Expanding The Map In Georgia

Going into the final days of the 2018 campaign, Democrat Stacey Abrams is in a neck-and-neck race with Republican Brian Kemp for the Georgia governor's race.  Kemp, who has not recused himself as Secretary of State and will remain in charge of counting the votes in his own race, has done everything he can to disenfranchise hundreds of thousands of Georgia Democratic voters in a race that will probably be decided by just tens of thousands of votes.  But if Abrams wins, it will be because of black women turning out at presidential election levels in order to expand Medicaid in the wake of a Republican-created public health crisis.

Money, lives, and change. Those three words could roughly summarize any political race, but seem especially important in the state today. The issues facing much of the Georgia electorate are fairly simple: The state is the fifth-poorest in the nation. Its median wages and minimum wages are both below the national average. Across all races, the poor are underserved, often lack insurance, and face remarkably high rates of mortality and morbidity from preventable diseases. The state has huge swaths of rural land whose communities often lack basic services. Outside the urban oasis of the Atlanta metropolitan area, Georgia faces as many challenges to the health and welfare of its citizens as any state in the country. The most important policy issues in the governor’s race boil down to each candidate’s ability to fill those gaps.

But there’s a special dimension in Georgia that could very well mean the difference next week. The state is in the grip of a crisis, one that affects, in particular, the lives of black women like Abrams and like those who form the foundation of her coalition and organizing base. Across the country, black women’s health—particularly the fate of mothers and their newborns—is in peril, and mortality rates have spiked. Nowhere is this truer than in Georgia: The issue has been front and center in mobilizing black women, and it’s central to the policy platform of the candidate seeking to be the first black woman governor in U.S. history. To black women in Georgia, the stakes of the debate over health-care access are no less than life or death.

Perhaps no one is more aware of those stakes than Joy Baker. Baker is an ob-gyn in Thomaston, a little more than an hour south of Atlanta. Thomaston is the picture of a small southern town. It has a Main Street and a Church Street. The town was built around a mill that’s long gone, but it’s still a hub for basic services for people living in the deeply rural surrounding areas. For hundreds of poor, rural women, Baker’s practice in the Upson Regional Medical Center is the sole lifeline. Half of the rural areas in Georgia don’t have any doctors’ offices, hospitals, or clinics where women can seek obstetric care. That means Baker is responsible not just for the care of people in and around Thomaston, but also for women from an average of 40 miles away.

“Twenty-five percent of my patient population lives below the poverty line, on less than $17,000 per year,” Baker told me. Her patients are disproportionately African American. The vast majority of them are on Medicaid, which by federal mandate covers pregnancy and perinatal services for women under or near the poverty line. They often have to rely on booking Medicaid vans three days in advance to get to doctor visits because they can’t afford gas or don’t have cars. “Some of my patients can’t even afford a prescription at Walmart for $4,” Baker says.

Baker told me that at least 60 percent of her patients qualify as having “high-risk” pregnancies, often because of obesity, high blood pressure, diabetes, and other comorbidities common among poor and rural populations. For most of those women, the nine-plus months of pre- and postnatal care they are guaranteed under federal law are the only regular primary and preventive care they’ll receive in a given year.

“I see an average of 30 to 40 patients per day in my clinic,” Baker says. “That’s way more than I’d like to be seeing, but I have to be able to accommodate.” Her average week includes two 24-hour shifts in a row, during which she alternates between working in the maternity ward, in the emergency room, and in the operating rooms of her hospital, as well as in her clinic across the street. For her and the one other doctor in her practice, it’s a Herculean task just to provide an adequate standard of care—often squeezed into 10-minute visits.

Baker’s patients often have chronic conditions that her office can address only while they’re there for pregnancy-related care. That includes the mental-health problems that have come to characterize rural American life. Most often, the mental-health dangers associated with pregnancy and childbirth involve postpartum depression, but Baker sees women who are already depressed, suffering from undiagnosed disorders, or having suicidal ideations before and during pregnancy. She’s also obtained a special license to treat opioid addiction among women who want to rehabilitate themselves during pregnancy. “We don’t have any mental-health services and supports,” Baker told me.

Her office tries to confront those challenges head on, counseling patients and finding psychiatric services for them. And Baker utilizes group prenatal care—an attempt to alleviate patients’ potential isolation and to provide women with support networks that can help their pregnancy outcomes.

But there are mounting structural issues that even Baker’s ingenuity and willpower can’t fix. Dozens of labor-and-delivery units across the state have faced closures in the past two decades. Eight rural hospitals in Georgia have shuttered in the past eight years. And that’s amid other stresses on rural and maternal health in Georgia, like the opioid crisis.

The biggest challenge is still insurance. Even though poor pregnant women are entitled to Medicaid coverage, that coverage is difficult to navigate, and under state law it comes with a firm expiration date. “Medicaid usually ends about six to eight weeks after the delivery,” Baker says. “But the American College of Obstetricians and Gynecologists has come out with a strong suggestion that we follow those patients for the entire year.” Baker estimates that after those six to eight weeks, she won’t see 90 percent of her patients until they’re pregnant again. In the dangerous medical crucible that is the first few weeks after childbirth, she estimates that some 30 percent of her patients won’t even make it to their first postpartum visit.

For Baker, the only solution is the one that’s at the center of the Georgia governor’s race: Medicaid expansion. “I feel like I’m kind of piecing things together here, and I would love to have the resources to do the things we need to do,” she told me. Because Medicaid expansion would offer health insurance to more low-income adults than the state’s current program, it would provide many residents of Thomaston with the first steady guarantee of coverage in decades. That would give them access to more regular care and reduce their own health-care costs. And it would give Baker’s patients year-round access to her services.

The Medicaid expansion would also signal that the state is serious about assisting Baker on the front lines of the crisis—and that it cares about her, too. “As a black woman, it is just really unacceptable to me that black women are more likely to die” than white women, Baker says. “I take it personally because I am a black woman and I would like to live if I should decide to have a baby.”

Nearly five million Georgians live outside the Atlanta metro, effectively the entire population of Alabama.   A lot of Georgia outside Atlanta is rural and poor and a full third of Georgia's population is black.  You can imagine then why Kemp is so eager to disenfranchise as many black voters as he can, and why Abrams appealing to black women -- one-sixth of the state's population -- to help her tackle the health care crisis is such an existential threat to the GOP there.

If black women showed up to vote at 2012 levels, Kemp would be obliterated.

That's how Abrams wins.