ATLANTA (AP) — The Georgia Senate on Thursday passed a plan to loosen health care permitting that proponents say will create new options for patients, as Democrats made a last-ditch attempt to expand health care coverage for lower-income adults.

Senators voted 43-11 for House Bill 1339, sending it back to the House for more debate. It’s likely to face pushback there from opponents who warn greater competition will undercut rural hospitals by drawing away the best-paying patients.

“It is not a wholesale elimination of certificate of need requirements,” Sen. Bill Cowsert, an Athens Republican, said of the Senate approach. “We’re targeting certain areas where we want to make it easier to provide medical services to Georgians.”

Certificates of need, in place in Georgia since the 1970s, require someone who wants to build a health facility or offer new services to prove an expansion is needed. The permits are meant to prevent overspending that would increase health care costs.

One key sticking point is likely to be whether to let outpatient surgery centers serve multiple medical specialties without a state permit, called a certificate of need. The Senate bill would let physicians from multiple specialties share one surgery center. The House has opposed such a move.

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The Senate measure could also allow the historically Black Morehouse School of Medicine to open a hospital in central Atlanta that could provide services once offered by the now-shuttered Atlanta Medical Center. It would also allow a hospital to open without a permit in any rural county where a prior hospital has been closed for more than 12 months. That could allow a hospital in the southwest Georgia town of Cuthbert that closed in 2020 to reopen.

The bill also includes a study committee to examine whether Georgia’s state-federal Medicaid program should be expanded to cover more lower-income adults. Right now, for many adults who make less than than the federal poverty level, or about $15,000 a year, the only option is Gov. Brian Kemp’s Pathways program. It requires adults to prove 80 hours a month of work, study or volunteering. Although hundreds of thousands of Georgia adults below the poverty line are uninsured, only a few thousand have attained Pathways coverage so far.

“Medicaid expansion is what you need to take care of all these folks,” said Sen. David Lucas, a Macon Democrat who introduced a separate expansion bill this year. He voted for Thursday’s bill, saying he wanted negotiators to consider full expansion when they meet to work out differences between House and Senate bills.

While some states have repealed certificate-of-need laws, Georgia is among the majority of states still using them. Incumbent hospitals and health care providers often oppose new developments. Those who dislike the certificates say they prevent needed competition and unfairly protect local monopolies.

“The Senate passed a measure today that would ensure that every Georgian, regardless of where they live, would have an opportunity to access quality care in their community,” Lt. Gov. Burt Jones, a Republican, said in a statement. Jones has advocated for full repeal of the permits

But Democrats say that new medical facilities in underserved areas won’t be able to sustain themselves without more insured patients.

“How does this bill allow a hospital operator, whether it’s 20 minutes from here or four hours from here, to avoid operating at a significant loss under the current mix of uncompensated care?” asked Sen. Jason Esteves, an Atlanta Democrat.

Now in Georgia, physicians can open a surgery center serving only their medical specialty without a permit. The Senate plan doesn’t directly say physicians can open a surgery center that provides medical procedures across multiple specialties. But it does say physicians from different specialties can share operating rooms, which means one building can be used for any procedure. Sen. Billy Hickman, a Statesboro Republican who supported the bill, said surgery centers skim off lucrative businesses from hospitals.

“They are not open seven days a week like our hospital is,” Hickman said. “They’re not open 24 hours a day like our hospital. They don’t have to take everybody that walks in the way our hospital does.”

The Senate plan would also abolish requirements for permits for outpatient birthing centers and imaging centers, which provide X-rays, CAT scans and PET scans.

The bill would let new hospitals be built in counties with less than 50,000 residents, as long as they agree to provide a certain amount of charity care, join the statewide trauma system and provide “comprehensive behavioral health services.”