ATLANTA — On a recent summer evening, Raymia Taylor strolled into a recreation center in a historic downtown neighborhood and was the only attendee at a nearly two-hour event for people enrolled in Georgia's experimental Medicaid expansion.
The state launched the program in July 2023 and requires participants to document that they work, study or do other qualifying activities for 80 hours a month in return for health insurance. Booths were set up at the event to help people join the Marines or earn a GED degree.
Taylor, 20, already meets the program's requirements – studying nursing and working at a fast food restaurant. However, she said it was not clear what documents she should submit or how she should upload her documents. “I had problems,” she said.
Georgia is the only state that requires certain Medicaid beneficiaries to work to receive coverage. Republicans have long touted such programs, arguing that they encourage participants to maintain employment. Approximately 20 states have applied to implement Medicaid work requirements; 13 received approval under the Trump administration. The Biden administration has worked to block such initiatives.
The Georgia Pathways to Coverage program highlights the hurdles facing states that want to follow its lead. Georgia's GOP leaders have spent millions of dollars rolling out Pathways. As of July 29, nearly 4,500 people had enrolled, the state's Medicaid agency told KFF Health News.
That's well below the state's own goal of more than 25,000 in the first year, according to the request to the federal government, and a fraction of the 359,000 who would have been eligible if Georgia had simply expanded Medicaid under the Affordable Care Act. is 40 other states did so.
So far, the costly endeavor has forced participants to jump through bureaucratic hurdles rather than promote employment. The state would not confirm whether it could even verify that people in the program are working.
Only one attendee attended a nearly two-hour event for participants in Georgia's experimental Medicaid program, which requires participants to document that they work, study or do other qualifying activities for 80 hours a month in exchange for health insurance. Booths were set up at the event to help people join the Marines or earn a GED degree.(Renuka Rayasam/KFF Health News)
Research shows that Black and Hispanic people are disproportionately affected by this bureaucracy.
“The people who most need access to health care are going to struggle with this administrative burden because the process is so complicated,” said Leah Chan, director of health equity at the Georgia Budget and Policy Institute.
At a press event in August, Republican Georgia Gov. Brian Kemp announced a $10.7 million advertising campaign to increase enrollment in Pathways, one of his administration's key health policy initiatives. The plan has cost more than $40 million in state and federal taxpayer money through June, with nearly 80% going to administrative and consulting fees rather than medical care funding, according to data compiled by the state Medicaid agency KFF Health News reported.
Enrollment consultants, consumer advocates and policy researchers blame Pathways' weak enrollment primarily on a cumbersome enrollment process, complicated program design and back-end technology deficiencies. They say the online application is difficult to navigate and understand, gives people no way to get immediate assistance, and that state employees do not respond to applicants in a timely manner.
“It’s just an administrative nightmare,” said Cynthia Gibson, director of the Georgia Legal Services Program’s health law division, which helps Pathways applicants appeal denials.
Administrative challenges have also undermined an important part of the program's philosophy: that people keep their jobs to maintain insurance coverage. The state did not remove participants in July because they did not meet Pathways' work requirements, according to Fiona Roberts, a spokeswoman for Georgia's Medicaid agency.
“We understand that people need to be held accountable to the spirit of the program for those 80 hours, and we intend to do that,” said Russel Carlson, the agency’s commissioner.
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Pathways will expire on September 30, 2025, unless the state asks the Centers for Medicare & Medicaid Services for an extension. Georgia officials say they don't have to file that request until next spring, well after the November election. So the state could request an extension from the Trump administration, which approved the program in the first place.
Georgia officials sued the Biden administration this year to keep Pathways running without going through the official renewal process, which requires the state to conduct public comment sessions, collect extensive financial data and demonstrate that Pathways has met its goals. A federal judge ruled against Georgia.
A CMS spokesman said the agency would not comment on the program.
During the August press event, Kemp said the Biden administration's attempt to stop the program in 2021 had delayed its launch and hindered enrollment. A federal court blocked the administration and allowed Georgia to proceed.
People familiar with the registration process said Pathways was mired in design flaws and system failures. According to state records, there were 13,702 applications waiting to be processed at the end of May.
The program's lengthy questionnaires and jargon are confusing, the instructions are opaque and the document upload tools are difficult to navigate, according to interviews with health insurance enrollment specialists conducted for the Georgia Budget and Policy Institute.
“It's not a simple, 'Oh, I want to apply for Pathways,'” said Deanna Williams, who helps people sign up for insurance plans with Georgians for a Healthy Future, a consumer advocacy group. People generally learn about the program after being denied other Medicaid coverage, she said.
In the online application, people click through pages of questions before being presented with a screen with information about Pathways, Williams said. They must then check a box and sign a form confirming that they understand the program's requirements.
Sometimes the Pathways application doesn't appear and you have to start over. The application process was “not smooth,” she said.
Data shows that people who don't make enough to qualify for free ACA plans but also make too much for Medicaid are disproportionately people of color. Pathways offers Medicaid coverage for adults earning up to the federal poverty level: $15,060 for an individual or $31,200 for a family of four.
Some people who are eligible for Pathways and work in retail or restaurants with fluctuating hours are worried they won't be able to meet the requirements every month, Williams said.
Many current enrollees don't know how to upload documents, and the website sometimes stops working, said Jahan Becham, pathways employment specialist at Amerigroup Community Care. Or people simply forget.
Each month, Becham receives a list of 200 to 300 enrollees who have not submitted their hours. “It’s something new and not many people are used to it,” Becham said.
“I would get memories,” said Taylor, who attended the registered event in August. “I just didn’t know how.”
At a meeting with Georgia Medicaid staff in June 2023, weeks before the program's launch, federal officials questioned why the state wasn't automatically verifying eligibility using existing data sources, according to meeting minutes obtained by KFF Health News as part of a statewide hearing had received an open records request. Georgia officials said they are unsure when they will be able to simplify the verification process.
Many potential participants face unreasonable rejections, advocates say. Gibson, of the Georgia Legal Services Program, said not enough staff are trained to properly evaluate applications.
As of May, fewer than one in five people whose Pathways applications were processed were accepted into the program, according to a KFF Health News analysis of state data. The state's Roberts said people were rejected because they made too much, didn't meet requirements or didn't complete paperwork.
A full-time student was wrongfully excluded from the program, and in February a state administrative law judge ordered her case to be reconsidered. In another case, a different judge ruled that a 64-year-old woman who was unable to work because she was the full-time caregiver of her disabled husband was not eligible for Pathways.
Despite the challenges, state records as of May show that no people have been removed from the program for failure to meet work requirements since the program began.
Georgia's experiment comes after Arkansas' 2018 attempt to implement work requirements for an existing Medicaid expansion population resulted in 18,000 people losing coverage, many of whom either met the requirements or would have been exempt.
Taylor learned about Pathways when she applied for food stamps last year. It wasn't until August that she learned she could submit her schedule to meet the required hours. With a full Medicaid expansion, Taylor would have been eligible for health insurance without the additional expense. But it's still worth it for them.
“It's important to have health insurance,” said Taylor, who has been to the dentist several times and plans to see a doctor. “I’m glad I have it.”
rrayasam@kff.org, @renurayasam
swhitehead@kff.org
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