Georgia is one of 10 states that have not expanded Medicaid under the Affordable Care Act (ACA), resulting in an uninsured rate of 12 percent, one of the highest in the country. In lieu of Medicaid expansion, the state launched the “Pathways” program, under a section 1115 waiver, in July 2023. Pathways covers individuals earning up to 100 percent of the federal poverty level (or $1,255 per month for an individual) who document 80 hours of work or other “qualifying activities” (e.g., job training) every month. In contrast, the ACA expansion would extend eligibility to people with incomes up to 138 percent of poverty (about $1,732 per month for an individual) without work-reporting requirements and a higher federal match rate for the state.
While the program was touted by the governor as an “innovative . . . solution . . . that puts Georgians and their access to care first,” enrollment is significantly below the state’s predictions. Georgia estimated 345,000 people would be eligible and 100,000 enrolled in the first year. The latest available data show that only 4,392 individuals have ever been enrolled, with only 2,344 “active” enrollees in mid-December 2023. After people are determined eligible for Pathways, it is unclear how many remain enrolled from month to month, and whether the work-reporting requirement prevents eligible people from retaining coverage, as similar requirements have done elsewhere.
As the only state with a work requirement, it is critical for Georgia to maintain transparency so results can be assessed and publicized. According to the Centers for Medicare and Medicaid Services (CMS), Georgia must submit quarterly monitoring reports and had planned to provide monthly reports. However, the only reports publicly released to date are for July through October 2023. It is unclear whether Georgia has not submitted subsequent reports or whether reports have been submitted but not publicly released. Failure to submit reports can result in corrective action, including deferred federal funds, and also will be considered by CMS when reviewing future waiver applications.
The older reports reveal discrepancies between the number of people determined eligible for Pathways and the number enrolled. For example, in October 2023, the state found 603 people were determined eligible but only 512 enrolled. The reports also don’t indicate why people are eliminated at early stages of the process and lack information about why many applicants are determined ineligible. The reports also omit the number of applicants who requested reasonable accommodations — for example, assistance with documentation or reductions in required hours — which are required by federal laws that prohibit discrimination against people with disabilities. Anecdotal accounts indicate that uninsured people with disabilities cannot receive a diagnosis that could qualify them for reasonable accommodations under Pathways, and uninsured Georgians are encountering administrative barriers to enrolling in Medicaid, such as misdirected mail, unreturned phone calls, full voicemail boxes, and lack of information about coverage options.
Despite low enrollment, Pathways has cost at least $26 million, with more than 90 percent going toward administrative costs and consulting fees, not health care. Pathways also is significantly more expensive for Georgia, while covering substantially fewer people, compared to the ACA’s Medicaid expansion. An analysis of the first year of operation estimated that Pathways would cost Georgia five times more per person ($2,490 vs. $496) compared to ACA expansion, which would offer enhanced federal funding and likely result in zero state costs for the first two years, given the American Rescue Plan Act’s incentives.
Moreover, low enrollment demonstrates that the waiver has not fulfilled its potential to provide a new coverage pathway for people who lose eligibility for traditional Medicaid, nor is there evidence that the waiver has increased the number of employed enrollees. Nearly 800,000 people lost Medicaid from May 2023 through April 2024, as Georgia renewed enrollees’ eligibility following the expiration of the continuous enrollment requirement that was in place during the pandemic. Notably, nearly three-quarters of people who lost coverage were disenrolled for procedural reasons, like failing to return paperwork, not because they were actually determined ineligible. Georgia’s operational plan indicated it would review and provide notice about Pathways eligibility to people losing traditional Medicaid, but the data do not show that these efforts have been successful.
Georgia’s governor “remains focused” on Pathways, and despite a substantial budget surplus, legislators recently rejected an opportunity to adopt the ACA expansion. Yet, few people are enrolled in Pathways, and despite high spending on administrative costs, thousands are waiting to have their applications processed. Georgia continues to condition Medicaid eligibility on monthly reporting by enrollees but has not released its own reports monitoring the waiver since October 2023. Without timely public data, it is unclear what specific policy changes are needed to ensure that eligible Georgians can enroll in and maintain coverage. After one year of implementation, what is clear is that Georgia’s claims about its “innovative” approach are ringing hollow for hundreds of thousands of uninsured residents.
