As of June 2024, a paltry 4,231 Georgians were enrolled in Georgia’s section 1115 Medicaid waiver, according to reports from the state recently posted by federal CMS. Data from the newly released reports confirm that Governor Kemp’s “Pathways to Coverage” alternative to the Affordable Care Act’s Medicaid expansion – approved during the last year of the Trump Administration – has been spectacularly unsuccessful. The demonstration is due to expire on September 30, 2025.
Georgia is one of 10 states (mainly in the South) that have not accepted generous federal funding to expand Medicaid for low-income adults. KFF estimates that an estimated 359,000 Georgians would be eligible for regular ACA Medicaid expansion – 175,000 of whom are under the poverty line who could theoretically be eligible for Pathways. Thus, a miniscule two percent of those in the coverage gap have been able to obtain insurance through Georgia’s approach.
Even by the state’s own low aspirations Pathways has failed to get off the ground. When the Trump Administration approved this section 1115 demonstration in 2020, the state and federal government estimated that 64,000 people would be covered; in late 2022 the Governor requested funds in his state budget for the following year for 100,000 enrollees. Enrollment began in July 2023 with coverage starting September 2023.
Here’s a kicker — the newly posted reports submitted by the state make clear that Georgia is not enforcing the work reporting requirement once someone is enrolled. Clearly if it were enforcing those administrative barriers, there would be even fewer people enrolled in Pathways. Georgia has also not implemented a key aspect of its waiver agreement – premiums – which would act as a further barrier for low-income people. We outlined the challenges in the original proposal here.
Contrast Georgia’s approach with what has happened in North Carolina where the Republican-controlled Legislature adopted Medicaid expansion after much prodding by the Democratic Governor Roy Cooper. Along with enhanced federal match and extra bonus federal incentive dollars that mean the state will make money in the first few years, North Carolina has already enrolled 553,890 people in coverage during a shorter period of time. Thirty-seven percent of those in North Carolina who are enrolled live in rural counties, which tend to have a higher share of adults enrolling relative to urban counties.
How much money has been spent on administrative costs and lawyers?
While very few people have been covered in Georgia, the state and federal government have spent a great deal of taxpayer dollars in getting this much publicized effort off the ground. More than 90% of expenditures in the early years have gone to administrative and consulting costs –mostly to Deloitte Consulting, according to data obtained by investigative reporters. Deloitte is a large national consulting firm that has recently been implicated in many failures during the Medicaid unwinding process and is the subject of a pending complaint with the Federal Trade Commission.
Add to this total spending on whatever the state has spent on lawyers, which at this point is a question mark. Georgia’s waiver has been heavily litigated as my colleague Leo Cuello has blogged repeatedly about, most recently here.
And to bolster the paltry Pathways enrollment numbers, the state recently announced a $10.7 million ad and outreach campaign. Where is the $10.7 million to reach low-income adults in Georgia going? The state contracted with Deloitte.
So, taxpayer dollars keep flowing to consultants but few Georgians in the coverage gap who need it have been able to access health insurance.
Meanwhile, many children lost coverage in Georgia during the Medicaid unwinding but the state has given little attention to outreach efforts related to children in recent years — even though generous federal funding is available to Georgia to do so through the Children’s Health Insurance Program (CHIP). A Georgetown CCF review of Georgia’s CHIP spending reported to the federal government from FY 2018 to FY 2023 shows no reported spending on outreach to encourage families to enroll children in Medicaid and CHIP.
During the recent Medicaid “unwinding,” net Medicaid child enrollment declined by 300,000 in Georgia – which ranks behind only Texas and Florida for numbers of children disenrolled in the country – and is the 10th highest percent decline (21%) among states nationwide.[1] These children have not turned up in Georgia’s separate CHIP program – which is one of the most logical places for them to go if they are no longer eligible for Medicaid – as enrollment has declined there too. And the state just reinstated premiums for children in PeachCare as of October 1, which will add another barrier to children reenrolling.
So Georgia’s unwinding outcomes for children are nothing to feel good about. The majority of children losing coverage nationwide during the unwinding are likely to remain eligible for Medicaid or CHIP according to federal researchers. And Georgia ranked 39th for its child coverage rates in the country as of 2023 (this will likely be worse when the full effects of unwinding are seen in the data).
And to make matters worse, Georgia’s Medicaid application processing times are literally the worst in the country, according to the most recent data from CMS, meaning that families and people with disabilities who are applying for Medicaid (and in some cases got kicked off erroneously during unwinding) have to endure longer periods of being uninsured. States are required to process most applications in under 45 days; more than half of applications in Georgia are failing to meet this standard.
This isn’t just about Georgia – remember that Pathways is potentially a model for the nation. Work reporting requirements were a top priority for the first Trump Administration and Congressional Republicans. In 2022, then Speaker McCarthy tried to attach a Medicaid work reporting requirement to the debt ceiling agreement – arguably one of the most consequential pieces of legislation that a Congress considers. So, it’s worthwhile to keep your eye on Pathways even if you don’t live in Georgia.
