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Limited Medicaid Expansion Covering Low-Income Georgians Begins in July

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by Jill Nolin, Georgia Recorder
June 30, 2023

Starting this weekend, more low-income Georgians will be eligible to sign up for health insurance under a new Medicaid program that slightly eases the state’s strict coverage rules.

This means adults who earn less than $14,600 a year will now clear the income threshold to apply for an insurance card through Medicaid. But the state’s unique rules for the program, called Georgia Pathways to Coverage, will limit the number of people who end up covered.

The official launch of the program will make Georgia the only state to partially expand Medicaid coverage while requiring the newly eligible people to satisfy a work requirement. Applicants must complete 80 hours of work, job training or other qualifying activity each month to gain and keep their coverage – and prove it through documentation.

Gov. Brian Kemp signs paperwork in 2020 for a scaled-down version of Medicaid expansion as Trump’s Centers for Medicare and Medicaid Services Administrator Seema Verma looked on. John McCosh/Georgia Recorder (file photo)

The estimated range for how many people may gain coverage through the public health insurance program varies significantly. State officials say about 345,000 people could be eligible, but far fewer people are expected to benefit, with the state planning for up to 100,000 to be enrolled. Other estimates put the number much lower. 

“The reason that there’s such a gap between those who will gain coverage and those who are potentially eligible is because this program really overloads people with paperwork,” said Laura Colbert, executive director of Georgians for a Health Future.

“It is a paperwork requirement rather than a work and community engagement requirement,” she said.

It’s this requirement built into the program that has stirred controversy ever since Gov. Brian Kemp first unveiled his proposal in his first year in office in 2019 after narrowly beating Democratic rival Stacey Abrams, who made full Medicaid expansion the cornerstone of her campaign.

Since then, Kemp’s proposal has encountered turbulence on the federal level. The Trump administration approved the plan just a few weeks before the 2020 presidential election. But President Joe Biden’s Centers for Medicare and Medicaid Services balked at the work requirement, withdrawing approval for two key components – the work requirement and a small monthly premium – in late 2021. The state then sued the feds.

A Brunswick-based federal judge sided with the state last fall, shortly before Kemp beat Abrams more convincingly to serve another term in office. In her ruling, Judge Lisa G. Wood, who was appointed by George W. Bush, blasted federal officials for their all-or-nothing approach to Medicaid expansion.

“The concept is simple: if Pathways increases Medicaid coverage in Georgia, then it inescapably follows there would be more Medicaid coverage in Georgia with Pathways than without it,” Wood wrote in her 2022 ruling.

The Biden administration did not appeal the Georgia judge’s decision to the surprise of many and has since shifted its focus to monitoring the state’s program.  

CMS Administrator Chiquita Brooks-LaSure talks to reporters during a May visit to Southside Medical Center in Atlanta. Jill Nolin/Georgia Recorder

“We’re continuing to work with the state and to make sure that the people of Georgia are covered in a way consistent with what’s been approved,” Chiquita Brooks-LaSure, who is the administrator for the Centers for Medicare and Medicaid Services, told reporters when she visited Atlanta in May.

“So, we’re really working to make sure that coverage is maintained, or as new people get enrolled, that it’s working well,” she said.

To gain health coverage through Pathways, Georgians will have to show they are already doing the 80 hours of a qualifying activity, such as work, job training, college or community service.

For community service, for example, acceptable documentation could be a signed statement on a nonprofit’s letterhead from a supervisor or a calendar.

And then they will provide records each month as proof to continue coverage. If a person’s monthly reporting is the same for six months, they will get a pass on providing the paperwork until it comes time for annual renewal.

The monthly reporting requirement has sparked concerns among those who see it as a barrier to coverage and who say it will put low-income Georgians without easy access to transportation and technology at a disadvantage.

Caylee Noggle, commissioner of the state Department of Community Health, which administers the state Medicaid program, says the state’s goal is to enroll as many people as possible and simplify the monthly reporting process to the extent possible. For example, the department is planning to launch a mobile app next month.

“We’re going to make it as easy as we possibly can for them to enroll and maintain coverage,” said Noggle, who will leave the agency at the end of July.

Participants will have until the 17th each month to submit documentation to continue their coverage into the next month.

A conservative approach or a squandered opportunity?

Not only is Georgia’s program the only one with a work requirement component, but it is also rolling out as congressional Republicans press for similar rules nationally.

That means what happens with Georgia Pathways to Coverage will likely help shape the national discussion on Medicaid access.

And after years of speculation, the program’s planned launch means there will also soon be hard numbers available for not just enrollment but also the cost.

Critics have long panned Georgia’s program as a costlier alternative to full Medicaid expansion, which could cover about a half million people. After North Carolina lawmakers voted to fully expand Medicaid this year, Georgia is now left as one of 10 states that have not.

“I think it’s fair to say some Georgians will gain coverage under the Pathways to Coverage program,” said Leah Chan, the director of health justice with the Georgia Budget and Policy Institute. “Healthy people make healthy communities, which makes a healthy state. So, people gaining access to coverage is a good thing.

“But I think the bottom line is that no matter how many people are gaining coverage through the Pathways to Coverage program, it will still cover fewer Georgians, and will cost substantially more for the state to implement than a fully expanded Medicaid program.”

It will cost state taxpayers five times more per newly eligible enrollee in Pathways, Chan said. Overall, if Georgia’s program enrolls 100,000 people, then Chan estimates it will cost about $10 million more than full expansion and cover far fewer people, and that’s without factoring in additional federal sweeteners for holdout states packed into the American Rescue Plan.

But the governor’s aides say Pathways is about more than just what shows up in the ledger. They frame it as a conservative, Georgia-tailored program that will ultimately steer people toward private coverage options.

“Success for us looks like providing coverage to as many Georgians as we can,” Noggle told reporters Wednesday. “Part of that original policy intent was that through job training, through education, hopefully some of these folks are graduating off of Medicaid onto the marketplace or on to an employer-sponsored plan.”

House Minority Leader James Beverly. Ross Williams/Georgia Recorder

Georgia Democrats still argue the plan amounts to a squandered opportunity to help more people in a state with one of the highest uninsured rates in the country while leaving federal dollars on the table. 

“It’s mere crumbs rather than getting us to address the real issues,” said state Rep. Kim Schofield, an Atlanta Democrat who sits on the House Health Committee and supports full Medicaid expansion. “It’ll work for some but it further divides what we know to be health disparities and health inequities.”

Pathways is launching as Georgia and all states go through the process of assessing the eligibility of all 2.7 million people on Medicaid as part of the end of a pandemic-era federal policy, known as the unwinding.

Hundreds of thousands of Georgians will likely lose coverage because they are no longer eligible. And of the 345,000 estimated to be a candidate for Pathways, about 200,000 are likely to lose Medicaid through the redetermination process.

The state started with a small group of people in the first round of the unwinding. Of the 12,526, who were still being processed when reported earlier this month, nearly 80 were no longer eligible for Medicaid and another 1,581 lost coverage for procedural reasons, such as not responding to notices.

House Minority Leader James Beverly, a Macon Democrat, said he is watching to see the overall effect that the unwinding and Pathways have on Medicaid enrollment. 

Beverly said he suspects the outcome of the combination to be “abysmal.” But he said he doubts it will change the contours of the long-running debate over Medicaid expansion in Georgia. That, he said, will only happen at the ballot box.

Even if Kemp’s plan does cover 100,000 people, it’s still far short of the impact full expansion could have, Beverly said.

“You’re still leaving 80% behind,” Beverly said. “We tout we’re the No. 1 state to do business, but it ain’t the No. 1 state if you get sick and you ain’t got no money. It’s a problem. We need to take care of the business at the base of the pyramid, not always at the top.”

What else you should know  

Pathways is for Georgia residents who are between the ages of 19 and 64 with an income up to 100% of the federal poverty level.

The program is expected to be online by Sunday morning.

Once the site is up, applications will be available for download here to print and return by mail or in person at a local state Division of Family and Children Services office. Starting Sunday, people should be able to apply online here.

To apply over the phone, call 1-877-423-4746 or 711 for those who are hearing or speech impaired.

If approved for Pathways in July, coverage would start Aug. 1. 

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Georgia Recorder is part of States Newsroom, a network of news bureaus supported by grants and a coalition of donors as a 501c(3) public charity. Georgia Recorder maintains editorial independence. Contact Editor John McCosh for questions: info@georgiarecorder.com. Follow Georgia Recorder on Facebook and Twitter.