Republicans forcefully rallied around it as a concrete step to help struggling Georgians. State Rep. David Stover, R-Newnan, called on his colleagues to "trust our governor" and give him the ability to seek the waivers. Others said even a partial step sent a strong signal.

"I wish I could feed everybody, I wish I could clothe everybody," said state Rep. Ed Rynders, R-Albany. "We should all do our share. And our share is a simple yes vote."

The vote was a victory for Kemp’s office, restoring powers the Legislature stripped during Gov. Nathan Deal’s re-election run in 2014. It now sets up a tight timeline: Kemp wants the waivers to be approved by 2020 — in time for the presidential election.

Shortly after the measure passed, Kemp highlighted the bipartisan nature of the final vote — six Democrats voted for it, while three Republicans opposed it — and promised a transparent waiver application process.

“I know that they’re giving me a lot of trust with this. But I promised them that I’d be a trustworthy public servant and do the right thing and move the needle on health care in Georgia,” he said. “And that’s what we plan on doing.”

Under pressure

SB 106 would allow Kemp to pursue two separate waivers from the Trump administration seeking more flexibility to use federal funds.

The first is an Affordable Care Act waiver, which became a staple of Kemp’s campaign in the final weeks before the election. It could create a fund designed to lower premiums on the health insurance exchange market, possibly by subsidizing private insurers’ coverage of high-risk customers with pre-existing conditions.

The second, and more contentious, waiver idea emerged shortly after Kemp took office.

It would involve very poor people with incomes up to the poverty level, which is about $12,000 for a single individual. But it forbids the waiver from covering Georgians who make above that level. Full Medicaid expansion would cover more people, up to those who make about $16,000 for an individual, or 138 percent of the poverty level.

The governor campaigned last year against an expansion, saying that adding more than 500,000 Georgians to the state’s rolls could be too costly in the long run. But pressure has built on Kemp since his narrow November election win to take more significant health care action.

Atlanta Journal-Constitution polls have consistently shown that more than 70 percent of Georgians support expanding Medicaid coverage for the poor. And a growing number of Republicans, unnerved by rural hospital closures and rising premiums, have embraced the idea.

Evans Republican state Rep. Jodi Lott, Gov. Brian Kemp’s floor leader, responds to questions from House Minority Leader Robert Trammell, D-Luthersville, while presenting Senate Bill 106. The measure, which would allow the governor to pursue health care waivers from the federal government, passed mostly along party lines in 104-67 vote. Bob Andres / bandres@ajc.com

A 2020 countdown

Still, the waiver process could put Kemp in dicey territory. The waivers are contingent on approval from the federal government — no certainty despite the governor’s ties to the White House. And some conservatives fear even a limited expansion could leave taxpayers on the hook if the federal commitment to cover most of the tab ever fades.

Kemp has budgeted $1 million to hire a consulting team to review statistical and population data, and begin the work of navigating the process with federal decision-makers in Washington. The federal government will chip in another $1 million.

Throughout the debate, Republicans accused Democrats of turning down help for the poor in an all-or-nothing political quest for a larger Medicaid program. Democrats said a “no” vote would force new negotiations to get a broader measure passed to help more constituents.

The legislation promises to have far-reaching consequences.

The Medicaid debate involves between 300,000 and 600,000 Georgians, according to estimates from health advocacy groups. Those people are too poor to be eligible for Obamacare subsidies but are not eligible for Medicaid. They have no coverage but sometimes show up at emergency rooms, where they run up costs for hospitals that treat them anyways.

An estimate prepared by state analysts earlier this year showed the cost of a full Medicaid expansion would be about $200 million a year, a sum that would be matched 9-to-1 by the federal government. It’s not yet clear how much the waiver proposal will cost the state.

Kemp’s aides say the Medicaid waiver could be modeled on other states that have used waivers to add hundreds of thousands of residents to their rolls through work requirements and other conservative elements. But they stressed that the governor wants to see all his options first. His allies also pleaded for patience.

"This is a big-picture debate. Health care is complicated," said state Rep. Jodi Lott, one of Kemp's top allies in the House. "It's complex. This is the first part. It's the first piece of the pie."

Democrats’ opposition centered on the people who would not be included in the bill, those who make between 100 percent of the poverty level and 138 percent.

Republicans stressed that those people are already eligible for heavily subsidized health insurance under the Affordable Care Act. “It is our intent to give health care options to all groups, not just those below 100 percent and not just those above, but all,” Lott said.

Democrats stressed that for many of them it’s not as good a deal as Medicaid. They must pay premiums, and for many of them the costs rise into thousands of dollars a year in out-of-pocket costs. Experts say that for people at that income level it’s a financial burden that is a barrier to health care.

"Aside from us to continuing to punish people for being born poor and deprive opportunities to rise out of poverty through hard work, the most bizarre thing about what we're doing is we're leaving out hardworking Georgians making between $25,000 and $35,000 a year" for a family of four, said state Rep. David Dreyer, D-Atlanta.

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