Congress wants Medicaid recipients to work. Georgia provides a model.

Instead of embracing traditional Medicaid expansion, Gov. Brian Kemp sought to grow the number of insured Georgians through a conservative framework; his program provides Medicaid to people earning up to 100% of the Federal Poverty Level — about $15,000 for a single person — if they work at least 80 hours per month or meet academic or other requirements.

But rather than leading to more Medicaid recipients working, Georgia’s experience has led to people who could be eligible for the program unable to receive Medicaid, mostly because of bureaucratic red tape.

While experts say Kemp’s program, called Georgia Pathways to Coverage, has different aims, it could still provide lessons in both politics and policy.

Health care as a carrot

Pathways is designed to use health care as an incentive to get able-bodied individuals into the workforce on a limited basis. Eventually, the thinking goes, those part-time workers would transfer into full-time employees and become eligible for company-sponsored private health care plans, moving them off the government’s rolls.

According to Kemp’s Office, at least 1,025 Pathways members have been referred to “better, private health care coverage” through Georgia Access, the state’s health care exchange, because their income increased.

“With this success it’s no surprise that others are starting to emulate our innovative approach to health care coverage,” said Garrison Douglas, a spokesperson for Kemp.

Chris Denson, the director of policy and research at the Georgia Public Policy Foundation, said Pathways is a way to increase health care coverage that is in line with the governor’s vision without expanding Medicaid under the Affordable Care Act.

States that expand Medicaid for people earning up to 138% of the Federal Poverty Level, about $21,000 for an individual, have received additional federal funding to pay for it. About 40 states have expanded; Georgia has not.

In Congress, lawmakers are looking for cuts that reduce the federal deficit, which is currently more than $1 trillion. Implementing work requirements nationwide among the existing able-bodied Medicaid population has been a Republican goal among those who believe there is waste and abuse in Medicaid.

“Medicaid has grown beyond its original intention to cover the aged, the blind, the disabled population, children, single mothers, and has grown to cover able-bodied individuals. That has long been an issue within conservative health circles,” Denson said.

As part of discussions last year around easing regulations to establish new hospitals in Georgia, state Sen. Matt Brass, a Republican from Newnan, had voted for a form of Medicaid expansion. His thinking has shifted since then, and he supports work requirements and the Pathways program.

“If you’re going to use public money to pay for something, outside of those who are deaf, blind and disabled, you need to have some skin in the game,” he said. “As long as you’re working and a contributing member of society, then absolutely, I’m good with providing health care to help you do that.”

Challenges with enforcement

Democrats understand that requiring Medicaid recipients to work for their benefits sounds like a good idea. A poll from the health research group KFF found that 62% of adults support work requirements.

“That actually makes sense to a lot of people. That sounds reasonable,” said state Rep. Michelle Au, a Democrat from Johns Creek.

The problem, she said, is not with the work, it’s with the administrative burden of reporting.

“There are people who actually are working and meet those hour eligibilities that still are not eligible for access through Pathways because of how onerous and difficult the reporting requirement is,” she said. “It’s building in a barrier to patients getting care.”

KFF found that support for work requirements drops to 32% “when those who initially support the proposal hear that most people on Medicaid are already working and many would risk losing coverage because of the burden of proving eligibility through paperwork.”

Kemp’s team initially expected fewer than 100,000 people to be enrolled in the program. As of earlier this year, there were about 6,500.

Heather Payne is one of the patients struggling to get care. After she began having strokes a few years ago, she was no longer able to work her nursing job and has been waiting to get her disability application to be approved. She can’t get Medicaid while her disability application is active, and she can’t get Medicare without a disability status.

Credit: Michelle Baruchman

Credit: Michelle Baruchman

Payne, 53, who lives in Dalton, recently decided to go back to school. Attending a public or private university of technical college is considered a qualifying activity for Pathways.

But in addition to working clinical rotations, she’s only taking nine credit hours right now, short of the 11.5 credit hours needed to be eligible for Pathways.

“I would have to take a full-time program at my school and work my clinical rotations to get the clinical experience I needed, to qualify to get Pathways,” she said.

Other Georgians have said the portal to report work is a “nightmare,” administrative support is lacking, and applicants are not given clear reasons why they are denied benefits.

When Arkansas implemented work requirements for Medicaid during the first Trump administration, one study found that 18,000 people lost coverage mostly because of the reporting requirements. The state then moved to a model where it purchased private health insurance plans for low-income people, but Gov. Sarah Huckabee Sanders asked the federal government in January to return to implementing work requirements.

When Pathways launched, Georgians were required to again prove their eligibility under the work rules every month.

A Georgia commission of health policy experts recommended in a December report that Pathways align with other human services programs that conduct annual verification to “improve participant user experience.” In the Pathways renewal request that Kemp’s office submitted in March, the state requested to remove the monthly reporting requirement and replace it with annual reporting at their time of renewal.

However, the “big, beautiful bill” the House approved would require reporting at least every six months.

Laura Colbert, the executive director of Georgians for a Healthy Future, said frequent checks are difficult and expensive. There is more churn within the system because people are often falling in and out of care.

Path forward

Proponents of work requirements say they offer flexibility while looking for employment

“If you can’t find a job, there’s no reason why you can’t volunteer your time to help others,” Brass said.

But, “if you’re between jobs, you want them to be applying, and interviewing and doing all these things,” Au said. “How are you supposed to find another job” if you’re busy volunteering?

“Medicaid is not an employment program,” she said. “The programmatic goal of Medicaid as a federal program is to provide health insurance coverage.”

Republicans want to pass a budget bill through Congress by July 4.