Chapter II of the Abrams interview (along with my own thoughts on Medicaid Expansion)

It’s taken me longer than I expected to finish this second write-up from my interview with Stacey Abrams, the Democratic Party’s nominee for governor of Georgia.  There are several reasons for that, but the main one is that I found myself thinking a lot about the consequences of Georgia’s refusal to accept Medicaid Expansion.  That decision is now 10 years old, so it’s ripe for an initial look-back and evaluation.

Before I get into that, though, I should note that Abrams says that implementing Medicaid Expansion would be her top priority as governor and that she believes Georgia’s political landscape has shifted enough over the past decade that even she — black, female, and Democrat — could persuade the Republican-dominated Georgia General Assembly to support the policy.

“The political realities that existed 10 years ago do not exist today,” she said.  “They have shifted in that we now see the direct economic impact.  We see the direct healthcare impact. 

“ … I very firmly believe that both the moral indignity and the economic reality has shifted the political will in the legislature,” she continued.  “But I also know as someone who served there for 11 years that it matters what the governor says she will sign and it matters what priority the governor places on the legislation put before her.”  

It’s probably also worth noting that at least one prominent Republican comes fairly close to publicly agreeing with her, at least about the chances for passage. Brian Robinson, who served as press secretary to Governor Nathan Deal when he rejected Medicaid Expansion 10 years ago, wrote in Georgia Trend a coupole of months ago that Governor Brian Kemp “can steal the issue from (Abrams) by calling a special session to expand Medicaid. It would pass, the governor would experience a net political benefit and Abrams would lose her best talking point.”

If Robinson’s Georgia Trend column was intended to nudge Kemp along and provide him with some political cover, it didn’t work. The Republican incumbent (and successor to Robinson’s former gubernatorial boss) has so far passed up probably the best free political advice he ever got.

This despite the fact that rejecting Medicaid Expansion ranks as arguably the second-worst public policy decision ever made by the leaders of Georgia state government. The worst, of course, was secession – the 1861 decision to leave the Union and go to war with Abraham Lincoln, Ulysses S. Grant and, of course, William Tecumseh Sherman. In rejecting Medicaid Expansion, the state’s Republican leaders didn’t slaughter their way across huge swaths of the state or set fire to entire towns, but the effect has been much the same. Communities have been decimated; people have died.

Medicaid Expansion was built into President Barack Obama’s signature healthcare legislation, known generally as the Affordable Care Act (ACA) and informally as Obamacare.  It would pour billions of dollars into the federal government program set up to provide healthcare to the nation’s poor while imposing minimal cost on the individual states. 

Republicans hated it and fought it every step of the way.  They had initially counted on the conservative U.S. Supreme Court to strike down the whole law (and were pretty much apoplectic when the court failed to do so). But they got something of a consolation prize when the high court ruled that the federal government couldn’t compel states to expand Medicaid; the Supremes held that states should have the right to reject billions of new Medicaid dollars that their own citizens were funding, and Georgia’s Republicans happily did just that.

To his credit, Nathan Deal, Georgia’s Republican governor at the time, initially left the door open to accepting Medicaid Expansion.  But that changed a short time later, when he attended the Republican National Convention in Florida and mysteriously gained new insight into the program’s fatal flaws.  No, no, no, he told reporters, Georgia would not be expanding its Medicaid program.

But even gubernatorial opposition wasn’t enough for Georgia’s GOP-controlled General Assembly.  In 2014, the state legislature passed a law (which Deal signed) stripping the governor of his power to unilaterally accept Medicaid Expansion and decreeing that the legislature would also have to approve it.  This was one more lock on the hospital door.

The early Republican rationale against Medicaid Expansion was that a.) it would cost too much in state funds to kick-start it and b.) the federal government couldn’t be counted on to sustain the level of funding required.  Both those arguments have now been consigned to the dustbin of history.

Even Robinson, the former Deal spokesman, has thrown in the towel on those arguments.  “This isn’t what we would do,” Robinson told Axios recently.  “But Republicans can’t agree on what we would do. This is the policy and the law, and it’s not going away. It would bring home hundreds of millions from a program we’re paying into already.”

The current GOP hedge is to modify the program to somehow better suit Georgia’s particular needs.  Brian Kemp, the incumbent Republican governor against whom Abrams is running, has dragged the state through a waiver process with proposals that would (according to every analysis I’ve been able to find) cost more and do less.

All this would be comical if it weren’t so tragic.  Solid calculations of the amount of money Georgians have paid into the expanded Medicaid fund are hard to come by, but back-of-the-envelope estimates of the amount Governors Deal and Kemp have passed up consistently come in at, give or take, $30 billion-with-a-b.

In the process, 14 Georgia hospitals have closed, eight of them in rural areas – including one in the North Georgia legislative district of House Speaker David Ralston.  A week or so ago, WellStar Atlanta Medical Center, one of Metro Atlanta’s two Level 1 Trauma Centers, announced it would shut down November 1^st.  WellStar management took pains to say Medicaid Expansion wouldn’t have made a difference, but that proclamation was met with a certain amount of skepticism. It’s impossible to get a body count, but Georgians have no doubt died because of the refusal to accept Medicaid Expansion.

All of which brings us back, finally, to my interview with Stacey Abrams and her focus on Medicaid Expansion.  I’ll add one more comment.  I’ve now been studying the decline of rural Georgia and the state’s widening urban-rural divide for a solid decade.  A number of drivers are contributing to those unhappy trends, but the judgment I’ve come to is that the biggest single factor is the collapse of rural healthcare. Hospital closures simply signal Stage 4 of the economic cancer afflicting much of rural Georgia.

Abrams sees Medicaid Expansion as vital to improving the health of individual Georgians and the communities they live in. “My intention is to say that Medicaid Expansion is my number one priority,” she said, “because it has the most salutary effect for the largest number of Georgians and it is the single largest economic development opportunity in our state’s history. There is no other economic development issue that will create 60,000 jobs. No one has ever done that.”

Indeed, Kemp’s two biggest economic development wins — a Rivian EV plant east of Atlanta and a Hyundai Motor Group facility in Bryan County — are projected to create a combined total of 15,600 new jobs at a reported cost of $3.3 billion in tax benefits and other incentives.

Abrams applauds those sorts of economic development wins, but with caveats. “My challenge and my critique is that bringing in those jobs is not the end of the story. It is part of the story,” she says, “but too often it becomes the whole of the story — that because you can tout some massive corporation coming in that will absolutely have economic benefit, then you are absolved of responsibility for all of the places that still have nothing.”

Once Georgia’s civil war over Medicaid Expansion is finally over, the reconstruction of rural Georgia will take time and great effort. Hospitals that have been shut down can’t be reopened simply because the federal dollars begin to flow toward their communities. Local hospital authorities and other owners will have to jump through multiple state and federal hoops, a process that is likely to take several years at best.

In the meantime, as the new Medicaid dollars begin to flow, Abrams envisions using some of the shuttered hospitals as sites for clinics that could be staffed by physicians, nurses and physician assistants willing to take a chance on rural Georgia.

” … (N)o one is bringing a company to a place where they can’t see a doctor,” she says, adding elsewhere in the interview that “the infusion of (Medicaid Expansion) cash is going directly to the counties that have the greatest need because what they need are paying customers, and Medicaid expansion means that the customers that are going to show up anyway can finally afford to be there.”

The tragedy is that, for a while at least, there probably won’t be anybody there to pay.

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