For a decade, Medicaid expansion has seemed like an intractable partisan issue, with Georgia Republicans hesitant to back a major component of the Affordable Care Act.

• But the tides may be turning.

Driving the news: In conversations with nearly a dozen bipartisan lawmakers and lobbyists who spoke on condition of anonymity, Axios has learned that some Georgia Republicans have quietly changed their minds about Medicaid expansion and that discussions about a path forward have been happening behind the scenes.

• Sources declined to speak on the record because of the topic’s political sensitivity.

Medicaid expansion 101: Expanding Medicaid means increasing access to federal health insurance coverage for low-income residents, in exchange for a 10% state match of the federal spend.

Why it matters: Georgia is one of 12 states still refusing the government's offer to extend coverage to people living up to 138% of the Federal Poverty Level or nearly $19,000 in annual income for one person.

• If it passed here, an estimated 500,000 more Georgians could gain coverage, compared to pre-COVID numbers.
• Polls have consistently shown a majority of Georgians support expansion and according to one national poll, most Republicans.

What they're saying: "There are many conversations happening in many rooms about how Medicaid could be expanded in Georgia, regardless of who is elected governor," Democratic state House Rep. Mary Margaret Oliver confirmed to Axios. Talks are happening among Democrats and Republicans, she said, in a way that feels new.

• "None of us have a clear path at this time, but everybody's fingers are crossed," she said.

Brian Robinson was spokesman for former Georgia Gov. Nathan Deal, the first to reject Medicaid expansion a decade ago. But Robinson is one of the rare Georgia Republicans arguing publicly that it's time to make the change, because of policy and politics, he told Axios.

• "This isn't what we would do," Robinson said of Medicaid's much-criticized structure. "But Republicans can't agree on what we would do. This is the policy and the law, and it's not going away. It would bring home hundreds of millions from a program we're paying into already."
• Robinson said Republicans' initial fear — the federal government pulling its 90% matching funds — hasn't come to pass in other states. And the “repeal and replace” movement against the Affordable Care Act has died in Congress and in the courts.

Yes, but: Georgia Republican leaders including Gov. Brian Kemp, who has rejected the idea of full expansion, have so far blocked the policy.

• In a July press conference, Kemp said he hasn't heard from Republicans who have changed their minds. "It's going to take a vote of the General Assembly," he said.
• He said Republicans have opted for "a more holistic approach to health care versus a one-size-fits-all government approach," including partial Medicaid expansion for mothers one year postpartum, state funding for rural health care providers and a waiver proposal to expand coverage to roughly 50,000 more Georgians.

Republicans in some of the 11 other non-expansion states have also been shifting their positions recently.

The big picture: North Carolina Republicans shocked many by nearly passing expansion this spring.

• A former Alabama governor, who had refused to expand Medicaid himself, is now urging his fellow Republicans to pass it for the benefit of rural parts of the state.
• Some bipartisan legislative movement on expansion this year has given advocates in Wyoming hope.
• Ballot initiatives to expand Medicaid by referendum have been approved by voters in several Republican states. The issue is on the South Dakota ballot this year.

"There is real momentum on Medicaid expansion in these conservative states that have been holding out," said Melissa Burroughs with Families USA, a health care advocacy group working with partners in non-expansion states to push the policy.

• The hold-up, she told Axios, "is more a question of the overarching political dynamics and leadership."

What's happening: Based on Axios' reporting, there are several reasons why the Georgia conversations have shifted.

• Hospital closures. In the last decade, eight rural hospitals have closed in Georgia, among the highest numbers in the country. While not a silver bullet, adding people to the Medicaid rolls would mean revenue for hospitals where they're otherwise getting none for uninsured patients.
• COVID-19. Under the federal state of public health emergency, Medicaid access was automatically extended. That state of emergency could expire soon, which could mean an estimated 250,000 to 450,000 Georgians may lose coverage.
• Money. While estimates vary, according to 2019 calculations from state budget writers and officials, full expansion could cost Georgia less in the first year than the governor's proposed waiver program. Plus, the 2021 federal pandemic relief law sweetened the deal for non-expansion states.
• Politics. Medicaid expansion continues to be broadly popular in this battleground state.

Stacey Abrams, who continues to make Medicaid expansion a core pillar of her campaign platform, told reporters last month she is certain expansion could pass the Georgia legislature today.

• "Republican governors one by one peeled off across the country, realizing that the economic benefits outweigh any political challenges that they might inherit," she said.

Flashback: In 2014, under Gov. Nathan Deal, nearly all Georgia Republicans united to pass a law preventing the governor from expanding Medicaid unilaterally.

Yes, but: In what was a remarkable shift for a Republican governor, Kemp championed partial Medicaid expansion through two waiver proposals in 2019, which would expand coverage to roughly 50,000 more Georgians. However, both have been rejected by the Biden administration.

• One was denied because it includes work requirements, which have been ruled unconstitutional in several courts but remains the subject of an active legal fight. Georgia sued the federal government over it.
• The other waiver would sever the state's relationship with Healthcare.gov, and was rejected last week.

The intrigue: Robinson, a Republican strategist, contends that Kemp actually has "a better chance of getting this passed with a Republican legislature than Abrams would."

• "No one questions Kemp's conservative bona fides, and it can fit into his message on expanding health care access and rural development," he told Axios.
• Kemp, Robinson said, has actually "led on the Medicaid issue [with the waivers] and the support he got in the General Assembly for his waiver plan shows the politics have changed."

While Robinson, who is supporting Kemp's re-election, understands why some are still holding out against full expansion, he argued the fear of backlash from Republican voters is less realistic today.

• Plus, "Politically, it would steal an issue where Democrats have a polling advantage," he said.

State Senate Majority Leader Mike Dugan told Axios that Republicans "are expanding Medicaid," citing partial expansions like the waivers and postpartum coverage. However, he said he doesn’t know whether full expansion would pass the state Senate.

• "We consistently review it, and we will continue to," he said. "It's just not as fast as some would like."

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