ATLANTA– Meanwhile, Georgia officials expected their new Medicaid plan, the only one in the country with a work requirement, to provide health insurance to 25,000 low-income residents and possibly tens of thousands more.
But a year after its launch, Pathways to Coverage has about 4,300 members. That’s far fewer than state officials had predicted, and just a fraction of the roughly half-million state residents who could be insured if Georgia joins 40 other states in fully expanding Medicaid.
Georgia Gov. Brian Kemp’s office has presented Pathways as a compromise that would add people to Medicaid while helping them get off it. Kemp’s office blames the Biden administration for delaying the program’s launch and says it is redoubling efforts to enroll people.
Health and public policy experts say the enrollment numbers, which even compare poorly with what Kemp’s office said Pathways could achieve, reflect a fundamental flaw: The work requirement is simply too burdensome.
“It is clear that the Georgia Pathways experiment is a colossal failure,” said Leo Cuello, a research professor at Georgetown University’s McCourt School of Public Policy.
Pathways requires all recipients to show at least 80 hours of work, volunteer work, education or vocational rehabilitation per month. It also limits coverage to able-bodied adults who earn no more than the federal poverty level, which is $15,060 for a single person and $31,200 for a family of four.
Cuello noted that the program makes no exceptions for people who care for children or other family members, lack transportation, suffer from drug addiction or face a myriad of other barriers to employment. Then there are those who work informal jobs that make it impossible to document their hours.
In rural Clay County in southwest Georgia, Dr. Karen Kinsell said many of her patients are too sick to work. Kinsell has suggested Pathways to about 30 patients in the past year who might meet the requirements, but none have signed up.
“I think the general idea is that it would be too much work and too complicated, with little benefit,” she said.
According to Harry Heiman, a professor of health policy at Georgia State University, simply submitting proof of employment online every month can be a major hurdle.
“For low-income people who are worried about housing and putting food on the table, one more thing is often one thing too many,” he said.
The program’s poor performance so far could have implications beyond Georgia. Republicans in other states have also proposed requiring work to qualify for Medicaid in recent months. In Mississippi, Lt. Gov. Delbert Hosemann in February cited Georgia’s Pathways program as a model.
A second term for former President Donald Trump would greatly increase the prospects for such programs. The Trump administration approved Medicaid work requirement plans in 13 states, but the Biden administration revoke these exemptions in 2021. Pathways survived a lawsuit.
Georgia launched the program on July 1, 2023 with small brass bandand public health experts say little effort has been made to promote it or sign people up.
The launch coincided with a federally mandated eligibility review of all 2.7 million Medicaid recipients in the state following the end of the COVID-19 public health emergency, another challenging task for Georgia officials.
Still, they haven’t scaled back their enrollment expectations. Days before the launch, then-Georgia Department of Community Health Commissioner Caylee Noggle told The Associated Press that Pathways could reach up to 100,000 people in its first year. The estimate of 25,000 was in the state’s 2019 application for Pathways.
Garrison Douglas, a spokesman for Kemp, said in a statement that Pathways had “received extraordinary interest from thousands of low-income, healthy Georgians” and that the state “continues to fight to reclaim the time stolen from it” by the Biden administration.
The program was set to start in 2021, but the Centers for Medicare and Medicaid Services objected to the work requirement in February and later repealed it. Georgia sued, and a federal judge reinstated the work mandate in 2022.
According to the Georgia Department of Community Health, Pathways had 4,318 members as of June 7, 2024. The agency said in an email that promotional efforts included social media content and streaming ads on TV and radio, while a “robust” outreach campaign was planned.
“Pathways deserves more time to see if it reaches its potential,” said Chris Denson, director of policy and research at the conservative Georgia Public Policy Foundation.
Denson said there’s general agreement even among Pathways supporters that the state could have done a better marketing job. But he said a fundamental tenet of Pathways — getting people to transition to private insurance through work, job training or other qualifying activities — is sound, especially given that many primary care physicians in the state aren’t accepting new Medicaid patients.
Critics find the actual first-year figure all the more galling given the number of people who could be covered by full Medicaid expansion without additional costs to the state, at least initially.
An analysis by the left-leaning Georgia Budget and Policy Institute found that Georgia’s Medicaid program would receive so much more federal funding at full expansion that the program could cover 482,000 residents in its first year for the same cost as 100,000 Pathways recipients.
North Carolina, which fully expanded Medicaid in December, has enrolled nearly 500,000 people in about half the time Pathways has been in effect.
That broader Medicaid expansion was a key part of President Barack Obama’s 2010 health care overhaul. In exchange for offering Medicaid to nearly all adults with incomes up to 138% of the federal poverty level, states would get more federal funding for the newly insured.
The higher limit for eligibility is $20,783 per year for a single person and $43,056 for a family of four. None of the 40 states that have accepted the deal require recipients to work to qualify.
But Kemp, like many other Republican governors, rejected full expansion, arguing that the long-term costs to the state would be too high.
Republicans in the Georgia Legislature have raised the possibility of full expansion in 2024 before to give up the effort.
For now, Georgia officials show no signs of giving up on Pathways. The program expires at the end of September 2025. But in February, the state will accused the Biden administration to try to extend it until 2028. A federal judge heard the arguments last month.
