As Republicans at the federal level prepare to take over majorities in both the House and Senate, some have proposed deeply damaging cuts to Medicaid, including taking health coverage away from people who don’t meet unnecessary and burdensome work requirements. Some state policymakers are interested in pursuing Medicaid work requirements as well. But a Georgia Medicaid program provides the latest evidence that work requirements are the worst sort of red tape — blocking health coverage for working people, people with serious health conditions, and people with disabilities.
Georgia is one of ten states that has not adopted the Affordable Care Act’s Medicaid expansion provision, instead applying for a waiver to provide Medicaid to certain low-income adults, conditioned on meeting work requirements. This waiver program, called Pathways to Coverage, requires adults with low incomes to report at least 80 hours of work or volunteer activities each month as a condition of getting and keeping their coverage. It is available to adults up to 100 percent of poverty, or $15,060 annually for an individual.
The results from over one year of Pathways to Coverage are in:
- About 5,500 people were covered as of November 2024, far less than the 110,000 who initially expressed interest, and well under the about 240,000 uninsured people estimated to potentially be eligible for Pathways.
- Application backlogs, excessive paperwork, and complex rules have left people waiting for coverage after they’ve applied and kept many other people from even applying for the program.
- Spending on administrative changes, such as systems updates, eclipsed spending on health care services and offered little return on investment in facilitating enrollment.
Work requirements prevent people from accessing health care for reasons that are outside their control. For example, many people working low-paying jobs are at the mercy of employers who can reduce their hours without notice. Family emergencies, inconsistent childcare, or sudden illnesses can also disrupt a person’s ability to work. Furthermore, people with disabilities and chronic illnesses are not exempt from the Pathways reporting requirements. They could face challenges finding enough hours to work because employers will not provide reasonable accommodations or their health conditions restrict the amount of time they can work. As a result, people are at risk of not receiving often life-saving health coverage.
Previous work requirement proposals conditioned continuing Medicaid coverage on reporting enough eligible work, or other qualifying activity, hours. Georgia’s Pathways program adds an additional hurdle: requiring work reporting at the time of application, which creates a complex process that deters eligible people from even applying. In June 2024, 42 percent of the people who expressed interest in applying for Pathways were not considered to have a complete application because they did not complete a report showing any number of qualifying activity hours. And among those who did have complete applications, 19 percent were denied due to reporting fewer than the required 80 hours per month or insufficient verification of hours.
Focus groups conducted by Georgia Budget and Policy Institute and Creative Research Solutions back up this data. Pathways applicants pointed to challenges getting support during the enrollment process, technology issues with the enrollment system, or frustrations with getting denied due to paperwork issues and having to wait to have the application checked again.
Georgia is among the slowest states to process Medicaid applications due to excessive bureaucratic strain. Others didn’t feel comfortable applying because they were concerned they would not get approved, likely due to the complex process and the high denial rate in the first year. The frustration with paperwork issues and the stress from not having health coverage are similar to findings from focus groups in Arkansas, the first state to implement a Medicaid work requirement temporarily in 2018.
And although only a small fraction of eligible people have enrolled, the program has cost about $13,360 per enrollee in combined state and federal Medicaid spending through the end of the first year. That’s significantly more than the about $2,490 per enrollee Pathways was initially estimated to cost in the first year. About 35 percent of spending went toward covering care, but most went to systems modifications to implement work reporting. And in August 2024, the state separately spent $10.7 million on an outreach campaign, directing millions to consultants while hundreds of thousands of people are still without insurance.
From the standpoint of ensuring access to health care and improving efficiency, it is clear from Georgia that work requirements do neither. Once again, the Pathways program shows us that work requirements are simply a way to keep people from getting health care by requiring them to navigate a complicated system to report work hours or claim exemptions. This is especially cruel because the few people who made it through the process and secured Medicaid coverage through Pathways reported being able to get lifesaving care, medications, and other health tools to manage or prevent long-term illnesses.
Even though Georgia sought to use this program as an alternative to expanding Medicaid, the same lessons would apply in states that already expanded coverage. Policymakers should reject work requirements, which leave people with higher health care costs and state agencies with increased burden.
