Once healthy and strong enough to “rassle a bear,” Wilson, 60, suffered a stroke in January that forced him to quit his job as a beer distribution manager and stripped his family of the health insurance that job provided. So, like nearly , Wilson turned to the Affordable Care Act’s insurance marketplace to buy the coverage he, his wife and daughter needed.

Wilson fears his new coverage may soon be ripped away too. He is one of roughly 413,000 Georgians who are at risk of losing their Obamacare insurance, depending on how the rules on a lawsuit later this month.

“I’m not a big Obama fan, but I don’t know how anybody could be against this,” Wilson said. “Prisoners get all of their health care paid for, so why can’t someone who’s worked all their lives also get some help?”

Yet conservatives in Georgia and across the nation are just that — staunchly opposed to the Affordable Care Act, its mandate that most Americans buy insurance and its use of billions of taxpayer dollars to help pay for Obamacare plans.

President Barack Obama, who offered a defense of his heath law last week, is misrepresenting Americans who oppose it, U.S. Rep. Tom Price, R-Ga., said.

Special Report

Watch KHN Video

“For the president to imply that those who oppose Obamacare do so in order to harm our fellow citizens is particularly insulting,” Price said in a statement. “It is precisely the president’s health care law that is driving up costs for families and businesses and kicking millions of people off of health care plans they had and liked.”

In the Supreme Course case, , the plaintiffs argue it’s illegal to give to Americans who bought health plans through the federal marketplaces, also called exchanges, versus those created and run by states. Without the credits, experts say, most people with Obamacare plans would be forced to drop coverage that they can no longer afford.

Such a blow could in the 34 states that chose not to build and run their own.

The Obama administration says it has no backup plan if the tax credits are struck down.

Neither has the state.

‘There Will Be Two Americas’

Access to health care for 6.4 million Americans hinges on just four words in the more than 900-page health care law: “.”

The plaintiffs in King v. Burwell argue those words mean individuals who live in states that chose not to set up their own Obamacare marketplaces — letting the federal government do it for them instead — aren’t eligible for the tax credits.

For most people, those credits are what make the actually affordable.

If the credits disappear, monthly premiums will spike by 200 to 300 percent, said Cynthia Cox, an associate director of health reform at the Kaiser Family Foundation, a nonprofit, nonpartisan organization specializing in health policy. Georgians would be among the hardest hit in the country. The average premium would jump from roughly $72 to nearly $350 per month — a 380 percent spike, Kaiser estimates show.

“There will be as far as health insurance is concerned,” she said.

The law’s supporters say the court should uphold the tax credits because the intent of the law is clear — all Americans who buy in an Obamacare marketplace should be eligible for the credits regardless of whether it’s run by the state or feds.

Critics argue the law’s language is unambiguous and it should be up to Congress to change it.

Kelly Rambis, 55, doesn’t care what happens to the tax credits.

The Kennesaw woman bought an Obamacare plan shortly after being laid off earlier this year. She was thrilled at first, learning the plan would only cost her $15 a month. But her elation quickly evaporated when she went to the doctor. She was turned away.

The plan’s network of doctors was so narrow and the deductibles and co-pays so high that Rambis felt as if she was barely insured. So she redoubled her efforts to find a job that provides insurance and jettisoned her Obamacare plan after only two months.

“It was just horrible,” she said. “I don’t ever want to deal with Obamacare again.”

Ron Bachman, a senior fellow at the conservative-leaning Georgia Public Policy Foundation, said he hopes the court will rule against the tax credits. Such a move may spur a much-needed national discussion of how best to provide Americans with insurance, Bachman said. Obamacare , since many who bought ACA , he said.

America needs a health care system that focuses on consumer responsibility, delivers patient-centered care and gives families more choice in what coverage to buy, Bachman added. The Affordable Care Act currently requires all plans to include certain “essential health benefits,” which drives up costs, he said. Those benefits include services, such as maternity care. But not everyone needs the same level of coverage.

“I think the people should be able to buy what they need, not what the government thinks they need,” he said.

‘Death Spiral’

If the rules against the government later this month, the fallout will be widespread.

People could lose their tax credits in as little as 30 days, some experts say. Others predict the court or Congress could phase out the credits over time to give people a chance to find other coverage options before cutting them off from financial help.

One is its “individual mandate,” which requires adults to buy health insurance. A court ruling that disallows tax credits for millions would severely weaken that mandate: people can’t be forced to buy insurance if they can’t afford it.

The result: healthy individuals will likely drop coverage, leaving only the sickest, most expensive individuals behind in the marketplaces.

Such an imbalance means the marketplaces will rapidly devolve into a so-called “death spiral” — pushing up premiums not just for those with marketplace plans but people with individual coverage outside of the marketplaces too, insurers say.

“Premium tax credits … are essential,” national trade group America’s Health Insurance Plans wrote to the court in support of the credits. “There is no practical reason to distinguish between state- and federally operated exchanges in this regard.”

Without the credits, will again be forced to seek care in hospital emergency rooms instead of clinics or doctors’ offices, said Earl Rogers, head of the Georgia Hospital Association. And that, Rogers said, will raise the cost of care for everyone.

Every year, people who do have insurance end up bearing the cost of those who don’t, to the tune of roughly $1,500 in higher hospital bills, insurance premiums and taxes, estimates from Georgia State University show.

Georgia hospitals dole out $1.7 billion in uncompensated care every year, even with the credits in place, Rogers said. He added that he has confidence that federal and state policymakers will take action to make sure Georgians’ needs are met.

‘We’ve Been Through That’

The states and federal government, however, seem to be sticking to their high-stakes game of chicken.

Few have offered solutions to the potential crisis even though the court is expected to rule in less than three weeks in the King v. Burwell case.

Earlier this year, Sen. Ron Johnson, R-Wis., introduced a bill that would let Americans keep any health care plans and tax credits they currently have until August 2017. It would also repeal the s coverage mandates.

Price, a Roswell Republican and chair of the House Budget Committee, also earlier this month.

Republicans acknowledge that abruptly taking away the credits could cause a hardship for millions. But many expect the credits to be phased out over time, avoiding such dire consequences.

Meanwhile, the Obama administration has remained firm in saying it has no backup plan.

In Georgia, Gov. Nathan Deal told The Atlanta Journal-Constitution recently that the state isn’t preparing a “Plan B” in case the tax credits are declared unconstitutional.

Deal and other Georgia leaders have remained to the 5-year-old from the outset. They declined to build a state-run insurance exchange and have refused to , another pillar of the law, calling such a move too costly for taxpayers.

“We’ve been through that thought process before and made the judgment call that this is a federal idea and the feds need to implement it,” Deal said.

He also closed the door on any efforts to revive a state-based exchange — an unlikely prospect given that legislators passed a law last year barring the state from creating its own marketplace.

Other states are weighing their options.

In some, governors could use an executive order to create a state-based marketplace, though not in those that banned it by law, such as Georgia, said Cox with Kaiser.

Setting up a marketplace in Georgia would take a lot of time and manpower, said Erin Fuse Brown, an assistant professor of law at Georgia State.

“It wouldn’t be up and running until 2017,” she said. “By that time, people would have lost their (credits).”

A Waiting Game

For now, like Ted Souris will .

No tax credit means no health insurance for Souris.

The Smyrna man isn’t a fan of the but decided to take advantage of it and retire early from his sales job. Now happily retired, there’s no going back to his employer and at 62 he’s still three years shy of qualifying for Medicare, the government health program for Americans 65 and older.

Souris’ tax credit lowered his monthly premium from about $460 to roughly $100. Without it, “there’s no way I could afford it,” he said. “I guess I’d just access the emergency room and try my best not to get sick.”

Wilson, the former beer distribution manager, worries how he could possibly afford the medications he must take following his stroke. One drug costs $400 per pill.

Without a tax credit, Wilson would have to pay $300 a month just for insurance for himself, a price he and his wife can’t afford on her minimum wage income. The couple already struggles to pay for frequent trips to Atlanta to see an eye specialist to treat Wilson’s low vision.

“I don’t know what the hell I’d do,” he said. “Probably die. I’m for real.”

Staff writers Greg Bluestein and Daniel Malloy contributed to this article.

Ìý

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Georgia isn’t one of those states. Indeed, the issue remains so politically toxic here that many Georgia Republicans are loath even to utter the phrase “Medicaid expansion” under the Gold Dome.

But experts say it’s just a matter of time before all states expand the health care program for the poor. They point to history: as now, many states were reluctant to embrace Medicaid when it was created in 1965, but all eventually did (Arizona was last to sign on, in 1982). And they cite economics, which they say turns the unpalatable into the inevitable. (Arizona, under a Republican governor, has already joined the states expanding Medicaid under Obamacare.)

“It makes too much sense from a state economic impact standpoint,” said Carter Price, a senior mathematician who studies health policy issues at the nonprofit Washington Center for Equitable Growth. “I don’t think I’ve [heard] a convincing argument against it.”

Every year Georgia passes on expansion, it turns away an infusion of roughly $3 billion in new federal money. Hospitals continue to lose about $1.7 billion a year in free care to the uninsured.

Often lost in the political and economic calculations is this harsh and simple fact: hundreds of thousands of poor Georgians continue to go without health care, and some of them are dying from conditions for which treatment is now available in other states. For that reason alone, supporters say, rejecting expansion is morally unconscionable. But for those who are unmoved by that argument, refusing to expand Medicaid is also financially reckless for the state, supporters say.

Even Georgians who do have insurance are bearing the burden of the state’s refusal to address its uninsured problem. They pay roughly $1,500 more on average in higher hospital and doctor bills, higher insurance premiums and higher taxes each year. Expansion could help solve that dilemma.

That is, of course, if Obamacare stays intact. Key Court Ruling Due In June

The U.S. Supreme Court is poised to rule in June on whether millions of Americans should be allowed to receive federal tax credits that make buying health insurance affordable. The decision could preserve or potentially destroy the Affordable Care Act.

It’s that uncertainty, in part, that Gov. Nathan Deal and other Obamacare critics say makes it wise to wait on making a decision on whether to expand Medicaid.

The health care landscape could radically change based on the court ruling, said state Rep. Butch Parrish, R-Swainsboro, who co-chaired a study committee on Medicaid reform in 2013.

Parrish and other conservatives have also raised concerns over whether the federal government will fulfill its promise to pay at least 90 percent of the cost of expansion. And, Deal says, the state can’t afford to expand a program that’s already bloated and inefficient.

“There are so many unknowns out there,” Parrish said. “We really don’t need to jump off this cliff before we know what we’re doing.”

‘The Right Political Combination’

Two Southern states — Arkansas and Kentucky — have expanded Medicaid so far. And those decisions are already paying big dividends.

The states experienced the biggest drops in uninsured rates in the country, the latest Gallup survey shows. (Georgia, meanwhile, now has the second-highest uninsured rate, second only to Texas.)

Under expansion in Arkansas, more than 233,000 low-income residents have received health insurance. The state stands to save nearly $1 billion over a decade thanks to expansion. Admissions of uninsured patients to hospitals fell by nearly half in the first six months of expansion.

Those benefits haven’t come easy.

To achieve expansion in this small red state, a group of Republican lawmakers teamed up with then-Gov. Mike Beebe, a Democrat, to develop a conservative twist on expansion known as the “private option.” The private option uses government money to buy private insurance on the state’s online insurance exchange set up under the health care law. (The state had to get special permission from the federal government to pursue a nontraditional expansion.)

“It’s a matter of finding the right path and the right political combination to get to a yes,” said Joe Thompson, head of the nonpartisan Arkansas Center for Health Improvement and former state surgeon general. Thompson played a key role in creating the private option.

The private option is working, and Arkansas will end up with a healthier workforce and a competitive advantage over its neighboring states when it comes to economic development, he said. ‘They’re Our Friends, Our Relatives’

Even Arkansans not on Medicaid have benefited. The addition of tens of thousands of generally younger, healthier Medicaid recipients on the insurance exchange has helped to lower overall premiums by 2 percent on average in 2015.

In Kentucky, which also has a Democratic governor, leaders went a more traditional route and expanded its Medicaid program as is.

Expansion in the Bluegrass State will add an estimated 40,000 new jobs and $30 billion to the state’s economy through 2021, according to a study released earlier this year by Deloitte Consulting and the University of Louisville.

Most importantly, expansion is already having a collective impact on the health of Kentucky, a historically unhealthy state, said Gov. Steve Beshear in a recent speech. Some 46,000 people have been screened for diabetes; more than 80,000 have had preventive dental visits. The list goes on.

Better access to care for all Kentuckians was the whole purpose of this effort, Beshear said.

“These are not aliens from some distant planet,” he said. “They’re our friends, they’re our relatives, they’re our neighbors.” ‘Time To Quit Trying To Be Obstructionist’

Georgia Rep. Pat Gardner, D-Atlanta, sometimes feels like telling the poor in her community to move to Kentucky.

Georgia taxpayers are funding the expansions in Kentucky and other states anyway, Gardner said.

A spate of pro-expansion bills proposed by Georgia Democrats over the past two years has been largely ignored by the Republican-controlled General Assembly.

Currently, Georgia’s Medicaid program provides health coverage to about 1.8 million low-income children, pregnant mothers, the elderly and disabled. Expansion could extend coverage to another roughly 600,000 people, mostly adults without children.

Gardner said that while the governor may have been right to wait a bit, it’s far overdue for Georgia to begin looking at what it can learn from states that have successfully expanded Medicaid.

“Is it not time to quit trying to be obstructionists and make it work for the people of our state?” she said. “It’s baffling to me.” ‘Too Good Of A Deal To Pass Up’

Gov. Deal has said everyone needs to wait until the Supreme Court hands down its ruling this summer before making any decisions, spokesman Brian Robinson said in a statement to The Atlanta Journal-Constitution.

Arkansas is one of six states to get permission from federal health officials to experiment with nontraditional Medicaid expansions. Iowa has adopted a variation on the private option. Indiana’s plan requires some Medicaid recipients to pay co-pays and contribute to health savings accounts. In Michigan, people can lower their out-of-pocket costs by changing unhealthy behaviors.

There are a variety of expansion alternatives for Georgia to look at, said Bill Custer, a health policy expert at Georgia State University.

“It seems a waste not to take one of those options,” Custer said. “The amount of money Georgia is passing up, the amount of jobs, it’s just too good of a deal to pass up.” States that haven’t yet expanded will likely end up doing so using the nontraditional route, said Joan Alker, head of the Center for Children and Families at Georgetown University. Expansion has been a point of discussion — and contention — in recent months in Tennessee, Missouri, Utah, Florida, Wyoming and other states.

Gardner remains hopeful there will be some movement toward expansion in Georgia within the next year.

“(Deal) can do the math,” she said. “He does care about these families that don’t have insurance.”

‘We’re Going To Do Something Great’

Arkansas’ Republican leaders say they have only just begun transforming the state’s health care system.

The private option’s three-year trial phase concludes at the end of 2016. In the meantime, a group of lawmakers will be exploring pro-free market ways to overhaul the entire health care system, not just Medicaid.

Starting in 2017, states can apply for permission to make larger changes to some parts of the Affordable Care Act within certain limits. They could, for example, do away with the individual mandate or penalties for employers with more than 50 full-time workers. They cannot eliminate other elements, such as the requirement that insurers cover anyone regardless of whether an individual has a pre-existing condition.

“We’re going to do something great for those in need of health care,” said recently elected Arkansas Gov. Asa Hutchinson, a Republican. “I’m an optimist.”

For now, individuals and health care providers across the state continue to reap the benefits of the private option. Once losing money, the safety net hospital at the University of Arkansas for Medical Sciences in Little Rock is now in the black and able to invest in technology and begin to grant raises again, said Dr. Dan Rahn, the university’s chancellor.

If Georgia expanded, there would be less pressure on Grady Memorial Hospital, the safety net facility in Atlanta, Rahn said. States have to have a strategy to foster better health and economic development in the future, he said.

“You’ve got to have some kind of plan,” he said. “’Let’s just repeal the Affordable Care Act’ is not a plan. Then what?”

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

How could they transform the Affordable Care Act, a law they detested, into a tonic for their unhealthy and poverty-stricken state, and still honor their conservative principles?

The result would be Arkansas’ “private option” Medicaid expansion, an innovative — and untested — program that has extended health coverage to more than 233,000 poor Arkansans.

Some Georgia lawmakers, consumer advocates and health care providers are pointing to the ambitious experiment in Little Rock as a possible way to expand health coverage to more than half a million low-income Georgians. A growing number of other red states are also taking note of Arkansas’ private market-based approach, which is seen as a more politically palatable path to expansion for Republicans.

“We knew the system was broken and needed to be reformed,” said Arkansas state Sen. David Sanders, a Republican and a chief architect of the Arkansas private option. “We’re just getting started.”

Medicaid expansion is a critical part of Obamacare’s aim to provide millions of uninsured Americans with health coverage. But when the U.S. Supreme Court ruled in 2012 that the federal government couldn’t force states to expand Medicaid, many Republican-led states, including Georgia, doubled down on their refusal to expand.

The Arkansas ‘Private Option’

• 223,000, The approximate number of low-income Arkansans who have gained health insurance under the private option expansion of Medicaid.
• 11.4 percent, Arkansas’ uninsured rate after Medicaid expansion took effect, down from 22.5 percent in 2013.
• 35.5 percent, Drop in uninsured patient visits to emergency departments.
• $16 billion, Amount of new federal funding coming into Arkansas over a decade.
• $1 billion, The estimated amount the program could save the state over a decade.
• $361.5 million, Estimated uncompensated care savings to the state over 10 years.
• 6,200, Estimated number of jobs the private option will create in 2016 alone.

Sources: Arkansas Department of Human Services, Gallup, RAND Corp., Arkansas Hospital Association

Georgia Gov. Nathan Deal and conservative state lawmakers say the state can’t afford to expand an already overwhelmed and broken Medicaid system. Deal has said of late that everyone needs to wait until the Supreme Court rules this summer on a new challenge to the law that threatens to strip millions of Americans of federal tax credits that made buying insurance possible.

“We can’t even begin to say what the playing field will be after that,” Deal spokesman Brian Robinson said. “No one could have predicted the nuanced ruling the court issued in 2012 that kept the law alive but drastically changed it.”

In the meantime, Georgia’s uninsured rate is now second highest in the nation at 19.1 percent, second only to Texas, while other states’ rates have plummeted. Under the private option, the Razorback state’s uninsured rate has dropped more dramatically than any other state in the nation.

Under traditional Medicaid in Arkansas, the state pays doctors and hospitals directly for providing health care to the poor. Each lab test, doctor visit, surgical procedure or X-ray is billed to the government. Under the private option, the state uses federal dollars for Medicaid expansion to buy private health insurance for the poor.

Hospitals like it: far more of their patients are now paying customers; doctors like it: insurance companies pay them much more than Medicaid does; insurance companies like it: they get a lot more business, much of it paid for by the government.

Supporters say the program will ultimately cost less than if the state had expanded its existing program as is. The theory goes that private insurers are more efficient and can help keep people healthier, and lower overall costs, by better managing patients’ overall care.

Critics in Arkansas, just like critics in Georgia, argue that their state can’t possibly afford the cost of extending health coverage to so many more people. And, they say, the federal government can’t be trusted to keep its pledge to pay 90 percent of the cost of Medicaid expansion.

• Established in 1965, Medicaid is a government program that provides health coverage to roughly 70 million low-income Americans. It’s jointly paid for by the federal government and states. Medicaid differs from Medicare, another massive federal health program for Americans 65 and older.

What is Medicaid expansion?

• A pillar of the Affordable Care Act, Medicaid expansion was supposed to be nationwide – extending coverage starting in 2014 to about 17 million low-income Americans. People with incomes up to 138 percent of the federal poverty level, roughly $27,700 for a family of three, could potentially qualify. The federal government promised to cover the full cost of expansion for three years. After that its share would steadily drop to 90 percent, but never lower than that. The Supreme Court ruled in 2012, however, that states can’t be forced to expand. So far, 28 states and Washington D.C. have chosen to expand the program. Federal health officials have given six states permission to pursue variations on traditional Medicaid expansion. At least six states are discussing the idea. Meanwhile, 16 states, including Georgia, remained opposed to growing the program. States can choose to expand at any time in the future but will miss out on the first few years of the feds picking up 100 percent of the tab.

Sanders said he sees Medicaid expansion as a stop-gap measure, allowing lawmakers time to work on even larger pro-market reforms to the health care system. In recent years, the state created a special office to investigate Medicaid fraud, improved how it verifies who is Medicaid-eligible and implemented a new payment system that pays doctors based on quality of care.

“We’re not talking about pouring concrete here,” he said. “We’re molding clay.”

‘A Deep And Abiding Concern’

So far, the private option appears to be paying off.

In the past year, Arkansas’ uninsured rate plunged from 22.5 percent to 11.4 percent, according to the latest Gallup survey. The number of uninsured patients flooding hospital emergency departments fell by more than a third in the first six months alone. Hospitals also saw the cost of caring for the uninsured drop by roughly $70 million.

Those benefits are undeniable, recently-elected Arkansas Gov. Asa Hutchinson said in a speech earlier this year. Still, the Republican leader isn’t convinced the private option is what’s best for his state.

While the federal government is paying 100 percent of the cost for three years, the state will eventually have to pick up 10 percent of the cost — more than $200 million annually. That’s almost a third of the budget for all state higher-education institutions, so there are real consequences for the budget and other services, Hutchinson said.

Those opposed to the private option were right to question its costs, said Hutchinson, who opposed the Affordable Care Act. The Legislature recently voted to continue the private option through its three-year trial phase, which concludes at the end of 2016.

In the meantime, lawmakers must look at ways to make Arkansas’ health care system affordable, while extending health coverage to the people who need it, Hutchinson said.

“Whether you are for or against the private option, there is a deep and abiding concern for those without health coverage,” he said. “The human side tugs at our heartstrings and rightfully is a factor in this debate.”

‘My Hands Were Tied’

Some jobs don’t offer insurance. Donna Foster’s is one of them.

The single mother of two works as a home caregiver for the elderly, cooking and cleaning, bathing and doing laundry. She makes less than $9 an hour, a wage that forced her to choose between buying insurance or paying rent and putting food on the table.

She chose the latter. So Foster, 44, skipped doctor’s appointments to monitor her high blood pressure. She suspected she might have diabetes, a chronic disease that runs in her family, but couldn’t afford the test to find out. Her legs and feet began to tingle. A constant feeling of exhaustion made it a challenge just to get out of bed in the morning.

“I know that it can cause congestive heart failure or diabetic coma. It can make you sicker than a dog,” said Foster, who lives in Morrilton, Ark., a town of roughly 7,000 northwest of Little Rock. “It worried me because I needed (the test), but my hands were tied. I just tried to control my diet.”

Foster is one of the more than 233,000 Arkansans who got insurance through the private option. Now, she can go to the doctor whenever she needs to for $8. Her medications cost $3 or so.

And she is indeed diabetic.

“I was tickled to death,” Foster said when she learned she qualified for the program. “I don’t have to worry about paying (my) doctor bill off or getting the lights cut off.”

The jump in health care coverage has cut Arkansas’ uninsured rate to its lowest level in more than a quarter-century. A majority of people on the private option work for a living. Many live in rural areas.

Before the private option, a parent with two children couldn’t qualify for Medicaid if she made more than roughly $3,300 a year. And, as in Georgia, adults without children couldn’t qualify at all.

“In our state, you had to be dirt poor,” said Dr. Rick Smith, dean of the College of Medicine at University of Arkansas for Medical Sciences. “They can support their families, but they can’t get their treatment.”

‘A Great Deal Of Discord’

State lawmakers voted earlier this year to continue funding the private option. (At least three-quarters of the Legislature must approve funding every year.)

But the governor and other Arkansas lawmakers have continued to raise concerns over the private option’s cost.

There has been “a great deal of discord between (lawmakers) and the general public,” state Rep. Kelley Linck said during a committee hearing last month. “Many people felt that Medicaid expansion, no matter how we did it, was a bad idea.”

One of Arkansas’ top health officials was skeptical of the private option too at first.

John Selig, head of the state Department of Human Services, worried that the private option might be too complicated and expensive. Private insurance typically pays providers far more than Medicaid, which often doesn’t cover the actual cost of care.

But that’s where the “private” aspect of the private option comes into play: insurers have a strong incentive to promote preventive care and other ways to keep people healthy.

“The private sector, in theory, is more efficient,” Selig said. “That’s part of what we’re testing. Are they more efficient? Can they keep costs down?”

Indeed, Selig’s agency estimates the private option could save Arkansas nearly $1 billion over 10 years. That includes the roughly $360 million the state would have paid for uncompensated care over that time, the department’s latest estimates show.

It’s expected to create thousands of new jobs and infuse hundreds of millions of dollars into the state’s economy.

Using Medicaid dollars to buy private health plans has also been a plus for the broader insurance market, Selig said. The Medicaid expansion population is healthier and younger than the rest of the population with insurance through the state’s online marketplace.

That’s helped reduce overall premiums on the marketplace by 2 percent for 2015, Selig said. It’s also attracted more insurers with five insurance companies now offering plans statewide, versus just one before, he said.

“The entire market is benefiting because we brought healthy lives into the market,” he said. “That’s a pretty big impact for a little state like Arkansas.”

‘It’s Tough For A Lot Of People’

The private option is working for Orlando Gonzalez.

The 27-year-old from a small town in southeast Arkansas had always been relatively healthy and never thought much about getting insurance. So he didn’t worry when he took a lumber mill job that didn’t offer it.

That is until one day last winter when he felt stabbing pains in his stomach and began to vomit violently. After Gonzalez made multiple trips to the emergency room, doctors discovered a large mass in his stomach. It wasn’t cancerous but still needed to be removed surgically to avoid damage to surrounding organs.

Gonzalez and his family could not afford the nearly $35,000 or so the surgery would cost, so he put it off.

“Around this part of the woods, it’s tough for a lot of people,” he said. “There’s not these big corporate jobs.”

He eventually applied for the private option and soon landed back in the hospital with a serious infection. Doctors removed the mass and Gonzalez is now on the mend and working toward his dream of opening his own gym.

Gonzalez is a Republican who doesn’t like Obama. But he believes the private option is a great thing when people need it.

People should work when they can and not rely on tax money, but you can’t always do that, he said.

“If you physically can’t work, I’m in full support of it,” he said. “If you’re not working just because you don’t want to work, then that’s a different story.”

‘We Are Arkansans’

Arkansas’ private option will continue as is — for now.

It is set to expire at the end of 2016; meantime, a task force will explore ways to keep health care costs in check, while maintaining coverage for individuals who got insurance under the private option.

Ultimately, the Legislature could decide to extend the private option or some variation of it. Or it could opt to do away with the program altogether and try something different, a fact that has consumer advocates and health care providers worried.

There’s concern that changes could create new barriers to people getting the care they need, said Marquita Little, health policy director of the nonprofit Arkansas Advocates for Children & Families. People with chronic illnesses are getting help. More children now have health coverage as a result of their parents getting private option coverage, she said.

“Having access to coverage allows us long-term to have a healthier population,” she said, calling the private option “hugely successful.”

During a speech in January, Gov. Hutchinson said Arkansas needs comprehensive health care reform based on the conservative principles of choice and competition while encouraging people to take responsibility for their own health care decisions. It must be a system that Arkansas can afford and doesn’t continually eat up more and more taxpayer dollars, he said.

And, Hutchinson added, leaders must look for ways to assure health care for those Arkansans who are now covered by the private option.

“We are Arkansans,” he said. “We look out for each other.”

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Arkansas is helping lead the shift by changing the rules: with Washington’s permission, the state has enabled the poor to buy private insurance policies using the federal Medicaid expansion money. Other red states, finding this tack more politically palatable, are exploring Arkansas’ approach. Tennessee Gov. Bill Haslam, for example, said he may submit a similar proposal to federal health officials.

Georgia, meanwhile, remains firmly opposed to expansion. But with November’s gubernatorial election less than two weeks away, the future of Medicaid expansion in the Peach State may yet be in play. At stake: access to health care for more than 600,000 low-income Georgians, $30 billion in federal funding and an estimated 70,000 new jobs.

“It seems like there’s quite a bit of momentum across the nation for states looking at different approaches to Medicaid expansion,” said Cindy Zeldin, head of Georgians for a Healthy Future, a nonprofit consumer group. “There’s a lot we can learn from Arkansas.”

A key element of the Affordable Care Act, Medicaid expansion was supposed to extend health care coverage to 17 million low-income Americans with incomes up to 138 percent of the federal poverty level, or about $27,300 for a family of three. But the U.S. Supreme Court ruled in 2012 that the federal government couldn’t force states to grow the program.

So far, 27 states and the District of Columbia have chosen to expand, and that number is poised to grow. Pennsylvania, Michigan and Iowa joined Arkansas in getting special approval from the Obama administration to experiment with alternatives to traditional Medicaid, such as requiring recipients to pay modest premiums and copays, maintain a health savings-type of account and participate in wellness programs.

Indiana is waiting for approval on its own variation on expansion. Two other red states, Utah and Wyoming, have also reportedly been in talks with the feds about expansion. More could follow.

When Medicaid first launched in 1965, it took some states years to get on board — a scenario that’s likely to play out again with expansion, said MaryBeth Musumeci, a health policy expert with the nonprofit Kaiser Family Foundation.

“(Expansion is) going to continue to be discussed as state legislative sessions start up again,” she said.

‘Put politics aside’

Georgia Gov. Nathan Deal and his supporters have remained steadfast in their rejection of expansion, saying the state simply can’t afford to grow an already overburdened and broken program. Deal’s office has estimated that doing so would cost the state $2.5 billion over a decade.

Medicaid provides health care coverage to about 1.8 million low-income Georgians, mostly children, pregnant women, the elderly and disabled. Expansion would add an estimated 600,000 people to the rolls, most of them adults without kids.

The program has already grown significantly in the number of people it serves, even though Georgia didn’t expand, Deal said in a debate with Democratic challenger Jason Carter earlier this month. He said Georgia spent $351 million this year to adjust to the new law, and that the cost would expand even more if Carter were governor.

“We had a good idea that would happen. And it did happen. And it’s costing us a lot of money,” he said. “I haven’t heard Sen. Carter explain to me where he’s going to get that new $2.5 billion.”

Expansion supporters, however, say the true cost of expansion to the state would be closer to $350 million over 10 years after factoring in new sales, income and other tax revenue — a drop in the bucket compared to the roughly $30 billion in additional federal funds it would bring. They also argue expansion is a moral imperative in a state where nearly one in five people doesn’t have insurance.

“There will be more acceptance and understanding that you don’t have to embrace the whole law to embrace parts of it that are sort of without question a good deal for the state,” said Tim Sweeney, a health policy analyst with the Georgia Budget & Policy Institute, a left-leaning think tank.

Georgia is being left behind by both red and blue states that are engaging in the debate, Carter said in a recent interview with The Atlanta Journal-Constitution.

“When people are looking for answers, they tend to find them – if you can put politics aside and look out (for) what’s best for your state, your residents and your economy,” he said. “This governor is not.”

The Arkansas Model

Health care providers, insurance executives and lawmakers from around the country are watching closely as the Arkansas approach unfolds. The state’s three-year waiver enables it to use Medicaid dollars to buy private insurance for the poor on its insurance exchange.

The idea behind the so-called “private option” is that even though commercial insurance is more expensive than Medicaid, the private sector is more innovative, efficient and more effective in treating patients, said Bill Custer, a health insurance expert at Georgia State University. Requiring Medicaid recipients to also share in some of the costs makes the idea of a private option more politically tolerable, Custer said.

The Medical Association of Georgia, a physician advocacy group with nearly 7,500 members, has advocated in favor of adopting Arkansas’s model.

Carter, too, has favored exploring the idea, enabling him to tap into Democratic angst over Deal’s rejection of expansion and pitch it as a way for Georgia to keep more tax dollars. Voters should be outraged, he says, that Georgia turns away roughly $9 million in health care dollars every day.

Deal said in an interview he isn’t worried about Georgia falling behind states opting to expand.

“Expanding an entitlement program is not going to solve the problem — either short term or long term,” Deal said.

‘Carrots and sticks’

Medicaid expansion is still unlikely if Republicans remain in control.

In April, Deal signed a new law that gives the final say over expansion to the Republican-controlled Legislature. Carter, a state senator, said he’s confident he could work with lawmakers to hash out a “creative solution.”

Whatever that solution is, it will face a steep challenge. Some GOP lawmakers say there’s little chance of any sort of expansion. But House Speaker Pro Tem Jan Jones, R-Milton, said recently that Carter’s plan isn’t necessarily moot.

“Jason would have numerous carrots and sticks at his disposal as governor because Georgia has a strong-governor structure as established in the state Constitution,” she said, adding: “Although I would not support such a costly proposal, who knows how a future Legislature would vote any given year?”

State Sen. Chuck Hufstetler, R-Rome, is among the few elected Republicans who has been supportive of a Medicaid expansion. He sounded more optimistic about the possibility of an expansion, no matter who wins.

“While I was against the ACA, I don’t want us to subsidize other states while many of our hospitals are struggling,” he said. “Now that the Legislature has taken on the responsibility for the issue, I believe the Senate will have hearings in January and look at the successes and failures in other states.”

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).