“This is an opportune time for Georgia to think creatively as the federal government has signaled a new willingness to entertain ideas and flexibilities that heretofore they had not,” the application says.

Kemp’s spokeswoman, Candice Broce, said in an email that Deloitte had barely gotten to work and the governor’s office was sharing information when it has it.

“Governor Kemp is committed to reducing healthcare costs, protecting individuals with preexisting medical conditions, and improving healthcare access and quality for Georgia families,” Broce said. “I would say that, at this time, speculating on any specific plan, population, etc. is premature.”

“Work-related activities”

First among the critical goals Deloitte listed was “incenting work-related activities in Georgia’s Medicaid program.”

Georgia Republicans have long favored work requirements in exchange for benefits. And Kemp’s focus on “hard working Georgians” in health care is nothing new.

As Kemp aides have previously pointed out, Georgia’s current Medicaid program is heavily weighted to benefiting children, and most adults currently on it are new mothers. If working-age adults were required to do something work-related, those likely wouldn’t be people already on Medicaid, said Kyle Wingfield, the CEO of the right-leaning Georgia Public Policy Foundation.

Laura Colbert, the director of the patient advocacy group Georgians for a Healthy Future, says most of the goals Deloitte listed could be accomplished without having a waiver at all, unless, for example, making a work-reporting requirement mandatory was a goal.

“Frankly, the documents themselves, just the way the work incentive is framed, and the direction that the federal government is pushing states, indicate that this work requirement will be mandatory, not a voluntary work support program,” she said.

That could mean simply reporting to the government a person’s attempts to find work, or his or her status as a student, or even volunteer work. Where Colbert sees a bureaucratic barrier, the Trump administration sees an opportunity to make people happier and healthier by pushing them to get jobs.

Full coverage

Deloitte also cited the goal to “re-frame ACA requirements” to stabilize the individual insurance market.

That could mean opening wide the door to insurance plans that offer less coverage in the hopes of being cheaper.

The Centers for Medicare and Medicaid Services, or CMS, oversees the ACA, which was written to mandate more comprehensive coverage for all individual health insurance plans. That meant insisting on coverage for mental health care, prescriptions and other “essential benefits” whether a policyholder wanted them or not. It meant preventing plans from pricing out coverage for people with pre-existing conditions. The Trump administration is trying to weaken those requirements.

Jennifer Tolbert, the director of state health reform at the research organization the Kaiser Family Foundation, said the Trump administration had “loosened the guardrails” around waiver applications that previously aimed to make coverage as comprehensive as possible.

“It is possible that Georgia may be contemplating something along the lines of what CMS has encouraged states to do,” Tolbert said, “by directing people to these alternative health plans, if you will, that don’t have to meet the consumer protections laid out in the ACA — these plans can deny coverage based on their health status; can refuse to cover pre-existing conditions; can charge people with health conditions more than other people.”

Healthy people would take those plans, Tolbert said, leaving the regular market with sicker, more expensive patients and requiring prices to go up.

Colbert, from Georgians for a Healthy Future, like Kemp, advocates for increased health coverage and better health of Georgians. She disagrees on the way to get there though, preferring Medicaid expansion for the poor and stabilizing the ACA insurance exchange with its comprehensive plans for the rest of the individual market.

She said it’s “confusing to consumers” to increase access to plans offering less coverage than what’s required by the ACA. She’s afraid customers won’t know they’ve bought skimpy coverage until it’s too late.

Wingfield, of the Georgia Public Policy Foundation, supports such conservative solutions and said the alternative is living a fantasy.

“Look — here’s what everybody seems to fail to acknowledge,” Wingfield said. “Yes, plans on the individual market right now cover a wide range of benefits. But they’re also really expensive. That’s why the market has been battered. People are opting out.

“What these other plans let you do is you have an option,” he said.

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