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off the charts

6 Months Into Georgia Pathways Program, Over 400,000 People Still Lack Health Coverage; Expanding Medicaid Would Improve Access for Low-Income Georgians

Georgia Pathways, a state program providing health coverage to certain low-income people, was always expected to underperform compared to a true Medicaid expansion, in terms of how many people would be helped. But even supporters didn’t expect the program to be this limited: as of mid-December 2023, roughly six months into the program, a scant 2,344 people had enrolled.

Rather than adopt a full Medicaid expansion under the Affordable Care Act, Georgia instead secured a Medicaid waiver to provide coverage to a subset of adults with low incomes: those who are not eligible for traditional Medicaid, who have incomes below the federal poverty level ($15,060 in annual income for an individual), and who complete initial and monthly paperwork documenting employment or participation in other qualifying activities such as job training.

The state had identified about 345,000 residents with incomes under the poverty level who could be eligible for the Georgia Pathways program, expecting about 100,000 people to enroll in the first year after the program launch in July 2023. But with fewer than 2,400 enrollees at the six-month mark, initial monitoring data (covering July through October 2023) suggest a number of problems. Application levels are low, and a significant portion of applications had not been processed. Of those that had, a mere 13 percent were approved.

Meanwhile, a true Medicaid expansion to people with incomes up to 138 percent of the poverty level (or about $20,000 annually for an individual), free of work verification requirements, would make 434,000 Georgians newly eligible for Medicaid — with the federal government picking up 90 percent of the cost and providing $1.2 billion over two years in additional federal funding. It would also bring a number of proven health and economic benefits, such as protecting people from significant medical debt and giving a boost to rural hospitals. As state lawmakers convene this year and consider ways to increase access to health coverage, they should consider a full Medicaid expansion.

Among the challenges with Georgia Pathways, the program requires people to take many steps to enroll, including signing a program contract and submitting documentation to prove they have completed 80 hours of work or other qualifying activities in a recent month. Of those denied coverage in the July through October period, 29 percent were denied because they did not meet this documentation requirement.

Keeping coverage also isn’t simple under Georgia Pathways. The program requires enrollees to report hours of work and other activities every month. But the reporting process is not always as straightforward as it appears. In many cases, people face bureaucratic hurdles and red tape that prevent them from reporting their work, and far too many people in low-wage jobs are at the mercy of employers who can reduce their hours without notice. Furthermore, people with disabilities and chronic illnesses are not exempt from the Pathways reporting requirements, and some could face challenges finding enough hours to work because employers will not provide reasonable accommodations needed for people with disabilities. As a result, people could have their often life-saving coverage taken away.

Beginning in early 2024, if one monthly activities report is missed, the state plans to suspend that enrollee’s coverage starting the following month, meaning they would not have coverage for any services they receive during the suspension. This would result in people showing up to the doctor or to pick up their prescriptions and finding out they can’t afford the care they need. After three months without completed reports showing at least 80 hours of activities, coverage will be terminated. The state also plans to require certain enrollees to pay premiums to keep their coverage but has delayed the start of premium payments until at least July 2024.

The early evidence on Georgia Pathways shows that the program is falling well short of meeting its stated goals of increasing access to affordable health coverage and lowering the state’s uninsured rate. By instead expanding Medicaid coverage, Georgia would be able to cover more people at a lower per-enrollee cost and get people covered much more quickly. For example, North Carolina enrolled more than 270,000 people in the first month of its Medicaid expansion, which started on December 1, 2023.

If the number of new Georgia Pathways enrollees each month increases at the most recent rate, fewer than 14,000 people would be enrolled by the end of the first program year. (This assumes 20 percent growth in new enrollees each month, which was the monthly growth rate for new enrollees between September and October 2023.) The numbers could be even lower if enrollees do not report or have trouble reporting 80 hours of qualifying activities or proof of paying premiums, once the state phases in those requirements. Once suspensions and terminations begin, we can expect the few people who make it through enrollment hurdles to face stress and difficulties staying healthy or continuing to work, as was the case for many enrollees in Arkansas’ 2018 Medicaid work requirement waiver.

Georgia leaders allocated $117 million in their annual budget to implement Pathways and are spending far more per enrollee than if the state implemented Medicaid expansion. Georgia should make better use of its funds and act quickly to help address the state’s health care concerns, including rural hospital closures and high rates of uninsurance. It is not too late for the state to extend Medicaid eligibility to more than 430,000 uninsured people — free of the limitations and barriers in Pathways — and bring hundreds of millions of dollars to the state to support access to care.