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- Illustration by Wes Duvall
Between Deal's political maneuvering on the bed tax and his adamant opposition to the Medicaid expansion, numerous sources close to Grady speculate that the governor is merely pandering to conservatives as he sets his sights on re-election in 2014. Only then, they say, will Deal consider changing his mind.
If that's the case, Deal appears to be more concerned about saving face than sustaining health care. "In a conservative state, it's good politics to be thumbing your nose at this law, to be thumbing your nose at Washington," says Jonathan Cohn, a senior editor for The New Republic who has covered health care policy for the better part of two decades.
Deal can expand Medicaid any time he wants. But because the program is front-loaded, the longer the state waits, the more money gets left on the table. Health care advocate Cindy Zeldin, who oversees Georgians for a Healthy Future, says that Deal's stance will prevent a quick legislative fix. More importantly, Georgia risks falling behind as national politics subside and more states expand. Despite those concerns, Zeldin says that the state could still benefit from the program years down the road — even if Deal wins re-election and doesn't leave office until 2018.
Deal's decision, whatever it may be, will undoubtedly affect how Grady's other contributors fund the safety-net hospital moving forward. "I think [Deal] recognizes the consequences of the tough decisions he has to make," says Hicks.
Most private hospitals treat some uninsured patients. But unless lives are on the line, they don't have to unconditionally treat them — doing that would kill the hospitals' profit margins. Because of Grady's size and mission, other metro Atlanta hospitals rely on it to shoulder the weight of indigent care.
Fulton and DeKalb counties financially support Grady in its efforts to treat their impoverished residents, according to the terms of a 1953 contract with the Fulton-DeKalb Hospital Authority, a politically appointed board once charged with overseeing the hospital's operations. But the 60-year agreement expires this year.
"Without [the contract], the ability to negotiate or receive federal and state funding [from] another public entity is critical," says State Rep. Lynne Riley, R-Johns Creek, a former Fulton County commissioner.
Between 2007 and 2012, the two counties halved their contributions to Grady from $126.1 million to $63.3 million. Currently, Fulton County pays for 80 percent of the care its indigent patients receive, while DeKalb ponies up a mere 40 percent. Fulton County Commission Chairman John Eaves says the commission has budgeted $50 million for Grady in 2013 — close to its proportionate share.
"We give almost the amount of money that we should give," he says. "DeKalb does not, but they're just not in the financial position to support the hospital."
DeKalb County Commissioner Larry Johnson says that the county's lack of funding isn't an indication of its wavering commitment. Instead, it's a reflection of DeKalb County's declining housing values in a predominantly residential county. Hicks notes that the county upped its funding by $500,000 in its 2013 budget. "It's not a lot, but it's a good direction," says Hicks. "[DeKalb County is saying] they need to support Grady more than they do."
Around 5 percent of Grady patients come from outside Fulton and DeKalb. Riley says the original FDHA agreement was based on the notion that "the center of all patient care was really the city of Atlanta." But over the years, the city's low-income residents have spread out across the metro area, diluting the amount of patients from the two counties.
Though 5 percent may seem like a paltry number, it amounts to more than 30,000 patients each year. Some are flown in by helicopter or diverted from other hospitals across the state. Haupert says those counties should carry their weight. "Do Cobb and Gwinnett and Henry [counties] benefit from having a burn center and level-one trauma center here? Yes," he says. "Are they contributing to that? No."
To ensure that Fulton County taxpayer dollars would only serve its residents, commissioners added provisions to its arrangement with Grady, requiring proof of treatment to receive funding. Eaves says the hospital has become "very aggressive" to make sure it collects payments from those that have insurance. "That was a big and valid conversation five years ago," he says. "That's not as nearly as much of an issue as it was before."
With the Medicaid expansion up in the air, the counties' involvement in Grady's future may vary based on federal and state policy decisions. Hicks says the best-case scenario would be for the state to expand Medicaid. If that happens, Grady could wean itself off of county funding. Otherwise, the safety-net hospital may need Fulton and DeKalb counties more than ever.