Georgia’s Medicaid work requirements have brought high costs, low enrollment

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A year ago this month, Georgia launched its own Medicaid expansion mandating work requirements for new enrollees. Called Pathways to Coverage, the program has delivered underwhelming results.

Low Participation, High Costs

An alternative to traditional Medicaid expansion under Obamacare, the program has added just over 4,300 new low-income patients, far below the 25,000 people it aimed to cover. It has cost at least $26 million so far.

Georgia’s program “hasn’t been effective at all in addressing the health care needs of people who really need health insurance in Georgia. And it’s been fairly disastrous for Georgia taxpayers in terms of what their money is being spent on,” said Joan Alker, executive director of Georgetown University's Center for Children and Families, in an interview.

Georgia is the only state in the country with work requirements for any of its Medicaid recipients. Federal courts and the Biden administration have blocked efforts by other states to impose them. 

A Special Case 

Georgia got special permission to operate its Pathways to Coverage program because the work requirements only apply to people who otherwise would not qualify for Medicaid.

Georgia is one of 10 states that have not expanded Medicaid to childless adults under the Affordable Care Act. Medicaid is jointly run by states and the federal government. It covers children, pregnant women, parents, seniors and individuals with disabilities, but states with ACA expansions also cover adults making less than 138% of the federal poverty level. With 83 million enrollees, it is the single largest source of health coverage in the country.

To qualify for Pathways to Coverage, adults have to make less than the federal poverty level (that’s $15,060 per year for an individual). Plus, they must document that they have spent 80 hours a month performing “qualifying activities” such as working, job training, volunteering for a nonprofit or attending school.

Governor Clashes with Feds 

Gov. Brian Kemp, a Republican, has championed Georgia’s unique approach to Medicaid expansion. The governor first proposed the idea in 2019, shortly after narrowly defeating Democrat Stacey Abrams, who made Medicaid expansion under Obamacare a cornerstone of her campaign.

Kemp has blamed the Biden administration for delaying the rollout of Pathways to Coverage. Under Biden, the federal government revoked permission for Georgia to impose work requirements. Georgia sued, and a federal judge reinstated it in 2022.

But Kemp has said the two-year fight with the federal government undermined the program. Georgia, in fact, went back to court to try to get a two-year extension of its Medicaid waiver to account for the lost time. But the same federal judge ruled against the state this week, finding that it didn’t follow the rules for getting an extension. That means the program is set to expire by fall of 2025.

The governor still backs the approach. “Just as before, we remain committed to this Georgia-specific, innovative initiative that leads not only to health care coverage but to better opportunity and coverage options for those who enroll in the program,” spokesperson Garrison Douglas said in a statement.

Barriers to Participation 

Robin Rudowitz, the director for the program on Medicaid and the Uninsured at KFF, a health policy group, said Medicaid isn’t designed to track work, so adding that requirement means setting up new administrative systems to process that information. In fact, more than 90% of the money spent on Georgia’s program so far has gone toward administrative expenses and consulting fees, according to KFF Health News.

But Rudowitz also pointed out that it is difficult for Medicaid recipients to keep up with the paperwork just to stay on the core program, a fact that became clear when states purged millions of people off the Medicaid rolls in an “unwinding” process after the pandemic.

“It’s hard to get in touch with people. It’s hard for people to get documentation,” she said. And proving someone’s work history is even more difficult to do than keeping tabs on someone’s income. “It’s just not something that can be tracked automatically.”

Georgia’s program also targets a relatively small group of potential participants, she pointed out. The income cut-off is little more than what someone would make if they worked 35 hours a week at the federal minimum wage of $7.25 an hour. Georgia expects that up to 350,000 people in the state could be eligible for coverage.

Plus, Georgia doesn’t make any exemptions from the work requirements for participants who are watching their children or taking care of elderly relatives. People who have work schedules that vary significantly could also have a hard time keeping on top of the reporting requirements, she said. Most people on Medicaid are already working full-time or part-time, while 13% don’t work because of caregiving duties and 11% don’t work because of illnesses or disabilities, she said.

The Georgia program “is not effective in supporting work, which is supposedly the objective,” added Georgetown’s Alkers. “People are better able to work if they are healthy and have access to health insurance. … If you want to support work, it’s better to do [an ACA-style Medicaid] expansion and help people get healthy, and to get their chronic needs addressed so they can work.”

National Questions 

Georgia’s experience stands in stark contrast with that of North Carolina, where half a million people have signed up for Medicaid coverage in the first seven months since the state began an ACA Medicaid expansion. North Carolina Gov. Roy Cooper, a Democrat, pushed Republican lawmakers in the state to adopt the expansion, which they approved last year.

North Carolina is receiving a higher reimbursement rate from the federal government for Medicaid expenses for new enrollees because of formulas in the 2010 law. But it also qualified for two years of extra incentives to expand Medicaid that Congress included in the 2021 American Rescue Plan Act.

Ten states—Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin and Wyoming—have not expanded Medicaid under the ACA. The Center on Budget and Policy Priorities, a left-leaning think tank, estimates that 1.6 million people in those states are left in a “coverage gap” that makes it financially impractical to obtain health insurance. Nearly two-thirds of those uninsured residents are people of color.

But the state of Medicaid work requirements—and maybe much bigger questions about health coverage—could hinge on the outcome of the presidential race. The Trump administration gave permission to a dozen states to impose work requirements, but federal courts intervened, saying the extra conditions undercut Medicaid’s primary purpose of helping people get health insurance. Arkansas was the only state to roll out the new rules, which led to 18,000 people losing coverage in seven months. The Supreme Court agreed to hear a case over the Arkansas dispute, but dismissed it as moot once the Biden administration revoked Arkansas’ waiver.

Akers said work requirements are popular with the Republican base, even if they are unworkable in practice. She worries that bigger changes might be in store if former President Donald Trump wins a second term.

“If Trump wins, and depending on the congressional outcome, there's very likely to be a full-scale assault on Medicaid, inflicting very deep cuts,” she said. “So I think we’re going to be looking at much bigger issues than work requirements.”

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News to Use

Trends, Common Challenges, Cool Ideas, FYIs and Notable Events

Cybersecurity
Many state, city government services disrupted by faulty CrowdStrike update. Several states and localities reported Friday morning disruptions, mainly to administrative systems, caused by a faulty CrowdStrike software update. States including Connecticut, Delaware, Michigan and Virginia have said they’re monitoring the incident and its effects on their Microsoft Windows machines. Cities including Washington, D.C., and New York are among those that have reported disruptions.

LGBTQ Rights
Two circuit court of appeals rulings dealing with drag shows and gender discrimination were issued this week. On Wednesday, a federal appellate court upheld blocking central parts of new Title IX rules from the Biden administration and granted an expedited hearing in October. The lawsuit was filed by Republican attorneys general in six states—Kentucky, Virginia, Indiana, Ohio, Tennessee and West Virginia. The rules, created by the U.S. Department of Education, were aimed at protecting students from discrimination based on gender identity and sexual orientation. Meanwhile, the 6th Circuit Court of Appeals has reversed a lower court’s ruling and upheld Tennessee’s 2023 ban on adult cabaret entertainment in front of children. The court found that Memphis theater group Friends of George’s, which puts on drag shows, failed to show standing in its challenge of the state law and instructed the U.S. District to dismiss the case.

Water
Invasive species in Colorado River could wipe out ecosystems, cause costly damage. Colorado Parks and Wildlife officials on Tuesday announced the discovery for the first time of zebra mussel larvae in the Colorado River. The mussels are invasive species that are nearly impossible to remove and pose an extreme risk to the most important river in the American Southwest. The river and its major tributaries provide drinking water and power for 40 million people, irrigate millions of acres that feed the country and provide crucial habitat for thousands of species. Federal and state agencies for decades have fought to keep the mussels from spreading into the West. They are already present in the Great Lakes region, and have spread via waterways and human transport across a huge swath of the eastern half of the country.

Natural Disasters
Texas launches an investigation into electric utility after Hurricane Beryl. The Texas Public Utility Commission has launched an investigation into CenterPoint Energy in the wake of its much-criticized performance after Hurricane Beryl struck the Houston region. More than 2.2 million customers lost power after the storm hit on July 8. The utility was criticized for its lack of preparations ahead of the storm, tree trimming and maintenance, communication with customers, and failure to give reliable information on outages. Gov. Greg Abbott said he’s giving CenterPoint until the end of the month to specify what it’ll be doing to prevent future problems in the event of another storm. The governor has also come under criticism for being on an economic development trip when the storm hit.

Death Penalty
Utah could be first state to use ketamine in execution. Taberon Honie, the state’s first death row inmate to face an execution warrant in more than a decade, is suing officials with the Utah Department of Corrections, claiming the novel approach could lead to unnecessary pain and suffering, while triggering hallucinations, paranoia and “mental anguish.” The suit asks the court to put the scheduled Aug. 8 execution on pause until the Department of Corrections takes the “reasonable and necessary steps to devise a new procedure.” 

Taxes
Federal judge upholds Maryland’s first-of-its-kind digital ad tax. The judge dismissed a claim filed by the U.S. Chamber of Commerce and three trade associations arguing that the state’s digital advertising tax violates First Amendment rights to free speech. The decision found that language included in the tax’s “pass-through prohibition,” which bars digital advertising companies from passing along the tax as a “fee, surcharge or line-item,” does partially restrict the speech of the companies. However, the plaintiffs failed to prove that the measure was wholly restrictive and unconstitutional, the judge ruled. The decision is the latest salvo in a lengthy legal dispute over the tax which was instituted in 2021. Wednesday’s ruling settles only the federal side of the claim. The state case is ongoing.

Infrastructure
New Tennessee law allows developers to hire their own building safety inspectors. Initiated by Gov. Bill Lee, the new law will allow developers to hire their own inspectors to check for environmental, safety and building violations on construction sites—bypassing city codes departments and the State Fire Marshal’s Office. Lee said it is intended to streamline the building process, particularly in rapidly growing Tennessee communities. Lee and state building associations that lobbied for the new law have cited lengthy wait-times for inspections. But opponents of the law, including the statewide association of codes officials, say privatizing building inspections introduces risks. They argue that for-hire inspectors paid by a builder seeking a favorable inspection have the potential to overlook key safety and building standards that apply to both single-family homes and high-rise office buildings.

Economic Development
Illinois lands federal partnership to further develop quantum projects. Gov. J.B. Pritzker on Tuesday announced that the Defense Department’s Defense Advanced Research Projects Agency, or DARPA, will take residency on the state’s quantum campus—the location of which will be announced soon—to establish a program where quantum computing prototypes will be tested. DARPA’s central mission is to invest in breakthrough technologies to enhance national security. Pritzker has been a strong advocate for positioning Illinois globally as “the Silicon Valley of quantum development.”

Guns
Growing list of Colorado cities, counties opt out of new gun-carrying restrictions. The recently enacted state law, which went into effect July 1, forbids people from bringing firearms into “sensitive spaces,” like government buildings and courthouses. It permits a local government to allow the carrying of a firearm in its buildings, and about a dozen counties, cities and towns across Colorado have so far opted out of the law. The decisions are motivated by the view that the people who live in those communities are best equipped to manage the safety of their public facilities. Meanwhile, Massachusetts House and Senate negotiators this week released a compromise version of a sweeping gun bill that, among other things, cracks down on “ghost guns” and expands the state’s red flag law. The bill is part of an effort by the state to respond to a 2022 U.S. Supreme Court ruling that citizens have a right to carry firearms in public for self-defense.

Data
Oklahoma tribal nation conducts census for the first time. About a quarter of Osage citizens participated in the tribal nation’s first-ever census, providing information about Osage language and culture that isn’t captured in the U.S. census. Less than 10% of the 3,900 citizens who participated, for instance, said they could speak the Osage language at a basic level or higher, and nearly 80% indicated interest in taking language classes. The Osage Nation’s census is the latest example of a broader push by tribal governments to collect and store their own information, rather than rely on outside agencies or federal officials to gather that data.

Picture of the Week

Here’s a look at @Ford F-150 customers in Houston generating at least 1 kilowatt of electricity with Pro Power Onboard immediately before and after #HurricaneBeryl caused outages around the region. pic.twitter.com/5upZgkQH5J

— Jim Farley (@jimfarley98) July 13, 2024

After Hurricane Beryl left more than 2 million people without power in Houston last week, Ford CEO Jim Farley noticed something interesting: Hundreds of F-150 owners in the Houston area were suddenly using their trucks to generate electricity. It’s a phenomenon that the company first noticed during the 2021 Texas ice storms and saw again last summer, when tornadoes hit Michigan, reports Slate. “The use of an EV for disaster response, especially for residences, has been theorized for a long time,” observed Scott Shepard, director of EV research at the Center for Sustainable Energy, a nonprofit research group. A few states have already taken initial steps to support such a reality, including California and Vermont. 

Government in Numbers 

1 million

The number of public chargers that are needed in California by the end of 2030, according to the state’s projections, to meet the needs of the 7 million electric cars expected on its roads in less than seven years. That’s almost 10 times more than the number available to drivers in December. To meet that target, 129,000 new stations—more than seven times the current pace—must be built every year for the next seven years. The sheer scale of the buildout has alarmed many experts and lawmakers, who say it is unlikely the state will be able to meet the 1 million goal.