Dive Brief:
Public health scholars are urging the HHS to refuse Georgia’s request to continue its Medicaid work requirements program, citing harm to patients, providers and the state’s own finances.
Last week, the American Public Health Association and 65 other public health researchers and academics filed comments outlining how work requirements cause eligible Medicaid beneficiaries to lose coverage and don’t cause any increase in employment.
Work requirements, a longheld policy dream for many conservatives, are at the center of steep Medicaid cuts currently being negotiated on the Hill. Beyond Georgia, three other states — Ohio, Arizona and Arkansas — have also asked the HHS for permission to impose work requirements in their Medicaid programs.
Dive Insight:
The first Trump administration approved Georgia’s request to test Medicaid work requirements in 2020. After a legal battle with the Biden administration, which tried to stop the state, Georgia began requiring eligible enrollees to log work hours to remain on Medicaid coverage in 2023.
The state’s “Pathways for Coverage” program allows Georgians with incomes of up to 100% of the federal poverty level to enroll in Medicaid, a far less generous threshold than the 138% cutoff under the Affordable Care Act.
Enrollees have to be employed at least 80 hours per month to maintain their coverage.
However, the program quickly ballooned in expense while failing to meet enrollment goals. Only 7,000 people were actively enrolled in Pathways as of March. Meanwhile, an estimated 300,000 people are eligible for Medicaid expansion under the ACA, which would come with higher federal funding, according to the Commonwealth Fund.
Pathways costs Georgia five times more on a per-capita basis than a full Medicaid expansion, according to a report from the Georgetown University Center for Children and Families.
Still, the state wants to keep going, with Republican Gov. Brian Kemp asking the CMS for a five-year extension of its Medicaid waiver earlier this year.
“Georgia continues to improve the access, affordability, and quality of healthcare for Georgians as well as encourage self-sufficiency through promotion of employment and employment-related activities,” the waiver request reads. “Georgia commits to continue this transformative initiative, with the goal of improving access to quality healthcare services for the State’s low-income population.”
The waiver request makes some tweaks to Pathways, including requiring enrollees to certify compliance once a year instead of monthly and adding additional activities enrollees can perform to qualify.
But the program will still have the same effect, public health experts argue in their new letter.
“Work requirements in any form substantially depress enrollment among eligible people, which directly contravenes Medicaid’s primary purpose of providing coverage to low-income people,” the letter reads.
A number of states attempted to institute work requirements during the first Trump administration, which ultimately approved 13 demonstration waivers. Only one actually went into effect for longer than one month — in Arkansas, and just for seven months before a court overturned the program.
Still, over 18,000 people lost Medicaid coverage while Arkansas’ work requirement was in effect. An estimated 95% of those people met the work requirement or were exempt, suggesting that they lost coverage due to problems reporting data to the state, according to a study published in Health Affairs in 2020.
Arkansas’ experience has served as a case study for work requirements, and led many researchers to conclude the policy is costly and kicks eligible people off coverage due to red tape.
In addition, work requirements don’t cause employment to rise, given most Medicaid beneficiaries already work or qualify for an exemption, research suggests.
“For the foregoing reasons, APHA and the individual public health deans and scholars listed below urge HHS to reject Georgia’s request to extend its Section 1115 demonstration waiver and encourage the state to adopt the ACA Medicaid expansion,” the letter dated May 29 reads.
The Biden administration revoked all the Trump-era waiver approvals in 2021, save Georgia’s. But Trump is back in office, and deep-red states are once again pursuing waivers from the HHS that would allow them to yoke Medicaid coverage to work, arguing the programs incentivize citizens to get a job and nudge them toward private coverage.
Despite occasional GOP efforts, Congress has never passed a national Medicaid work requirement. Still, that could change this year as Republicans, leaning on their majority in both houses, attempt to push through a party-line megabill that includes the policy.
Almost 11 million Americans would lose health insurance as a result of the bill, with 7.8 million from Medicaid alone, according to the nonpartisan Congressional Budget Office.
