In rural Clay County, Georgia, access to health care is not always easy to come by. So when an area hospital that had long been on the financial brink closed in October because of the pandemic, Dr. Karen Kinsell, the only doctor in the county, was left with even fewer resources to treat her neighbors.
It's rare that Kinsell's patients have insurance or are even covered by Medicaid, the federal and state program aimed to help the country's poorest receive medical care. In this southwest corner of Georgia, one of the dozen states that still hasn't expanded Medicaid, it's typical for her patients to have no health care coverage at all.
So Kinsell charges $10 for a doctor's visit, less if patients can't afford it.
"Everybody is born, everybody dies, and most people get sick in between," Kinsell said. "For one of the richest countries in the world, one of the most medically advanced, to just be leaving out 10 to 20 percent of their population from participating in that service is just wrong. It's immoral and not sustainable. It hurts the entire system."
It hurts particularly bad in Georgia, which has the third highest rate of uninsured people in the country, according to the Census Bureau. It's also a state where lawmakers have forgone billions of federal dollars that would have helped provide hundreds of thousands of Georgians with health care coverage by expanding Medicaid enrollment.
The Biden administration hopes to quickly help those uninsured in Georgia, as well as in 11 other states, by providing incentives to expand Medicaid. The efforts won't be easy, however: Some state leaders, like Gov. Brain Kemp last year, pursued a variation of Medicaid expansion pushed by the Trump administration — a version that undercuts the federal insurance program, implements work requirements and leaves hundreds of thousands of people without access to coverage.
Republican lawmakers maintain that expansion is too heavy a financial burden for states to take on, even though the federal government will pay for 90 percent of it. There is also ideological opposition to the program, especially as it was formed under the umbrella of Obamacare.
The governor's office did not respond to a request for comment.
So far, 38 states have expanded Medicaid; Georgia, Mississippi, Tennessee, Alabama, Florida, North Carolina, South Carolina, Texas, Wyoming, Kansas, South Dakota, Florida and Wisconsin have not. That has left millions of people without coverage more than a decade after states were eligible to enroll in Medicaid expansion through the Affordable Care Act.
Hours after Joe Biden took the oath of office as president, the White House dedicated last Thursday to the signing of an executive order to take steps to "strengthen Medicaid and initiate an open enrollment period under the ACA," also known as the Affordable Care Act or Obamacare, which Trump refused to do when coronavirus infections surged.
Biden's executive action on Thursday moved to reopen enrollment of the Affordable Care Act's marketplace and ordered federal agencies to reexamine rules implemented by the Trump administration that stymied access to health care coverage.
The unraveling of those rules could take months, but one of the biggest challenges facing Biden are the waivers Trump gave states, including Georgia, to place a work requirement barrier between the uninsured and Medicaid.
During the Trump administration, the Centers for Medicare & Medicaid Services, or CMS, provided a series of waivers — in essence, agreements between states and the federal governments about the implementation of Medicaid — for states to pursue their own goals with the program.
Most notably, the Trump White House pushed to provide waivers to allow states to enact work requirements to receive state Medicaid benefits, which no administration had done before and which Congress had voted down in 2017.
Now many wonder what it will take for the Biden administration to unwind some of those policies and expand access to health care as he promised.
"Each administration does have some discretion and flexibility, but given all the litigation we saw, that discretion is not unlimited," said Robin Rudowitz, vice president of the Kaiser Family Foundation's Program on Medicaid and the Uninsured. "It certainly is still being tested in the courts, but I think it's not disputed that there's flexibility for a new administration to rescind and issue new guidance on what waivers they'd like to promote and encourage. For anything that's pending, those are negotiations between the administration and the state."
That has, in essence, left behind a political bomb for Biden and the new administration to defuse, most likely at the cost of political capital, while increasing tension between states and the federal government.
Some criticize the Trump administration's oversight of health care coverage, especially during the pandemic.
"The fact that during a pandemic, when Medicaid is a first responder, they were spending so much time trying to booby-trap the program and handcuff the Biden administration when they walked in the door is abhorrent," said Joan Alker, executive director of Georgetown University's Center for Children and Families.
Nineteen states have approved or pending work requirement waivers, which critics say damaged Americans' access to a vital safety net program and could cause quite a bit of trouble for the Biden administration to dismantle.
Arkansas, New Hampshire, Kentucky and Michigan have Trump administration-approved waivers that are held up by litigation; Utah, Nebraska, Arizona, Wisconsin, Indiana, Ohio, South Carolina and Georgia have waivers approved by the Trump administration; and Idaho, Montana, South Dakota, Oklahoma, Mississippi, Alabama and Tennessee are waiting for approval.
As of October, Georgia was one of the states most recently to have adopted a variation of expansion with the approval of the Trump administration's Department of Health and Human Services.
Georgia got a waiver from the department, essentially allowing it to bend the policy and cover Georgians only up to 100 percent of the federal poverty line as long as they worked 80 hours a month or pursued educations. Most would also have to pay monthly premiums, and they would lose coverage if they couldn't afford to pay.
The policy would allow only about 64,300 to get coverage, according to state estimates — rather than the state's estimate of 480,000 to 600,000 who would gain access through full Medicaid expansion.
Critics say requiring people to work to get health care coverage during a pandemic that has sparked the worst employment crisis since the Great Depression completely misses the mark.
"As we've seen with many, many big policy changes, this is a lot more about politics than the actual data and policy, which the vast majority of Georgians and Americans agree on," said Laura Colbert, executive director of Georgians for a Healthy Future, who added that she expected a lawsuit challenging the state's work requirement waiver to be filed soon.
Kemp has taken a fair amount of flak for the initiative from Democrats and policy experts, but the Trump administration had already provided the waiver, which creates a particularly difficult path forward.
The Trump administration also went further, trying to bolster the agreements by establishing new procedural rights for any future waiver withdrawals by the Centers for Medicare & Medicaid Services.
"At the very end of the Trump administration, the CMS director, Seema Verma, was encouraging states to sign letters of agreement basically trying to make it more difficult for the next administration to go back on some of these approved waivers," Rudowitz said. "I think that we're going to see that tested."
The Biden administration also has to figure out how to contend with the lawsuits that have blocked four of the waivers.
The Supreme Court has taken up the Arkansas and New Hampshire cases for consideration, and Trump's health and human services secretary, Alex Azar, filed a brief supporting the cases the day before he left office.
"Fundamentally we're in unprecedented territory here," Alker said, noting that Biden's Justice Department will have to figure out its position in the litigation. "We've never had an administration that essentially attempted to rewrite the Medicaid statute through the waiver process and authorized things that Congress had explicitly not allowed, like work requirements."
Georgia and the Trump administration did not stop at Medicaid and work requirements in their attempt to undercut the Affordable Care Act. The state also received a waiver that allows them shutdown Georgians' access to healthcare.gov and send them instead to private insurers and brokers, which critics say are oftentimes the same ones offering short-term junk plans.
That waiver, filed late last year, is already challenged in court by Planned Parenthood Southeast and the Feminist Women's Health Center, both located in Atlanta. They are suing the Department of Health and Human Services, which is now under the leadership of the Biden administration.
The agency directed all questions to the White House, which declined to comment, but Thursday's executive order addresses this waiver as well.
"People can can disagree whether the ACA is the best policy, the former Trump administration can be mad that they couldn't replace it, but the bottom line is that doesn't mean that you can violate the law with your waiver," said Megan Gordon-Kane, the lobbyist and public affairs manager for the center said.
Still, contending with all this will likely create a policy and political headache for the Biden White House, as well as the states that hope to maintain work requirements.
On the ground in Georgia, though, Kinsell and others are left to navigate the realities of those policy choices. For her, the choice is simple, and she doesn't understand why the state's leaders wouldn't pursue a program that would cover as many as 600,000 Georgians, rather than 64,400.
Every day in her office, Kinsell said, she sees unmet health care needs that lead to disability and unemployment. A patient who couldn't afford to treat her diabetes lost both her legs, and it is cases like that that weigh heavy on her mind.
"That can't be fiscally responsible or a good idea," she said. "It's really not moral, Christian or smart from where I'm sitting, either."