescription drugs; rehabilitative and habilitative services and devices (services and devices that help people with injuries, disabilities, or chronic conditions gain or recover mental or physical skills); laboratory services; preventive and wellness services (including chronic disease management); and pediatric services, including pediatric dental and vision services.


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Medicaid – 06/03/2019

The state selects Deloitte Consulting to fulfill the $2 million consulting contract to develop the two health care waiver plans.


Medicaid – 03/27/2019

Georgia’s Governor signs SB 106 into law.


Risky Medicaid Proposal Hurtles through State Legislature

Risky Health Proposal Hurtles through Gold Dome

Updated Mar. 25, 2019. Flawed legislation to expand access to health insurance is hurtling through the state legislature, and hundreds of thousands of uninsured Georgians are being left behind. Senate Bill 106, the Patients First Act, passed the Georgia Senate on Feb. 26 and advanced to the House. The proposal could expand health insurance coverage to more Georgians, though an arbitrary restriction in the bill is setting Georgia up for lengthy delays or outright failure. As currently written, the proposal could cost Georgia twice as much as alternate plans while covering only half as many Georgians with health insurance.

Earlier this year, Georgia leaders announced a plan with a risky restriction to seek federal waivers that could extend health care access across the state. Senate Bill (SB) 106, the Patients First Act, aims to partially expand Medicaid in Georgia. This change could impact individuals earning up to 100 percent of the federal poverty level (FPL): about $12,100 a year for an individual or $25,100 for a family of four. About 240,000 Georgians may eventually qualify for Medicaid coverage under the proposal.

However, restricting Medicaid eligibility to those only under the poverty line could strand hundreds of thousands of Georgians without affordable health insurance options while also forfeiting an enhanced funding deal from the federal government. That means SB 106 could cost Georgia twice as much as traditional Medicaid expansion while covering only half as many Georgians. And although the legislation is quickly advancing through the Gold Dome, the state has yet to release any estimates of how many Georgians will gain coverage or how much the plan will cost taxpayers.

How could the Patients First Act cover half as many Georgians while costing twice as much as Medicaid expansion? As part of the Affordable Care Act, the federal government agrees to pay 90 percent of the costs if states expand health care access to people earning less than 138 percent FPL—about $35,000 for a family of four. States can leverage this 9-to-1 funding match through Medicaid expansion or a state plan, called an 1115 waiver, to accomplish similar goals with more tailored approaches. Without the enhanced 90 percent match, states receive a lower funding commitment instead (about 67 percent for Georgia).

By arbitrarily limiting the state’s ability to negotiate coverage, SB 106 represents a risky gamble while Georgia’s worsening health care crisis hangs in the balance. Other states have previously submitted waivers asking for the enhanced funding match while offering to cover people up to 100 percent FPL, similar to SB 106. None were approved. Every 1115 Medicaid waiver approved under the Affordable Care Act for the enhanced match—including the most conservative examples in Arkansas, Indiana and Kentucky—expanded eligibility up to 138 percent of the poverty line. Georgia should too.

State lawmakers can fix SB 106 by allowing Medicaid eligibility up to 138 percent of the federal poverty level.


Key Points

Bottom Line

Senate Bill (SB) 106 is an unnecessarily risky proposal that threatens to leave hundreds of thousands of Georgians out of expanded health coverage and restricts Georgia from negotiating the best possible health plan.

An arbitrary restriction in SB 106 will lock Georgia to a failed approach that deprives state leaders of the flexibility needed to negotiate a strong health plan.

SB 106 may cost Georgia twice as much money while covering half as many people compared to other plans, including traditional Medicaid expansion.

A simple change to SB 106 would give Georgia a clearer, more certain path to success. State lawmakers can amend the bill to allow Medicaid eligibility up to 138 percent of the federal poverty level.

The Legislation

The Patients First Act, Georgia Senate Bill (SB) 106, would authorize the Department of Community Health to negotiate two waivers with the federal government that could improve health care in Georgia.

Senate Bill 106 would allow the Department of Community Health to request waivers to increase Medicaid coverage up to 100 percent of the federal poverty level (FPL)—about $12,000 for an individual or $25,000 for a family of four. This could potentially expand health coverage to about 240,000 Georgians.

SB 106 Leaves Hundreds of Thousands of Georgians Behind

The proposal falls far short of covering all eligible Georgians with incomes up to 138 percent of the federal poverty level (FPL). Many of the Georgians who are left out will remain uninsured and continue to struggle to get the health care they need.

About 230,000 uninsured Georgians earn between 100 to 138 percent FPL and would not receive expanded coverage through Medicaid. Georgians earning more than 100 percent FPL currently qualify for financial support to buy health insurance, but many still struggle to afford coverage.

Georgia has the 4th highest number of uninsured kids in the nation, many of whom are eligible for Medicaid but remain uninsured. When more parents and caregivers are covered, more kids are more likely to be insured too.

Other plans would put health insurance cards in the pockets of almost half a million Georgians while likely still costing less than the plan authorized by SB 106.

The Critical Difference Between 100 and 138 Percent

As part of the Affordable Care Act, the federal government agrees to pay 90 percent of the costs if states expand health care access to people earning less than 138 percent of the federal poverty level (FPL)—about $35,000 for a family of four.

Without this enhanced 90 percent federal match, states receive a lower funding commitment instead. That lower match is about 67 percent for Georgia.

SB 106 Represents Unnecessarily Risky Gamble

SB 106 represents an unnecessarily risky gamble with Georgia’s health crisis in the balance. Georgia’s leaders are putting forward ideas that have previously failed in other states.

Other states have submitted waivers asking for the enhanced match while only proposing to cover people up to 100 percent FPL, similar to SB 106. None were approved.

Every 1115 Medicaid waiver approved under the Affordable Care Act for the enhanced match—including the most conservative examples in Arkansas, Indiana and Kentucky—expanded eligibility up to 138 percent of the federal poverty level. Some states simply expanded Medicaid while others have developed state-specific plans called 1115 waivers to accomplish similar goals with more tailored approaches.

By restricting Medicaid eligibility to 100 percent of the poverty line, the best plan possible will likely cover half as many Georgians while costing twice as much as alternative.

The arbitrary coverage restriction in SB 106 is setting Georgia up for failure. Preventing Georgia’s 1115 waiver from helping Georgians earning up to 138 percent of the federal poverty level (about $35,000 for a family of four) means that our state is unlikely to get a good deal any time soon.

Unclear Proposal Could Result in Massive Changes with Limited Oversight

SB 106 gives Gov. Brian Kemp’s administration broad authority to make extensive changes to health care in Georgia without input from the legislature or public during the drafting stage.

The Governor’s plan offers no guiding principles, assurances of good governance or safeguards for fiscal responsibility.

No fiscal note or cost estimate has been provided for the proposed waivers being authorized even though this bill has been called “the most significant issue” being discussed this year

The governor’s proposal will likely result in covering fewer Georgians at a greater cost to taxpayers.

Simple Solution

There’s a simple solution for this unnecessarily risky gamble: change one number. State lawmakers can amend SB 106 to authorize an 1115 waiver up to 138 percent of the federal poverty level, instead of the current 100 percent.

Or lawmakers can include a back-up plan authorizes Medicaid eligibility up to 138 percent if the current approach is rejected.


Key Questions About SB 106

How many Georgians will gain access to health insurance through the waivers authorized by SB 106?

Georgia’s uninsured rate in 2017 was 13.4 percent. How much will the proposed waivers reduce our growing uninsured rate?

About 240,000 Georgians make too little to get financial help to buy health insurance and do not currently qualify for Medicaid. This coverage gap represents people earning below the poverty line. Will the waiver offer Medicaid eligibility to everyone in this gap?

When can Georgians expect to see expanded access to health insurance from this proposal?

When will Georgians finally get a health insurance card in their pocket from this plan?

What guarantee does Georgia have that an 1115 waiver which only covers people up to the federal poverty level will receive approval from the federal government for the enhanced 9-to-1 funding match? All similar plans that were previously submitted by other states have been rejected.

Why should state lawmakers arbitrarily limit Georgia’s flexibility to negotiate the best deal possible, especially when that restriction is likely to cause significant delays or outright rejection?

If Georgia’s 1115 waiver is not approved for the enhanced federal funding match, will state leaders choose to cover half as many Georgians as traditional Medicaid expansion for twice the cost?

Will the waivers from this proposal protect Georgians with pre-existing conditions?

Will the waivers maintain essential health benefits for Georgians?

What opportunities will Georgia’s legislative branch have to review and inform the waiver proposals?

How will locking Georgia into a risky waiver approach that’s destined for long delays or failure help address our state’s pressing health care crisis?

 

 


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Medicaid – January 2019

Governor Kemp submits his first budget recommendations which includes $1 million for the Department of Community Health “to review and analyze Medicaid waiver options” for consideration by the Governor’s office. This waiver could include a pathway to health coverage for low-income Georgians.


Health Insurance Would Help Matt and Other Georgians Recover From Mental Illness

Matt Hiltman lowered his shoulder as his horse galloped down the windswept field, kicking up clods of earth in its wake. His steel armor gleamed in the bright sun, and the audience on the sidelines roared with anticipation. Two horses and two riders fast approached each other on a collision course. The crowd fell silent as wood crumpled into metal with a loud crunch, and Matt’s lance struck true. The opponent careened off his horse and tumbled to the ground. Cheers burst out across the tournament field. Another victory for a professional jouster.

A lifelong Georgian, Matt is a world-class, full-contact jouster who competed in the sport for five years while also pursuing studies at Georgia State University. “If I had to describe myself, I would say that I’m an adrenaline junky,” said Matt. Beyond scuba diving, hang gliding and other high-octane activities, Matt’s thirst for adventure also inspired him to study diverse fields at college, including geology, chemistry, biology and history. He graduated magna cum laude from Georgia State University with a major in philosophy and minor in psychology, looking forward to a career in law or another field where he could serve the greater good.

Matt, seen here posing on horseback during a show, worked for five years competing and performing as a jouster.

“I’ve spent a lot of my life and a lot of time thinking about how I can best help the world,” Matt said, “And I’ve got some ideas that I’d like to share.”

The future was brimming with opportunity when Matt’s life hit an unexpected obstacle. At age 29, Matt was hospitalized due to mental illness. “He had an episode of psychosis, and it became obvious at that point that he had bipolar I,” said his mother, Dianne. In Matt’s words, “It was a major shake to my foundation … to discover that my brain is a tool that can be corrupted.”

Bipolar disorder is a mental illness that causes intense shifts in a person’s mood, energy and ability to think clearly, according to the National Alliance on Mental Illness. People with bipolar disorder experience debilitating mood swings, known as mania and depression. About 4.4 percent of adults in the United States experience the disorder at some point in their lives, which generally starts showing symptoms when people reach their mid-20s.

Many treatments can help people living with bipolar disorder, including medications, therapy and lifestyle adjustments. People can lead successful lives after finding the right care regimen and combination of treatments, but that usually requires extensive trial and error. Doctors still have a limited understanding of how the brain works and how best to treat mental illness.

Once I’m healthy, I’ll be able to get out there and help people.
-Matt Hiltman

“It’s been difficult, it’s been very difficult over the last few years,” Matt said.

For Matt, health insurance has been a major barrier to finding the effective treatments that would allow him to begin recovery. Bipolar disorder caused him to lose his job and his health insurance. Untreated, the symptoms make it nearly impossible to work a full-time position with benefits. Matt doesn’t earn enough money to receive subsidies for individual health insurance, so he can’t afford coverage from the private marketplace. He also doesn’t qualify for Georgia’s current Medicaid program.

Watch Matt share his story in his own words.

“He can’t work ‘til his treatment is better,” said Dianne.

Matt sees hope in an advanced brain therapy called Transcranial Magnetic Stimulation. Unfortunately, he cannot receive this cutting-edge procedure without health insurance. Matt is stranded in his recovery process without any affordable health care options.

“There are several treatments that I don’t have access to because I don’t have health care insurance,” says Matt. “That’s frustrating knowing that I might feel relief . . . knowing that it’s out there, and I can’t get it, is very frustrating.”

Matt has virtually exhausted his options for treatment without health insurance.

While Matt and his family have struggled to access treatment, Georgia lawmakers have repeatedly rejected a policy that would provide affordable health coverage to Matt and almost half a million Georgians: Medicaid expansion. About 25 percent of uninsured Georgians who would qualify for coverage through Medicaid expansion suffer from mental illness or substance use disorder.

“He’s not afraid to work hard,” says Dianne. “He’s not unwilling. He just can’t right now. And there’s not anything we can do.”

A new wave of state leaders will have a fresh opportunity in 2019 to tackle Georgia’s growing health crisis and draw down federal funds to broaden health coverage. By allowing Georgians like Matt to access and afford needed medical services, lawmakers can help thousands statewide to get healthy and stay healthy. The policy is popular with the public as well, with more than 70 percent of Georgians supportive of Medicaid expansion according to recent polls.

He’s not afraid to work hard. He’s not unwilling. He just can’t right now. And there’s not anything we can do.
-Dianne Hiltman

For Matt, the idea of getting healthy brings him back to his dream of helping others. “Really it just comes down to . . . you know, once I’m healthy, I’ll be able to get out there and help people.”

Before he’s able to help others, Matt will need to find the right combination of tools to treat his mental illness. He and his family continue to pursue every possible lead, including out-of-state research studies and charity care. But without health insurance, Matt’s recovery appears stuck, and a promising future seems just beyond his reach. In the past, Matt’s hard work helped him succeed in the classroom and in the saddle. Now, his future success rests in the hands of the 236 men and women of Georgia’s General Assembly.

“Having affordable health care and health insurance would give me hope. It would give me more access to different treatments. Mostly, it would give me hope.”


If you or loved ones are living with mental illness, please consider visiting the National Alliance on Mental Illness – Georgia or calling their helpline at 770-408-0625 for more information and support.

To show your support for expanding health coverage in Georgia, please consider sending a short e-mail to your state lawmakers through an easy-to-use form.


Tags:

Matt Hiltman: Health Insurance Would Help Matt and Other Georgians Recover From Mental Illness

Matt Hiltman lowered his shoulder as his horse galloped down the windswept field, kicking up clods of earth in its wake. His steel armor gleamed in the bright sun, and the audience on the sidelines roared with anticipation. Two horses and two riders fast approached each other on a collision course. The crowd fell silent as wood crumpled into metal with a loud crunch, and Matt’s lance struck true. The opponent careened off his horse and tumbled to the ground. Cheers burst out across the tournament field. Another victory for a professional jouster.

A lifelong Georgian, Matt is a world-class, full-contact jouster who competed in the sport for five years while also pursuing studies at Georgia State University. “If I had to describe myself, I would say that I’m an adrenaline junky,” said Matt. Beyond scuba diving, hang gliding and other high-octane activities, Matt’s thirst for adventure also inspired him to study diverse fields at college, including geology, chemistry, biology and history. He graduated magna cum laude from Georgia State University with a major in philosophy and minor in psychology, looking forward to a career in law or another field where he could serve the greater good.

Matt, seen here posing on horseback during a show, worked for five years competing and performing as a jouster.

“I’ve spent a lot of my life and a lot of time thinking about how I can best help the world,” Matt said, “And I’ve got some ideas that I’d like to share.”

The future was brimming with opportunity when Matt’s life hit an unexpected obstacle. At age 29, Matt was hospitalized due to mental illness. “He had an episode of psychosis, and it became obvious at that point that he had bipolar I,” said his mother, Dianne. In Matt’s words, “It was a major shake to my foundation … to discover that my brain is a tool that can be corrupted.”

Bipolar disorder is a mental illness that causes intense shifts in a person’s mood, energy and ability to think clearly, according to the National Alliance on Mental Illness. People with bipolar disorder experience debilitating mood swings, known as mania and depression. About 4.4 percent of adults in the United States experience the disorder at some point in their lives, which generally starts showing symptoms when people reach their mid-20s.

Many treatments can help people living with bipolar disorder, including medications, therapy and lifestyle adjustments. People can lead successful lives after finding the right care regimen and combination of treatments, but that usually requires extensive trial and error. Doctors still have a limited understanding of how the brain works and how best to treat mental illness.

Once I’m healthy, I’ll be able to get out there and help people.
-Matt Hiltman

“It’s been difficult, it’s been very difficult over the last few years,” Matt said.

For Matt, health insurance has been a major barrier to finding the effective treatments that would allow him to begin recovery. Bipolar disorder caused him to lose his job and his health insurance. Untreated, the symptoms make it nearly impossible to work a full-time position with benefits. Matt doesn’t earn enough money to receive subsidies for individual health insurance, so he can’t afford coverage from the private marketplace. He also doesn’t qualify for Georgia’s current Medicaid program.

Watch Matt share his story in his own words.

“He can’t work ‘til his treatment is better,” said Dianne.

Matt sees hope in an advanced brain therapy called Transcranial Magnetic Stimulation. Unfortunately, he cannot receive this cutting-edge procedure without health insurance. Matt is stranded in his recovery process without any affordable health care options.

“There are several treatments that I don’t have access to because I don’t have health care insurance,” says Matt. “That’s frustrating knowing that I might feel relief . . . knowing that it’s out there, and I can’t get it, is very frustrating.”

Matt has virtually exhausted his options for treatment without health insurance.

While Matt and his family have struggled to access treatment, Georgia lawmakers have repeatedly rejected a policy that would provide affordable health coverage to Matt and almost half a million Georgians: Medicaid expansion. About 25 percent of uninsured Georgians who would qualify for coverage through Medicaid expansion suffer from mental illness or substance use disorder.

“He’s not afraid to work hard,” says Dianne. “He’s not unwilling. He just can’t right now. And there’s not anything we can do.”

A new wave of state leaders will have a fresh opportunity in 2019 to tackle Georgia’s growing health crisis and draw down federal funds to broaden health coverage. By allowing Georgians like Matt to access and afford needed medical services, lawmakers can help thousands statewide to get healthy and stay healthy. The policy is popular with the public as well, with more than 70 percent of Georgians supportive of Medicaid expansion according to recent polls.

He’s not afraid to work hard. He’s not unwilling. He just can’t right now. And there’s not anything we can do.
-Dianne Hiltman

For Matt, the idea of getting healthy brings him back to his dream of helping others. “Really it just comes down to . . . you know, once I’m healthy, I’ll be able to get out there and help people.”

Before he’s able to help others, Matt will need to find the right combination of tools to treat his mental illness. He and his family continue to pursue every possible lead, including out-of-state research studies and charity care. But without health insurance, Matt’s recovery appears stuck, and a promising future seems just beyond his reach. In the past, Matt’s hard work helped him succeed in the classroom and in the saddle. Now, his future success rests in the hands of the 236 men and women of Georgia’s General Assembly.

“Having affordable health care and health insurance would give me hope. It would give me more access to different treatments. Mostly, it would give me hope.”


If you or loved ones are living with mental illness, please consider visiting the National Alliance on Mental Illness – Georgia or calling their helpline at 770-408-0625 for more information and support.

To show your support for expanding health coverage in Georgia, please consider sending a short e-mail to your state lawmakers through an easy-to-use form.