Georgia: Oh, yeah: Work requirements for some new Medicaid enrollees start on July 1st after all

During this springs Congressional kabuki theater regarding raising the federal debt ceiling, one of the biggest points of contention was House Republicans insistence on tying work requirements (w/stringent reporting) to Medicaid eligibility.

"Work requirements" is as old a saw for Republican politicians as "selling insurance across state lines," and it's just as ineffective and counterproductive (as well as simply being cruel). This debate has been held numerous times before, and the upside of such requirements has been debunked repeatedly, but here he go again:

As Joan McCarter of Daily Kos put it way back in 2015:

Most of these people are already working, assholes. How about instead of trying to embarrass them further for being poor, you work on embarrassing their employers for refusing to provide them health insurance or refusing to pay enough that they can buy it with Obamacare subsidies? And why isn't the fact that most people who would qualify for Medicaid who are now in the gap are working the beginning point in any discussion about Medicaid expansion and work requirements?

To Politico's credit, they do report (about 15 paragraphs in) that the majority of these people work, and add that among "those who don’t work, about a third said they were taking care of a home or family member, 20 percent were looking for work, and 17 percent were mentally ill or disabled." They point out that those numbers are close to the national labor force participation rate. There's a reason why this population is called the "working poor." Because they are working!

As noted by Madeline Guth of the Kaiser Family Foundation last year:

As most Medicaid enrollees are already working or face barriers to work, work and reporting requirements may result in coverage loss among eligible enrollees without increasing employment. Prior to the pandemic, the majority (63%) of non-elderly adult Medicaid enrollees who did not qualify based on a disability were already working full- or part-time. Most who were not working would likely meet exemptions from work requirement policies (e.g., had an illness or disability or were attending school), leaving just 7% of these enrollees to whom work requirement policies could be directed. Although few Medicaid work and reporting requirements were ultimately implemented due to litigation, state withdrawals, and/or pauses during the COVID-19 pandemic, available implementation data from Arkansas suggests that these requirements were confusing to enrollees and result in substantial coverage loss, including among eligible individuals.

As I've noted before: Are there some Medicaid enrollees who are "lazy bums," lying around on their couches eating bonbons while soaking up that sweet, sweet free healthcare coverage? I mean, probably; any population of millions of people is bound to have a small number of "shiftless layabouts," or whatever the term du jour is.

But it's a pretty tiny percent; certainly not enough to justify making millions of others jump through bureaucratic hoops just to "prove" that they're worthy.

As I said 8 years ago, the "get off your ass and work!" requirements appear to be nearly as big a waste of time and resources as the infamous "drug testing for welfare recipients" bandwagon which a bunch of states jumped on board with a decade or so ago.

As for the "kicking them off Medicaid will force 'em to work" talking point, that was roundly debunked years ago as well:

The first major study on the nation’s first Medicaid work requirements finds that people fell off of the Medicaid rolls but didn’t seem to find more work.

Since Arkansas implemented the nation’s first Medicaid work requirements last year, a new study published in the New England Journal of Medicine has found, Medicaid enrollment has fallen for working-age adults, the uninsured rate has been rising, and there has been little discernible effect on employment.

The research appears to confirm some of the warnings from Medicaid advocates who opposed the Trump administration’s approval of work requirements in Arkansas and other states. People are losing Medicaid coverage, often as a result of confusion rather than failure to meet the work requirements, but they aren’t finding jobs and getting insurance that way. They are simply becoming uninsured.

The good news is that in the end, work requirements for Medicaid did not end up being part of the final debt ceiling package (although they were tweaked & expanded slightly for some SNAP recipients in the end).

However, in spite of nearly every state which tried to (or succeeded in) implement Medicaid work requirements having their programs shut down by the courts, one state's work/reporting managed to survive: Georgia. As explained in the Kaiser article:

In August 2022, a Federal District Court judge issued a decision in favor of the state, vacating CMS’s rescission thus reinstating these provisions. Although CMS generally reserves the right to withdraw waiver authorities at any time, the judge found that its rescission of Georgia’s waiver provisions was arbitrary and capricious due to agency errors, including that it failed to weigh that the waiver would have increased Medicaid coverage. CMS did not appeal this decision. Georgia Governor Brian Kemp allocated $52 million in his proposed state fiscal year (FY) 2024 budget to implement the Georgia Pathways program beginning July 1, 2023.

The key distinction between Georgia's waiver and every other state is that the other states were trying to impose work requirements on populations which they had already expanded Medicaid eligibility to. This would amount to something of a bait & switch. In addition, the court seems to reason that seeing how over 250,000 low-income Georgians caught in the Medicaid Gap don't have any viable healthcare coverage options at the moment (due, of course, to Georgia refusing to fully expand the program to them under the ACA), allowing some of them to gain Medicaid coverage, even with pointless/stupid work & reporting requirements attached, is better than not allowing them to enroll at all.

In any event:

Once implemented, Georgia’s waiver will expand eligibility to 100% of the federal poverty level (FPL), with initial and continued enrollment conditioned on meeting work and premium requirements. These and other provisions of the Georgia Pathways waiver, including additional eligibility and benefit restrictions, are summarized in more detail in Table 1. The work requirement would apply to enrollees below age 65, with “good cause exceptions” (for those who cannot fulfill the requirement in a given month due to a circumstance such as a family emergency) and “reasonable accommodations” (to enable individuals with disabilities to meet the requirement) available.

"Reasonable accommodations" seems to be doing some pretty heavy lifting here, and I won't be surprised if there's some absolutely absurd stories coming out of Georgia about, say, quadriplegics being kicked off for not meeting the work requirements or whatever, but we'll see.

The state originally estimated that the Georgia Pathways waiver would provide coverage to about 64,000 individualssignificantly less than the estimated 269,000 uninsured individuals in the Medicaid coverage gap (parents with incomes that exceed Medicaid eligibility levels but are below the FPL, plus childless adults with incomes below the FPL) who could be covered if Georgia adopted the ACA Medicaid expansion.

Here's some more details, again via Kaiser:

  • Expands eligibility to parents 35-100% FPL and childless adults 0-100% FPL
  • Enrollment conditioned on compliance with work requirements and premiums
  • Enrollees 50-85% FPL subject to $7 monthly premium; enrollees 85-100% FPL subject to $11 monthly premium
  • Enrollees who miss 3 monthly premiums in a benefit year (fail to pay each within a 2 month grace period) will face a 90 day suspension period; if they fail to make at least one payment during this period, they will be disenrolled
  • For enrollees who self-attest to using tobacco: enrollees 50-85% FPL subject to $3 premium surcharge; enrollees 85-100% FPL subject to $5 premium surcharge
  • 80 hour/month work requirement; age exemption for those 65+
  • No retroactive eligibility, no hospital presumptive eligibility
  • Enrollees get Member Rewards Account (MRA) that deducts copays/premiums & deposits incentive points for completing healthy behavior incentives (e.g. attending smoking cessation classes, annual well visits, or complying with diabetes prevention/management program). These points are non-monetary credits which beneficiaries may use to access dental services, glasses, contacts, and OTC drugs not covered by Medicaid.
  • Only individuals eligible for EPSDT will receive non-emergency medical transportation (NEMT)
  • Enrollees also subject to $30 charge for each non-emergency use of the emergency department

I could write an entire post about the uselessness/ineffectiveness of "wellness programs" in this context (and others already have), but whatever.

In any event, policymakers in other states will be keeping a very close eye on Georgia's "Pathways" program going forward.

In the meantime, I'll try to focus on the positives of this development: ~64,000 more low-income Americans gaining comprehensive healthcare coverage is still a good thing...assuming that's what actually happens. We'll see.