Across the country, the 40 states that expanded Medicaid under the Affordable Care Act are now scrambling to respond to the Trump administration’s new restrictions — some of the biggest changes to the program since the law passed in 2010.

Not here.

In contrast, Georgia’s Legislature just wrapped a special session, a procedure typically used to address some of the most important state issues of the day. Nowhere near them was Medicaid expansion, the issue that long dominated political fights and discussion in the state.

The reason, say some close observers, is politics.

For more than a decade, Georgia Republicans have treated full Medicaid expansion not just as a health policy question, but also as a proxy fight over federal spending and Democratic priorities.

The majority party’s electoral base was reborn in the Tea Party era fighting Obamacare, shorthand for the ACA. A governor won office in its wake eight years ago, after fighting a Democrat who focused on that issue. And that governor then built his own set of health insurance subsidies relying on other parts of Obamacare besides full Medicaid expansion.

Georgia opponents of full expansion say the idea was simply overreach, and was never right for Georgia.

But Charles Bullock, a professor of political science at the University of Georgia, notes that the foremost original argument against Medicaid expansion was that Washington might abandon the states that expanded, stop paying the massive federal subsidy and force states to pick up the bill. And that hasn’t happened.

“I have to think maybe part of it is that this was a big issue that Stacey Abrams used when she was running against Brian Kemp,” Bullock. “And therefore Kemp dug in his heels at that point, and said, you know, we’re not doing this.”

Among legislators, “the will is there,” claims state Rep. Michelle Au, a Democrat from Johns Creek. Au, an anesthesiologist who supports Medicaid expansion, says she did a head count at a pivotal moment a couple of years ago, and found there were enough votes in her chamber to pass expansion if GOP leaders moved to bring it up.

“But,” she concurred with Bullock, “I think that the politics get in the way.”

What ACA Medicaid expansion does

Expanding Medicaid to all of a state’s poor under the Obamacare law, the Affordable Care Act, touches off some big shifts.

One of the biggest is that the federal government pours a lot more money than it used to into a state’s Medicaid coverage, covering 90% of the bill for the people who join Medicaid as part of the expansion.

Then the marquee shift is that more impoverished people get health coverage. In Georgia, estimates have ranged from over 100,000 to half a million newly insured people. Those numbers would likely change under the new restrictions in President Donald Trump’s One, Big, Beautiful Bill law last year.

Perhaps the least expected shift is that thousands of Georgians just above the poverty line would lose their private health plans — which they get now on the ACA marketplace — and be switched to Medicaid. There are pluses and minuses to that: Medicaid pays doctors lower rates, but for the patient there are lower costs.

That’s recently been Kemp’s big argument against expansion. Under pandemic-area additional subsidies, ACA marketplace membership exploded in Georgia, and many of those people are still enrolled in private ACA plans.

The feds are still paying

Sixteen years after the passage of the ACA, the basic problem that Medicaid expansion was supposed to address still exists: huge numbers of people remain uninsured. More than 1 million Georgians lack health insurance, or 12% of the population at last count in 2024. That’s the second-worst among U.S. states.

That in turn is a big problem for Georgia hospitals, where uninsured people drag down ERs. And sometimes for the economy, when those people have treatable illnesses but can’t get treatment.

The Affordable Care Act that passed in 2010 aimed to solve that by covering all poor adults with Medicaid.

But the U.S. Supreme Court ruled that Congress and then-President Obama couldn’t force states to expand Medicaid. It had to be a state’s choice. Medicaid expansion instantly became a political litmus test. Republican Tea Party activists loathed it, while Democratic-led states signed on.

“Certainly then the explanation (for opposing Medicaid expansion) was that it was risky,” says Bullock. “That anybody who signs up for it, they’ll say, ‘Yeah we’re going to pay for it’ in the beginning – but ultimately then it might become an unfunded mandate, right?”

Laura Colbert, executive director of Georgians for a Healthy Future, which supports Medicaid expansion, experienced the wave of opponents.

“I think people often forget just the volume of opposition to the law,” among Republicans and related groups, she said. “Elected officials from the Tea Party movement came in with the deep belief that everything about the Affordable Care Act was wrong or bad.”

But then years passed and one by one, from Kentucky to Louisiana and beyond, purple and then Republican-led states started expanding Medicaid for their own populations. As of now, 40 states have Medicaid expansion.

That’s the rub, says Bullock.

“Here we are, what, 10 years, 12 years into it, whatever – and so far,states haven’t been left holding the bag,” Bullock says. “That explanation maybe was reasonable at the beginning back when Nathan Deal was saying that; seems less reasonable today.”

A basic question

There were a few months, in 2023 and 2024, when full Medicaid expansion suddenly got the attention of House Speaker Jon Burns and sparked a conversation at the Capitol. That’s when Au did her informal head count. Burns never brought it to the floor.

Burns provided a statement to PeachPol through his spokesperson that Georgia has other methods of expanding health care access.

“The Georgia House’s approach to expanding access to quality, affordable healthcare has been to increase our investments in growing our healthcare workforce,” he said. “We are strengthening our healthcare workforce and driving down the cost of care for every patient and family across the state.”

When Kemp took office in 2019, he had barely defeated Democrat Stacey Abrams, who ran on Medicaid expansion. He has focused on mini-expansions of Medicaid, such as a recent expansion for mothers of young children.

A spokesperson for Kemp pointed to the governor’s prior statements arguing against full expansion.

“The state’s approach ultimately led to more Georgians having health coverage than the initial projections for traditional Medicaid expansion from the Abrams campaign in 2018,” (through the pandemic-era skyrocketing ACA enrollment), said the spokesperson, Carter Chapman.

Chapman added that President Trump’s One Big, Beautiful Bill Act now is set to impose work requirements on every state that has expanded Medicaid: “The entire country is now moving towards a model similar to the conservative, state-centric approach Georgia has taken.”

If Georgia’s experience with the complex system of implementing individual eligibility categories is any guide, that also means that eligible people, including working people, will fall through the cracks. Yet state leaders make the impassioned case that Georgia programs should value work.

In the end, the question that has shadowed Georgia for more than a decade remains unresolved: Should some people simply not be covered?