Beyond Medicaid: Health Care for Low-Income Georgians

By Benita M. Dodd

In his State of the State address to the Georgia Legislature this week, Governor Nathan Deal succinctly justified his resistance to expanding Medicaid to low-income, able-bodied Georgians.

Deal recited the costs already imposed by the Affordable Care Act: Reporting requirements alone add $2.1 million in state spending, and even without Medicaid expansion, enrollment increased due to heightened eligibility awareness. This “woodwork effect” increased program costs 15.7 percent from fiscal years 2013-17, to $3.1 billion.

Unsurprisingly, critics denounced the governor for “leaving” federal money on the table and poor Georgians uninsured while missing an economic opportunity. But “no” to expanding this entitlement program does not equate to “no” to health care or to economic opportunity in Georgia.

A three-state study on Medicaid expansion published in the journal Health Affairs this month, meanwhile, found “less evidence that the improved access was delivering better health, as residents’ self-reported health changed little in all three states.”

Three market-friendly approaches could expand access to care and improve the health of low-income Georgians. Best of all, each is a solution that embraces limited government policy by reducing government regulations.

Eliminate Certificate-of-Need (CON) requirements. Amazingly, the federal government eliminated CON requirements in the 1980s, but Georgia remains one of 36 states that require government permission to add a hospital, nursing home, transitional facility, new medical equipment or new operating room at a medical facility. Facilities must even obtain such approval for renovations.

A 2015 Mercatus Center study found Georgia’s CON program is the 18th most restrictive in the nation, requiring prior approval for 17 devices and services – including acute hospital beds, positron emission tomography (PET) scanners and open heart surgery.

This costs the state in hospital beds and in competition, “increasing the cost of health care for some, and in return medical providers use these contrived profits to increase the care they provide to the poor,” according to the Mercatus report, which found that CON requirements do not increase charity care, as many claim.

The Georgia Supreme Court is expected to rule on a lawsuit filed by the Goldwater Institute on behalf of a Cartersville, Ga., ob-gyn practice whose expansion plans are on hold after its CON was denied. Ending CON is a limited-government solution that encourages greater competition in the health care marketplace, and could lead to more facilities and services, thereby lowering health care costs while enhancing access and quality.

Allow mid-level providers in dental care. Dentists often refuse to accept Medicaid patients, citing low reimbursement rates. The tragic 2007 death of 12-year-old Deamonte Driver of a brain infection that could have been prevented by affordable, timely dental care serves as a reminder of how crucial dental care is to individuals’ health.  

There are just 5,088 active dentists in Georgia – for a population of 10 million residents. By lowering the barriers to entry, mid-level providers – dental therapists who train for two to four years – can provide routine care under the supervision of a dentist. They do so already in Maine, Minnesota and Alaska, providing preventive and routine restorative care such as filling cavities.

According to Pew Charitable Trusts, 1,100 studies from around the world show dental therapists deliver safe care. If this is the case, dental therapists should become part of Georgia’s health care landscape, much as nurse practitioners and physician’s assistants are. The benefits: mid-level health care jobs for Georgians; greater access to care at a lower cost than a dentist, without taxpayer subsidies and without government mandates: Dentists must choose to accept these providers in their practices.

Remove barriers to direct primary care. Allowing direct pay and “concierge” practices to flourish will encourage innovation while helping meet market demand for health care – not just coverage – at lower prices. With direct-pay, a patient contracts with a provider for a fixed fee. Clarifying that this does not count as insurance will encourage more physicians to participate in this approach, providing care to more individuals who face high co-pays and high deductibles for their wraparound insurance.

Other solutions are available, too; these are just three. But they are one way Georgia policy-makers can show good faith intentions to facilitate health care to low-income individuals by seizing the low-hanging fruit that doesn’t involve taxpayer funds, federal mandates or expanding government.  

Dental care, by the numbers:
1.8 million Georgians currently live in areas with a shortage of dentists
35 percent of dentists do not accept Medicaid

47 percent of children on Medicaid (PeachCare) didn’t see a dentist in 2014
The percentage of dental emergency room visits paid for by Medicaid rose from 48.2 percent in 2006 to 57.3 percent in 2012
36 percent of adults in Georgia didn’t see a dentist in 2012
19 percent of Georgia third graders had untreated tooth decay in 2010-2011

Source: Pew Charitable Trusts, American Dental Association

Benita Dodd is vice president of the Georgia Public Policy Foundation.