ATLANTA (AP) — Georgia state officials meanwhile expected their fresh Medicaid program — the only one in the country with a work requirement — would provide health insurance to 25,000 low-income people and possibly tens of thousands more.
But a year after its launch, Pathways to Coverage has about 4,300 members, far fewer than officials had projected and only a minuscule fraction of the state’s roughly half a million residents who could be covered if Georgia, like 40 other states, agreed to a full expansion of Medicaid.
Georgia Governor Brian Kemp’s office has presented Pathways as a compromise that would enroll people in Medicaid while helping them exit the program. Kemp’s office blames the Biden administration for delaying the program’s launch and says it is redoubling its efforts to get people into the program.
Health care and public policy experts say the enrollment numbers – which are dismal even compared to Pathways’ goals projected by Kemp’s office – reflect a fundamental flaw: The workload is simply too burdensome.
“It is clear that the Georgia Pathways experiment is a major failure,” said Leo Cuello, research professor at Georgetown University’s McCourt School of Public Policy.
Pathways requires all recipients to work, volunteer, complete training or complete vocational rehabilitation at least 80 hours per month, and limits coverage to able-bodied adults who earn no more than the federal poverty level, which is $15,060 for an individual 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, are drug addicts or face myriad other obstacles to finding work. Then there are people with informal jobs where it is impossible to document their work hours.
In rural Clay County in southwest Georgia, Dr. Karen Kinsell said many of her patients are too ill to work. Over the past year, Kinsell has suggested about 30 patients to Pathways who might qualify, but none have signed up.
“I think the general idea is that it would be too much work, too complicated and would have little benefit,” she said.
Simply going online every month and submitting proof of employment can be a significant obstacle, says Harry Heiman, a professor of health policy at Georgia State University.
“For low-income people who are worried about how they’re going to keep their housing and put food on the table, one more thing they have to do is often one thing too many,” he said.
The program’s impoverished performance so far could have consequences beyond Georgia. Republicans in other states have also proposed in recent months that work be a prerequisite for receiving Medicaid. In Mississippi, Lieutenant Governor Delbert Hosemann cited Georgia’s Pathways program as a model in February.
A second term for former President Donald Trump would significantly improve the prospects for such programs. The Trump administration approved work requirement plans under Medicaid in 13 states, only to have those waivers revoked by the Biden administration in 2021. Pathways survived after a legal battle.
Georgia launched the program on July 1, 2023, without much fanfare, and public health experts say they have seen little effort to promote it or recruit people to join.
The launch coincided with a federally mandated review of the eligibility of all 2.7 million Medicaid recipients in the state after the end of the COVID-19 health emergency – another challenging task for Georgia authorities.
Still, they haven’t scaled back their expectations for enrollment. A few days before the launch, Caylee Noggle, then commissioner of the Georgia Department of Public Health, told the Associated Press that Pathways could cover up to 100,000 people in its first year. The 25,000 estimate was included in the state’s 2019 Pathways application.
Garrison Douglas, a spokesman for Kemp, said in a statement that Pathways has received “extraordinary interest from thousands of able-bodied, low-income Georgians” and that the state is “still fighting to reclaim time stolen from it by the Biden administration.”
The program was supposed to start in 2021, but the Centers for Medicare and Medicaid Services objected to the work requirement in February and later overturned it. Georgia sued and a federal judge reinstated the work requirement in 2022.
According to the Georgia Department of Public 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 television and radio, while an “intensive” outreach campaign is 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 is general agreement even among Pathways supporters that the state could have done a better job of marketing. But he said a fundamental tenet of Pathways — moving people into private health insurance through employment, job training or other qualifying activities — is sensible, especially given that many primary care physicians in the state are no longer accepting fresh Medicaid patients.
For critics, the actual number in the first year is all the more galling considering how many people a full expansion of Medicaid could insure, at least initially, at no additional cost to the government.
An analysis by the left-leaning Georgia Budget and Policy Institute found that if fully expanded, Georgia’s Medicaid program would receive so much more federal funding that it could serve 482,000 residents in the first year at the same cost as 100,000 Pathways recipients.
In North Carolina, where Medicaid was fully expanded in December, nearly 500,000 people were enrolled in half the time Pathways was in effect.
This comprehensive expansion of Medicaid was a central part of President Barack Obama’s 2010 health care reform. In return for offering Medicaid to nearly all adults earning up to 138 percent of the federal poverty level, states receive more federal funding for newly insured people.
The higher eligibility limit is $20,783 per year for an individual and $43,056 for a family of four. None of the 40 states that have adopted the agreement require recipients to work to qualify.
But Kemp, like many other Republican governors, rejected a full expansion, arguing that the costs to the state would be too high in the long run.
Republicans in the Georgia state legislature had considered the possibility of a full expansion in 2024, but then abandoned the plan.
Georgia authorities are currently showing no signs of abandoning Pathways, which is set to expire at the end of September 2025. But in February, the state sued the Biden administration to extend it until 2028. A federal judge heard the arguments last month.
