Gov. Nathan Deal’s decision to reject the expansion of Medicaid prescribed by the Affordable Care Act would leave thousands of the poorest Georgians uninsured and threaten the bottom lines of hospitals that were counting on new income from the changes.
Deal’s spokesman noted Wednesday that the governor might agree to expand Medicaid if the federal government gave Georgia a “block grant” of money and the freedom to tailor the program as it saw fit — none of which is currently in the health care law. Without that flexibility, Deal believes the state could not afford the expansion.
“The fix for an unsustainable program is not to make it even more unsustainable,” spokesman Brian Robinson said.
Word of Deal’s decision set off a wave of anxiety among hospital officials and patient advocates in the state, with one saying that the governor is “certainly putting hospitals at risk,” and another calling the decision a mistake.
“I have diabetics who lose legs because they do not get wound care or get to see a podiatrist,” said Carole Maddux, CEO of Good Samaritan Health & Wellness Center in Pickens County. “These are people who will be applying for disability and going on Social Security. They were perfectly healthy, contributing members of society before that. It’s very short-sighted.”
Maddux’s clinic cares for people who do not have insurance. She said about 85 or 90 percent of the clinic’s patients would have qualified for Medicaid in 2014 if the state expanded the program as called for under the law.
The federal health care law calls for anyone under age 65 with an income up to 133 percent of the federal poverty line to be eligible for Medicaid, starting in 2014.
Under the law, the feds would pay between 90 and 100 percent of the cost of the Medicaid expansion, which would add 650,000 Georgians to the program’s rolls. But Georgia projects its share of the expansion would reach $4 billion over 10 years.
Failing to expand Medicaid will be a costly decision for many hospitals around the state, especially those that care for uninsured Georgians when they are sick or injured.
About 1 in 5 Georgians is uninsured.
In many Northeast Georgia counties, that number is higher, according to numbers released by the U.S. Census Bureau this week.
With about 27.7 percent of its residents uninsured in 2010, Rabun County has one of the highest rates of uninsured people in the state, according to the numbers.
Only one other county in the state, Gilmer, has as high a rate of uninsured. Habersham County, with an estimated 26.5 percent of its population uninsured in 2010, ranks high on the state’s list.
Hall’s rate of uninsured, at 25.8 percent, is also somewhere near the top; Banks County, at 25.7 percent uninsured, isn’t far behind.
Because the estimates released this week were the first of their kind on a county level, it’s hard to compare how those counties’ rates of uninsured have changed in the economic recession.
Hall County Health Department statistics show that numbers of uninsured patients there dropped slightly from 2010 to 2011; the time frame also saw an increase in patients covered by Medicaid.
And Cheryl Christian, executive director of Gainesville’s Good News Clinics, which provides medical care to uninsured residents, said the clinics’ demands are steadily growing.
“In the medical clinic alone, we’re averaging about 60 new patients every month,” Christian said.
Good News Clinics is the largest of its kind in the state. Aside from basic medical care, the clinic provides dental care, opthamology, X-ray and laboratory tests to the area’s uninsured.
The dental clinic gains about 75 new patients each month, Christian said.
The clinics’ patient visits are set to exceed the number of visits from last year. The clinics’ patient count last year was also larger than the year before.
One new patient Christian described as a “well-trained professional” with a master’s degree who had previously done consulting work in seven different states before he lost his job. For a few years, the patient lived off his 401(k) retirement savings, thinking a new job was right around the corner, Christian said.
When it didn’t, he strung together several part-time jobs, but still can’t afford insurance.
“Obviously, it’s not slowing down here,” Christian said. “We’ve seen more and more people that are uninsured, because they’re working part-time jobs or obviously, if they’re unemployed, they can’t afford insurance.”
But Christian said in Hall, the uninsured may have greater access to health care than other counties. There’s nothing else like Good News Clinics in the state that’s as far-reaching as the local clinic is.
“No other county has the resources that we have for the uninsured,” she said.
Here’s why hospitals are worried: When the health law was passed, hospitals agreed to accept cuts in Medicare payments and in payments from a program that helps cover the cost of providing care to people without insurance. In a world where almost everybody had insurance, as envisioned by the law, hospitals could afford to take those cuts.
Without the expansion, however, hospitals will still be stuck providing care to lots of poor patients without insurance. They will have to do that on an even tighter budget than in the past.
“The decision by the governor yesterday certainly puts us in a spot where we have the cuts but we still don’t have the coverage,” said Kevin Bloye, spokesman for the Georgia Hospital Association.
Bloye said the governor understand that “hospitals are sort of in a conundrum” without the expansion and said the hospitals plan to work with Deal to find a way to keep health care strong statewide.
Bloye said the state’s hospitals now provide about $1 billion in uncompensated care.
A spokesman for Northeast Georgia Health System said the amount of uncompensated care the hospital system provides has grown annually.
In 2011, the health system alone provided $26.6 million in uncompensated care costs, Sean Couch, spokesperson for NGHS said Friday.
Robinson, Deal’s spokesman, said the governor wants to improve health care in Georgia — and he is hoping the November elections might eventually lead to alternatives to the Affordable Care Act.
“We’re still hopeful that the American people will demand change in this upcoming election and Congress can deliver change,” Robinson said.
Under the fine print of the health law, some of those who would have been covered by an expanded Medicaid program might be able to shop for a heavily subsidied health plan on the new state-based insurance exchanges that are also a cornerstone of the law.
But only those with incomes at or above 100 percent of the poverty line are eligible for the subsidies under a quirk of the law. The poorest of the poor can’t get the subsidies, under the law.
The state’s safety-net hospitals and its rural hospitals are the most vulnerable going into a future without an expanded Medicaid program.
Last year, Northeast Georgia Health Systems received about $6.2 million in DSH payments to offset the costs of uncompensated care, Couch said.
While it’s unclear exactly how much those payments would go down for hospitals in Georgia, experts said the health law calls for specific reductions in the disproportionate share payments nationwide, and cuts will be coming.
The way the health law was written was a balancing act, says Shawn Gremminger, who heads legislative affairs at the National Association of Public Hospitals and Health Systems.
“The idea was, on the plus side we were going to get a whole lot of new covered patients,” Gremminger said. “To help offset that for the federal government, we took cuts in Medicare reimbursements and DSH.”
Eliminating the Medicaid expansion throws everything out of balance, he said.
“I think Gov. Deal is certainly putting hospitals at risk,” Gremminger said.
Couch said the hospital system was “supportive” of the governor Friday.
“We’re supportive of Gov. Deal’s leadership regarding financial concerns we face as a healthcare provider, and we hope to continue to participate in the DSH program,” Couch said.
Shaky hospital finances aren’t just a problem for people without insurance. It can also hurt patients with the best coverage. That’s because hospitals may have to shift even more of their costs onto their paying patients, if they are getting less from the government to cover uncompensated care. Staffing may be reduced, or some services might be eliminated, some experts said.
Gerard Anderson, director of Center for Hospital Finance and Management at Johns Hopkins University Bloomberg School of Public Health, said hospitals will have to charge more to paying patients along with making painful cuts.
“They’re already lean and mean — it’s not like they have a lot of fat in the system,” Anderson said.
Staff writer Ashley Fielding and The Associated Press contributed to this report.