Background: In 2019, Georgia submitted a plan to the Centers Medicare and Medicaid Services (CMS) to expand Medicaid to a certain subset of Georgians. Under the plan, called the Georgia Pathways waiver, the state planned to allow individuals aged 19-64 making up to 100% of the federal poverty line (FPL) ($12,880 for an individual and $17,420 for a family of 2) to apply for Medicaid coverage. The Georgia Pathways plan also required these newly eligible adults to complete and document 80 hours of work or other “qualifying activities” each month to enroll in and maintain coverage. The plan further required some enrollees (those making 50-100% FPL) to pay a monthly premium to maintain their coverage, which is not required for traditional Medicaid.
In late 2020, the Trump Administration approved the Georgia Pathways plan and implementation was slated for the following July. In spring 2021, the Biden Administration changed the status of Georgia’s plan from “approved” to “pending” and stated they needed to review the plan, specifically the work and premium requirements, to ensure they were in keeping with the spirit, goals, and intent of the Medicaid program. You can learn more about the Georgia Pathways program and the approval timeline here.
As most of us were preparing to head out for our holiday breaks, the Centers for Medicare and Medicaid Services (CMS) issued a decision on the Georgia Pathways plan after more than 10 months of review. Ultimately, CMS approved the Georgia Pathways plan and will allow Georgia to expand Medicaid to Georgians making up to 100% FPL (as a reminder: under the Affordable Care Act (ACA), Medicaid expansion is up to 138% FPL). However, CMS denied the state’s request to include work requirements and premium payments as a condition of enrolling in and maintaining Medicaid coverage. Much of CMS’s reasoning for denying these provisions stemmed from concerns about the devastating impact the COVID-19 impact has had on both the health and economic security of Georgians. In her response, CMS Administrator Chiquita Brooks-LaSure wrote:
“The COVID-19 pandemic has had a significant impact on the health of low-income people, and the effects of the pandemic are likely to continue after the pandemic has ended. Uncertainty regarding new variants of the virus, the duration of the pandemic and its overall aftermath, and its potential impact on economic opportunities (including job skills training, work, and other activities used to satisfy the work requirement), as well as on access to transportation and affordable child care, have greatly increased the risk that implementation of the work requirement approved in this demonstration will create barriers to coverage in a time of great health care need among low-income people. The lingering health consequences of COVID-19 infections further exacerbate the harms of these barriers to coverage for low-income people.”
Now that CMS has issued its decision, Governor Kemp must decide how he wants to proceed. Essentially, he has four options before him:
- The Governor can do nothing. Even though CMS approved a modified version of the Georgia Pathways waiver, Georgia is under no obligation to implement it. This action would mean the coverage gap remains in place and vulnerable low-income Georgians would largely remain uninsured.
- The state can appeal CMS’s decision on the work and premium requirements. Under this option, the state would pursue a lengthy appeal process with CMS (a process made even slower by the pandemic). While the state pursues the appeal, thousands of Georgians would remain without coverage. This action would maintain the status quo and vulnerable low-income Georgians would largely remain too poor to qualify for affordable, comprehensive health coverage.
- The Governor can decide to move forward with the Georgia Pathways plan as approved. Under this option, Medicaid would be expanded to all Georgians below 100% FPL, and an estimated 269,000 uninsured Georgians would gain coverage. (Under the Governor’s original plan only 31,000 Georgians would gain coverage.) However, because this plan is not the full Medicaid expansion envisioned by the ACA, it would cost the state almost twice as much to implement. This increased cost is because the federal government will only cover 67% of the program’s costs, compared to 90% of costs if Georgia did a full Medicaid expansion.
- The state can fully expand Medicaid as intended by the Affordable Care Act to individuals and families making up to 138% FPL. Under a full Medicaid expansion, as many as 500,000 Georgians would be covered. Since expansion under these parameters would qualify for a 90% cost match from the federal government, the state would save millions of dollars and earn a $1.3 billion bonus in the first two years. Billions of dollars in new funding would flow into Georgia’s health care system and communities.
With CMS’s approval of the Georgia Pathways program, the state is at a crossroads. Our state leaders can choose to fully expand Medicaid and rise to meet the pressing health care needs of the state, or they can choose to cover a smaller population at a higher cost under the Pathways program.
However, the state should not and cannot choose to do nothing. Too many Georgians are suffering without access to affordable, quality health coverage. It is far past time to act and now the ball is entirely in Governor Kemp’s court to decide the way forward.