How Georgia, U.S. could address the Peach State’s health disparities

Over the past 11 months, the COVID-19 pandemic has opened many Georgians’ eyes to health disparities affecting people across a wide spectrum. But the health disparities affecting Black Americans in particular are far from new — and in several categories, Georgia’s have for years been among the worst in the nation.

Although rates of HIV infection, maternal death, and preterm birth are higher among Georgians than among residents of most other states, Black communities in the state experience these health crises in higher numbers than do their counterparts of other races and ethnicities. Meanwhile, 13.4% of the state’s residents are uninsured — the third-highest number in the nation, and one that also does not affect all communities equally: although about half of Georgia’s population is white, only 39% of its uninsured population is.

Experts say these high rates of poor health, health disparities, and uninsurance are related — and they are all, at least in part, connected to the years-long refusal of Georgia’s elected officials to opt in to Medicaid expansion, which was offered to states as part of the Affordable Care Act (ACA) and became effective in 2014. Since its inception, the program has offered states billions of dollars to make the Medicaid public insurance program available to a broader range of people.

Medicaid expansion generally has positive effects on outcomes related to health, care access, and states’ economic health. Expansion increases the number of people in a state who have insurance, and people with insurance are more likely to go to the doctor when they need to. Meanwhile, doctors and hospitals make money when they provide care to people with insurance. The result is an incentive for healthcare facilities to stay open even in lower-income neighborhoods, where by virtue of the stresses of poverty, people are more likely to have chronic medical conditions that benefit from regular medical care.

State leaders have rejected Medicaid expansion, and Georgia is not the only state to do so: 11 others have also declined to adopt the program, including six of Georgia’s southeastern neighbors. Policy experts have argued that the pandemic’s enormous strain on the state’s people and healthcare systems present an opportunity for Medicaid expansion to save lives and improve health equity. Georgia’s general assembly could vote to expand Medicaid during the current legislative session.

If they don’t, advocates say there is hope that the newly elected Biden administration, with the help of Georgia’s two newly elected Democrat senators, could take action at the federal level to attempt to improve the health of all Georgians — including historically disadvantaged communities.

“At the fore of the conversation right now around health equity is addressing the pandemic,” says Seft Hunter, who directs Black-led organizing and power building at Community Change, a national nonprofit organization aimed at politically empowering low-income people of color.

COVID-19 has not affected all communities equally: in Georgia, as in many other states, Covid-19 deaths have occurred at higher rates in Black people than in any other racial or ethnic group.

But it’s not just medical outcomes that determine the health impacts of a public health emergency, says Hunter. Economic stress and inadequate or unsafe housing are strongly linked to health — and both have more severely affected Black Georgians than others. According to the non-partisan, non-profit Georgia Budget and Policy Institute, Black Georgians filed 71% more unemployment claims than other racial and ethnic groups combined in November last year — a massive increase from April, when Black Georgians filed 25% fewer claims than their counterparts combined. And Georgia is a leader in evictions, with most cases filed against tenants living in poor, non-white neighborhoods.

“We have to kind of come back to the basics here, to what folks need: safe housing — shelter — and food,” Hunter said.

Most immediately, he said, he’d like to see the new administration place a moratorium on evictions during the pandemic — an action President Biden took by executive order on the same day he was inaugurated. Hunter said direct cash payments would also play an important role in reducing some of the economic pain low-income communities are experiencing. The American Rescue Plan, the pandemic relief package Biden outlined earlier this month, includes a proposal for stimulus checks of $1,400 — and those could increase, depending on the results of lawmakers’ negotiations.

Equity and the coronavirus vaccine rollout

Hunter believes a vigorous and equitable rollout of the COVID-19 vaccine is also key to reducing the pandemic’s painful footprint. Georgia’s current vaccine plan allows healthcare workers, first responders, and adults over 65 years old to sign up for vaccine appointments at a local pharmacy, facility, or county health department.

The reliance on internet and phone availability and on proximity to health care facilities favors better-resourced people to get the vaccine, said Harry Heiman, an associate professor at the Georgia State University School of Public Health. Additionally, both rural and Black communities are more likely to hesitate to take the vaccine, making education and outreach an important strategy for improving vaccine uptake.

“The reasons for their hesitancy to take the vaccine is different, and requires targeted communication strategies using trusted community members, and community organizations, religious organizations and others,” Heiman said.

The Biden administration is launching a vaccine plan aimed at rapidly scaling up distribution of the vaccine by engaging the Federal Emergency Management Agency in setting up community vaccination centers and mobile units nationwide. The President’s vaccine plan also includes a public awareness campaign aimed at overcoming vaccine hesitancy — but it’s still unclear what that will entail and whether it will include the targeted strategies Heiman favors.

These strategies address immediate needs, says Hunter — but in the longer term, expanding insurance access to Georgians would be one of the highest-impact moves toward reducing the state’s health disparities.

Georgia’s smaller Medicaid expansion attempts

Although Georgia’s legislators have so far declined to fully expand Medicaid according to ACA rules, they received the blessing of the Trump administration to attempt a smaller expansion of the program. Last year, the government granted Gov. Brian Kemp two waivers, which act as permission slips of sorts allowing Kemp’s administration to create homegrown versions of Medicaid plans and make other changes to insurance access.

The 1115 waiver, sometimes called a partial Medicaid expansion, lowers the income threshold Georgians must meet to qualify for Medicaid. Several elements of the waiver make it “partial”: for starters, it includes a requirement that recipients do either paid or volunteer work 80 hours each month in order to be eligible.

Additionally, the program’s income threshold is so low that only the poorest of the poor qualify for it — that is, people earning an annual income below the Federal Poverty Level, which is $26,500 for a family of four. (Meanwhile, full federal Medicaid expansion allows people making less than 138% of the Federal Poverty Level — $36,570 annually for a family of four — to qualify for the program.) Lastly, unlike federal Medicaid expansion programs, Kemp’s partial expansion plan requires enrollees to pay a premium.

These requirements add up to exclude many Georgians from Medicaid: while 450,000 Georgians would be newly insured under a full Medicaid expansion, only 60,000 people would be insured under Kemp’s partial expansion plan. The people occupying the coverage gap are primarily people of color: 36% are Black and 22% are Hispanic/Latino.

The Biden administration could take several steps to reduce the inequities in this plan, says Laura Harker, a health policy analyst at the Georgia Budget and Policy Institute. It could potentially outright reverse the waiver — and if it didn’t, it could challenge the work requirement involved in the program.

Work requirements are rooted in racist attempts to “paint people of color as lazy and not hardworking and not deserving,” said Harker.

Given the pandemic-related job losses in hospitality and in other industries that employ frontline workers who are more often than not people of color, work requirements now make it particularly difficult to get and keep health insurance.

“People shouldn’t have to prove they’re working to get health care,” she said during a recent conference. “It’s the other way around: you need to be healthy to go to work.”

Because work requirements attached to other states’ Medicaid expansions have been struck down in the courts, Harker is optimistic about the likelihood the requirement would be struck from Georgia’s proposal. Last week, the Biden administration moved to forbid states from including work requirements in their Medicaid programs, following on the heels of a Jan. 28 executive order establishing a special ACA enrollment period and directing agencies to re-examine policies that reduce healthcare coverage access. waivers, the Biden administration is expected to soon turn to addressing that issue.

Lowering premiums, eliminating Healthcare.gov

The other waiver for which Kemp received approval last year was a 1332 waiver, sometimes called the ACA innovation waiver. This waiver has two components, the first of which is a reinsurance program that reduces healthcare premiums by compensating insurance companies directly for particularly expensive care. Although equity advocates generally view this component as a positive one, they have greater concerns about the other component of the plan, which would eliminate Healthcare.gov.

This online insurance plan marketplace is a website where Georgians who neither qualify for Medicaid nor have job-provided private insurance can comparison-shop for insurance plans that meet ACA requirements. Without it, people would have to do all the comparisons themselves by calling (and, usually indirectly, paying) insurance brokers, or by calling insurance companies directly.

Already, a lawsuit challenging this component of the waiver has been filed in a D.C. federal district court, alleging the waiver would lead to higher premiums and out-of-pocket costs for plans that would provide less coverage — and potentially cost the federal government more money. The Biden administration could likely reverse this waiver as well, says Harker.

The Biden administration could take other steps to expand insurance access on a national level, says Harker, including raising the subsidy reimbursements people receive for buying COBRA insurance (which covers recently laid-off or furloughed workers), expanding subsidies for ACA plans, or incentivizing states to fully expand Medicaid by offering more federal funds to support it.

In addition, the new administration could take action on a wide variety of health policy-related administrative actions affecting the health of women, LGBTQ people, immigrants, and seniors, and in the domains of mental health and substance use, according to a report by the Kaiser Family Foundation.

These long-term changes are critical, says Community Change’s Seft Hunter, but he takes an even wider view of how a new administration can address health disparities. We wouldn’t be having this conversation, he says, if access to the ballot had not been ensured in the 2020 election and the 2021 Senate runoffs.

“I might even broaden the conversation to look at... democratic access as a health equity issue when we think about the importance of policy change as a way to actually address systemic health issues,” he said.

Keren Landman is a practicing physician, epidemiologist, and journalist who covers topics in medicine and public health. She is trained in internal medicine and pediatrics with specialties in infectious diseases and clinical microbiology, and served as a disease detective at the U.S. Centers for Disease Control and Prevention. She lives in Atlanta, Georgia

This story was originally published February 22, 2021 at 4:00 PM.