ATLANTA – Just 10 states have not expanded Medicaid – mostly in the South, where Republicans dominate state legislatures. But a decade after the Affordable Care Act made the option available, Medicaid expansion is becoming harder to resist.
In December, North Carolina became the latest state to expand Medicaid. And now, GOP power brokers in Mississippi, Alabama and Georgia suggest there might be an opening to join them – eventually.
Over plates of fried chicken and mashed potatoes, Georgia legislators and policymakers – including many Republicans – gathered near the State Capitol to hear from neighboring states that took the plunge.
"It was not a very pleasant journey very early on," North Carolina Republican Rep. Donny Lambeth told the assembled group. "I was one of the few Republicans. My party would not accept it. But I would tell you, you need to be patient and don't give up."
Lambeth says he spent almost a decade trying to convince his colleagues in the GOP-controlled legislature to expand Medicaid. Several times, he almost gave up.
But Lambeth stuck with it, framing his pitch as "closing the coverage gap" instead of "expanding Medicaid" and telling his colleagues the stories he heard from people around the state.
"The tree farmers in Ashe County, the strawberry farmers down east – the thing they all told me is, 'We don't have health insurance, but we have a family farm we're going to lose if we have a catastrophic event," he said.
Lambeth also assured Georgia lawmakers that none of his GOP colleagues lost a primary over their support for expansion.
Now roughly 600,000 low-income North Carolinians are eligible for coverage. Expansion in Georgia would cover roughly 400,000 people.
But for many Republicans, "Medicaid expansion" is still a toxic phrase tied closely to former President Barack Obama, so some GOP-led states have put their own spin on the program.
Republican lawmakers in Georgia are eyeing a model deployed by Arkansas, where Medicaid expansion dollars fund the purchase of private insurance plans.
Cindy Gillespie, the former Arkansas health secretary, says her state's approach infused money into rural communities over the last decade.
"In the surrounding states, you had 58 hospitals close," she told the gathering. "None were in Arkansas."
In rural Georgia, nine hospitals have closed since 2010 and free clinics have had to help fill the void.
"Our patients depend on us for their routine check ups and medications," says nurse Glenda Battle, who volunteers at the Samaritan Clinic in Albany, Ga. "They have high morbidity and mortality rates."
That was from Battle's testimony to a recent Georgia legislative hearing on Medicaid expansion. Attendees packed the committee room and an overflow crowd stretched down the hallway outside.
"Medicaid expansion is an economic agent," Battle told lawmakers. "It will allow struggling hospitals to remain open to serve the uninsured, low-income in their area and keep others employed."
Many Republicans have come to acknowledge these gaps. But the response so far from Georgia Republican Gov. Brian Kemp – a more limited expansion with a work requirement – has enrolled only about 2,300 people since it launched last year.
That's about half a percent of what full Medicaid expansion could cover at a higher cost per person.
But despite some tepid interest from top Republicans in the legislature and cautious optimism from Democrats who have long pushed for expansion, Kemp sued the Biden Administration this month to keep his program going and says he is not interested in full expansion.
"You'll have to talk to the people that are proposing that," Kemp told WABE in January. "I mean, those are not my proposals. People have known what my plan is, so that is what I'm pushing forward on."
On Tuesday, after just a month ago signaling openness to exploring Medicaid expansion this year, top Republicans in the Georgia House unveiled a bill suggesting another session will pass without action.
The bill focuses on reforming hospital regulations – often discussed as a component of a potential deal on Medicaid expansion – that merely sets up another study committee to research the Arkansas model.
Meanwhile, Georgia is leaving billions of federal dollars on the table.
"The numbers show that we're being penny wise and pound foolish if we don't get forward with this," Georgia Republican Sen. Chuck Hufstetler said during the panel of Southern health policymakers in January.
Hufstetler, an anesthesiologist who chairs the powerful Senate Finance Committee, noted that Georgia has attracted billions in new investments from companies that make batteries, solar panels and electric vehicles.However, he worries it could become harder to compete for jobs with states like North Carolina that have expanded Medicaid.
"We need workers. We need healthy workers," Hufstetler says. "The number one issue we have in Georgia right now is workers."
For now, a lot of the recent rumblings about Medicaid expansion have been just talk. But as more Republican states sign on, a growing number of lawmakers believe the question is not if, but when.
WABE's Rahul Bali and Jess Mador contributed to this report.
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