ATLANTA — Georgia officials expect their new Medicaid plan, currently the only one in the nation with work requirements, will provide health insurance to 25,000 low-income people and potentially tens of thousands more.
But a year after its launch, Pathways to Coverage has about 4,300 members — far below state officials’ projections and a tiny fraction of the roughly 500,000 Georgians who would be covered if Georgia joined 40 other states in fully expanding Medicaid.
Georgia Gov. Brian Kemp’s office has presented Pathways as a compromise that would help get more people on Medicaid while also helping them move out of it. Kemp’s office has blamed the Biden administration for delaying the program’s launch and said it is redoubling efforts to get more people enrolled.
Health and public policy experts say the dismal enrollment figures, compared with what Kemp’s office said Pathways could achieve, reflect a fundamental flaw: Work requirements are far too burdensome.
“It’s clear that the Georgia Pathways experiment is a spectacular failure,” said Leo Cuello, a research professor at Georgetown University’s McCourt School of Public Policy.
Pathways requires all recipients to demonstrate at least 80 hours of work per month, volunteer work, schooling, or vocational rehabilitation, and covers only able-bodied adults earning less than the federal poverty line, which is $15,060 for a single person and $31,200 for a family of four.
Cuello noted that the program doesn’t make exceptions for people who care for children or other family members, don’t have transportation, have drug addictions or face a variety of other barriers to working, including some who work informal jobs that make it impossible to log hours worked.
Dr. Karen Kinsel, who lives in rural Clay County in southwest Georgia, said many of her patients are too sick to work. Over the past year, she has recommended Pathways to about 30 patients who might qualify, but none have applied.
“My general view is that it’s too much work, too complicated, with very little benefit,” she said.
Harry Hyman, a health policy professor at Georgia State University, said even submitting verification of employment online each month could be a major hurdle.
“For low-income families who are worried about housing and putting food on the table, having one more thing to do is often too much,” he said.
The program’s poor performance so far could have ramifications beyond Georgia: Republican lawmakers in other states have proposed work requirements for Medicaid in recent months. In Mississippi, Lt. Gov. Delbert Hosemann in February cited Georgia’s Pathways program as a model.
A second term for former President Donald Trump would significantly improve the prospects for such programs: His administration approved Medicaid work requirement plans in 13 states, but the Biden administration revoked those waivers in 2021. Pathways survived a court battle.
Georgia launched the program on July 1, 2023, without much fanfare, and public health experts say there was little effort to promote the program or sign people up.
The launch coincides with a federally mandated review of the eligibility of all 2.7 million Medicaid recipients in the state once the COVID-19 public health emergency ends, posing another challenge for Georgia officials.
Still, they didn’t scale back their enrollment projections. Days before the launch, then-Georgia Department of Community Health Commissioner Kaylee Noggle 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.
Kemp’s spokesman, Garrison Douglas, said in a statement that Pathways has “received tremendous interest from thousands of low-income, healthy Georgia residents” and that the state is “still fighting to make up for the time lost to it by the Biden Administration.”
The program was set to begin in 2021, but the Centers for Medicare and Medicaid Services challenged the work requirement in February and later rescinded it. Georgia sued, and a federal court reinstated the work requirement in 2022.
According to the Georgia Department of Community Health, as of June 7, 2024, Pathways had 4,318 members. The department said in an email that promotional efforts will include social media content and streaming ads on television and radio, with an “intense” outreach campaign planned.
“It’s worth giving Pathways a little more time to see if it can live up to its potential,” said Chris Denson, director of policy and research at the conservative Georgia Public Policy Foundation.
Denson said there’s a general consensus among Pathways supporters that the state could have done a better job of marketing it, but he said the underlying idea of Pathways — moving people to private insurance through employment, job training and other eligibility activities — is sound, given that many primary care doctors in the state aren’t accepting new Medicaid patients.
For critics, the actual first-year figures are all the more infuriating when you consider how many people a full Medicaid expansion could cover without any additional cost to states, at least initially.
Georgia’s Medicaid program would receive more funding from the federal government if it were fully expanded, and could cover 482,000 residents in the first year for the same cost as the 100,000 Pathways recipients, according to an analysis by the left-leaning Georgia Budget and Policy Institute.
In North Carolina, which fully expanded Medicaid in December, about 500,000 people have signed up in about half the time since Pathways was implemented.
This broader expansion of Medicaid was a key part of President Barack Obama’s health care overhaul in 2010. In exchange for offering Medicaid to nearly all adults earning up to 138% of the federal poverty level, states would get more federal funding for new enrollments.
Eligibility is capped at $20,783 per year for a single person and $43,056 for a family of four. Of the 40 states that have accepted the agreement, none require recipients to work in order to qualify.
But Kemp, like many other Republican governors, rejected a full expansion, arguing the long-term costs to the state would be too high.
Republicans in the Georgia Legislature floated the possibility of a full expansion in 2024 but then abandoned that effort.
So far, Georgia officials show no signs of giving up on Pathways. The program is set to expire at the end of September 2025. But in February, the state sued the Biden administration, seeking an extension through 2028. A federal judge heard arguments last month.
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