Georgia is now the only state with work requirements under Medicaid


Georgia is now the only state in the U.S. to implement work requirements in its Medicaid program — an achievement that many Republican lawmakers across the country will be watching closely.

But unlike Republican-led states' previous attempts to impose work requirements in Medicaid, Georgia's efforts are expected to increase the number of people with health insurance rather than strip coverage from untold numbers of low-income residents. That allowed it to stand up in court, although critics still deride the program as complicated, ineffective and expensive.

“Pathways to Coverage,” which began July 1, comes as House Republicans in Congress are pushing to expand work requirements in the nation's safety net programs, particularly Medicaid and food stamps.

There is no federal work mandate for Medicaid, but 13 states received permission during the Trump administration to require existing enrollees to work, volunteer or meet other criteria to maintain their health coverage. In Arkansas, the only state to implement work requirements and end coverage, more than 18,000 people were disenrolled in 2018 before the health insurance waiver was invalidated by a federal court.

States paused their initiatives due to litigation or the Covid-19 pandemic, and then the Biden administration withdrew the waivers. But Georgia objected to the withdrawal, and in August 2022, a federal judge ruled in the state's favor and allowed it to implement Pathways to Coverage.

Who can protect themselves and how

Georgia has the strictest Medicaid eligibility requirements in the country. It is one of 10 states that have not expanded the program to all low-income adults under the Affordable Care Act. Parents are eligible only if they earn less than 31% of the federal poverty level for a family of three — or about $7,700 this year, according to KFF, a health policy research organization.

Under Pathways to Coverage, adults making up to 100% of the federal poverty level — about $14,600 for an individual — can enroll in college courses if they work at least 80 hours, participate in job training or community service or other criteria meet one month.

“In our state, we want more people covered at lower costs and more options for patients,” Gov. Brian Kemp said in his State of the State address in January.

How many people are expected to be insured varies. In his speech, Kemp said up to 345,000 Georgians would potentially be eligible for the program, while the state Department of Health said the state had an estimated enrollment of 100,000 residents in the first year.

Interest in the program continues to grow, said Fiona Roberts, the department's press secretary. The agency is working with insurers, community groups and others to spread the word.

However, others assume that significantly fewer people will be insured. According to the Georgia Budget and Policy Institute, a left-leaning advocacy group, state funding allocated to the program in the current fiscal year will enable enrollment of about 47,500.

A full expansion of Medicaid would cover far more people and at a lower cost to the state, said Leah Chan, the institute's director of health equity. About 482,000 Georgians earning up to 138% of the federal poverty level — or about $20,100 for an individual — could be covered.

In addition, the federal government would cover a larger portion of the costs for participants enrolled in the full expansion and would temporarily block federal funding for it under a provision of the American Rescue Plan Act aimed at encouraging declining states to expand Increase existing traditional Medicaid enrollees.

If Georgia were to fully expand Medicaid, each newly eligible enrollee would cost the state about $496, Chan said. But under Pathways to Coverage, each program costs $2,490 because the program does not qualify for expanded federal matching.

“It makes no sense for us to implement a program that covers fewer people at a higher cost when we have an option that could close the coverage gap and divert millions and millions — some estimates are billions — in federal dollars. Chan said.

Additionally, it may be difficult for low-income residents, particularly in rural areas of the state where many uninsured people live, to consistently work enough hours to qualify, she said. And those who do may find themselves in trouble when submitting the required monthly paperwork.

Another problem: There are no exceptions for parents of dependent children or other caregivers, said Joan Alker, executive director of the Center for Children and Families at Georgetown University. Other states that sought to implement work requirements during the Trump administration had such exemptions.

“A small number of people may get coverage, but the likelihood that they will retain that coverage for a while is not very high,” Alker said. “And that is a particularly problematic structure for parents.”

But Georgia officials say Pathways to Coverage is the right program for the state.

“This approach is Georgia-focused and ensures we can expand Medicaid coverage to those who were previously ineligible without forcing others to give up their preferred private insurance,” Roberts said. “Unlike the top-down approach of traditional Medicaid expansion, Georgia Pathways was developed and operated by Georgians to address the specific needs of our state.”

This story has been updated with additional information.