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Yves here. Anyone who has interacted with US programs billed as helping the poor knows that the effect of the article, that they are caught in the trap of administrative procedures, is a feature, not a bug. The complex requirements favored by the PMC result in delays at best (reduced payments) and at worst denied assistance due to lack of ability to produce documents or meet other paper obstacles, despite being among the people who should receive benefits. The case study here is Georgia’s Medicaid operating laws, but this kind of thing always exists.
Yet most American liberals think they are better than the Victorians who punish Dickens for trying to shame them.
By Renuka Rayasam, senior correspondent for KFF Health News, who has written for Politico, the Austin American-Statesman and US News & World Report and Sam Whitehead, a correspondent for KFF Health News, who has reported for public radio station WABE and -Georgia Public Broadcasting. Originally published on KFF Health News
On a late summer night, Raymia Taylor wandered into the downtown recreation center, the only person registered to attend a two-hour event for enrollees in Georgia’s pilot Medicaid expansion.
The state launched the program in July 2023, which requires participants to document that they work, study, or do other eligible activities for 80 hours a month to receive health care. At the event, booths were opened to help people join the Marines or pursue a GED diploma.
Taylor, 20, has already met the program’s requirements — she’s studying nursing and working at a fast-food restaurant. But he said it is not clear what documents should be brought or how to upload his documents. “I was struggling,” she said.
Georgia is the only state that requires certain Medicaid beneficiaries to work to get coverage. Republicans have long favored such programs, saying they encourage participants to keep jobs. About 20 states have applied to freeze Medicaid work requirements; 13 received approval under the Trump administration. The Biden administration has worked to block these plans.
The Georgia Pathways to Coverage program shows the obstacles ahead for states that want to follow their lead. Georgia GOP leaders spent millions of dollars to launch Pathways. On July 29, about 4,500 people have registered, the federal Medicaid agency told KFF Health News.
That’s well short of the state’s goal of more than 25,000 in its first year, according to its application to the federal government, and half of the 359,000 who would have been eligible if Georgia had just expanded Medicaid under the Affordable Care Act, as it is 40 years old. some states do.
So far, the expensive effort has forced stakeholders to navigate bureaucratic hurdles rather than supporting employment. The government could not guarantee that it could guarantee even if the people in the program were working.
Research shows that such red tape affects blacks and Hispanics equally.
“People who need access to health care the most will struggle with that administrative burden because the process is complicated,” said Leah Chan, director of health justice at the Georgia Budget and Policy Institute.
At a press conference in August, Georgia Republican Gov. Brian Kemp announced a $10.7 million ad campaign to increase enrollment in Pathways, one of his major health policy initiatives. The program has spent more than $40 million in federal and state tax dollars through June, with nearly 80% going toward administrative and consulting costs rather than paying for medical care, according to data the state Medicaid agency shared with KFF Health News.
Enrollment consultants, consumer advocates, and policy researchers largely blame the cumbersome enrollment process, complex program design, and technical flaws behind the Pathways flagging enrollment. They say the online application is challenging to navigate and understand and lacks a way for people to get immediate support, and that government workers are not responding to applications in a timely manner.
“It’s an administrative nightmare,” said Cynthia Gibson, director of the Georgia Legal Services Program’s Health Law Unit, which helps Pathways applicants file objections.
Management challenges also undermined an important part of the program’s philosophy: that people keep a job to keep informed. Since July, the state has been removing enrollees who do not meet Pathways’ work requirements, according to Fiona Roberts, a spokeswoman for Georgia’s Medicaid agency.
“We understand that people need to be accountable for those 80 hours in the spirit of the program, and we intend to do that,” said Russel Carlson, commissioner of the organization.
Pathways is set to expire on September 30, 2025, unless the state asks the Centers for Medicare & Medicaid Services for an extension. Georgia officials say they won’t have to make that request until next spring, after the November election. So it’s possible that the state has asked for an extension from the Trump administration, which approved the program in the first place.
Georgia officials sued the Biden administration this year to keep Pathways operating without going through the formal extension process, which requires the state to hold public comment periods, collect more financial information, and prove that Pathways has met its goals. A federal judge ruled against Georgia.
A CMS spokesperson said the agency would not comment on the program.
During an August press event, Kemp said the Biden administration’s attempt to stop the program in 2021 delayed the rollout and halted enrollment. A federal court blocked the administration and allowed Georgia to proceed.
People familiar with the registration process say Pathways is riddled with design flaws and system failures. As of the end of May, there are 13,702 applications pending processing according to the state’s paperwork.
The program’s lengthy questionnaires and technical language are confusing, guidance is unclear, and document upload tools are tricky to navigate, according to interviews with health insurance enrollment experts conducted by the Georgia Budget and Policy Institute.
“It’s not easy, ‘Oh, I want to apply for Pathways,'” said Deanna Williams, who helps people sign up for insurance plans at Georgians for a Healthy Future, a consumer advocacy group. People often learn about the program after being denied other Medicaid coverage, she said.
In the online application, people click on the question pages before being shown a screen with information about Pathways, Williams said. They must then check a box and sign a form stating that they understand the requirements of the program.
Sometimes the Pathways program doesn’t appear, and he has to start over. The application process is “not smooth,” she said.
The data shows that people who don’t earn enough to qualify for free ACA programs but also make the most of Medicaid are disproportionately people of color. Pathways provides Medicaid to adults who earn up to the federal poverty level: $15,060 for an individual or $31,200 for a family of four.
Some Pathways-eligible people who work in stores or restaurants with flexible hours are worried they can’t meet the demands every month, Williams said.
Many current enrollees don’t know how to upload documents, and the website sometimes stops working, said Jahan Becham, employment specialist for Pathways at Amerigroup Community Care. Or people just forget.
Each month Becham receives a list of 200 to 300 subscribers who have not yet submitted their hours. “It’s a new thing, and not many people are used to it,” Beckham said.
“I was going to get souvenirs,” said Taylor, who attended the registrant’s event in August. “I just didn’t know how.
At a June 2023 meeting with Georgia Medicaid staff a few weeks before the program began, state officials asked why the state didn’t automatically verify eligibility through existing data sources, according to meeting minutes KFF Health News obtained through a state open records request. Georgia officials said they are not sure when they will be able to streamline the verification process.
Many potential participants face unjustified denials, advocates say. Gibson, of the Georgia Legal Services Program, said there are not enough trained staff to properly screen applications.
Fewer than 1 in 5 Pathways applicants have been accepted into the program since May, according to a KFF Health News review of state data. Roberts, together with the state, said that people are denied because they earn too much, do not meet the requirements, or do not complete the paperwork.
A full-time graduate student was unfairly barred from the program, and in February a federal administrative judge ordered a retrial. In another case, a different judge ruled that a 64-year-old woman who was unable to work because she was a full-time carer for her disabled husband was ineligible for Pathways.
Despite the challenges, government records as of May show that no one has been kicked out of the program since its inception for failing to meet job requirements.
Georgia’s test comes after a 2018 attempt in Arkansas to implement work requirements in the existing Medicaid center resulted in 18,000 people losing coverage, many of whom either met the requirements or would have been exempted.
Taylor found out about Pathways when she applied for food stamps last year. It wasn’t until August that she learned she could move her school schedule around to meet the qualifying hours requirement. With the full expansion of Medicaid, Taylor would have been eligible for health care without much effort. But, for him, it’s still worth it.
“It’s important to have health insurance,” said Taylor, who has been to the dentist several times and plans to visit the doctor. “I’m glad I have it.”
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