ATLANTA — There is growing concern in Georgia that the U.S. Senate’s proposed healthcare plan may penalize the state for not expanding its insurance program for the poor and disabled under current federal law.

Georgia is one of 19 states that did not expand Medicaid under the Affordable Care Act, with officials citing the long-term expense. The state is also one of the lowest spenders in the nation when it comes to Medicaid.

The Senate’s proposal would put caps on Medicaid spending based on historical costs. Some Georgia leaders have said they are concerned that the plan essentially rewards the states that expanded their Medicaid programs with more funding.

“I think we should be congratulated,” State Sen. Renee Unterman, R-Buford, told reporters Friday. “We’ve saved a lot of federal money, and instead of punishing us and taking away money from us, we should be rewarded.”

Her words echoed similar comments made by Gov. Nathan Deal, who told the Atlanta Journal-Constitution in an interview Thursday that he’s concerned about the Senate bill’s potential impact on Medicaid. He did not, however, say he opposes the measure.

Deal told the AJC that Georgia shouldn’t be “punished” for choosing not to expand Medicaid. “We want to be treated fairly,” he said.

Unterman, who chairs the Georgia Senate Health and Human Services Committee, said she is hopeful that Georgia’s Medicaid funding will be on par with what expansion states receive in the final version of the plan. She said she wants to see the bill progress.

The state senator also sent Georgia’s U.S. senators a letter urging them to be aware of the “far-reaching effects of the opioid crisis and how the proposed cuts to Medicaid could exacerbate the financial stress that opioid overdoses are putting on the emergency medical system.”

Senate Republicans have proposed devoting $45 billion for opioid addiction treatment over a decade, but critics say that this approach would be no replacement for insurance coverage. It’s also unclear if it would be sufficient to offset the proposed cuts to Medicaid.

Overall, the Senate plan is projected to cut Medicaid spending by 26 percent in 2026, according to the nonpartisan Congressional Budget Office. That would drop to 35 percent in two decades.

Laura Harker, a health policy analyst with the left-leaning Georgia Budget and Policy Institute, said this week that — unlike the earlier House version that passed — the Senate version includes measures designed to help non-expansion states such as Georgia.

“But those efforts would be term-limited for a certain number of years, and it would still really incentivize states to spend less instead of investing more in the health of people on Medicaid,” she said.

Either way, the Republican bill is expected to land a blow to Medicaid here in Georgia, Harker said. The House version was projected to lead to $4 billion in cuts over 10 years; the Senate plan could result in even deeper cuts over time.

That drop in federal funding will shift costs to the state and leave state legislators with difficult decisions to make on cuts to Medicaid eligibility and benefits, Harker said.

The proposal has prompted an outcry from the state’s hospitals, which stand to lose revenue under the plan. Earl Rogers, who is president of the Georgia Hospital Association, called the bill a “giant leap backward” in a statement Thursday.

“It’s important to understand that cuts to Medicaid take away resources not only from Medicaid patients, but from the entire healthcare delivery system,” Rogers said.

That means, he added, that tough decision will have to be made on which services to scale back or eliminate entirely, which hurts all patients. Meanwhile, non-paying patients will still show up at the emergency room, adding to the financial strain on hospitals.

“The rural hospitals, by the nature of their payer mix, are going to have a much more substantial hit,” said Jimmy Lewis, CEO of HomeTown Health, which represents dozens of small hospitals in the state.

Georgia’s Medicaid program is already one of the leanest in the country, Lewis noted.

“You start cutting anything out of something that is that thin, you go straight to muscle on the bone and it’s pretty short order death knell,” he said.

Jill Nolin covers the Georgia Statehouse for CNHI’s newspapers and websites. Reach her at jnolin@cnhi.com.