Georgia’s Medicaid Plan: A Cautionary Tale on Work Requirements

Drozd Irina / shutterstock.com
Drozd Irina / shutterstock.com

Many Republicans in Congress are pushing to implement work requirements for Medicaid nationwide, arguing that such measures will promote self-sufficiency and reduce dependency on government aid. Georgia’s Pathways to Coverage program, which includes a work requirement, has become a focal point in this debate.

The program’s underwhelming performance, with only 4,300 enrollees out of the projected 25,000, underscores potential challenges and flaws in such an approach. If Georgia’s model continues to struggle, it could significantly influence the national conversation, providing ammunition to opponents who argue that work requirements are impractical and overly burdensome for vulnerable populations.

Georgia Governor Brian Kemp’s office has touted Pathways as a middle-ground solution to add people to Medicaid while facilitating their transition through employment. The governor’s office blames the Biden administration for delaying the program’s start and asserts that efforts to increase enrollment are being intensified.

However, health and public policy experts argue that the low enrollment figures indicate a fundamental flaw: the work requirement is overly burdensome. Leo Cuello, a research professor at Georgetown University’s McCourt School of Public Policy, described the program as a “huge failure.”

Pathways mandates that all recipients demonstrate at least 80 hours of work, volunteer activity, schooling, or vocational rehabilitation each month. It also restricts coverage to able-bodied adults earning no more than the federal poverty line ($15,060 for a single person and $31,200 for a family of four). The program does not account for individuals facing significant barriers to employment, such as caregiving responsibilities, lack of transportation, addiction issues, or informal jobs that are difficult to document.

Dr. Karen Kinsell has reported that many patients are too ill to work. Over the past year, she has recommended Pathways to about 30 patients who might meet its criteria, but none have enrolled. She believes that the perceived complexity and effort required for what is viewed as minimal benefit discourages potential participants.

The program’s disappointing performance could have broader implications, as other states, particularly those led by Republicans, have shown interest in similar Medicaid work requirements. Mississippi’s Lieutenant Governor Delbert Hosemann cited Georgia’s Pathways program as a model earlier this year.

The potential return of Donald Trump to the presidency could strengthen the outlook for such programs. The Trump administration had approved Medicaid work requirements in 13 states, only for the Biden administration to revoke them in 2021. Georgia’s Pathways program persisted after a legal battle reinstated the work mandate in 2022.

Public health experts have noted a lack of significant effort to promote Pathways or sign people up. The program launched on July 1, 2023, coinciding with a federally mandated review of the eligibility of all 2.7 million Medicaid recipients in Georgia following the end of the COVID-19 public health emergency.

Despite these challenges, officials did not lower their enrollment expectations. Shortly before the launch, former Georgia Department of Community Health Commissioner Caylee Noggle estimated that Pathways could cover up to 100,000 people in its first year, based on the state’s 2019 application for the program.

Garrison Douglas, a spokesperson for Governor Kemp, stated that Pathways had garnered “extraordinary interest” from thousands of low-income Georgians. The state was working to recover lost time due to the Biden administration’s delays.

As of June 7, 2024, the Georgia Department of Community Health reported that Pathways had 4,318 enrollees. The agency indicated that promotional efforts included social media content and streaming ads, with a more comprehensive outreach campaign in the planning stages.

Chris Denson, director of policy and research at the conservative Georgia Public Policy Foundation, believes Pathways deserves more time to realize its potential. He acknowledged that marketing efforts could have been better. However, he maintains that the program’s core principle of transitioning individuals to private insurance through work or other qualifying activities is fundamentally sound.

Critics argue that the program’s meager first-year enrollment figures highlight the potential benefits of a full Medicaid expansion, which could initially cover many more people at no additional cost to the state. For instance, North Carolina, which expanded Medicaid in December, has enrolled nearly 500,000 people in about half the time Pathways has been operational.

Despite the challenges, Georgia officials remain committed to Pathways. The program is set to expire in September 2025, but the state has sued the Biden administration to extend it until 2028.