On October 5, 2023, CMS certified as complete Georgia’s implementation plan (the implementation plan itself starts on page 50) for phase one of its “Pathways to Coverage” section 1115 demonstration that the state had already started implementing more than 3 months earlier, on July 1, 2023. Yes, you read that right. And no, it doesn’t make sense. Nor will the rest of this story, for that matter.
More troubling than the timing in Georgia is the actual content. My colleagues Joan Alker, Allie Gardner, and I issued a report prior to the Georgia launch date identifying many policy shortcomings in the underlying Pathways demonstration. In short, Pathways is a partial expansion of Medicaid with work requirements, premiums, and other features that will massively suppress enrollment and discriminate against women and parents because caregiving does not count as work. Georgia’s implementation plan drew a new red flag from CMS and exposes all of the policy problems we identified in our report.
Let’s start with CMS’s new red flag. Georgia has designed Pathways to make it very hard for people to become or stay eligible. Workers would need to report and document working hours every month to stay eligible (after six months they could qualify for an exemption on reporting for the duration of that year). However, as CMS correctly identified, Medicaid regulations require states to use available data sources to confirm most eligibility criteria, when possible, instead of making people provide documentation. CMS has thus informed the state that it cannot deny, suspend, or terminate eligibility for individuals for failure to document work if data sources could confirm employment. This is more than a technicality; it ameliorates one core policy design feature that will keep Georgia’s enrollment low.
It also raises a pair of interesting side questions. First, how will the state assess which enrollees have available data sources? Second, since the income data sources report total income, but the work requirement is based on hours worked, how will the state use the data to ascertain compliance? In any event, Georgia will have to figure out how to use data to reduce the documentation burden on applicants and enrollees.
This issue, however, does not change the broadly problematic design of the Georgia demonstration. Here’s an example of how the Georgia eligibility and enrollment flow “works”:
John Smith files an application (which must include reporting and documentation of work hours) on July 1. The state has 45 days to make an eligibility determination – so that would be done by about August 15. Coverage would start on the first of the next month – September 1. Qualifying hours are to be repeatedly reported and documented by the 3rd day of every month – so reporting would be due September 3 in our example. If hours aren’t reported and documented, the enrollee is sent a notice, and a final cut-off for reporting is the 17th of the month – September 17. If the enrollee fails to meet that deadline, then their coverage is suspended effective the first of the next month – October 1. It is critical to understand that suspension is not a grace period – coverage is terminated during suspension. If there is no reporting and documentation by the 17th of that first suspension month – October 17 – then a termination warning is sent. If there is no reporting and documentation in the next month submitted by the 17th – November 17 – a termination notice is sent, and enrollment is terminated December 1.
So, first, individuals who fail to report and document sufficient hours in any month (even, for example, someone with variable job hours) are suspended the next month – their health coverage completely stops. This means that many individuals will cycle on and off coverage, based on whether they are able to report and document enough hours every month. This isn’t a three-strikes policy such as Arkansas had – it’s one strike and you’re out. This policy will be devastating to enrollment and continuity of care in Georgia Pathways and will create an incredible amount of administrative hassle for individuals, providers, and state staff. Georgians won’t get far on this “Pathway” lined with red tape.
Second, of course, the strict requirements on documentation will lead to many reporting failures. Consider, for example, individuals who have informal employment arrangements or are self-employed. While the state does offer some good cause exceptions, they are time-limited and also almost always require submitting documentation. So this too will be a failure point.
Finally, as we have discussed from the outset, one of the most harmful and anti-family features of the Pathways model is that, unlike every work requirement proposal before it, there is no exemption of any kind for parents or caregivers. Parents will have to choose between taking care of their children or having health insurance – a terrible situation for parents and children alike.
When you add up these policies, the outcome is predictable: Not many people will be able to run the gauntlet to get enrolled, and the few who do get enrolled will cycle on and off coverage – and frequently get terminated from the program entirely.
Unfortunately, this isn’t just theory. According to Georgia state projections, a full expansion in Georgia would have covered about 491,000 people in 2022. But Georgia predicted its Pathways model would enroll just 64,336 people – about 1 out of every 8 people who would be eligible under a normal Medicaid expansion. That goal is atrocious, but even that currently looks like a pipe dream. The latest numbers indicate that, as of November 3, only 1,809 people have enrolled since the state started accepting applications in July. That’s about 1 out of every 271 people that would be enrolled in a full expansion. That’s right, Georgia’s work requirement “demonstration” has enrolled a whopping 0.4% of the potential new Medicaid expansion enrollees. To call Pathways a failure would be generous. North Carolina by contrast, which is preparing to implement a full Medicaid expansion next month, is planning to auto-enroll 300,000 people from the very start.
And under the implementation plan, things will get even messier for enrollees in Georgia. Consider again the incredibly complex process and deadlines for John Smith described above. Well, in July 2024, when the implementation goes into Phase 3, the state will add premium payments to the mix, which will also have a schedule of monthly deadlines every month – on different dates than the work reporting and documentation. Keeping track of your Pathways insurance reporting, documentation and payment deadlines will itself be a full-time job—but not one that qualifies you for coverage! (Maybe that’s what the state meant by work requirement?)
Another concerning feature of the Georgia implementation plan is that the state’s substantive consumer support strategy appears to be: pass the buck to the managed care plans. The state’s plan largely dumps the burden of helping people understand and comply with reporting and documentation requirements onto managed care plans.
Finally, an important question that is insufficiently addressed in the implementation plan is how the Pathways program interacts with unwinding—which the implementation plan does not even directly mention. The state has not committed to ensuring that every nonelderly adult who has been and will be reviewed and terminated in unwinding (and isn’t eligible for some other category of assistance, such as transitional medical assistance) gets dedicated outreach and screening for Pathways. This is necessary because, for Medicaid enrollees covered in other categories, the state has no reason or basis to know that they meet the superfluous Pathways eligibility requirements related to work reporting hours. Without taking the extra step of reaching out to adults who have lost or are losing other Medicaid coverage to get the needed Pathways eligibility information, Pathways will be a theoretical island of coverage on the map, but enrollees terminated in unwinding will be unlikely to find the bridge to get to it.
Georgia will never be able to fix Pathways. We’ve extensively covered the many reasons that work requirements are simply a bad policy in Medicaid. Full stop. The Pathways model, like the brief Arkansas work requirement debacle in 2018, is yet another unmistakable piece of evidence that the policy just doesn’t work. Georgia could be covering half a million Georgians paying only 10% of the cost of coverage, and has instead, at great effort, and adding a whole new layer of bureaucracy, designed a demonstration covering less than 2,000 people while paying a much higher percentage of their cost of coverage.
One of the ironies of this coverage flop is that the whole reason that there is a Pathways model in operation is that, after the Biden administration rescinded the demonstration approval precisely because they believed it would not promote coverage, Georgia filed a lawsuit and got a partisan judge to step outside of her lane and reinstate the approval because she found it would promote coverage. Who wants to let the judge know that she was less than half of one percent correct?
I’m an optimist who wishes I could tell you the glass is half-full. But the truth is it’s over 99.6% empty. And the roughly 489,000 Medicaid expansion eligible Georgians who are left without health insurance deserve a whole lot more from their state.