Proposed 2017 Physician Fee Schedule Includes Telehealth Changes

Proposed 2017 Physician Fee Schedule Includes Telehealth Changes

Yesterday CMS released its proposed changes to the Medicare Physician Fee Schedule for Calendar Year 2017, which include several provisions related to telehealth.

First, CMS proposes to expand on Medicare's reimbursable tele-nephrology codes by adding three “per-day” end-stage renal disease CPT codes, 90967-90970. It also proposed making reimbursable two advance care planning codes (99497-99498) and creating new G-codes for critical care consultations, GTTT1 and GTTT2, valued at work RVUs of 4.0 and 3.86 respectively. 

CMS declined to add codes related to observation care, emergency department visits, psychological testing, physical and occupational therapy, and speech language pathology. 

Finally, CMS is proposing to introduce a telehealth place of service (POS) code to clarify that distant-site physicians should use the POS code of the patient's location, not their own. The proposed telehealth POS code would be paid using facility PE RVUs. 

Comments on the proposed rule must be submitted by September 6, 2016. 

Listen to the 2016 Georgia Law Rural Healthcare Symposium

Listen to the 2016 Georgia Law Rural Healthcare Symposium

In March, Boling & Company co-hosted with the University of Georgia School of Law an academic symposium calling attention to the national rural health crisis. The event was a terrific gathering of rural health advocates and interested students aimed at identifying solutions for rural providers and patient populations. 

The event was also sponsored by the Georgia Partnership for Telehealth and Healthcare Georgia Foundation. 

Listen to and/or download the various panel discussions featuring healthcare policymakers, executives, and entrepreneurs, (full list below) along with a keynote presentation from CEO of the National Rural Health Association Alan Morgan, here

Full list of panelists:

  • Alan Morgan (keynote speaker), CEO, National Rural Health Association
  • State. Rep. Sharon Cooper, Chair of Health and Human Services Committee
  • Carol Alexander, Consultant, Stroudwater Associates
  • HD Cannington, CEO, Cannington Healthcare Consulting, LLC
  • Lisa Carhuff, MSN, RN, Director of Hospital Services, Georgia State Office of Rural Health
  • Jim Coleman, SVP of Southeast Hospital Operations, Community Hospital Corporation
  • Kay Floyd, CEO, Monroe County Hospital (GA)
  • Troy Heidesch, DNP, CEO of Smart House Calls, LLC
  • William Kanto, MD, Augusta University 
  • Gary Nelson, PhD, President, Healthcare Georgia Foundation
  • Robin Rau, CEO, Miller County Hospital (GA)
  • Jeff Robbins, Director of Telemedicine, Tift Regional Medical Center (GA)
  • Ben Robinson, Executive Director for the Center for Health Planning and Workforce Analysis, University System of Georgia
  • Sherrie Williams, Executive Director, Georgia Partnership for Telehealth
  • Baha Zeidan, CEO, Azalea Health  

HRSA Grant Boosts Interstate Medical Licensure Compact

HRSA Grant Boosts Interstate Medical Licensure Compact

The U.S. Health Resources and Services Administration has awarded $750,000 to accelerate the progress of the Interstate Medical Licensure Compact, an initiative aimed at reducing medical licensure barriers from state to state. 

The grant funds will be used to support the Compact's administration and expand outreach to non-participating states, according to a release from the Federation of State Medical Boards. 

The Compact, enacted by 17 states since 2015 and introduced in another nine, is viewed as a potential catalyst for the practice of interstate telemedicine. 

New Law Targets Online-Only Eye Exams in Georgia

New Law Targets Online-Only Eye Exams in Georgia

In the latest example of mobile health apps battling the traditional healthcare industry, Georgia Governor Nathan Deal signed a law this week banning the practice of prescriptions based on online-only eye exams. Specifically, the law prohibits prescriptions for “contact lenses or spectacles” without an eye examination that includes an “in-person assessment.” 

The law does not outlaw all eye exams via telemedicine, as it specifically exempts from its prohibition telemedicine assessments at a physician’s office, optometrist’s office, hospital, or “hospital health system setting.” However, direct-to-patient mobile apps offering eye exams appear to fall squarely within the law’s ban, which may be punishable by imprisonment of up to five years. 

Reports have linked the legislation to the rise of Internet-based eye exam services like Opternative, which allow patients to conduct eye tests from any location using their smartphones and computers. Direct-to-patient healthcare apps have faced resistance from doctors' and hospital lobbies, in part due to concerns over quality, and have earned the attention of legislatures and licensing agencies

Georgia’s new law also limits contacts and spectacle prescriptions to physicians and licensed optometrists. 

 

Disclaimer: The foregoing materials are provided for informational purposes only, and are not to be construed as legal advice. The information relies on limited authority and has not been screened or approved by any governmental agency. Please consult an attorney before applying this guidance to any particular facts or circumstances. 

Georgia Legislature Approves Modified Rural Health Tax Credit

Georgia Legislature Approves Modified Rural Health Tax Credit

After eleventh-hour negotiations in the General Assembly, Georgia's tax credit benefitting rural hospitals may become law after all. Georgia Health News reports that the credit, thought dead after the senate rejected the original version on March 14, was revived via Senate Bill 258 and passed after midnight Friday morning.

The bill grants to individuals and corporations a substantial tax credit for donating to rural hospitals that meet one or more of a few criteria, including critical access status. Under the bill, the Georgia Department of Community Health would maintain a list of eligible rural hospitals. The donor would be permitted to choose its recipient(s). 

For corporations, the tax credit would be 70 percent of the donation or 75 percent of the corporation’s income tax liability, whichever is less. For individuals and couples, the annual tax credits would be capped at $2,500 and $5,000 respectively. The new bill would take effect in earnest in tax year 2017. 

Detractors have challenged the bill as a stopgap measure that would distract from other rural health solutions such as expanding Medicaid. 

The bill now heads to the governor’s desk for final approval. Please contact us at 678-974-7707 for more information about the status of this bill. 

 

Disclaimer: The foregoing materials are provided for informational purposes only and are not to be construed as legal advice. The information relies on limited authority and has not been screened or approved by any governmental agency. Please consult an attorney before applying this guidance to any particular facts or circumstances. 

The Emerging HIPAA/FERPA Conundrum in School-Based Telehealth

The Emerging HIPAA/FERPA Conundrum in School-Based Telehealth

The advent of school-based telemedicine has brought renewed focus on the intersection of two federal laws governing patient privacy: the Health Insurance Portability and Accountability Act (HIPAA) and the Family Education Rights and Privacy Act (FERPA). Many are trying to navigate the tricky confluence of these laws in the context of telemedicine, but there is hardly a well-traveled course. 

By way of background, HIPAA protects the privacy of patient records in nearly all healthcare settings, whereas FERPA protects only student health records maintained in school settings (where the school receives Department of Education funding). The laws are similar in that they generally limit the situations in which a healthcare provider can disclose health information without patient (or parental) consent. However, the laws have a few key differences. For example, under HIPAA, protected health information may be disclosed without consent for “payment, treatment, and operations”; FERPA has no such broad consent exception, but does allow disclosures without consent for “legitimate educational interests” to certain school officials, which might not be permitted recipients under HIPAA.

These differences have historically led school-based health providers to carefully examine whether a record is governed by HIPAA or FERPA. The overly simple answer is that an education record governed by FERPA is specifically exempt from HIPAA’s requirements. That is, In a traditional school-based clinic, a nurse or other provider would be held to confidentiality by FERPA, not HIPAA. 

HHS/DoED 2008 GUIDANCE

The involvement of outside parties in school-based care caused the Department of Education and the Department of Health and Human Services, in 2008, to release joint guidance on the intersection of HIPAA and FERPA in school-based healthcare. Beyond clarifying the two distinct zones of HIPAA and FERPA privacy regulation, the report aimed to address some of the scenarios where the distinction was not self-evident. 

Significantly, the agencies identified the HIPAA/FERPA boundary in the context of outside healthcare providers serving schools. Where a person or entity is providing services “on behalf of” a FERPA-regulated school, the report states, the record is subject to FERPA, and therefore not subject to HIPAA; as an example the report cites “a school nurse that provides services to students under contract with or otherwise under direct control of the school.” On the other hand, if an outside party is not acting “on behalf of” the school, such as “a public health nurse who provides immunization or other health services to students on school grounds or otherwise in connection with school activities but who is not acting on behalf of the school,” the record would be governed by HIPAA. 

The “on behalf of” test may not meet many providers’ desired level of certainty. The FERPA regulations provide slightly more insight, adding that FERPA applies to a contractor performing “institutional services or functions…for which the agency or institution would otherwise use employees…under direct control of the school with respect to the use and maintenance of education records.” 

TELEHEALTH IN FOCUS 

Alas, the 2008 joint guidance did not specifically contemplate the use of telehealth as a delivery mechanism for school-based healthcare. Because many school-based telehealth programs involve the frequent exchange of student health records between school personnel and independent contractors, the line dividing “education records” from HIPAA records is a constantly moving target. 

One might view an outside tele-provider as clearly not “under direct control” of a school with respect to its use and maintenance of medical records, which would mean the provider could treat such records as it normally would under HIPAA. However, such a provider could also be said to act “on behalf of” the school if it is serving as the school’s primary healthcare service, and therefore would be subject to FERPA. 

Moreover, consider this scenario: a provider engaged in school-based telehealth receives a FERPA record from a school nurse. Even if the provider’s own records would be treated as HIPAA records, the record received from the school would be subject to FERPA’s rules regarding redisclosure — essentially, the FERPA disclosure rules themselves. 

Outside providers are not the only parties affected by this overlap; school personnel also must be mindful of their potential HIPAA requirements. In practice, many providers contracting with a school will mandate that the school sign a HIPAA business associate agreement (BAA) as a condition of participation. Thus, even if a school is not statutorily subject to HIPAA because of the FERPA exemption, the school might have contractually committed to comply with certain (if not all) HIPAA provisions via the BAA. 

SO, WHAT’S A PROVIDER TO DO?

While this complexity no doubt presents a conundrum for school-based telehealth providers, their outlook is not all doom-and-gloom. In reality, many of the protective measures a provider would take under HIPAA would be similarly beneficial under FERPA’s regulatory scheme, and vice versa. Once a provider commits in earnest to patient privacy, the mastery of the HIPAA-FERPA overlap boils down to a select few details. 

For the outside tele-provider, it is largely academic to think of a scenario HIPAA would not be followed — the gargantuan 1996 law is a fixture in most healthcare settings. But, to protect against the possibility that their records would might be FERPA records, such providers might seek to obtain advance consent that meets the form requirements of FERPA (34 CFR 99.30) and authorizes the HIPAA-permitted disclosures that would require consent under FERPA, i.e. disclosures for payment and operations. 

For school personnel, the question of HIPAA liability will depend on the school’s particular circumstances, including the presence and scope of a BAA. If a school is required to comply with HIPAA’s Privacy Rule, it must be mindful of disclosures that would be routine under FERPA (e.g. to non-treating school officials) that would require consent under HIPAA, and obtain consent for such disclosures before delivering treatment. If a school is required to comply with HIPAA’s Security Rule, it should consult a healthcare attorney in developing policies and procedures to safeguard health records. 

 

Disclaimer: The foregoing materials are provided for informational purposes only and are not to be construed as legal advice. The information relies on limited authority and has not been screened or approved by any governmental agency. Please consult an attorney before applying this guidance to any particular facts or circumstances. 

Georgia Medicaid Waiver Program Hits Snag

Georgia Medicaid Waiver Program Hits Snag

Georgia Health News reported today that the proposed Medicaid waiver program to insure low-income Georgians is facing significant pushback from the Department of Community Health. Grady Health System has led the charge on the program, known as a Section 1115 Waiver, that would serve as alternative to expanding Medicaid under the Affordable Care Act. 

According to the GHN report, the state health agency has taken issue with the proposed program's costs. Grady officials are studying the response and exploring possible adjustments. 

Medicaid waivers have become a popular alternative to the Medicaid expansion, expanding access to health insurance through premium assistance rather than state-administered coverage. The federal government has approved a handful of such waiver programs already and will match funds for qualifying programs as it would under the Medicaid expansion. 

 

CMS Capsules

CMS Capsules

The Center for Medicare and Medicaid Services has released a flurry of rulemaking announcements in recent weeks, touching a broad range of delivery models. We review some notable items here:

End-of-life counseling 

As part of its proposed rule revising the Medicare physician fee schedule, CMS announced it intends to reimburse physicians and other qualified health professionals for conversations with patients and their families regarding end-of-life planning. These new “advance care planning” codes would mark a significant development in Medicare’s treatment of end-of-life care. 

Stark law exception

The physician fee schedule rule also proposed a new exception to the physician self-referral law, known as the “Stark” law, allowing certain health facilities to pay physicians in exchange for assistance in employing "nonphysician practitioners" (nurse practitioners, physician assistants, clinical nurse specialists, certified nurse midwives) in the facility’s service area. Under this exception, physicians could refer patients to the facilities paying for their recruitment assistance without fear of penalties under the Stark law. 

New telehealth services 

The physician fee schedule rule proposed two new reimbursable health services under Medicare: prolonged service in the inpatient/observation setting (CPT 99356-7), and end-stage renal disease (ERSD) services for home dialysis (CPT 90963-5). Reimbursement for these services would be subject to Medicare’s usual geographic restrictions on telehealth. 

Chronic care management in RHCs, FQHCs

Consistent with its introduction of a new code for non-face-to-face chronic care management, CPT code 99490, CMS’s physician fee schedule rule would extend the same payment to rural health clinics (RHCs) and federally qualified health centers (FQHCs). To qualify for reimbursement, the RHC or FQHC must provide at least 20 minutes per month of CCM services to patients with two or more chronic conditions, defined as conditions that are expected to last at least 12 months and place the patient "at significant risk of death, acute exacerbation/decompensation, or functional decline." 

Nursing home CoP overhaul

On July 13, CMS announced a series of major revisions to the Medicare and Medicaid conditions of participation (CoP) for long-term care facilities, the first major rewrite of such rules since 1991. The proposed rule largely brings the CoP into conformity with new technologies and practices that most nursing homes have already adopted, according to the press release. Among the possible impacts, “unnecessary hospital admissions and infections would be reduced, quality care increased, and safety measures strengthened.” 

Home health quality initiative 

On July 7, CMS announced revisions to its home health prospective payment system, including, notably, the introduction of a value-based purchasing program (VBP) for home health. Like hospital VBP, the program would penalize or reward select home health agencies based on quality of performance. The payment adjustment would be a penalty or bonus of up to 5 percent of Medicare payments in 2018 and 2019, increasing to 8 percent by 2021. The list of applicable quality measures can be found here

New joint replacement payment model

Added to the increasing list of innovative payment models tied to quality is CMS’s new “Comprehensive Care for Joint Replacement” program. Like ACOs and other alternative payment models, the new program would make hospitals accountable for the costs and quality of knee and hip replacements, the most common type of inpatient surgery for Medicare beneficiaries. Hospitals that fare comparatively well will be rewarded with bonuses, while those faring poorly will be forced to repay some of their costs. 

Florida hospitals get relief — but will still face deficit

Florida hospitals get relief — but will still face deficit

The standoff between the state of Florida and the Obama administration was settled Thursday when Governor Rick Scott announced a dismissal of his suit against the administration in exchange for certain hospital funds that had been withheld. 

The lawsuit arose after CMS announced it would not renew Florida’s “Low-Income Pool” (LIP) funding, which aids safety net hospitals through a Section 1115 waiver and was set to expire on June 30. Florida had received about $1.3 billion annually through the waiver. 

Florida alleged the federal government was coercing the state into expanding Medicaid by withholding the funds. 

Under Thursday’s settlement, Florida will receive $1 billion in LIP funds for the 2015-16 budget year, slightly less than the state has received in the past. But, in 2016-17 CMS will reduce the funding to $600 million. No promises were to made as to subsequent years. 

While the settlement is a near-term victory for Florida, shortfalls await both providers and patients if the state does not expand Medicaid or take other action to offset the impending cuts. 

$27 Million Nursing Home Boon Receives Final Approval

$27 Million Nursing Home Boon Receives Final Approval

On Thursday, the Georgia Department of Community Health approved a $27 million adjustment for select nursing facilities effective July 1. Governor Nathan Deal included the change is his latest budget proposal, which the General Assembly approved. 

The windfall will benefit nursing facilities that changed ownership from January 1, 2012, through July 30, 2014, and will come in the form of a Medicaid rate increase for SFY 2016.

According to DCH's report, the adjustment is "intended to recognize changes in cost related to operational changes implemented under new ownership." 

The Atlanta Journal-Constitution reports that controversy surrounds the decision, as two DCH board members who questioned the rate increase were ousted last September. 

More Than a 'Doc Fix': a Look Inside MACRA for Hospitals, CHCs

More Than a 'Doc Fix': a Look Inside MACRA for Hospitals, CHCs

As news outlets have widely reported, the U.S. Senate has followed the House in passing a measure to repeal Medicare’s payment formula, known as the Sustainable Growth Rate (SGR). The bill would replace the SGR formula with a new model tied to quality and value. This is another significant development in healthcare’s increasingly rapid shift toward alternative payment models. 

But the “doc fix” bill, titled the Medicare Access and CHIP Reauthorization Act (MACRA), contains numerous other items impacting health providers. Namely, the legislation offers much-needed (albeit short-term) breaks to hospitals and community health centers. These provisions include: 

  • Medicaid DSH cuts postponed: The Affordable Care Act’s cuts to Medicaid disproportionate share (DSH) payments would be further delayed under the bill. These cuts were to reduce federal subsidies to certain hospital serving a disproportionate number of uninsured patients. Perhaps due to many states’ declining to expand Medicaid under the ACA, the reductions have been postponed multiple times, and are now scheduled to begin in fiscal year 2018. 
  • Community Health Centers receive extension: Unlike its cuts to DSH payments, the ACA offered a bonus to designated Community Health Centers. This federal funding was slated to expire this year, but MACRA would extend it through fiscal year 2017. The nation's 1,302 CHCs would share a fund of $3.6 billion annually under the law. 

President Obama is expected to pass the bill, which received bipartisan support. 

Telemedicine Capsules

Telemedicine Capsules

Newest ACOs to be paid for more telemedicine

Medicare’s recently announced “Next Generation ACO Model” includes a waiver of the program’s existing restrictions on telemedicine reimbursement, allowing such ACOs to be paid for telehealth services in urban areas. Medicare’s existing reimbursement rules limit telehealth services to patients 1) in rural areas (Health Professional Shortage Areas) and 2) receiving care in specific facilities (“originating sites”). The waiver for Next Generation ACOs will extend reimbursement to services performed for patients in metropolitan areas and in their own residences, with some limitations. 

It does not appear this waiver will be extended to existing ACOs. Applicants for Next Generation ACOs may apply in either 2015 or 2016, with the first Letter of Intent due by May 1, 2015. 

Interstate licensure compact gaining steam

The Interstate Medical Licensure Compact, a proposal that could greatly benefit providers pursuing interstate telemedicine, has been enacted by four states and introduced in another 12. This marks a promising debut for the Compact, which was proposed in late 2014 by the Federation of State Medical Boards. 

While the Compact would still require physicians to apply for a license in every participating state before treating patients in that state, it would significantly streamline the licensing process. An interstate commission would administer the process and enforce the Compact’s recommended rules. These rules tie a physician’s eligibility to his/her licensure and good standing in — and a recommendation from — the physician’s “state of principal licensure.” 

The states that have enacted laws joining the Compact are Wyoming, South Dakota, Idaho, and Utah. If three more states join, which appears likely, the Compact will take effect in participating states. 

B&Co speaks at GPT conference 

Last week at the Georgia Partnership for Telehealth’s 2015 Conference in Savannah, Boling & Company presented on telemedicine law. The conference was a strong showing of telemedicine advocates, entrepreneurs and policymakers both in and outside of Georgia. Thanks to Ms. Paula Guy and the GPT team for hosting this event. 

OIG Pushes for Swing Bed Reform

OIG Pushes for Swing Bed Reform

In an increasingly difficult regulatory environment for rural health providers, the U.S. Office of Inspector General has recommended a cut to one of rural health’s few remaining lifelines. The OIG's recent recommendation takes aim at “swing bed” services offered by Critical Access Hospitals, proposing that reimbursements for such services be significantly reduced. 

Swing bed services allow certified Critical Access Hospitals to use their beds to furnish either acute or post-acute Skilled Nursing Facility-level care. Critical Access Hospitals are reimbursed for these services at 101 percent of the reasonable cost of the services — a common adjustment afforded to such hospitals. 

The report recommends that Critical Access Hospitals be reimbursed for swing bed services under the regular payment system for SNF-level services, both as a cost-saving measure for Medicare and because many such services are being offered within 35 miles of adequate, alternative SNF care (effectively defeating the purpose of the special CAH reimbursement). 

The OIG’s report does not address the possible ramifications of the proposed cut on the viability of Critical Access Hospitals. The recommendation still must be implemented by CMS before it becomes law. 

What does King v. Burwell mean for Georgia?

What does King v. Burwell mean for Georgia?

This week, the U.S. Supreme Court will hear oral arguments in King v. Burwell, the case that threatens to undo a critical element of the Affordable Care Act. The Court will consider whether the subsidies that have allowed many to purchase health insurance were legally awarded to consumers using the ACA's federally run exchanges, and whether those subsidies should now be taken away. 

The ACA called for federal health insurance exchanges to fill the void left by states choosing not establish their own exchanges. This void was larger than expected, as only 14 states opted to operate their own insurance exchanges. Consequently, 8.84 million Americans have signed up for insurance via the federally run exchange, HealthCare.gov. 

However, the provision calling for subsidies that would help make insurance affordable on the exchanges — the provision at issue in King — perhaps mistakenly limited those subsidies to “exchange[s] established by the state.” While other portions of the law suggest subsidies were intended to be available through state and federal exchanges, the challengers in King contend the law means what it says: subsidies are limited to state-run exchanges.

Georgia is one of the states that declined to establish an insurance exchange. Approximately 425,000 Georgians have purchased insurance through the federal exchange, 90 percent of whom receive subsidies. 

If the Supreme Court rules against the government in King, these half-million Georgians will lose their subsidies and face significantly heightened premiums. The effects of this change will likely be felt by anyone who holds private insurance in Georgia: unaffordable insurance means fewer insured, and fewer insured means higher premiums across the board

Such a ruling would reduce the financial support available to Georgians under the ACA to roughly zero, as the state has already rejected the law’s Medicaid expansion. From a practical standpoint, dismantling the law in such piecemeal fashion would continue to be highly problematic, given that much of the ACA would still impact Georgia. (For example, certain individuals and employers will still be mandated to purchase insurance.) 

The worst victim of this selective undoing of the ACA might be providers, as the law's reimbursement and disproportionate share cuts will remain in effect, but would not be offset by increased privately insured or Medicaid patients. Providers would also continue to bear the same amount of uncompensated care they did before the ACA. 

The Department of Health and Human Services has announced it is not pursuing a contingency plan in the event of an adverse ruling, though some Republican legislators have proposed alternatives to the law they have long maligned. The Court’s decision is expected in late June. 

 Gov. Deal’s Rural Health Committee Proposes Telemedicine Endeavor, Backs CON Program

Gov. Deal’s Rural Health Committee Proposes Telemedicine Endeavor, Backs CON Program

Governor Nathan Deal’s new rural health committee has revealed an ambitious program aimed at saving rural healthcare in Georgia. The Rural Health Stabilization Committee, created in March 2014, released a report Monday introducing a pilot program centered on hard-hit rural emergency departments. 

The program would use “hubs and spokes” — i.e. hospital hubs and off-site monitoring/diagnostics — in an effort to “ensure that each patient is being transported to the appropriate setting,” and “monitor chronically ill patients to help them avoid repeat trips to the hospital.” 

According to the report, the “spokes” would include telemedicine-equipped ambulances, school clinics (also relying heavily on telemedicine), smaller hospitals, and local physicians. The Committee’s stated goal in employing these off-site resources is “to prevent the over-utilization of the ED as a primary care access point.”

The Committee requested $3 million for implementation of the program, which would be piloted at four hospitals serving different rural areas.

CON Support

The Committee’s report also contained a formal recommendation in support of Georgia’s Certificate of Need (“CON”) program. This program has often been the subject of legislative debate, but the Committee firmly endorsed the CON process for its role in maintaining and protecting rural hospitals. 

Freestanding EDs No More?

While Monday’s report served primarily to advance the Rural Health Stabilization Committee’s first major project, it also marked a setback for an earlier initiative brought before the Committee. Last year the Committee considered a proposal by the Department of Community Health to facilitate the establishment of freestanding emergency departments in rural areas. While the rules governing such freestanding EDs remain in effect, the Committee’s report all but recalled the program, stating that reimbursement issues made it financially unworkable. 

Medicaid Expansion a Non-Starter

One way of immediately benefiting rural healthcare in Georgia was conspicuously absent from the committee’s report: the Affordable Care Act’s Medicaid expansion. Georgia Health News reports that Gov. Deal has never considered the Medicaid expansion a realistic outcome of the Committee.