The state's plan, which has drawn opposition from ACA supporters, proposes to jettison consumer access to the federal insurance enrollment website — healthcare.gov — and instead send people buying individual policies to private companies to choose coverage.

It would also cap how much is spent on premium subsidies, which could mean some consumers would be put on a wait list if they needed financial help to buy a plan. ACA subsidies are not capped in any state now.

The state's proposal is the boldest yet under new guidelines the Trump administration issued in 2018 and 2019. Those guidelines widen the opportunity for states to try different approaches to expanding coverage and lowering costs for consumers who buy insurance themselves because they don't get it through their job or a government program.

Georgia officials say the initiative would help drive down insurance costs — for the state and consumers — by providing more choices, permitting cheaper plans to be offered and capping financial assistance to consumers.

Last year, 450,000 Georgians enrolled in a health plan through the ACA, 88 percent of whom received a federal subsidy to help pay their premium.

Nationwide, 11 million people got health insurance through the marketplaces in 2019.

Ryan Loke, who handles special projects for Gov. Kemp, said state officials expected that the federal government would need more details as it reviewed the proposal. Georgia's request "is a first in the nation approach to reforming the individual marketplace, and given the novelty to the approach — we expected that supplemental information would be required, and have worked with our federal partners to begin putting together the necessary information for their review."

But critics in Georgia and two detailed analyses released in late January have slammed the proposal, initially submitted for federal review Dec. 23.

"If CMS were to approve this waiver in its current form, I would expect lawsuits on behalf of Georgia consumers and families," said Laura Colbert, executive director at Georgians for a Healthy Future, a consumer group based in Atlanta that has called the proposal "terrible for Georgians." "The proposal would encourage enrollment in substandard plans and likely cause many Georgians to lose coverage. People with preexisting health conditions would be put at risk."

Such a lawsuit would add to the mountain of litigation surrounding the ACA, including two cases before the Supreme Court and an appeals court decision in December that threatens the entire law.

A decision favoring Georgia's proposal would also add to the continuing high-profile political debate over the fate of the ACA.

"This is the first time a state has tried to take advantage of the Trump administration's new approach to waivers, to implement some of the ideas the administration's been pushing," said Justin Giovannelli, a health policy expert at Georgetown University in Washington, D.C. "Other states and a lot of lawyers are watching closely."

Georgia is making the request for new marketplace rules under a procedure known as a 1332 waiver. Under the law, states using such a waiver must still hew to strict rules set by the ACA.

For example, a state experiment can't cost the federal government more money (for premium subsidies), raise costs for consumers on average, or result in fewer people gaining coverage than would be the case without the experiment.

Georgia's proposal is in two parts. The first part seeks to establish a reinsurance program that picks up the tab for the care of high-cost patients using both state and federal funds. That allows insurers to keep costs down so they can offer lower premiums to consumers. The program, if approved, would go into effect in January 2021.

CMS says it will evaluate that part separately, with an eye toward swift evaluation and approval after a 30-day comment period. Final approval would make Georgia the 13th state to gain permission to use a reinsurance program.

Kemp has dubbed Georgia's proposal for more far-reaching changes, starting in January 2022, the "Georgia Access Model."

Instead of using the federal marketplace, Georgia would require consumers to enroll in coverage directly through insurance companies, brokers or private-sector websites.

At the same time, Georgia proposes to take over the administration of subsidies and cap the amount each year.

Insurers would also be allowed to sell plans that don't comply with ACA requirements, under Georgia's request. For example, one proposed type of plan could cover just half of a consumer's costs for care, as opposed to the 80 percent to 90 percent levels of ACA's silver and gold plans. Such a plan would have lower premiums but sharply higher out-of-pocket costs (such as deductibles and copays) if extensive care was needed.

Insurers and brokers would also be allowed to promote cheaper plans that don't cover all the benefits required of current ACA plans.

Two studies released late last month concluded that Georgia's proposal does not meet the guidelines for marketplace experiments set out in the ACA.

"There are very clear errors in Georgia's proposal," said Christen Linke Young, co-author of one of the reports and a fellow at the Brookings Institution in Washington, D.C. "The numbers don't add up, and the proposal doesn't meet the standards the ACA established. The plan would harm consumers if approved, and we don't believe it can or should be approved."

The second study, by the left-leaning Center for Budget and Policy Priorities (CBPP), also in Washington, concluded that Georgia's proposal would "cause thousands of Georgians to lose coverage and … likely also leave many with less affordable or less comprehensive coverage than they would otherwise have."

If premiums or enrollment rose by 10 percent, for example, CBPP calculates that Georgia would have to deny subsidies to between 15,000 and 34,000 people under the proposed cap.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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