“The anguish and stress on me has been a lot,” she said.

The Affordable Care Act, also known as Obamacare, gave states the ability to expand Medicaid to all low-income adults, with the federal government paying 90% of the cost. Forty other states have expanded the joint state-federal program to cover more uninsured citizens, but Georgia has not.

Earlier this year, Republican state lawmakers considered — then abandoned — a measure that would have expanded Medicaid access in the state. Gov. Brian Kemp opposed the effort, citing its high price tag and his fear that federal support for expansion would dry up.

Instead, lawmakers created a commission of health policy experts to study the issue, set to begin meeting this month. Over a two-year period, members are expected to study potential improvements to the state’s health care system, which could include limited Medicaid expansion, and produce a report of findings by December 2026.

“All options are on the table for us to look at and see what might be the best fit for Georgia,” said Caylee Noggle, Kemp’s appointee to chair the commission, who previously served in his administration.

‘Work and worry about dying’

A full expansion of benefits to low-income residents seems unlikely. Kemp, like his predecessor as governor, Nathan Deal, has opposed such a plan since the ACA was signed into law 14 years ago — despite consistent criticism from Democrats. Last year, Kemp set up an alternative system, called Georgia Pathways to Coverage. The program operates under a federal Medicaid waiver to provide coverage for adults making below the federal poverty line, provided they work at least 80 hours per month, attend a technical college or perform another state-approved activity.

However, as Harrell ticked through the categories to determine her eligibility, she kept coming up short.

Harrell had been receiving money through Supplemental Security Income from the Social Security Administration, which made her eligible to receive Medicaid coverage in Georgia. But when her disability status changed because of her cancer diagnosis, she was moved to the Social Security Disability Insurance system.

That put her in a bind: Her SSDI payments, combined with her income as a Publix grocery clerk, pushed her over the income threshold for that federal program, so she had to decrease the number of hours she works.

Now, because of her pain level, she’s only able to work a few hours per week — not enough to qualify for Pathways. And while people who receive SSDI payments can qualify for Medicare, the federal insurance program for the elderly and disabled, as a new recipient, she must wait 24 months for benefits.

“I had to make a decision: Either work and worry about dying or get my health together and be homeless,” she said. “Every day I have to figure out how I can get someone to help me with my bills because I can’t work too much or they will cut me off.”

A social worker helped Harrell qualify for Georgia’s Women’s Health Medicaid, which provides cancer treatment coverage for women diagnosed with breast or cervical cancer, but that coverage ended in June, she found out. She said she’s been switched to Medicaid for Pregnant Women, even though she had a hysterectomy in 2021.

“It’s the weirdest thing,” she said.

Because that plan doesn’t cover her cancer treatment, she canceled her appointments and hasn’t had care for her diagnosis since December.

“It’s kind of getting overwhelming. I don’t know what’s going on with me,” she said. “I haven’t been to the doctor. I haven’t gotten medication. I haven’t had treatment or blood work done since December. My cancer could be growing or it could be decreasing. I wouldn’t know.”

Pathways ‘here to stay’

Pathways’ mandate that recipients work or fulfill another state-approved activity to receive coverage has put the program at odds with the Biden administration, which overruled the state requirement. The state sued the administration in February, arguing that the rescindment delayed implementation of the program and has contributed to a poor start.

Pathways has seen dismal enrollment rates, drawing just 4,500 uninsured applicants out of an estimated 370,000 eligible Georgians. More than 90% of the $26 million cost has gone toward administrative and consulting fees.

A federal judge ruled Tuesday that the Biden administration was within its rights to refuse an extension for the Pathways waiver plan, which had been originally approved for a five-year term.

And as the new state committee begins its work, Noggle said, “Pathways is here to stay.”

Credit: Georgia House of Representatives

Credit: Georgia House of Representatives

Discussions in the commission will center on how to improve or expand the program, not replace it, she said.

One method could be through another plan, piloted in Arkansas, where the state used federal expansion dollars to buy plans for people with lower incomes on the Health Insurance Marketplace. Proponents say this waiver plan would allow health care providers to get paid higher commercial rates.

“We’re still full speed ahead on Pathways. That’s where our focus is going to be while the study commission is doing its work,” said Garrison Douglas, a spokesperson for Kemp.

In a speech at the annual convention of the Georgia Hospital Association in July, Kemp maintained his opposition to Medicaid expansion, saying, “To me, this is not the best path forward.”

He and Deal before him questioned whether the federal incentives are sustainable. Kemp worries that federal support could vanish, leaving the state on the hook financially to care for thousands more people.

Natalie Crawford, executive director of Georgia First, which supports Medicaid expansion, said allowing more access to subsidized health care could provide an economic boost to Georgia.

“There’s an opportunity to get people back into the workforce who have not been able to participate for some time because of a chronic illness and lack of coverage,” she said.

Kemp has also said that expansion would force 700,000 Georgians off private insurance and into a government program.

That figure is in reference to the subsidized plans on the federal ACA exchange that anyone who makes more than the federal poverty level qualifies to receive. That population would otherwise qualify for Medicaid coverage under a full expansion through the Affordable Care Act.

Should Georgia proceed with an Arkansas-style waiver plan, that group of newly insured Georgians would not be put on government-run health care plans.

Kemp and some Republican allies have also said they want to give the governor’s signature health care program a chance to play out.

State Senate Rules Chair Matt Brass, R-Newnan, voted in favor of advancing Medicaid expansion in March.

“What we’ve been doing hasn’t worked. We’ve continued to see the cost of health care rise. We’ve seen insurance premiums rise. We’ve seen co-payments rise. We’ve got backlogs in our emergency rooms,” he said. “For me, it was just, OK, if what we’re doing is not working, and we don’t really have any other answers, then why not?”

Brass said the delayed rollout of Kemp’s plan meant that he “wasn’t all that versed on Pathways at that point.”

“A lot of people didn’t know about it because it’s obvious with the numbers of sign-ups we’re seeing. I do believe we’ve got to give Pathways that chance to work,” he said.

Credit: Natrice Miller/AJC

Credit: Natrice Miller/AJC

Brass also said he supports a work requirement to qualify for Pathways.

“We’re just not a state that’s going to pay people to sit at home to do nothing unless you’re disabled or elderly, and we’ve got programs for that,” he said.

However, he’s “potentially” open to full Medicaid expansion “if there’s still a large gap out there uninsured” after Pathways has had a fair attempt to reach all eligible Georgians.

Kemp’s approach to health care is based in the conservative axiom that tying government benefits to a work requirement will lift people out of poverty and put them in a position to receive private coverage independently or through an employer-sponsored plan.

However, Harrell and others exemplify why it’s sometimes not that simple: They want to work but can’t.

Credit: Michelle Baruchman

Credit: Michelle Baruchman

Heather Payne, a 52-year-old woman who lives in Dalton, stopped working as an emergency room nurse two years ago after she began having strokes. Being on her feet for 12 hours was too difficult.

“If you really can’t work, you can’t work. It doesn’t matter how much you want to,” Payne said.

Payne was U.S. Sen. Raphael Warnock’s guest at this year’s State of the Union address.

Since leaving her job, Payne has been unable to get health care coverage and has spent tens of thousands of dollars paying medical bills. Part of her challenges are bureaucratic. She has been waiting for two years for her disability application to be approved. She can’t get Medicaid while her disability application is active, and she can’t get Medicare without a disability status.

“Disability cases can take years. All the while, you’re sitting around waiting,” she said.

She loved her job, but after her strokes, there are days when her speech is slurred, and she has trouble walking around without fainting. She’s interested in going back to school but worries about her “profound brain fog” and ability to “memorize and learn large portions of material again.”

Understanding the health system, even as a former nurse, has been a challenge, she said.

“A lot of the issue with health care is that it’s hard to navigate. It’s not like somebody’s calling you and saying, ‘Hey, why don’t you sign up for this?’” she said.

Payne could go to a state that has expanded Medicaid and have more health care options, but she prefers to stay here.

“For all its warts, Georgia is my home. I care about Georgia. My family lives here,” she said. “As appealing as it would be to do the grass-is-greener kind of thing, it would be much more satisfying to fight for what I would like to see.”

‘Designed to fail me’

Harrell and Payne said they’ve grown tired of partisan politics preventing them from getting care.

“The health care system is so degrading,” Harrell said. “It’s a system designed to fail me, not only as a mother but as a patient.”

Because she couldn’t get clear answers from state agencies about how her disability status, cancer diagnosis and Social Security Disability Income payments fit her into the system, Harrell got tossed back and forth. It took her emailing county officials to get a response, she said.

“Why should I have to fight? I’m already fighting cancer. Why do I have to stress about how I’m going to be taken care of?” she said.

Harrell said her doctor gave her five years to live with her diagnosis, so there is urgency.

“The No. 1 determinant of cancer survivorship is access to health coverage,” said John Hoctor, the managing director at the American Cancer Society Cancer Action Network. “The longer we wait (to expand Medicaid), the more difficult it is for these cancer patients.”

This story has been updated to reflect the most current number of enrollees in the Georgia Pathways to Coverage program.