Georgia is the only state that requires some able-bodied adults to work to qualify for Medicaid, in a program that has reached its one-year anniversary, despite the opposition of the Biden administration.
Under the Trump administration, the Centers for Medicare and Medicaid Services (CMS) approved waivers allowing states to condition Medicaid benefits for nondisabled adults on work efforts and payment of minimal premiums. The Biden administration began withdrawing federal approval of the waivers, although 13 states had received them, and nine other states’ waiver requests were pending.
Georgia was one of the states that moved to implement work requirements and challenged the recission of its waiver by CMS. A federal judge ruled that the agency’s action was arbitrary and capricious, in August 2023. CMS did not challenge the ruling. As a result, Georgia is currently the only state with a work requirement for any Medicaid beneficiaries.
Alternative to Medicaid Expansion
Medicaid is a state-run program that was originally envisioned as a means of providing health care to low-income Americans, including the destitute and individuals with debilitating chronic illness and disability.
Medicaid was expanded by the Affordable Care Act in 2010 to cover able-bodied single adults and families with incomes up to 138 percent of the federal poverty level. Coverage of the expansion population became voluntary for each state following a lengthy court battle. In 2024, there remain only 10 states that have not expanded Medicaid, including Georgia, according to KFF. The other nine states are Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming.
These states, and others that eventually expanded Medicaid, applied for federal permission to implement alternative health plans for various Medicaid-eligible populations, with such features as managed care, financial contributions by enrollees, and work or training requirements.
Peachtree State’s Pathways Plan
Georgia’s program, Pathways to Coverage, is designed for individuals who are not otherwise eligible for Medicaid. It requires these able-bodied adults to work 80 hours a month in either a job, volunteer opportunity, training, or education. To qualify, an individual can earn no more than $15,600 per year, or $31,200 for a family of four.
While a full expansion of Medicaid in Georgia would have made an estimated 430,000 additional individuals eligible for Medicaid, the Pathways program was projected to enroll 25,000. However, only 4,300 individuals have signed up, according to an Associated Press (AP) article, published on July 13.
Critics say the low enrollment proves requiring Medicaid recipients to work has been a failure. “First year of Georgia experiment is not promising,” reported the AP, citing “barriers to employment,” including drug addiction, lack of transportation, and difficulty documenting hours.
Not Worth the Effort
Low enrollment might be a sign of the success of work requirements, rather than the failure of the program, according to Devon Herrick, a health economist and policy advisor to The Heartland Institute and editor at the Goodman Institute Health Blog.
“It’s pretty clear that many low-income people in Georgia do not consider Medicaid enrollment worth the effort of documenting their employment,” said Herrick. “Perhaps they don’t consider it enough of an incentive even to get a job.
“The purpose of work requirements is twofold: not subsidize sloth; and to reward people for working, or at least encourage them to look for a job. It’s not clear that low enrollment represents a failure of the work requirement program.”
Seeking Better Life Outcomes
The reporting requirements for Medicaid could be less burdensome, says Rea S. Hederman, Jr., executive director of the Economic Research Center and vice president of policy at The Buckeye Institute.
“State governments need to continue to make the administrative burden of work requirements as light as possible so the program is effective and Medicaid enrollees can complete the paperwork,” said Hederman.
However, increasing Medicaid enrollment is not the principal reason for programs like Georgia’s Pathways, says Hederman.
“Work requirements are not an end goal for this Medicaid reform but are instead a way to encourage enrollees to work, earn more money, and become better off,” said Hederman. “With a solid labor market, some potential enrollees in Georgia’s program may have started working in excess of 80 hours a month and finding alternative health coverage to Medicaid. It is too early to make a final decision on how effective that program is.”
Contribute What You Can
Work requirements for the abled-bodied is common sense, says Matt Dean, a senior fellow for health care policy outreach at The Heartland Institute, which publishes Health Care News, and a former seven-term member of the Minnesota House of Representatives.
“It is reasonable to limit access for those who can afford to contribute something to their care but do not,” said Dean. “Recipients should be willing to contribute as much as they can, even if it’s only a dollar. People making enough money to support themselves is a good thing.”
Minnesota has no work requirement or asset test for Medicaid eligibility.
Kevin Stone (kevin.s.stone@gmail.com) writes from Arlington, Texas.