Georgia launches Medicaid expansion in closely watched test of work requirements

Georgia is offering a new bargain to some adults without health insurance beginning Saturday: Go to work or school and the state will cover you.

But advocates decry the plan, which will insure far fewer people than a full expansion of the state-federal Medicaid program, as needlessly restrictive and expensive.

The program is likely to be closely watched as Republicans in Congress push to let states require work from some current Medicaid enrollees. Georgia would be the only state that requires Medicaid recipients to meet a work requirement.

Democratic President Joe Biden’s administration is unlikely to approve work requirements, but a future Republican president could, said Madeline Guth, a senior policy analyst with KFF, a nonprofit that studies health care issues.

“I think there will be a lot of eyes on Georgia,” Guth said.

Georgia is one of 10 remaining states that hasn’t expanded Medicaid eligibility to include individuals and families earning up to 138% of the federal poverty line, or $20,120 annually for a single person and $41,400 for a family of four.

Medicaid expansion was a key part of President Barack Obama’s health care overhaul in 2010, but many Republicans have fought it, including Georgia Gov. Brian Kemp, a Republican.

Instead, Kemp is limiting expanded coverage to adults earning up to 100% of the poverty line — $14,580 for a single person or $30,000 for a family of four. And coverage is only available if able-bodied adults document they are working, volunteering, studying or in vocational rehabilitation for 80 hours per month.

It fits Kemp’s argument, as he tries to drag his party away from former President Donald Trump, that the GOP needs to show tangible conservative achievements for everyday people

“In our state, we want more people to be covered at a lower cost with more options for patients,” Kemp said in his State of the State speech in January.

Those who earn more will remain eligible for subsidized coverage, often with no premium cost, on the federal marketplace. Kemp’s administration argues commercial coverage is better because it pays providers more than state-set Medicaid rates.

The Trump administration ultimately gave permission to 13 states to impose work requirements on some Medicaid recipients. The Biden administration revoked all those waivers in 2021, ruling work isn’t a primary purpose of Medicaid. But Kemp’s administration won a federal court fight last year to preserve Georgia’s plan, in part because it applies to new enrollees and not current Medicaid recipients.

Caylee Noggle, commissioner of the Department of Community Health, told The Associated Press this week that Pathways to Coverage is a “Georgia-specific approach” that could insure up to 100,000 people in its first year.

But 100,000 is far less than the nearly 450,000 uninsured Georgians that the Urban Institute estimates could gain coverage with a full Medicaid expansion.

Others say the nearly $118 million in state money, combined with another $229 million in federal money, isn’t nearly enough to cover 100,000 people. The liberal-leaning Georgia Budget & Policy Institute estimates the funds will cover fewer than 50,000 people.

And state taxpayers will pay much more per person. Partly at the behest of Democratic Georgia Sen. Raphael Warnock, the federal government is offering to pay 95% for a full Medicaid expansion for two years and 90% afterward. Instead, refusing federal largesse, Georgia will continuing paying the same 34.2% share the state foots for its existing Medicaid program and spurn extra federal funding that has been pledged.

“The inappropriately named ‘Pathways to Coverage’ will cost Georgia more money and cover fewer people than if the state simply joined 40 other states in expanding Medicaid,” Warnock said in a statement to the AP.

“While state politicians continue playing games with people’s lives, Georgians are dying because they can’t afford the health care they need,” he said.

Noggle and other Georgia officials say working, studying or volunteering leads to improved health, a key argument for why those requirements should be part of a health insurance program.

But those who treat uninsured people say many can’t work because they are in poor health.

“The reason they have their challenges, that they can’t work, is because they’ve got a mental illness or they’ve got a medical illness that is affecting their ability to do that,” said Dr. Reed Pitre, an addiction psychiatrist and interim chief medical officer at Mercy Care, a federally subsidized nonprofit in Atlanta.

Enrolling people in the new program is a priority for Mercy Care, Pitre said, while noting that no one will qualify until a month after they establish compliance with the work requirement.

The Kemp administration anticipates the program will serve people in low-wage jobs who can’t afford employer insurance, as well as students. The state also is redetermining eligibility for 2.4 million adults and children now covered by Medicaid.

Georgia has delayed decisions on people it thinks are ineligible for regular Medicaid but could transfer to the Pathways program, Noggle said.

Either way, once on the new program, people will have to meet activity requirements or lose coverage beginning the following month, which could impact thousands. When Arkansas imposed work requirements in 2018 for some adults, more than 18,000 people lost coverage in less than a year.

Georgia will be different, Noggle argued. Recipients will only have to certify compliance with activity requirements for the first six months of the year.

“I think we are going to make it as easy as possible as we can for our members to verify their eligibility,” she said.

But only time will tell. Kemp’s expansion plan in Georgia could provide a blueprint for other states and other Republicans looking to require more from those on Medicaid.

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