Commenters question state Medicaid waiver plan for work requirements

The governor announced his Medicaid waiver proposal last month, kicking off a series of public meetings held around the state and a written comment period that wrapped up last week. Macon's Trudy Posner commented on the governor's plan at Mercer University auditorium in November. Stanley Dunlap/Georgia Recorder

About 1,000 written comments poured in during the first public airing of Gov. Brian Kemp’s proposals to slightly expand Medicaid under a now-delayed waiver application process.

The governor announced the proposal – one of two federal waiver applications – at a press conference last month, kicking off a series of public meetings held around the state and a written comment period that wrapped up last week.

The $120 million plan – $36 million of which would be the state’s share – would allow adults earning up to about $12,000 annually to sign up for health care coverage. The program would likely extend coverage to about 50,000 people, so long as they work, attend school, undergo job training or complete community service.

A final vote on the proposal was teed up Thursday for the state Department of Community Health board but was pushed back to next week because of some last-minute “challenges” during the public comment phase, according to Blake Fulenwider, the state agency’s chief health policy officer.

The state’s online submission form was down for about an hour and a half after a data center crashed just hours before the deadline to submit a comment. One group also mistakenly mailed hundreds of comments to the wrong office address.

As a result, the state kept the online submission form open the morning after the deadline and accepted the large batch of comments.

“We’re close but despite our best efforts, we’re unable to complete that and have complete confidence that we are 100% responsive for today,” Fulenwider told the board Thursday.

Fulenwider said that the comments represented “only maybe half a dozen to a dozen different distinct areas of focus.” He said he would present a summary of the comments at a special called meeting likely held next week.

Even with the setback, a spokesman from DCH said Thursday afternoon that the state is still aiming to have the submission on its way to the federal government by next Friday. The state is also processing comments submitted for a second waiver that would let Georgia create a reinsurance program, bypass healthcare.gov and combine government subsidies with employer contributions.

No mere formality

The written comments are from advocates, health care professionals, business interests, politicians and everyday Georgians simply interested in the future of health care in the state, according to copies of written comments acquired from DCH. The Georgia Recorder reviewed dozens of the letters for this story.

Some of the comments are based on a suggested template, such as the dozens that came in from people with cystic fibrosis arguing for full Medicaid expansion and against a work requirement. But many of them were uniquely written missives that addressed a range of concerns or offered suggested changes.

Several comments were extraordinarily brief – “It sounds like a good idea,” one said – while others were exhaustively detailed and filled pages with their concerns and specific objections.

The comments can be a way to influence public opinion, with some people and groups like the Carter Center in Atlanta, sharing their contribution through social media.

The submissions are no mere formality, though. They’ve been a stumbling block for some states seeking waivers, such as Kentucky and Arkansas.

“The public comments are important because they become part of the legal record,” said Laura Colbert, who submitted a letter opposing the proposal on behalf of Georgians for a Healthy Future.

“And so, it is one of the most powerful ways that consumers can express their needs and concerns about what the state is doing related to health care,” she said.

Some of the letters include not-so-subtle foreshadowing of potential legal showdowns to come, such as one from the Southern Poverty Law Center that also makes the case for full Medicaid expansion.

“If the agency decides not to withdraw this disastrous and cruel proposal, and the waiver is approved, the SPLC will stand by the families who will be impacted and defend their ability to fully participate in the Georgia Medicaid program,” wrote senior staff attorney Emily C.R. Early.

State Democrats urged the public to send their comments in hopes of influencing the process, with Democrats holding a press conference on the afternoon of the deadline to urge last-minute commenters to weigh in.

Democrats and advocacy groups like Colbert’s have argued that the state could cover far more people, or about 500,000, by fully expanding Medicaid. They argue it would be a more efficient use of state and federal dollars and provide a boost to rural hospitals and the health care workforce. Georgia is one 17 states that have not expanded Medicaid under the Affordable Care Act.

“I think the governor has the opportunity to read those public comments and actually take heed to some of those public comments and fully expand Medicaid,” said state Rep. William Boddie, an East Point Democrat who called the state’s application “doomed to fail.” “We could do that almost instantaneously. We don’t have to wait to 2021 or 2022. We can do that today.”

The Republican governor anticipated the criticism, lambasting full Medicaid expansion even as he unveiled his proposal last month.

“Medicaid expansion is a risky, one-size-fits-all approach that costs too much and fails to deliver,” he said. “Georgia Pathways is innovative, it’s affordable and it’s tailored to meet the health care needs of Georgians in every part of the Peach State.”

‘Not at all by choice’

The public feedback ranged from recurring objections over the state’s long-standing resistance to fully expand Medicaid to narrower concerns about the impact of the proposed work requirements and other provisions that respondents argued would make it harder for the newly eligible people to gain – and keep – the health care coverage.

There were also concerns raised about lesser known aspects of the proposal, such as a request to waive non-emergency medical transportation services that some argue poor Georgians count on to make their appointments.

Earl Rogers, president and CEO of the Georgia Hospital Association, called the overall proposal a “positive first step toward the goal of making affordable, comprehensive health care coverage available across the state.”

But Rogers urged the state to remove the work requirement, which federal courts have struck down when enacted by some states, along with other suggested changes.

“Given the current legal landscape, the inclusion of a work requirement as part of the 1115 Waiver may serve to delay implementation, possibly for years,” he wrote. “Georgia cannot wait any longer to increase access to affordable health care coverage of individuals earning less than 100% of the (Federal Poverty Level).”

Many of the letters struck a similar note on the proposal to require new enrollees to complete 80 hours of work, school, training or community service. They said they saw it as too narrow or predicted the monthly reporting task could trip people up and cause them to slip back into uninsured status. They also questioned the fairness of premiums and co-pays for this low-income population.

The commenters outlined scenarios where people might be unable to work – like while undergoing cancer treatment – or have responsibilities that pull them away from their job, such as caring for an aging parent.

“We emphasize the importance of patients not being faced with delays or barriers to treatment and find that disruptions to care are linked to worse cancer outcomes,” wrote Aaron Segel with the American Society of Clinical Oncology.

“Moreover, cancer is an unexpected and life-altering event, and research has shown that those in active treatment for cancer often stop working entirely or dramatically reduce the number of hours worked, not at all by choice,” Segel wrote.

The state is planning to allow for a “short-term exception” for those who can’t muster the hours required because of a serious illness, a family emergency, temporary homelessness, a new baby or other reasons, according to the state’s application. The details of how the exception would work are currently unclear.

Several people and organizations, such as the Georgia Council on Aging, object to the potential omission of caregivers from the coverage and are urging the state to let caring for an older adult family member count toward the work requirement.

“We believe that it is in the best interest of the state to facilitate affordable health care coverage to low-income caregivers so that they may remain in good health and be able to continue to provide this valuable and critical care for elderly family members,” wrote Vicki Johnson, chair of the Georgia Council on Aging.

Johnson wrote that there’s also this to consider: Enabling caregivers would help keep Georgia’s seniors out of costly nursing homes.

Correction: Due to an editing error, an earlier photo caption misidentified the woman pictured.