Hector visits the emergency room every month when he runs out of insulin. Like 1.4 million Georgians, Hector falls into the “coverage gap,” meaning he does not qualify for Medicaid but cannot afford the subsidized insurance offered on the healthcare exchanges. This is despite working multiple jobs – employment that puts food on the table but does not provide health insurance or guarantee reliable hours.
According to one group of experts, Georgia ranks last in Medicaid coverage due to severely restrictive eligibility. This shortcoming has led Georgia to the 4th-highest uninsured rate, some of the poorest health outcomes and a disturbing number of rural hospital closures. By just about every metric, Georgia is failing its citizens at providing quality, cost-effective healthcare.
Georgia’s new “Pathways to Coverage” (“Pathways”) is a step in the right direction but does not go nearly far enough. Beginning in July, the state will expand Medicaid to individuals and families making 100% of the federal poverty level (FPL), which is $14,580 for an individual or $30,000 for a family of 4; however, the impact of this policy will be greatly curtailed by a waiver that enforces an 80-hour-a-month work requirement. The state estimates 100,000 individuals will gain health insurance under “Pathways” compared to the 500,000 who would gain coverage under full expansion.
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The rationale for this requirement contends it will “increase the number of persons who become employed.” However, evidence suggests this is not the case; rather, access to Medicaid itself (free from work requirements) may increase the likelihood of entering the job market. Furthermore, Arkansas, the only state to implement work requirements thus far, saw no net effect on employment, leading to the policy being struck down in the courts. In Georgia, work requirements are similarly unlikely to affect employment. The majority of uninsured Georgians, like Hector, are already working and those who aren’t working are in school, caregivers or not working due to illness or disability.
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Work requirements do not increase employment, but do create barriers to care and lead to worse health outcomes. In Arkansas, within 7 months of implementation of a work requirement, one out of four Medicaid recipients lost coverage. Of those who lost coverage, over half had medical debt, delayed seeking treatment and were unable to afford medications after the policy took effect.
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There is no reason to suspect a work requirement will have a different outcome in Georgia. Moreover, it will cost Georgia taxpayers dearly. The Georgia Budget and Policy Institute (GBPI) estimates that Georgia will spend $2,490 per new enrollee (or $249 million in total) under “Pathways” versus just shy of $550 per new enrollee (or $239 million in total) under full expansion. Furthermore, “Pathways” would deprive Georgia of $650 million in federal funding each year. Under “Pathways,” Georgians who pay federal income tax will continue subsidizing the healthcare of 39 states without any benefit to themselves. Expanding Medicaid would ensure that this federal money comes home to Georgia; the $650 million would be more than enough to cover the cost to add 500,000 new enrollees with a surplus of funds to invest in infrastructure, schools and public safety.
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Perhaps those with the most to lose under the new policy are rural communities. Georgia has lost 9 rural hospitals in the past decade and an additional 1/3 are in immediate risk of closing. Medicaid work requirements have been shown to worsen hospitals’ vulnerability; conversely, rural hospitals demonstrate improved financial performance in states that have expanded Medicaid, allowing them to provide better care and create new jobs. It is estimated that 12,000 new jobs and $1.3 billion in new economic output would be created in rural communities each year if Georgia were to fully expand Medicaid; statewide, those numbers swell to 50,000 new jobs and $6 billion in economic growth.
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While we support any attempt to close the coverage gap and are pleased to see Gov. Brian Kemp and the legislature seeking solutions to our crisis of the uninsured, Georgians deserve better than “Pathways.” Under “Pathways,” hundreds of millions of federal dollars a year will continue to be diverted away from Georgia to other states, the uninsured rate will remain high and rural hospitals will continue to close. We urge the legislature and Gov. Kemp to heed the lessons learned from Arkansas and follow the successes of those states that have fully expanded Medicaid.
Georgians deserve a healthier future.
Toby Terwilliger, M.D., is an assistant professor in the Division of Hospital Medicine at Emory School of Medicine. Justin L. Williams, Ph.D., is a clinical psychologist and an assistant professor within pediatrics at Emory University. Jacquelyn O’Banion, M.D. is an associate professor of ophthalmology and the director of Global Ophthalmology at Emory University School of Medicine. Veda Johnson, M.D., FAAP, is a professor of pediatrics and Marcus Professor in General Academics and Pediatrics at Emory University School of Medicine. Tracey L. Henry, M.D., M.P.H., M.S. is an associate professor of medicine at Emory University School of Medicine. Their views are their own and do not represent those of their employer or any of its affiliates
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