ATLANTA (AP) — The prospect — albeit still dim — that Georgia could fully expand Medicaid has prompted Democrats and patient advocates to turn up the pressure on Republicans in the state legislature to act.

But political experts, advocates and policy analysts say GOP lawmakers face significant headwinds to approving a plan they have long derided as wasteful, and that could ultimately doom the effort.

“There’s reason to be a little more optimistic than one year or two years ago, but there’s not a groundswell of support and willingness to change the status quo on the part of the Republican members of the legislature,” said Harry Heiman, a health policy professor at Georgia State University.

The biggest obstacle is Georgia Pathways, the state’s limited Medicaid expansion that includes the nation’s only work requirement for Medicaid recipients, said Laura Colbert, executive director of the advocacy group Georgians for a Healthy Future.

Republican Georgia Gov. Brian Kemp has championed the program, which launched in July. Though it is off to a rocky start, with just under 2,350 people enrolled as of mid-December, the Kemp administration has sought to extend it past its September 2025 expiration date.

“Governor Kemp has put a lot of political capital into Pathways,” Colbert said.

Colbert said she was optimistic that Georgia lawmakers would eventually approve a fuller expansion of coverage for low-income adults, but not necessarily this year.

Kyle Wingfield, president of the conservative Georgia Public Policy Foundation, said he, too, was skeptical Kemp would be willing to retreat from Pathways.

He also warned that Republican lawmakers could face backlash for any Medicaid deal from Republican primary voters.

Expanding Medicaid to low-income adults who make up to 138% of the federal poverty level, with the federal government picking up 90% of the cost, was a key part of the Affordable Care Act. Georgia is among 10 states that have not done it.

Wingfield said he thinks Republicans in Washington, and to a lesser extent in Georgia, have accepted that the Affordable Care Act is here to stay, but that acceptance may not be shared by rank-and-file GOP primary voters.

“When it comes to the voters in a Republican primary, I don’t think I’d want to be the one finding that out,” he said.

But Brian Robinson, a Republican political consultant who counts the Georgia Alliance of Community Hospitals and House GOP caucus among his clients, says he thinks Republicans face little risk from primary opponents if they vote for Medicaid.

“The political issue of the danger has faded over the time,” Robinson said. “We’ve had some mini-expansions in Georgia and there’s been no blowback on Republicans. In fact they’ve proudly touted it for groups like new mothers.”

Republicans in Georgia also risk alienating the conservative organization Americans for Prosperity with a vote to expand Medicaid coverage.

The group is opposed to expansion, even as part of a deal that would repeal permitting requirements for hospitals and health services, said Tony West, the group’s Georgia State Director. That sort of deal has emerged as a possible compromise between Republicans and Democrats.

West wants lawmakers to focus solely on repealing the permitting requirements and leave Medicaid expansion by the wayside.

“I think we’re taking our eye off the ball,” he said.

Conversely, Wingfield raised the possibility that some Democrats could balk at a deal, noting that Medicaid expansion has been a key political issue for the party in Georgia.

“What do they gain from taking one of their signature issues off the table and letting the Republicans claim a large share of the credit for it?” he asked.

At least for now, Democrats in the General Assembly don’t appear concerned about losing their ability to hammer the GOP on Medicaid. The Democratic caucus organized a lengthy hearing Wednesday focused on the economic and health benefits of expansion that featured health care providers, advocates and policy experts.

In opening remarks, Democratic state Rep. Michelle Au, a doctor, noted Georgia had one of the highest rates of uninsured residents in the country and some of its worst health outcomes.

”As we start this 2024 legislative session, it is my hope that all options are on the table,” she said.

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ATLANTA (AP) — A federal judge has blocked the state of Georgia from enforcing part of a new law that bans doctors from starting hormone therapy for transgender people under the age of 18.

In a ruling issued Sunday, U.S. District Court Judge Sarah Geraghty granted a preliminary injunction sought by several transgender children, parents and a community organization in a lawsuit challenging the ban.

“The imminent risks of irreparable harm to Plaintiffs flowing from the ban — including risks of depression, anxiety, disordered eating, self-harm, and suicidal ideation — outweigh any harm the State will experience from the injunction,” the judge wrote.

Geraghty said her ruling will block enforcement of the ban on hormone replacement therapy until a further court order or a trial.

“We are disappointed in the judge’s decision and plan to immediately appeal to protect the health and well-being of Georgia’s children,” said Kara Richardson, a spokeswoman for Georgia Attorney General Chris Carr.

The Georgia law, Senate Bill 140, allows doctors to prescribe puberty-blocking medications, and it allows minors who are already receiving hormone therapy to continue.

But it bans any new patients under 18 from starting hormone therapy. It also bans most gender-affirming surgeries for transgender people under 18. It took effect on July 1.

Geraghty’s ruling was an “incredible victory for Georgia families,” attorneys for the plaintiffs said in a statement. The American Civil Liberties Union of Georgia, the Southern Poverty Law Center, the Human Rights Campaign Foundation and the law firm O’Melveny & Myers are representing the plaintiffs.

“This law unapologetically targets transgender minors and denies them essential health care,” they said. “The ruling restores parents’ rights to make medical decisions that are in their child’s best interest, including hormone therapy for their transgender children when needed for them to thrive and be healthy.”

At least 22 states have now enacted laws restricting or banning gender-affirming medical care for transgender minors, and most of those states face lawsuits. A federal judge struck down Arkansas’ ban as unconstitutional, and federal judges have temporarily blocked bans in Alabama and Indiana as well.

The plaintiffs in the Georgia lawsuit did not ask to immediately block the surgery ban, which remains in effect.

Doctors typically guide kids toward therapy or voice coaching long before medical intervention.

At that point, puberty blockers and other hormone treatments are far more common than surgery. They have been available in the U.S. for more than a decade and are standard treatments backed by major doctors’ organizations including the American Medical Association.

During two days of hearings earlier this month, Geraghty heard conflicting testimony about the safety and benefits of hormone therapy to treat adolescents with gender dysphoria — the distress felt when people’s gender expression does not match their gender identity.

Experts for the families said the benefits of gender-affirming care for adolescents are well-established and profound. State government experts raised concerns about the risks of hormone treatment and the quality of studies establishing its effectiveness.

In her ruling, Geraghty said witnesses for state health officials set a very high bar for evidence of hormone therapy’s benefit and a low bar for evidence of its risks. She noted that experts agreed that prolonged use of puberty blockers was harmful to a person’s health and inadvisable.

For the transgender children in the suit, “time is of the essence,” she wrote, and SB 140 could cause them to suffer heightened gender dysphoria and unwanted and irreversible puberty.

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ATLANTA (AP) — A judge determining whether to strike down Georgia’s abortion limits heard conflicting views Tuesday about how such restrictions affect doctors who care for pregnant women.

Georgia’s law bans abortions as early as six weeks into pregnancy, though it allows for later abortions to prevent a woman’s death or “the substantial and irreversible physical impairment of a major bodily function.”

That exception is unclear and has “hand-tied” doctors in the state, who are struggling to determine what conditions meet the standard and when, said Martina Badell, a doctor who specializes in maternal and fetal health at Emory University School of Medicine.

“In some situations now, we may counsel and say, ‘That is the standard of care and you should have this option, but I’m sorry, it’s not clear we can provide that for you here in Georgia,’” she testified on the second day of the trial over Georgia’s abortion law.

Badell, a witness for the plaintiffs seeking to invalidate the law, noted that doctors face possible criminal prosecution for performing an illegal abortion.

Doctors in Texas were initially confused about when they could intervene to provide an abortion that would not violate that state’s ban, which took effect before Georgia’s, said Ingrid Skop, an obstetrician and gynecologist who testified later as a witness for Georgia officials defending the law. But Skop said hospitals have since provided helpful guidance, and she expects the same thing will happen in Georgia.

She said obstetricians have always faced a heightened risk of being second-guessed, as evidenced by the large number of malpractice suits they face.

“I understand how a felony is scary, but there is nothing that this law is telling doctors to do or not do that we haven’t always done,” she said of Georgia’s abortion restriction. “We’ve always intervened when we needed to to save a woman’s life.”

Skop is the director of medical affairs at the Charlotte Lozier Institute, part of an advocacy group that seeks to end access to abortion.

Fulton County Superior Court Judge Robert McBurney scheduled a two-day trial in a lawsuit that argues Georgia’s abortion ban violates the state Constitution’s right to privacy and liberty by “forcing pregnancy and childbirth upon countless Georgians.”

The state attorney general’s office said in a court filing that Georgia’s privacy protections do not extend to abortion because it affects another “human life.”

McBurney heard from additional witnesses Tuesday, the second and final day of the trial.

Farr Curlin, a physician at Duke University who also holds an appointment at the college’s divinity school, testified for the state in support of Georgia’s abortion law and said a heartbeat is an indicator that an animal is alive.

Gloria Nesmith, an ultrasound technician at an abortion clinic in Atlanta, recalled a woman who didn’t have child care wailing when she learned she was just past the period when she could have received an abortion in Georgia.

McBurney said earlier that he will not issue a ruling until after Nov. 8.

Georgia’s law bans most abortions once a “detectable human heartbeat” is present. Cardiac activity can be detected by ultrasound in cells within an embryo that will eventually become the heart as early as six weeks into a pregnancy. That means most abortions in Georgia are effectively banned at a point before many women know they are pregnant.

The law also includes exceptions for rape and incest, as long as a police report is filed.

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The Republican head of Georgia’s election board said Tuesday a recently released film alleging ballots were illegally collected and dropped off during the 2020 presidential election falsely suggests there were tens of thousands of illegitimate votes in the state.

Still, State Election Board Chairman Matt Mashburn promised a “fair” investigation of its claims.

“It’s not going to be a witch hunt,” he said at a meeting of the board. “It’s going to be done soberly and with great care by people who know what they’re doing.”

The movie, called “2000 Mules,” paints an ominous picture suggesting Democrat-aligned ballot “mules” were supposedly paid to illegally collect and drop off ballots in Arizona, Georgia, Michigan, Pennsylvania and Wisconsin. It has been praised by former President Donald Trump as exposing “great election fraud,” but election security experts say it is based on faulty assumptions, anonymous accounts and improper analysis of cellphone location data.

Mashburn, who said he watched the film, said it suggested there were 92,000 “illegitimate, manufactured votes” in the state, but he said that’s not true. Even if a ballot is illegally dropped off, it goes through the same checks as other ballots to ensure the vote is legitimate, he said.

“A ballot harvested vote might be a perfectly legal vote,” he said. “It’s just the manner of its delivery was illegal.”

The movie uses research from the Texas-based nonprofit True the Vote, which has spent months lobbying states to use its findings to change voting laws. In an email, a representative for True the Vote said the movie presented “a wide variety of information, including summary data from 5 jurisdictions in 5 states, showing only a fraction” of the available evidence.

“It included elements that were not about Georgia at all,” Catherine Engelbrecht said.

An investigator with the Secretary of State’s office told the board Tuesday that he had investigated three complaints that people had delivered ballots illegally in Georgia and found in each case that the person was legally dropping off ballots of family members. The board dismissed all three cases.

Engelbrecht said True the Vote had also submitted complaints to the Georgia Secretary of State’s office, but those had not been investigated.

“We look forward to the advancement of an official investigatory process, based on the full scope of data and video that support our complaints,” she said.

One of the video clips the investigator reviewed had appeared in the background of a Fox News program. Republican board member Ed Lindsey cautioned people making the allegations not to publish them before a thorough investigation is completed so as not to “bring into question someone’s good name.”

“Claiming that someone is committing a crime without fuller investigation carries with it some legal liability as well,” he said. “I would like for folks who are simply exercising their right to vote and exercising the right of their family to vote not to have an allegation thrown about.”

The board’s only Democrat, Sara Ghazal, said the claims in the movie had been “reviewed and refuted by numerous Republican appointed and elected officials.”

“The analysis is flawed and there are assertions there that are wholly unsupported by any evidence that I’ve been provided aside from individual isolated instances that I can count on one hand with fingers to spare,” she said. “I’ve seen no credible evidence of any organized efforts of unauthorized persons delivering ballots let alone widespread invalid votes being cast.”

Despite the film’s dubious claims, Georgia officials have issued subpoenas to True the Vote to investigate them. Ryan Germany, an attorney for the Secretary of State’s office, told the board Tuesday the group has genuine concerns about confidentiality and has not yet turned over information.

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Citing increased revenues, Georgia Gov. Brian Kemp on Wednesday signed an amended budget that includes pay boosts for state employees, hundreds of millions of dollars to restore education cuts and an earmark of more than $1 billion for tax refunds.

Kemp said the state was in a “unique” economic position that he credited to his decision to reopen businesses early during the coronavirus pandemic.

“This budget funds our priorities and sets our state on a clear path to a continued strong recovery in the coming months as we fully turn the page on the pandemic,” he said at a signing ceremony that included Lt. Gov. Geoff Duncan and state House Speaker David Ralston.

House Bill 910 covers the budget year ending in June. It includes $5,000 pay boosts for state agency employees and $2,000 bonuses for teachers and other school workers. It also restores more than $380 million to the state’s K-12 funding formula that had been cut when lawmakers feared revenue decreases at the beginning of the pandemic.

Kemp said the bill also includes more than $460 million to upgrade prisons.

Kemp and lawmakers, who are up for reelection this year, have moved to dramatically increase spending thanks to bountiful state tax collections.

A $2.35 billion surplus was left at the end of the 2021 budget even after filling the state’s savings account to its legal limit of $4.3 billion.

That prompted the tax rebate plan, which was approved by the state Senate on Wednesday after it passed earlier in the state House.

People who filed income taxes in Georgia in 2020 and 2021 will get a refund when they file taxes this year. Single filers will receive as much as $250.

That number will increase to $375 for those heading a household and $500 for couples filing jointly.

“House bill 1302 is the fulfillment of our beliefs that when government takes in more money than it needs, the surplus funds should go back to the taxpayers,” state Sen. Clint Dixon, a Gwinnett Republican, said on the Senate floor. “Ultimately, it’s our citizens, not our government, that move our state forward, and they know best how to spend their hard-earned money.”

The measure passed by a vote of 47 to 4.

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ATLANTA (AP) — Private health insurers would face additional pressure to provide the same level of benefits for mental health disorders as they do for other medical problems under a wide-ranging bill to address Georgia’s dismal mental health care system that cleared a key state legislative committee on Wednesday.

The House Health and Human Services Committee voted in favor of HB 1013 after hearing from a powerful backer of the bill, House Speaker David Ralston. The bill, which would cost $29 million, must go through one more House committee before it can be voted on by the full House and then the state Senate.

Ralston said he saw it as the start of a “multiyear” conversation about improving Georgia’s mental health services. The state has seen a spike in substance abuse and rural suicides and consistently ranks near the bottom of U.S. states for access to mental health care.

“We did not get in this place we are today overnight, and we will not get out overnight,” Ralston said. “But I can’t think of a better big first step to take than this bill.”

HB 1013 would require the state’s insurance commissioner to collect data to ensure private insurers provide the same level of benefits for depression, anxiety and other mental disorders as they do for other medical conditions. The commissioner would also have to set up a process for responding to consumer complaints of potential violations of the parity requirement.

The bill would also force companies that cover Medicaid recipients to spend more money on mental health services and other patient care. A separate provision aimed at boosting the state’s mental health workforce would extend loan forgiveness to people studying to become mental health professionals.

HB 1013 also tries to improve existing tools aimed at keeping people with mental health and substance abuse problems out of jail. A grant program under the bill would give a board or private provider authority to identify people who should be forced into treatment and then establish procedures to ensure a petition seeking their involuntary commitment is filed in probate court.

Police, additionally, would have the authority to take people for mental health treatment without witnessing a crime.

Some advocates have raised concerns about the forced-treatment provisions, but state lawmakers say the current system is not working to keep people suffering from mental health or substance abuse problems out of emergency rooms and the criminal justice system.

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Georgia Republicans advanced a bill Wednesday that would ban the delivery of abortion pills by mail and require women to be examined by a physician in person before the pills are dispensed.

The state Senate’s health and human services committee voted 7-5 in favor of the legislation after an expedited hearing that drew abortion opponents and supporters. The bill would still need approval from the state Senate and House before it could become law.

More than a dozen other Republican-led states have passed measures limiting access to the pills, including outlawing delivery by mail. The conservative-majority U.S. Supreme Court recently signaled it was ready to make seismic changes to the nationwide right to abortion that has stood for nearly half a century. If the court overturns the landmark Roe v. Wade decision entirely, GOP-controlled states such as Georgia would be likely to severely restrict abortion access, potentially causing more women to seek out abortion pills by mail.

Proponents of the Georgia bill say drug-induced abortion can lead to complications, so physicians need to closely monitor patients. Critics say the procedure carries little risk, and the bill’s true aim is to impede access to abortions.

“In the name of safety, this bill sets out requirements for which there is no current medical justification,” said Dr. Melissa Kottke, a specialist in pregnancy and contraception at Emory University and the past president of the Georgia Obstetrical and Gynecological Society. “Indeed, it denies medical advancements, and ultimately this bill will put into law substandard medical care. It will do harm.”

Kottke and other speakers were cut off by committee chairman Ben Watson, who warned at one point that security was outside the hearing room.

The Georgia legislation responds to the U.S. Food and Drug Administration’s December decision that changed a federal rule that required women to pick up the medication in person. The federal government had already set aside the rule temporarily during the COVID-19 pandemic.

The in-person requirement had long been opposed by medical societies, including the American Medical Association, which say the restriction offers no clear benefit to patients.

Watson, a Republican from Savannah, said the Georgia bill was written narrowly and returned things to the way they were before the COVID-19 emergency.

“There is no bill that is ever perfect,” he said. He added, “But we don’t want to let the good get bogged down by the perfect.”

Republican Sen. Bruce Thompson, a co-sponsor of the legislation, said its aim was to keep women safe.

“This bill is simply intended to protect these women from the reckless actions of those mailing these drugs to women without ensuring she receives the proper and necessary care to ensure her health and safety, and that it’s not compromised,” he said.

Right now, abortion pills can be prescribed in Georgia 24 hours after a telephone consultation by a physician or someone working for the physician. Under the new bill, physicians would have to examine the patient in person and perform an ultrasound in advance. They would also be required to schedule a follow-up visit seven to 14 days after the drugs are administered.

The bill would also ban abortion pills from being provided at secondary schools, colleges and universities in the state.

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Georgia sued the Biden administration Friday over its decision to revoke approval of a work requirement in the state’s plan to expand Medicaid coverage to more low-income Georgians.

The lawsuit filed in federal court in Brunswick, Georgia, says the decision last month by the U.S. Centers for Medicare and Medicaid Services was an illegal and arbitrary “bait and switch of unprecedented magnitude.” It seeks a court order reinstating the original plan with the work requirement.

“Simply put, the Biden administration is obstructing our ability to implement innovative healthcare solutions for more than 50,000 hardworking Georgia families rather than rely on a one-size-fits-none broken system,” Georgia Gov Brian Kemp, a Republican, said in a news release announcing the lawsuit.

He accused the Democratic president’s administration of playing politics.

CMS said it does not comment on litigation.

The work requirement was approved by then-President Donald Trump’s administration, but CMS announced last month that it was revoking approval of both that plan and a related Georgia proposal to charge some Medicaid recipients monthly premiums for their health coverage.

“This case is about whether the federal government must keep its promises,” the lawsuit says.

CMS Administrator Chiquita Brooks-LaSure said in a letter to the state that the work requirement could be impossible for people to meet during the pandemic, when it was critical that low-income Georgians have access to health coverage. The Kemp administration said at the time it planned to challenge the decision in court.

Republicans had presented Georgia’s plan as a financially responsible alternative to a full expansion of Medicaid services under the Affordable Care Act, which 38 states have already done. The plan sought to add an estimated 50,000 poor and uninsured Georgia residents to the Medicaid rolls in its first two years. But to be eligible, new Medicaid recipients would have to engage in a minimum number of qualifying hours through work, job training, education, volunteering, or other similar activities.

Democrats in Georgia say full expansion would cover hundreds of thousands of people at a much lower cost to the state. That’s because the ACA, President Barack Obama’s signature health care law, gave states the option of expanding Medicaid to low-income adults who make up to 138% of the federal poverty level, with the federal government picking up 90% of the cost. More than 10 million people in the U.S. have gained coverage that way.

Kemp has said full expansion would cost the state too much money in the long run.

The Biden administration is separately reviewing Georgia’s plan to overhaul how residents buy health insurance under the Affordable Care Act. That plan — under which Georgia residents would bypass healthcare.gov and shop for federally subsidized health insurance through private agents — was also approved by the Trump administration.

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Martin Luther King Jr.’s daughter used an address Monday to push for federal voting rights legislation and slam the twisting of critical race theory to create what she called “false narratives.”

Rev. Bernice King said there is a “very urgent need” for voting legislation, and that it is “crucial to humanity across the globe that the United States of America stands as a democratic nation.” Her remarks came ahead of a scheduled visit Tuesday to Georgia by President Joe Biden and Vice President Kamala Harris to talk about voting rights.

“I also know that there are many people who are not as urgently concerned about that unfortunately,” King said during the address at The King Center in Atlanta to announce events for the upcoming holiday in honor of her father. “There’s a wind of discontent for some and a wave of apathy for others that has settled into the hearts and minds of not only an increasing number of people in the United States, but throughout the world.”

Voting legislation backed by Democrats is currently stalled in the U.S. Senate in the face of Republican opposition, and the party is mounting an effort to change the chamber’s rules to get it passed. Senate Majority Leader Chuck Schumer, D-N.Y., has set the Martin Luther King Jr. holiday on Jan. 17 as the deadline to either pass the voting legislation or consider revising the rules. King said she was frustrated by the lack of progress on voting rights, but she believed legislation would pass and urged dialogue with Republicans.

“This is not just a Black issue,” she said. “This is an issue about democracy.”

King also addressed critical race theory, a way of thinking about America’s history that centers on the idea that racism is systemic in the nation’s institutions and that they function to maintain the dominance of white people in society. Republican-controlled states have invoked it in legislation restricting how race can be taught in public schools, and it’s become a lightning rod for the GOP.

She said the nation needed a shift in priorities that “helps us understand we can’t commemorate my father on the one hand while also promoting false narratives under the banner of critical race theory.”

She added: “CRT is not the problem. Racism is the problem, poverty or extreme materialism is the problem and militarism, war is the problem.”

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Drenzek updated the state Board of Public Health on the spike in COVID cases since the end of June. The increase is being fueled by the delta variant of the virus among people who are unvaccinated.

Since the beginning of September, the seven-day average of new cases has fallen. But Drenzek warned the state is coming down from steep peaks, and its hospitals and schools are still facing great strain. The “risk of transmission” through communities remains high, she said.

“We’re very much at peak levels even though we’re starting to go down,” she said.

The state recently set a record for the number of patients hospitalized with COVID-19. And Drenzek said the recent surge has affected school-aged children much more than previous waves. Children up to the age of 17 now account for more than a quarter of all cases.

She urged continued adherence to precautions such as maintaining social distance, wearing masks and quarantining when sick or exposed. Increasing the state’s vaccination rate also remains vital, she said.

Only 45 percent the state’s population is fully vaccinated, well below the national average.

State health officials want to make the COVID-19 vaccine a normal part of visits to primary care doctors, and are trying to understand barriers to getting more of them to administer inoculations, said Chris Rustin, a senior advisor to Department of Public Health Commissioner Kathleen Toomey. Rustin also addressed the board.

Board Chair James Curran urged the health department to avoid the “partisan politics of vaccine mandates” and continue its effort to stress the importance of getting vaccinated.

Toomey told the board that health workers have been forced to close several vaccination sites because they’ve been booed and jeered.

“We’re not only not valued. We’re ridiculed. We’re lambasted in social media,” she said. “This is absolutely unprecedented in my public health experience.”

Her voice choking with emotion, she thanked public health staff and said the state and country need to do a better job of supporting them through an exhausting period that has left many burnt out.

“We really have to think how can we continue to support our staff even as we continue to fight a pandemic,” she said.

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