Spotlight Exclusives

Georgia Advocates Continue Fight for Medicaid Expansion Without Work Requirements

Laura Colbert Laura Colbert, posted on

Ten states—six of them in the South—have not adopted Medicaid expansion as provided under the Affordable Care Act. In Georgia, Gov. Brian Kemp has implemented a conservative alternative that offers government health insurance to people earning up to the federal poverty level—$15,060 for an individual adult—if they can document that they’re working, in school, or performing other qualifying activities. Laura Colbert, executive director of Georgians for a Healthy Future, spoke with Spotlight recently about Kemp’s plan and GHF’s support for more traditional Medicaid expansion. The transcript of the conversation has been lightly edited for length and clarity.

Why don’t we start by explaining more about what Georgians for a Healthy Future does.

We are a health, advocacy and policy organization based here in Georgia and we collaborate with partners and community members across the state to advance policy changes or advance policies that promote health equity in Georgia. For us, what that means is we are really working to change the laws, systems and policies that are in place so that all Georgians have access to quality, affordable healthcare and have the supports they need to live healthy, thriving lives.

We wanted to focus on Medicaid, so perhaps you could explain for our readers what Governor Kemp has put in place instead of a more standard Medicaid expansion?

In Georgia, we have a unique Medicaid program called Georgia Pathways to Coverage, and I will usually just call it Pathways. And what Pathways does is it makes Medicaid available for adults with incomes up to the poverty line, but only if they meet some pretty stringent work or school or other community engagement requirements. People have to demonstrate before they can enroll in Medicaid that they are doing at least 80 hours per month of work, school, volunteering, or some combination of those things. Georgia is the only state in the country that is currently implementing a work requirement for any Medicaid program.

And that has been in place for how long?

The program began July 1st, 2023. So, it’s been in place about nine months and currently there are about 3,800 people enrolled in the program.

I haven’t looked at the latest numbers, but in your neighboring state of North Carolina, the enrollment numbers for their Medicaid expansion are astronomically higher.

In December, I think because they had adopted a really smart strategy of automatic enrollment for some of their folks, I think they already had upwards of a quarter million people enrolled. The North Carolina coverage has really dwarfed Georgia’s.

And what is the sense of why people aren’t signing up? Obviously one reason is they can’t meet the requirements, but are you finding anecdotally that there are other reasons?

In Georgia, about six out of 10 low-income, uninsured adults live in a working household—they’re either working themselves or they live with a worker. So, we know that there actually are a very high number of Georgians should qualify for this program. I’d say reason number one for why folks aren’t signing up is that given that our state has not closed its coverage gap, we’ve spent 10 years telling people that they don’t qualify for health insurance. It takes a lot of time to unwind that awareness—people understand that if you are low income and don’t have job-based health coverage, it’s going to be really difficult for you in Georgia. And unfortunately, that understanding is pretty widespread.

The second reason is the program just really doesn’t match the realities of people in this income bracket. We’ve met lots of folks whose income varies from month to month, so they might qualify this month, but they don’t qualify next month. Or maybe they are going through a serious health problem right now and can’t work full-time because of this health condition. And in order to get the health condition resolved, they need health insurance and instead of having health insurance to help them get back to work, they are stumbling over the inability to get health insurance because they can’t work. We know from plenty of other work requirement implementations, whether that’s through Medicaid or other public programs, that work requirements don’t work. And this is illustrating that again.

In terms of litigation around this program, I’m assuming that a waiver had to be obtained. Where is all of that right now? Is this being litigated at all or is there anything happening in the courts?

No. Pathways is authorized under a 1115 Medicaid waiver and the waiver is authorized through September of 2025. If my memory serves, the Trump administration approved this waiver within a month of the November 2020 elections. The Biden administration ultimately withdrew its approval. The state of Georgia sued over that decision. and the court decision that came down was that the federal government had made an arbitrary, capricious rescission of its approval. The court decision does not weigh the benefits or consequences of a work requirement—it’s simply about how the decision got made. That’s an important point for us policy wonks.

You’re one of a handful of states that has not accepted Medicaid expansion. What’s the outlook? I’m assuming that’s your ultimate goal.

Georgia would just massively benefit from closing the coverage gap. It’s clearly the right policy decision as we would see more than half a million Georgians gain coverage. There’s a new economic analysis out that demonstrates Georgia would gain more than 51,000 jobs for the first three years of closing the gap and of course the federal financial incentives are just really dramatic. So, yes, closing the gap is what we at GHF are working towards as well as a coalition of other partners and policy makers who understand that that’s the best decision for our state.

During this past legislative session, there were two really important steps forward. The first is that the Senate held the Legislature’s first-ever hearing on a bill that would’ve closed the coverage gap. Georgia also has never had live legislation that would close the gap and that happened this year. There was a really fruitful discussion in that committee, though the legislation ultimately didn’t move forward. There was a second piece of legislation that kind of helps keep the ball moving forward and sets up a commission called the Comprehensive Health Coverage Commission that has been charged with looking at opportunities to improve healthcare for Georgia uninsured. We anticipate that this commission is really going to help keep that conversation alive among legislators and will be an important engagement opportunity.

Is a referendum a possibility under the Georgia constitution?

No, we do not have ballot signature options.

And is it helpful that you increasingly have neighboring southern states moving toward Medicaid expansion? You have Mississippi at least taking some action in the legislature and we talked about North Carolina. Does that increase the political pressure a little bit?

Yes and no. I think in this way it’s a little like football. Schools have rivalries across state lines and so do the decision makers in in each state. So, in that way, our Georgia leaders will say, well, that’s Mississippi. That’s not necessarily what we want to do here. But in other ways, yes, it does kind of provide some political cover for our leaders and demonstrates that even in states that have been hesitant to take this up, it’s important to consider the pros and cons of this policy decision.

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