Limited Medicaid expansion, for those who make the grade, starts July 1

Critics say the cost to state may outstrip full Medicaid expansion, while covering fewer people
Dr. Reed Pitre is shown here outside the charity clinic where he works in downtown Atlanta, Mercy Care.  Pitre, a psychiatrist, is showing the area where a patient who lived outside the clinic in a truck for years finally agreed to receive care.  Mercy Care works with patients in need, including the homeless. (PHOTO by Michael Blackshire/

Credit: Michael Blackshire /AJC

Credit: Michael Blackshire /AJC

Dr. Reed Pitre is shown here outside the charity clinic where he works in downtown Atlanta, Mercy Care. Pitre, a psychiatrist, is showing the area where a patient who lived outside the clinic in a truck for years finally agreed to receive care. Mercy Care works with patients in need, including the homeless. (PHOTO by Michael Blackshire/

EDITOR’S NOTE: This story has been changed to clarify that a homeless man with outdated residency papers was given some treatment by Mercy Care, but he was not eligible for specialty treatment that he needed that Mercy Care could not provide.

On July 1, Georgia will make state history by opening Medicaid to thousands of poor adults who live in the state, a step that state leaders once rebuffed as unthinkable.

But most of the state’s uninsured poor won’t qualify.

For more than a decade, Georgia has fought against adopting a full expansion of Medicaid under the Affordable Care Act to insure the state’s 400,000 or so poor adults with no health insurance. Instead, the state is opening its own limited expansion of Medicaid, called Pathways to Coverage, which will require enrollees to work or do other specific activities.

The state predicts that after it’s ramped up, fewer than 100,000 of those without insurance will be enrolled because most won’t meet the requirements for work or activities. Those covered under standard Medicaid will get to keep their coverage without meeting work requirements or going onto the new Pathways program.

Thirty-eight states have already expanded Medicaid, including many that have engineered their own expansion programs. But Georgia will be the only one to launch an expansion with built-in work requirements. Arkansas briefly enforced work requirements for its existing Medicaid program, but was shut down by the courts. Georgia says its program is different.

Georgians will be able to qualify for the expanded Medicaid program not just by working, but by performing other activities for at least 80 hours a month. Recipients must file a monthly report documenting their activities. Qualifying activities include attending college, volunteering for a registered nonprofit, or on-the-job training. Supporters say requiring work or other activities will help lift beneficiaries out of poverty. Opponents say most who don’t work can’t, and actually may need health care in order to be able to do so.

October 15, 2020 Atlanta - Governor Brian Kemp and Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma celebrate with fist bump after they signed on healthcare reform at the Georgia State Capitol on Thursday, October 15, 2020. The federal government approved Gov. Brian Kemp’s plan to reshape Medicaid and individual insurance in Georgia under the Affordable Care Act, the governor and a top Trump administration health official announced on Thursday. (Hyosub Shin /


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Overseeing and enforcing the work requirements will cost the state money. One research organization predicts that Georgia taxpayers will pay more to build and run its unique new program, all while covering fewer people than they would if the state simply expanded regular Medicaid as the federal government has offered.

Gov. Brian Kemp, who has worked on the program since he first took office, said it will be sustainable and will benefit both beneficiaries and the state.

At a press conference Wednesday, Kemp aides said they were going through final checks of the new system and expected it to open to the public this weekend, on Saturday or at the latest by 7 a.m. Sunday. “As of today we’re ready and we’re set to go,” said state Department of Community Health Commissioner Caylee Noggle.

The program “will voluntarily expand Medicaid to tens of thousands of otherwise-ineligible Georgians if they take measurable steps towards improving their communities,” Kemp said in a letter last fall defending the program. His more limited program, he wrote, is “a far better approach to increasing healthcare coverage than ‘full’ Medicaid expansion.”

An expensive undertaking

The new program is a lot for Georgia’s Medicaid workers to take on. They are just now beginning a year-long project to re-evaluate all of the state’s 2.8 million existing Medicaid enrollees to ensure they still qualify.

The Department of Community Health estimated that the cost of new workers and computer software to launch Pathways would be $24.5 million.

But the biggest cost to the state of starting the Pathways program will be losing out on money the federal government gives to states that fully expand Medicaid for all their poor. Those states pay only 10% of the cost of the new recipients’ medical bills, while the federal government pays 90%. In contrast, for enrollees in its Pathways plan, Georgia will pay 35%, with the feds paying 65%.

On top of that, Georgia is forgoing a bonus paid to states that implement full expansion. That’s a temporary increase in the money that the federal government promises to contribute to the state’s existing Medicaid program. For Georgia, that increase from the feds would total more than $1.3 billion over two years, according to estimates by the KFF, a nationwide health research nonprofit.

Several health research organizations calculated that the Georgia program will cost more money to cover fewer people, at least in the initial years. Joan Alker, executive director of Georgetown University’s Center for Children and Families, said there’s no question about the overall finding. “It’s become an even more fiscally foolish approach for the state,” she said.

Leah Chan of the left-leaning Georgia Budget and Policy Institute estimates if Georgia’s expansion covers 100,000 people, it will cost state taxpayers $10 million more than if the state simply expanded Medicaid as the federal government has offered, to all uninsured, low-income Georgians.

Kemp aides who worked on the Pathways program on Wednesday declined to address the calculations that the state will spend more Georgia tax dollars to cover fewer people than if it had fully expanded Medicaid to all its poor.

Lives changed, or left out

Few dispute that there is a problem that needs tackling: Georgia ranks third-worst among states for the rate of people who are uninsured with 12% of residents lacking health insurance as of 2021, the latest data available.

A primary reason for that is Georgia’s “coverage gap.” That’s people who don’t qualify for Medicaid but also make less than the federal poverty level of $14,580 per year for a one-person household, which makes them too poor to qualify for subsidies on the Affordable Care Act marketplace. If those people don’t get Medicaid through Pathways, they likely will remain uninsured.

Dr. Reed Pitre talks to Clinical Nurse Manager Jarene Merritt on Thursday, June 22, 2023 at Mercy Care in Atlanta. He works with patients in need. His speciality is psychiatry. Dr. Pitre has dedicated his time working with low income patients, including the homeless. (Michael Blackshire/

Credit: Michael Blackshire

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Credit: Michael Blackshire

Dr. Reed Pitre, who treats poor people at the charity clinic Mercy Care in downtown Atlanta, sees both kinds of patients: those who will qualify for Medicaid under the new Pathways program, and those who won’t.

He says that simply by having hoops to jump through, such as documenting proof of their activity with the state once a month, many vulnerable patients will not qualify.

“People who are poor ... we’re lucky if they have a smartphone. So the idea that they have to have a an email address, have access to technology — these are presumptions,” he said. “These are routine parts of our lives now. But most of our (Mercy Care’s) people don’t even have a cell phone.”

Pitre spoke of one man, disabled by treatable psychiatric illness, who lived in his truck in front of Mercy Care for years.

When staff coaxed him inside, they found his outdated residency status had him living in his native Hall County, making him ineligible for certain local services. Because of his paranoid delusions, standing in line for hours at a government office to get his birth certificate and update his residency wasn’t something that man could do.

Pitre said the man needed medical care first in order to be able to register for programs and hopefully, eventually, work. Mercy Care treated him.

Eventually, the staff at Mercy Care took on much of his bureaucracy burden themselves. Pitre himself spent an hour filling out forms to get the man qualified as disabled under Medicaid — an hour the the clinic was not paid for, since before the disability was granted, the man was not covered.