Georgia is set to become the only state to have work requirements for Medicaid coverage.

Republican Gov. Brian Kemp’s reelection — and a surprising Biden administration decision not to appeal a federal court ruling — have freed the state to introduce its plan that would allow for a limited increase in the pool of low-income residents eligible for Medicaid.

Questions remain about the rollout of Kemp’s plan. But it would set up Georgia as a test case for a work provision that has been proposed by several states and struck down in federal courts and by the Biden administration.

Meanwhile, advocacy groups are concerned about barriers to obtaining and maintaining the coverage. They also point out that the Kemp plan would be more expensive per enrollee and cover a fraction of the people who would get Medicaid under a full expansion. The new Georgia eligibility program would require a minimum of 80 hours of work or volunteering a month.

“The best-case scenario is that some uninsured Georgians would get coverage for some amount of time,’’ said Laura Colbert, executive director of the consumer advocacy group Georgians for a Healthy Future. “It’s going to be a big headache for the state and for people who enroll or try to enroll.”

The Trump administration approved Medicaid work requirements for Georgia and 12 other states. Georgia got approval under a “waiver,” or a federal permission that lets states run programs that differ from standard rules on Medicaid, the government insurance that covers the poor and the disabled.

But the Biden White House rejected the Georgia plan.

In August, though, a federal judge in Georgia ruled the Biden administration overstepped its authority, clearing the way for the Kemp plan to proceed. The federal government allowed the 60-day appeal window to lapse without making a move.

The rationale behind the White House decision not to appeal the court decision remains murky. A Centers for Medicare & Medicaid Services spokesperson, Bruce Alexander, said “as a matter of policy, CMS does not comment on matters of litigation.”

CMS’ reluctance to appeal may be connected to where the case would head next, said Leonardo Cuello, a research professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families. If appealed, the case would go to a conservative federal court that may be favorable to the lower-court decision — and establish it as a stronger precedent. 

“The decision not to appeal may have been based on fear that the result would get confirmed on appeal, since most of the appellate judges in the 11th Circuit are Republican-appointed,’’ he said.

Biden administration officials could also be waiting for the plan to play out before they step in, said Catherine McKee, a senior attorney with the National Health Law Program, a nonprofit advocacy program. Federal health officials “could let the state go forward and monitor it, and take action in the future,’’ she said.

Kemp’s office did not respond to KHN’s requests for comment on the status of the plan, but the governor celebrated the federal court’s August ruling in a series of tweets.

“Despite the Left’s efforts to claw back good policy for partisan politics, this week the judiciary … Ruled the Biden Admin erred in striking down our innovative healthcare waiver which would better serve Georgians than a one-size-fits all Medicaid expansion,” the tweets said.

The Georgia Department of Community Health, which oversees the Medicaid program in the state, declined an interview to answer questions about the work requirement plan.

But the agency recently posted on its website two pages related to the “Georgia Pathways” program: one with information on how to sign up, the other with details on the plan’s requirements. Both pages were taken down after KHN asked the agency about them.

“Pathways is not yet going live so the links were disabled to avoid confusion,” said Fiona Roberts, an agency spokesperson.

Work requirements for Medicaid have a short history of implementation nationally.

The only state to run a full-fledged work requirement program was Arkansas, which launched the rule in 2018. It led to about 18,000 people losing Medicaid coverage. A federal court suspended the requirement the next year.

Kemp’s victory over Democrat Stacey Abrams in this month’s midterm election also stymied — at least for now — Georgia Democrats’ long-standing push for full Medicaid expansion, projected to cover an estimated 450,000, versus about 50,000 under the Kemp plan. On Nov. 8, South Dakota voters approved a ballot measure for full expansion, which would cover more than 40,000 additional people in that state.

Georgia’s per-enrollee cost for the work requirement program is expected to be at least three times higher than it would be under a regular Medicaid expansion, said Colbert.

The federal government would have paid for at least 90% of the costs of insuring hundreds of thousands of Georgians under a full expansion. That compares with the expected 67% matching rate from the feds under the slimmer Kemp plan. And that difference doesn’t account for a Biden administration incentive for expansion that would net Georgia $710 million, according to a KFF estimate.

The administrative barriers to the Kemp work plan would be significant, consumer advocates say. Full-time caregivers, people with mental health conditions or substance use disorders, and people unable to work but who have not yet qualified for disability coverage would find it hard to qualify, Colbert said.

Other challenges could include a lack of transportation that makes it hard for enrollees to get to work and, for potential enrollees, limited access to computers to sign up.

Besides volunteering, other qualifying activities for coverage in the Kemp plan include education and job training.

Many people struggling with homelessness in Georgia would likely not meet the work or volunteer thresholds, said Kathryn Lawler, CEO of Saint Joseph’s Health System, an Atlanta-based nonprofit. Sixty percent of patients at its Mercy Care community health centers are homeless, she said. Coverage through Medicaid expansion would let patients afford health care, address chronic conditions, and relieve the stress of medical bills, she said.

People who need medical care often are too sick to go to work, Lawler said, adding that a single mother with three small children could be deemed ineligible. Full Medicaid expansion, through increased payments to providers, would ultimately allow Mercy Care to serve more people in need, she said.

The decision by CMS not to appeal “was a little surprising,’’ Colbert said, but she added that another unfavorable court ruling could pose a risk to other states’ Medicaid programs, by clearing the way for other work requirements.

The CMS inaction could inspire similar bids for work requirements in other GOP-led states, McKee said.

The Georgia plan, meanwhile, would probably not start until the end of the covid-19 public health emergency, which has provided continuous coverage for many Medicaid enrollees during the pandemic, and looks set to continue into early next year.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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