Georgia is now the only state in the US to implement work requirements in its Medicaid program -- a feat many Republican lawmakers nationwide will be closely monitoring.
But unlike GOP-led states' prior attempts to impose work mandates in Medicaid, Georgia's effort is expected to increase the number of people with health insurance, rather than strip coverage away from an untold number of low-income residents. That allowed it to pass muster in court, though 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 in Medicaid, but 13 states received permission during the Trump administration to require existing enrollees to work, volunteer or meet other criteria to retain their health insurance. In Arkansas, the only state that implemented work requirements and terminated coverage, more than 18,000 people were disenrolled in 2018 before its waiver was voided by a federal court.
States paused their initiatives because of litigation or the Covid-19 pandemic, and then the Biden administration withdrew the waiver approvals. But Georgia challenged the withdrawal, and a federal judge ruled in the state's favor in August 2022, allowing it to implement Pathways to Coverage.
Who can gain coverage and how
Georgia has among the nation's strictest eligibility requirements for Medicaid. It is one of 10 states that has not expanded the program to all low-income adults under the Affordable Care Act. Parents only qualify if they make 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 if they work, participate in job training or community service, take higher education classes or meet other criteria for at least 80 hours a month.
"In our state, we want more people to be covered at a lower cost with more options for patients," Gov. Brian Kemp said in his State of the State address in January.
Just how many people are expected to gain coverage varies. In his speech, Kemp said up to 345,000 Georgians could qualify, while the state Department of Community Health has said up to 100,000 residents could enroll in the first year.
The department did not return a request for more information about the program and enrollment projections.
Others, however, estimate far fewer people will gain coverage. The state funds allotted for the program in the current fiscal year will allow about 47,500 to enroll, according to the Georgia Budget and Policy Institute, a left-leaning advocacy group.
Fully expanding Medicaid would cover far more people and at a lower cost to the state, said Leah Chan, the institute's director of health justice. Some 482,000 Georgians earning up to 138% of the federal poverty level -- or about $20,100 for an individual -- could gain coverage.
Also, the federal government covers a larger share of the costs of the full expansion enrollees and would temporarily provide a boost in federal funding for existing traditional Medicaid participants under a provision of the American Rescue Plan Act aimed at enticing holdout states to expand.
If Georgia fully expanded Medicaid, each newly eligible enrollee would cost the state about $496, Chan said. But under Pathways to Coverage, each will cost $2,490 because the program does not qualify for the enhanced federal match.
"It doesn't make sense for us to implement a program that's going to cover fewer people at a higher cost when we have an option that could close the coverage gap and draw down millions and millions -- some estimates say billions -- in federal dollars," Chan said.
Plus, it could be tough for low-income residents, particularly those in rural areas of the state where many of the uninsured live, to work enough hours consistently to qualify, she said. And those who do may get tripped up in submitting the necessary monthly documentation.
Another issue: There are no exemptions 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 of them retaining that coverage for a while is not very high," Alker said. "And this is an especially problematic structure for parents."