The path is clear for Georgia to implement work requirements for Medicaid

[UPDATED at 2 p.m. ET]

Georgia is expected to be the only state with employment requirements for Medicaid coverage.

Republican Gov. Brian Kemp's reelection — and the Biden administration's surprise decision not to appeal a federal court ruling — have given the state the freedom to roll out its plan to allow a limited increase in the pool of low-income residents eligible for Medicaid would.

Questions remain about the implementation of Kemp's plan. But it would make Georgia a test case for a work provision that has been proposed by several states and rejected by federal courts and the Biden administration.

Meanwhile, stakeholders are concerned about barriers to obtaining and maintaining insurance coverage. They also point out that the Kemp plan would be more expensive per participant and would cover only a fraction of the people who would receive Medicaid under a full expansion. Georgia's new grant program would require at least 80 hours of work or volunteer work per month.

“In the best case scenario, some uninsured Georgians would receive coverage for a period of time,” said Laura Colbert, executive director of the consumer advocacy group Georgians for a Healthy Future. “It’s going to be a big headache for the state and the people who are enrolling or trying to enroll.”

The Trump administration approved Medicaid work requirements for Georgia and 12 other states. Georgia received the approval under a “waiver,” or federal authorization that allows states to operate programs that deviate from standard rules for Medicaid, the government insurance that covers the poor and disabled.

But the Biden White House rejected the Georgia plan.

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However, in August, a federal judge in Georgia ruled that the Biden administration had overstepped its authority, paving the way for Kemp's plan to proceed. The federal government allowed the 60-day appeal period to pass without taking any action.

The reasoning behind the White House's decision not to appeal the court decision remains unclear. A spokesman for the Centers for Medicare & Medicaid Services, Bruce Alexander, said: “For policy reasons, CMS does not comment on litigation.”

CMS's reluctance to appeal could have to do with where the case would go next, said Leonardo Cuello, a research professor at the Center for Children and Families at Georgetown University's McCourt School of Public Policy. If appealed, the case would be sent to a conservative federal court that might favor the lower court's decision — establishing it as a stronger precedent.

“The decision not to appeal may have been based on fear that the outcome would be upheld on appeal, since most appellate judges in the 11th Circuit are Republican-appointed,” he said.

Biden administration officials may also wait for the plan to be put into action before stepping in, said Catherine McKee, a senior attorney at the National Health Law Program, a nonprofit advocacy program. Federal health officials “could leave it to the state to go ahead and monitor the situation and take action in the future,” she said.

Kemp's office did not respond to KHN's request for comment on the status of the plan. But after this article was published, the governor's office confirmed that it was moving forward with the plan and aimed to have it in place by July.

Previously, Kemp celebrated the federal court's August ruling in a series of tweets: “Despite the left's efforts to reclaim good politics for partisan politics, the judiciary this week … ruled that the Biden administrator made a mistake when he “Eliminated our innovative health care waiver that would better serve Georgians than a unified Medicaid expansion.”

The Georgia Department of Community Health, which oversees the state's Medicaid program, declined an interview to answer questions about the work requirement plan.

But the agency recently posted two pages on its website about the Georgia Pathways program: one with information about how to enroll, the other with details about the plan's requirements. Both pages were removed after KHN asked the agency about them.

“Pathways is not yet live, so the links have been disabled to avoid confusion,” said Fiona Roberts, a spokeswoman for the agency.

Medicaid work requirements have a short implementation history at the national level.

The only state to operate a full work requirement program was Arkansas, which implemented the rule in 2018. This resulted in approximately 18,000 people losing Medicaid coverage. A federal court suspended the requirement the next year.

Kemp's victory over Democrat Stacey Abrams in this month's midterm elections also scuppered – at least for now – Georgia Democrats' longstanding push for a full expansion of Medicaid, estimated to cover 450,000, up from about 50,000 under Kemp's plan. On Nov. 8, South Dakota voters approved a full expansion ballot measure that would cover more than 40,000 additional people in the state.

The cost per participant for Georgia's work requirement program is expected to be at least three times higher than a regular Medicaid expansion, Colbert said.

If the expansion were complete, the federal government would have covered at least 90% of the costs of insuring hundreds of thousands of Georgians. By comparison, the government expects a 67% compliance rate under the leaner Kemp plan. And that difference doesn't take into account the Biden administration's expansion stimulus, which would bring $710 million to Georgia, according to a KFF estimate.

The administrative hurdles for the Kemp work plan would be significant, say consumer advocates. Full-time caregivers, people with mental illness or substance use disorders and people who can't work but don't yet qualify for disability insurance would have a hard time qualifying, Colbert said.

Other challenges could include a lack of transportation making it difficult for enrollees to get to work and limited access to computers for potential enrollees to log in.

In addition to volunteer work, other qualifying activities for insurance coverage under the Kemp Plan include education and vocational training.

Many people struggling with homelessness in Georgia likely don't meet the minimum work or volunteer requirements, said Kathryn Lawler, CEO of Saint Joseph's Health System, an Atlanta-based nonprofit. Sixty percent of patients at Mercy Care's community health centers are homeless, she said. Coverage through Medicaid expansion would allow patients to afford health care, manage chronic conditions and reduce the stress of medical bills, she said.

People who need medical care are often too sick to go to work, Lawler said, adding that a single mother with three young children could be considered ineligible. Fully expanding Medicaid through higher payments to providers would ultimately allow Mercy Care to serve more people in need, she said.

CMS's decision not to appeal “was a little surprising,” Colbert said, but added that another unfavorable court ruling could pose a risk to other states' Medicaid programs by clearing the way for other work requirements.

CMS inaction could lead to similar offers of work requirements in other Republican-led states, McKee said.

The Georgia plan, meanwhile, likely would not take effect until after the end of the Covid-19 public health emergency, which has allowed many Medicaid enrollees to receive continued coverage during the pandemic, and is expected to last until early next year.

[Update: This article was updated at 2 p.m. ET on Nov. 18, 2022, to include comments from Gov. Brian Kemp’s office delivered after publication.]

Andy Miller:, @gahealthnews

Sam Whitehead:, @sclaudwhitehead

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