The Georgia Budget & Policy Institute (GBPI) would like to thank the Georgians who showed courage and vulnerability in sharing their stories and insights with us during the focus groups and interviews. Their expertise makes this work possible.
Executive Summary
In July 2023 Georgia launched the Pathways to Coverage program and became the only current state in the nation to offer Medicaid coverage to non-pregnant, non-disabled, low-income adults contingent upon completion and reporting of at least 80 hours per month of work, higher education, volunteering or other qualifying activities. In August 2023 the Georgia Budget & Policy Institute (GBPI) launched a project to monitor the implementation of the first year of Georgia’s Pathways to Coverage program. The project aimed to generate timely data and uplift lived experience to inform the discussion around increasing access to affordable, high-quality health care for Georgians with low incomes.
The findings from this project are intended to educate and spark action among policymakers, state agency leadership, advocates and others. In December 2023 GBPI launched a project microsite to highlight new project-related data and resources. In April 2024 GBPI released initial key findings based on data collected on the Pathways to Coverage enrollment experience. This report builds upon those previous efforts and offers a deeper dive into the first year of Georga’s Pathways to Coverage program, including:
- Enrollment, eligibility and fiscal trends
- Georgians’ perspectives on enrollment and monthly reporting
- Georgians’ perspectives on the qualifying activities requirement
- Recommendations for moving forward
Here are some key takeaways based on the program’s first year:
- Enrollment in the Pathways to Coverage program fell far short of expectations and need. More than 40% of Georgia’s counties still had fewer than 10 enrollees despite the state having one of the highest percentages of uninsured populations in the nation.
- A cumbersome enrollment process and restrictive eligibility criteria appeared to contribute to the program’s lack of success in the first year. Potentially eligible Georgians face a steep ‘paperwork’ burden – from completing a lengthy online or paper application to compiling documents to verify qualifying activities and hours, and only about half of individuals who showed initial interest in applying to the program submitted a complete application. Preliminary data also indicate that at least one in every five denials for those who do submit a complete application is due to failure to meet the qualifying hours and activities requirement.
- For Georgians able to enroll, the Pathways to Coverage program provides access to critical health care coverage—allowing Georgians to see the doctor, fill prescriptions and gain access to life-saving care.
- Pathways to Coverage is a costly program for Georgia taxpayers. Since the program was approved through the end of the first year of implementation, an average of $13,000 was spent per enrollee in combined state and federal funds. Spending on upgrades to Georgia’s online eligibility and enrollment system represents the largest proportion of total program costs and was almost five times higher than spending on healthcare benefits for enrollees.
As the Pathways to Coverage 1115 waiver approaches its expiration in September 2025, Georgia has an opportunity to build upon lessons learned and make pivots that best serve the needs of Georgians and are the best deal for Georgia’s taxpayers.
Pathways to Coverage: Program Basics and Project Impetus
Unequal access to affordable, high-quality health care continues to impact Georgians across the state. Georgia is tied with Oklahoma for the second highest proportion of residents without health insurance in the nation.[1] The burden is heaviest on Georgians living in rural communities and Georgians of color—particularly Latinx Georgians.[2] Across states, Georgia’s health care system ranks 45th overall based on measures like health care access, cost, avoidable hospital use, reproductive care and women’s health, as well as prevention and treatment.[3]
In response to Georgia’s issues with access to high-quality, affordable health care for Georgians with low incomes, Governor Kemp signed the Patients First Act of 2019 into law.[4] This health care legislation paved the way for Georgia to seek federal approval for an 1115 demonstration waiver (see page 3 on our recent Pathways to Coverage Brief for more information on 1115 waivers). The waiver received initial approval from the federal government in October 2020. Approval for premium payments and work requirements was withdrawn by the federal government under a new presidential administration in December 2021. The state pursued legal action in federal court, and ultimately a federal judge ruled in favor of the state in August 2022.[5] Pathways to Coverage officially launched in July 2023. You can access a more detailed timeline here.
The Pathways to Coverage program offers health care coverage for adults with low incomes who are currently in the health insurance coverage gap and can meet certain requirements. These adults do not qualify for traditional Medicaid coverage and do not earn enough to qualify for tax credits that make health insurance marketplace plans affordable. This program does not impose new requirements on Georgians already covered under traditional Medicaid eligibility, such as older adults over 65 years old or pregnant and postpartum people. Instead, this program expands coverage to Georgians ages 19 – 64 years old who have a household income of up to 100 percent of the federal poverty level. To be eligible they must work, attend school, volunteer or complete another qualifying activity for at least 80 hours per month. The program covers the cost of many of the same medical services as traditional Medicaid, including doctor visits, hospital stays and prescriptions. You can access a more detailed program overview here.
GBPI launched its Pathways to Coverage monitoring project in August 2023 and collaborated with researchers and community partners on data collection, stakeholder education and storytelling. Project activities focused on better understanding the barriers and enablers to gaining and maintaining coverage under Pathways to Coverage with a particular focus on the impact of administrative processes (i.e., initial enrollment and monthly reporting) and the impact of the qualifying activities requirement. Throughout, the project aimed to center the perspectives and experiences of Georgians who already face persistent and systemic barriers to good health, particularly Black and Latinx Georgians with low incomes. From August 2023 – October 2024, GBPI worked with research partners to interview health insurance navigators and enrollment assisters, to conduct focus groups with Georgians who were potentially eligible for Pathways to Coverage and to interview Georgians who had applied for or were enrolled in Pathways to Coverage. GBPI complemented this qualitative data with data on enrollment trends and fiscal impact obtained through publicly available sources and Open Records Requests.
Pathways to Coverage: Enrollment, Eligibility and Fiscal Trends in Year One
To track program impact and outcomes, GBPI collected data on enrollment, program costs, eligibility staffing and more from publicly available sources and through Open Records Requests. Some of that data is highlighted below, and some is available on the project microsite, GeorgiaPathways.org. All Pathways to Coverage data included in the sections below cover July 1, 2023 – June 30, 2024, with the exception of the program costs data, which cover program-specific expenditures reported to the Centers for Medicare & Medicaid Services (CMS) from January 1, 2021 through June 30, 2024.
During the first year, the state did not implement two key elements of the program’s original design.
The Pathways to Coverage program design includes two distinctive features: 1) audits of monthly reporting to ensure enrollees are completing and providing verification of their 80 hours of qualifying activities and 2) collection of premium payments for enrollees earning 50 – 100% of the federal poverty level. Although this program design was originally approved under the Trump administration, the Biden administration withdrew approval for the qualifying activities requirement and premium collection. However, the state fought and won in court to maintain the original program design. During the first year, neither automated monthly audits nor premium collections were implemented. As of October 2024, the state had not announced a date for when they would be. Lack of automated audits means the state is not currently suspending or terminating coverage based on monthly reporting. However, most enrollees are still required to report their hours and upload their verification, such as a pay stub, every month. (A small proportion of enrollees are exempt from reporting qualifying hours and activities because, at initial enrollment, they reported hours to demonstrate that they met the qualifying hours and activities requirement for six consecutive months.)
On average about 437 Georgians enrolled in Pathways to Coverage each month during the first year.
In the first year over 110,000 Georgians demonstrated initial interest in applying for the Pathways to Coverage program. These were Georgians who either applied for Medicaid, were up for Medicaid renewal or had a change in circumstance. They were presented in Gateway (the online eligibility and enrollment system) with information about Pathways to Coverage, and they elected to be considered for the program and signed the contract acknowledging that they had read the requirements of the program. Of those over 110,000 interested Georgians, only about 5% ended up enrolling in the Pathways to Coverage program. In total, 4,231 Georgians were actively enrolled at the end of the first year – with an average of 437 Georgians enrolling each month.
Pathways to Coverage enrollment in the first year fell short of expectations and need.
Estimates of how many Georgians would enroll in the Pathways to Coverage program have fluctuated over time. Though the state has not provided full details to explain the changes in enrollment projections, it may be due in part to significant shifts in the health care landscape over the past several years. These shifts have changed the overall number of uninsured, non-elderly adult population earning less than the federal poverty level who are potentially eligible for Pathways to Coverage. Considering even the most conservative estimate of how many people might have enrolled in the first year (25,028), the program achieved only about 17% of its projected first-year enrollment. If the state continues to enroll about 4,231 enrollees per year as it did in the first year and assuming no one is disenrolled, it will take more than 12 years to achieve the original five-year enrollment goal (52,509). That five-year enrollment goal itself is still a fraction of the estimated 240,485 uninsured Georgians with low incomes who are potentially eligible for the program.
Graphic Sources: [6], [7], [8], [9], [10], [11], [12], [13]
Many Georgia counties with high uninsurance rates saw negligible enrollment in the first year.
Georgians in many of the counties with the highest proportions of uninsured residents appear to be facing barriers to accessing the program. Sixty-six of Georgia’s 159 counties still had fewer than 10 residents who had ever been enrolled in the program in the first year. In 56 of those same counties, the percentage of residents without health insurance is higher than the state average. For example, one in every five residents in Webster County is uninsured, but they had zero Pathways to Coverage enrollees as of June 30, 2024.[14] At the same time, enrollment across most counties is low in proportion to the need irrespective of population size. As indicated by the following map, counties with larger populations and near Georgia’s major cities tended to have higher enrollment numbers. For example, Cobb County, DeKalb County, Fulton County and Gwinnett County in metro Atlanta were the only counties in Georgia that had 200 or greater enrollees as of June 30, 2024. The comparatively higher enrollment in higher population counties obscures the overall minimal impact on reducing uninsured rates. For example, Fulton County’s 462 enrollees represented only about 1% of county residents who are potentially eligible for the program (i.e., non-elderly, uninsured population earning below the federal poverty level).[15]
Over half of Pathways to Coverage applicants were denied eligibility in the first year.
Over 40,000 Pathways to Coverage applications were processed during the first year. Of those, 56% were denied, and only 17% were approved for coverage under the Pathways to Coverage program. The remainder were approved for traditional Medicaid.
Based on available data from the first year, failure to meet the qualifying activities requirement accounted for 19% of denials.
In March 2024 the state began reporting the number of applications that were denied for not meeting the qualifying hours and activities requirement. This includes applications denied for reporting inadequate hours or failing to provide sufficient verification of hours. In March – June 2024, 19% of denials were due to this failure to meet the qualifying activities requirement. This only accounts for complete applications. Due to the complexity of the application process, this metric does not paint the full picture of the impact of this requirement on applicants’ ability to gain coverage. For example, even after an individual has elected to be considered for Pathways to Coverage and acknowledged that they read the requirements of the program, if they do not report valid qualifying hours and activities they are not able to move on to the next step and are not considered to have a complete application. In June 2024 alone, the failure to report a non-zero number of qualifying hours and activities or request a reasonable modification (for individuals with disabilities) eliminated about 42% of those who demonstrated interest in applying for Pathways to Coverage.
Pathways to Coverage generated a backlog of over 14,000 unprocessed applications in the first year.
About 74% of complete applications were processed during the first year, which left a backlog of over 14,000 applications. The Pathways to Coverage program launched in July 2023 when the state was re-determining the eligibility of the over two million Georgians enrolled in traditional Medicaid as part of the unwinding of the pandemic-era Medicaid continuous eligibility policy.[16] This unprecedented effort put stress on Georgia’s public benefits eligibility and enrollment infrastructure. The Pathways to Coverage backlog is likely a reflection of a technology system and frontline eligibility workforce that was already overtaxed pre-pandemic and faced historic pressures during this Medicaid unwinding. The ‘standard of promptness’ for Medicaid application processing is 45 days. As of June 2024, about 54% of Medicaid applications in Georgia were exceeding that 45-day standard, which was the highest proportion of delayed processing in the nation for that month.[17] Given the backlog, it is likely that some Pathways to Coverage applications are included in that overall Medicaid processing figure, and some applicants likely experienced long wait times to hear back about the status of their application.
Pathways to Coverage cost about $13,360 per enrollee on average in combined state and federal spending from waiver approval through the end of the first year of program implementation.
The primary categories of Pathways to Coverage spending are allocated to design, development and installation of the eligibility and enrollment technology system known as Gateway; health insurance payments; eligibility staff; and other administrative costs. When spread out evenly across each enrollee, the almost $58 million in combined state and federal spending from waiver approval through the end of the program’s first year amounts to about $13,360 per enrollee. It is important to note that the combined $58 million does not account for expenses related to preparing and submitting the 1115 waiver, expenses related to the two Pathways to Coverage lawsuits filed by the state or funding for a pilot media campaign that ran in early 2024. That total amount also does not account for the $10.7 million in federal American Rescue Plan funding allocated to a new awareness campaign launched in August 2024 after the end of the program’s first year. Lastly, this combined state and federal spending reflects quarterly expenditure reporting submitted to CMS by the state; however, it is higher than the amount reported by the state.[*]
More than half of state spending has been allocated to technology modifications.
About $8.8 million in state funds have been spent on the Pathways to Coverage program during the period between when the waiver was approved and the end of the first year of program implementation. As previously stated, that amount does not account for expenses related to preparing and submitting the 1115 waiver, expenses related to the two Pathways to Coverage lawsuits filed by the state or funding for a pilot media campaign that ran in early 2024. Pathways to Coverage qualifies for Georgia’s standard federal match, which means that for every dollar spent on health care costs for enrollees, the state pays about 34 cents, and the federal government pays the remainder. About 35% of state spending on Pathways to Coverage was directed to health insurance payments for care management organizations to cover enrollees’ health care services. Georgia—like all states—pays about 10 cents on the dollar for designing and installing new functionality in its eligibility and enrollment technology system, which means the federal government covers most of the cost. Even with the high federal match, about 52% of state spending (and 80% of total combined spending) on Pathways to Coverage went toward Gateway, Georgia’s online eligibility and enrollment system.
Pathways to Coverage: Georgians’ Perspectives in Year One
To go beyond the numbers and better understand how Georgians might perceive and be directly impacted by the program, GBPI collaborated with Creative Research Solutions to conduct focus groups and interviews (for more details on qualitative data collection methods, please see Appendix 1). Participants shared their experiences and perspectives as well as those of their community and had lived expertise around the challenges of accessing affordable, high-qualify health care. Questions focused primarily on access to health care coverage, enrollment and monthly reporting and the qualifying activities requirement. All focus group participants were individuals with household incomes near or below the federal poverty level and were currently uninsured or had previously experienced periods of uninsurance. All interview participants had either applied for, were currently enrolled in or had been previously enrolled in the Pathways to Coverage program.
Overall Perspectives on Health Care and the Pathways to Coverage Program
Theme 1. Lack of Health Care Insurance Coverage Negatively Impacts Georgians with Low Incomes
Participants reported that lacking health insurance forced them to delay medical care or make difficult financial choices, which resulted in increased stress. Participants also noted that going without health care allows health conditions to become both more acute and more expensive to treat. One participant described the cascading impact he had seen in his community of unpaid medical bills – leading to debt that can damage one’s credit score and ultimately hinder one’s ability to access housing. Participants reported that not having access to health insurance and the ability to see a doctor and fill prescriptions impacts their ability to work. Participants also noted that tying one’s health insurance to work can limit their life choices, such as which job they are able to take.
Theme 2. For Georgians Who Have Been Able to Enroll, the Pathways to Coverage Program Provides Critical Health Care Coverage
Participants reported satisfaction with the health insurance they received when enrolled in the Pathways to Coverage program. Participants reported that getting covered under the Pathways to Coverage program meant getting access to life-saving health care – from critical specialty care to affordable medications.
Theme 3. Expanded Education and Outreach about the Pathways to Coverage Program Is Needed to Reach Potentially Eligible Georgians
Participants indicated that there was a general lack of awareness of the Pathways to Coverage program among their communities and among potentially eligible Georgians. They reported that people needed more information about who is eligible, what services would be covered, which doctors and hospitals would accept it and how to apply. Another participant noted that sending information by mail can often get missed, and direct phone calls, social media and other tactics may reach more eligible, uninsured adults.
Perspectives on the Pathways to Coverage Enrollment and Monthly Reporting Process
Theme 1. The Process for Reporting and Verifying Qualifying Hours and Activities Through Georgia’s Online Eligibility and Enrollment System Is Perceived as Reasonable
Participants stated that reporting qualifying hours and providing verification of those hours through Georgia’s online eligibility and enrollment system (Gateway) was feasible. Some participants expressed an initial lack of understanding around the monthly reporting process. One participant noted specific confusion among students around the equivalence of course enrollment/semester hours to 80 qualifying hours per month.
Theme 2. Certain Populations May Face Specific Barriers During the Pathways to Coverage Enrollment Process
Participants noted that particular groups of people, such as individuals who do not have access to a computer or to high-speed internet and individuals who are unhoused, may have unique challenges when attempting the Pathways to Coverage enrollment process.
Theme 3. Customer Services Challenges and Lack of In-Person Support Complicates the Enrollment Process
Participants reported challenges when communicating with eligibility caseworkers, such as a lack of response to requests for phone-based support. Participants reported seeking out in-person support at local Division of Family and Children Services (DFCS) offices only to find that no one is available, or they get re-directed to a computer kiosk.
Theme 4. Clear and Consistent Communication is Needed for Individuals Who are Denied Coverage in the Program
Participants who applied for the Pathways to Coverage program and were rejected reported confusion about why they were not eligible. Participants also expressed frustration with denials for ‘paperwork’ issues, such as a missing form.
Perspectives on the Pathways to Coverage Program’s Qualifying Activities Requirement
Theme 1. Broadening the Qualifying Activities Beyond Just Work and Offering Another Health Care Coverage Option for Georgians with Low Incomes Is Viewed Positively
Participants who were potentially eligible for Pathways to Coverage but had not applied or enrolled reported that the broader definition of the qualifying activities requirement is better than simply a work requirement. Participants also felt that by expanding access to health care coverage for adults with low incomes who can show they are engaged for 80 hours per month, the Pathways to Coverage program may appeal to those who do not qualify for or who cannot afford other forms of health insurance.
Theme 2. The Qualifying Activities Requirement May Be a Barrier to Accessing Pathways to Coverage for Some Applicants
Participants expressed some concerns about access to the Pathways to Coverage program being tied to 80 hours per month of work, volunteering, higher education or some other qualifying activity. Participants noted the dilemma that securing the part-time employment necessary for the qualifying activities requirement can end up putting the applicant over the income limit, resulting in a loss of coverage under Pathways. One participant emphasized the barriers an individual with low-income might face in securing stable employment, such as lack of transportation. Another participant noted the challenges that certain communities, such as individuals with disabilities, might face in securing employment to meet the qualifying activities requirement.
Beyond Year One: Recommendations and Next Steps
With Pathways to Coverage up for renewal in September 2025, the state has an opportunity to leverage lessons learned from the first year to make the program more effective and less costly and to streamline bureaucratic red tape that burdens both enrollees and state agency staff. As policymakers, state agency leadership and advocates consider options moving forward, GBPI offers the following recommendations. The recommendations are on a spectrum: programmatic recommendations build upon the original Pathways to Coverage program design; systems-level recommendations represent changes that are needed to increase transparency and build a stronger foundation for the state’s public benefits eligibility and enrollment infrastructure; and transformational recommendations capture opportunities for more inclusive, person-focused access to health care coverage for all low-income Georgians.
Programmatic recommendations
During year one the state did not implement monthly reporting audits and paused any suspensions or disenrollments related to monthly reporting of qualifying activities. Implementing this policy in the future would be an additional drain on the already overburdened frontline caseworkers who would have to support the monthly auditing process.[18] Although most enrollees are still reporting and submitting documentation to verify their qualifying activities, the monthly audits could result in disenrollment of otherwise eligible Georgians for ‘paperwork’ issues and further decrease the already low enrollment numbers. For example, when Arkansas implemented a similar monthly reporting requirement on its traditional Medicaid population, 17,000 people lost coverage in just four months. Most who lost coverage met the requirements but lost coverage due to the administrative burden of learning about and complying with the monthly reporting.[19] Going forward, the state should eliminate monthly reporting and only require submission of qualifying hours and activities at initial application and yearly renewal. In addition, the state should make permanent the paused implementation of premium collections. Prior research indicates that imposing premiums on populations with low incomes can reduce coverage and increase financial burden. Moreover, data from other 1115 waiver programs with premium requirements show that a high number of enrollees fail to pay premiums and report confusion over premium policies.[20]
2. Expand automated verification of qualifying hours and activities at initial application and yearly renewal using electronic data sources.
Before requiring an applicant or enrollee to submit documentation like a pay stub, the state should attempt to automatically verify self-reported qualifying hours and activities. The state can use existing state data sources and expand data-sharing with federal and other electronic data sources. For example, the state could increase automatic verification of reported work hours using a state wage database or federal data from the Internal Revenue Service.[21] The state could also increase automatic verification of higher education course hours through data-sharing agreements with University System of Georgia and the Technical College System of Georgia as well as automatic verification of job readiness and vocational rehabilitation hours through data-sharing with organizations like Georgia Department of Labor Career Center, Workforce Development Board, Georgia Vocational Rehabilitation Agency, Goodwill, and others. Prior research shows that increasing the use of electronic data sources to verify eligibility can reduce the burden on applicants/enrollees and on the frontline caseworkers processing their applications as well as potentially reducing overall costs to the state.[22]
3. Expand work requirement exemptions to enable eligible veterans, full-time parents of young children, former foster youth and others to receive access to critical health care coverage.
Pathways to Coverage applicants have essentially no ability to claim an exemption from the qualifying activities requirement (other than the short-term ‘Good Cause Exception’). That leaves Georgians, such as full-time parents or caregivers of young children and veterans, who are meaningfully contributing to their communities and who are otherwise eligible but do not meet the qualifying activities requirement without access to health care coverage. It also leaves Georgians working to get on their feet without the health care coverage they need to survive and gain access to employment. That might include Georgians who are unhoused, former foster youth, and people undergoing treatment for addiction. At minimum, the Pathways to Coverage program should align the work hour reporting exceptions and work requirement exemptions with Georgia’s food assistance program known as SNAP. This could help streamline enrollment for dually eligible SNAP-Pathways to Coverage enrollees while also decreasing confusion among potentially eligible Georgians who may currently qualify for an exemption under SNAP but not under Pathways to Coverage. It is important to note that work requirement exemptions are an opportunity for reducing the red tape and barriers to coverage created by the qualifying activities requirement itself. However, as evidenced by Arkansas’ attempt at imposing a work requirement on its traditional Medicaid population, the work requirement exemption policies still generate confusion, and reporting the exemption regularly places an added administrative burden on enrollees.[23]
4. Make Pathways to Coverage an ‘opt-out’ versus ‘opt-in’ program.
At the outset of the enrollment process potential applicants are shown screens that share more information about the Pathways to Coverage program, and they elect to be considered for the program. They are then asked to ‘opt-in’ by acknowledging that they have read the program requirements through a signed contract. This ‘opt-in’ step, among many in the application process, may result in potentially eligible Georgians dropping out before an application has even been submitted. In fact, on average, over 700 Georgians per month from December 2023 to June 2024 were not electing to be considered for the program. Shifting to has proven successful for other Medicaid programs. For example, the state uses existing data to automatically enroll or renew children in Medicaid and PeachCare—a process known as Express Lane Eligibility (ELE). When first implemented, potentially eligible applicants and enrollees had to ‘opt-in’ to ELE. However, the state now allows them to ‘opt out’ of the ELE process once their eligibility has been confirmed. At minimum, the state should make the Pathways to Coverage program ‘opt-out’ for Georgians who enrolled in another Medicaid eligibility category and have a had a change in circumstance. For example, transitioning to ‘opt-out’ could be particularly helpful for ensuring Pathways-eligible women nearing the end of their year of postpartum Medicaid coverage maintain access to continuous health care coverage.
5. Improve education and outreach for potentially eligible Georgians.
Although more robust data on this topic is needed, awareness and understanding of the Pathways to Coverage program during the first year of implementation appeared low among Georgians who are potentially eligible for the program—including those engaged for this project. all center data are not a substitute for intentionally collected data on program awareness and understanding; however, records indicate that only 0.06% of cumulative calls to the state-run call center were about Pathways to Coverage.[24] While some applicants may have heard about the program from their doctor, a health insurance navigator or by other means, most applicants likely first learned about Pathways to Coverage when they were presented with information about the program when logging into the online eligibility and enrollment system to renew their traditional Medicaid eligibility or submit a new application for traditional Medicaid. It is critical that education and outreach efforts move beyond the existing traditional Medicaid population. Individuals who have not previously been eligible for Medicaid, such as a non-disabled adult male with no children, would have no way of knowing that Pathways to Coverage is an option available to them. Simply put, individuals cannot apply to a program that they do not know exists. During the first year, the state launched a pilot paid media campaign that ran from January to March 2024. Starting in August 2024, the state launched a more robust awareness effort that includes a marketing campaign, influencer outreach and engagement and website updates. It will be important to monitor that campaign and its impact on awareness, understanding and increases in enrollment.
6. Improve communication with applicants and enrollees.
Georgians who are applying to Pathways to Coverage need clear, concise, timely communication that is tailored to the realities and preferences of each group potentially eligible for the program (e.g., rural residents far from a DFCS county office, young adults in college who prefer texting, older adults who lack computer literacy, etc.). The Georgians engaged in this project also indicated a strong desire for greater in-person and one-on-one support. GBPI’s prior research found that applicants experienced significant communication challenges during the first year. For example, the bureaucratic and technical language used in the application is lengthy and difficult to understand, and the application lacks visual examples. Moreover, applicants lack consistent support options outside of the online system. The focus groups and interviews reinforced those challenges and cited a lack of appropriate staff at county DFCS offices and lack of callbacks from overburdened caseworkers across all Medicaid programs. In addition, they specifically pointed to a need to improve the language used to explain why applicants are denied for the Pathways to Coverage program. The state could put in place evidence-based practices to make the online system more accessible and user-friendly; simplify and shorten applications and other written communication; increase communication through texting, electronic notices, and language-accessible call centers; and expand and strengthen localized, person-to-person support options.[25],[26]
Systems-level recommendations
1. Modernize Georgia’s public benefits eligibility and enrollment infrastructure.
Public benefits programs in Georgia, like Pathways to Coverage, will only ever be as successful as the foundation upon which they are built. The first year of the Pathways to Coverage program highlighted long-standing weaknesses in the overall public benefits eligibility and enrollment infrastructure, which includes 1) the online eligibility and enrollment system known as Gateway and 2) staff at the Division of Family and Children Services’ Office of Family Independence, particularly the frontline caseworkers. The backlog of 14,000 unprocessed applications in Pathways to Coverage’s first year underscores how strengthening this infrastructure is necessary for maximizing program success. Gateway, the online eligibility and enrollment system, is a costly, outdated technology system that creates challenges for both applicants/enrollees and frontline caseworkers.[27], [28], [29] Although the challenges with Gateway are pervasive across public benefits programs, it has created specific issues for the Pathways to Coverage program. For example, because of a defect in the backend of the Gateway system, the 12-month re-determinations required of all Medicaid programs was stalled for the Pathways to Coverage program. This forced the state to extend the renewal end dates in the system.[30] Addressing defects like these is time-consuming and creates more work for state agency staff and contractors. Along with faulty technology, the heavy workloadsalso contributes to the flawed eligibility and enrollment infrastructure.[31], [32], [33] The difficult circumstances in which the frontlines caseworkers must do their work contribute to applicants and enrollees not being able to get the support they need. While improving this infrastructure will take strategic investment and long-term, intentional planning, it is crucial that the state transition to a more user-friendly online eligibility and enrollment system and build up a workforce that is equitably paid, well-trained and co-located in the communities they serve.
2. Increase transparency and public data reporting and open opportunities for stakeholders to engage.
Increased programmatic data reporting and greater opportunity for stakeholder engagement could increase trust, collaboration and ultimately program effectiveness. During the first year the state maintained a data reporting webpage (https://dch.georgia.gov/pathways-reports) that was not regularly updated. The webpage included Pathways to Coverage monthly monitoring reports for July – October 2023. Finalized monthly monitoring reports for July 2023 – June 2024 were not added to the webpage until October 2024. The state should build upon lessons learned from the Medicaid unwinding, during which the state consistently reported data to the public through a data dashboard and monthly press releases. To expand opportunities for engagement, the state should host regular touchpoints with community stakeholders. By empowering stakeholders with data, they can help take action to fill gaps, such as targeting community-based outreach to counties with low enrollment. In addition, a two-way communication channel allows stakeholders to weigh in on materials, messages and tactics that might resonate with their specific communities. It also allows them to provide feedback around the on-the-ground realities of program implementation that can inform continuous program improvement. Lastly, public data reporting increases efficiency by reducing redundant Open Records Requests and other inquiries for programmatic information. A allows states to test state-specific approaches to better serve Medicaid populations. As with any experiment, it is critical to examine what went well and learn from what went poorly; public reporting and stakeholder engagement are critical parts of that collective learning process.
Transformational recommendations
1. Meet people where they are and make systems, programs and outreach campaigns more human-centered.
The people closest to the problem are often best suited to develop the solution. When developing new public benefits enrollments systems, new health care programs and new awareness and education campaigns, the state could leverage the lived expertise of uninsured Georgians with low incomes. As currently designed, Pathways to Coverage does not account for the realities of many uninsured Georgians with low incomes. For example, data indicate that Black and Latinx adults are less likely than white adults to own a computer or have access to the high-speed internet that is needed to log into Gateway to apply and report their monthly qualifying hours and activities.[34] This may mean that, although they are eligible, some Black and Latinx Georgians may be less likely to enroll or remain enrolled in the program and thus become uninsured. To drive toward greater health equity, the state should co-design solutions with potential Black and Latinx applicants to remove potential barriers to accessing the program. Meaningful, bidirectional engagement rooted in trust and shared power can ensure the resulting program or policy is shaped by the real needs and preferences of those who are most impacted. For example, Mississippi employed human-centered design with end users to ensure its online eligibility and enrollment website, AccessMS, has a ‘welcoming front door’ on their landing page so that applicants can quickly start the application process and know what to expect.[35] Similarly, when working to reach potentially eligible but uninsured populations, best practices emphasize the importance of localized grassroots outreach, including partnering with trusted community organizations, going where people feel most comfortable and prioritizing in-person interaction.[36], [37] While the Pathways to Coverage awareness campaign that launched in August 2024 does have an influencer outreach and engagement strategy, it is unclear if and how the campaign will engage deeply with communities.
2. Eliminate the qualifying activities requirement to make health care access more inclusive for Georgians with low incomes.
Two of the Pathways to Coverage program’s stated aims are to increase access to affordable health care and support enrollees’ financial independence. Prior research indicates that work and qualifying activities requirements stand in the way of achieving those two goals. Rather than promoting self-sufficiency, work requirements make it more challenging to access health care and move people further into poverty.[38] Prior research also demonstrates that work requirements have minimal impact on long-term employment gains, while expanding health care coverage without a work requirement makes it easier to job hunt and perform well at work.[39] Work requirements can also worsen racial disparities. Long-standing, racist policies and practices like regressive tax policies and occupational segregation have created inequitable access to economic opportunity for Georgians of color. Across the board, most non-elderly, non-disabled Medicaid enrollees work; Black women, for example, participate in the labor force at a higher rate than other adult women.[40], [41] However, low-income Black and Latinx Georgians are less likely than white adults to have access to employer-sponsored health care coverage and are overrepresented in Georgia’s health insurance coverage gap.[42], [43] The negative impacts of work requirements on employment and the increased administrative burden they place on enrollees disproportionately impact Black, Latinx and other people of color.[44] Lastly, work and other qualifying activities requirements are costly for taxpayers as evidenced by the almost $58 million in total spending up through year one – most of which went to designing and installing upgrades to Georgia’s online eligibility and enrollment system. By removing the qualifying activities requirement, the state could be more responsive to the needs and realities of uninsured Georgians with low incomes rather than imposing arbitrary and harmful eligibility criteria. Georgia could also explore alternative policies. For example, programs with work supports, like subsidized childcare for single parents and intensive job-search assistance, see increased employment among participants.[45]
3. Raise the Medicaid income limit for non-elderly adults up to 138% of the federal poverty level and unlock billions in federal funds.
Because it only offers coverage to Georgians earning up to 100% of the federal poverty level, Pathways to Coverage fails to draw down federal financial incentives offered under the Affordable Care Act and the American Rescue Plan. Currently, the federal government pays about 66% of health care costs for Georgians covered under both traditional Medicaid and the Pathways to Coverage program. If the state expands access to health care for Georgians up to 138% of the federal poverty level (about $43,000 or less in annual household income for a family of 4), the federal government would cover 90% of the health care coverage costs for those who are newly eligible. For the first two years, the federal government would also pay 71% of health care costs for Georgia’s over 2 million traditional Medicaid enrollees. That translates into more than $1 billion in additional federal funds to the state over two years.[46] This ‘signing bonus’ more than covers the state cost of expanding coverage, which makes the net state cost $0 for the first two years.[47] This infusion of federal funds and increased demand for health care services would positively impact our state economy in other ways. Economic modeling found that expanding eligibility would create over 51,000 jobs and increase the state’s GDP by $5.5 billion.[48] The economic benefits extend beyond just the state economy; increased access to affordable health care for Georgians with low incomes could help stabilize finances for hospital and providers, particularly in rural areas, and increase families’ financial security.[49] Whether the state decides to offer Medicaid coverage (traditional Medicaid expansion) or buy a qualified health plan on the health insurance marketplace (‘private option’ expansion) for Georgians earning up to 138% of the federal poverty level, slightly raising the income limit and activating those federal funds for Georgia’s benefit is a more fiscally responsible choice for the state.
Acknowledgements
GBPI would like to thank the following project partners for the support and expertise that made this work possible.
Funder: Robert Wood Johnson Foundation
Research Partners: Code for America; Coy Forrest Strategy and Innovation, LLC; Creative Research Solutions
Community Partners: Coalición de Líderes Latinos (CLILA), Georgians for a Healthy Future, Peach Concerned Citizens, The Arc of Georgia, SOWEGA Rising
Appendix 1. Qualitative Data Collection Methods and Limitations
In November 2023, GBPI’s research partner, Creative Research Solutions, conducted two synchronous, online (via Zoom) focus group sessions with a total of 30 participants. Participants were recruited through statewide, regional and local community-based organizations that serve Georgians with low incomes. Participants could text or call a recruitment phone line or complete an online form expressing their interest. Each participant then completed a screening phone call with GBPI to ensure that they self-identified as 1) being between 19-64 years old; 2) being Black and/or Latinx; 3) being currently uninsured or having experienced significant periods of uninsurance in the past; and 4) earning a household income of less than 138% of the federal poverty level. Participants who met the screening criteria were then asked to sign a consent form. Only participants who met the screening criteria and had a signed consent form were allowed to join the online focus group. Participants self-identified on their online form or in their screening phone call as living across the state – from Albany to Atlanta to Augusta. Each participant received a gift card upon completion of the focus group.
In May – July 2024, Creative Research Solutions conducted eight individual interviews. Participants were recruited through statewide, regional and local community-based organizations that serve Georgians with low incomes and through advertisements at public transportation bus stops in the metro Atlanta area. Each participant then completed a screening phone call with GBPI to ensure that they self-identified as 1) being between 19-64 years old; 2) either having applied to the Pathways to Coverage program or being currently or previously enrolled in the program; and 3) earning a household income of less than 100% of the federal poverty level. Although self-identifying as Black and/or Latinx was not part of the inclusion criteria for these interviews as it had been for the focus groups, most participants self-identified in the online form as Black. Participants who met the screening criteria were then asked to sign a consent form. Only participants who met the screening criteria and had a signed consent form were invited to participate in an interview. Each participant received a gift card upon completion of their interview.
The purpose of the focus groups and individual interviews was to learn about Georgians’ perspectives on health care coverage for individuals with low incomes, assess their familiarity with the Pathways to Coverage program, and understand their experiences with applying for and/or enrolling in the program. Each focus group session was 60 – 90 minutes in length, and the individual interviews were 30 – 60 minutes in length. The audio-recordings from the focus groups and interviews were transcribed, cleaned, coded and analyzed by the Creative Research Solutions team. The Creative Research Solutions team then generated a report that summarized key themes and sub-themes along with illustrative quotes (without identifying information to preserve the anonymity of the participants).
It is important to note that findings from the focus groups and individual interviews do not reflect all possible perspectives or experiences of Georgians who are potentially eligible for, have applied for, or who are currently or were previously enrolled in the Pathways to Coverage program. Systemic barriers faced by many people with low-incomes, such as lack of access to stable housing, lack of access to high-speed internet and inconsistent ability to afford and access a mobile phone, can make them a hard-to-reach population. Moreover, the Pathways to Coverage program’s very low enrollment in the first year further complicated GBPI’s ability to recruit people who were currently or previously enrolled in the Pathways to Coverage program during the recruitment period. Additionally, while the focus group sessions and interviews were meant to be an inclusive and respectful space for participants to share their experiences and insights, it is not expected that all perspectives were fully captured during the limited discussion time frames. The findings from the focus groups and interviews are not generalizable; instead, they are intended to provide contextualized understanding of the experiences of those who were engaged in the focus groups and interviews. Findings should be used cautiously and in conjunction with other evaluation and research studies. Notably, additional research is needed to understand more about the typical profile of an enrollee who has successfully gained coverage versus enrollees who lose coverage versus applicants who are denied coverage. In addition, more robust qualitative and quantitative data collection is needed to better understand awareness and perception of the Pathways to Coverage program and its unique requirements among potentially eligible Georgians.
[*] As previously cited in the media, the Department of Community Health (DCH) reports having spent about $40 million in combined state and federal funds on the Pathways to Coverage program through June 2024. GBPI’s calculations are based on expenditures reported in the quarterly Medicaid statements of expenditures (CMS-64 form) through June 2024 and obtained through Open Records Requests. GBPI asked DCH to clarify the discrepancy between the two amounts, and they had not yet done so at the time of this report’s publication.
Endnotes
[1] KFF (2023). Health insurance coverage of the total population [Data Set]. https://www.kff.org/other/state-indicator/total-population/
[2] KFF (2023). Uninsured rates for people ages 0-64 by race/ethnicity [Data Set]. https://www.kff.org/uninsured/state-indicator/people-0-64-uninsured-rate-by-raceethnicity/
[3] Radley, D. C., Baumgartner, J. C., Collins, S. R., & Zephyrin, L. C. (2023). Scorecard on state health system performance. The Commonwealth Fund. https://www.commonwealthfund.org/publications/scorecard/2023/jun/2023-scorecard-state-health-system-performance
[4] O.C.G.A. § 49-4-142.3. https://law.justia.com/codes/georgia/2022/title-49/chapter-4/article-7/section-49-4-142-3/; SB 106, Patients First Act (2019). Georgia General Assembly. https://www.legis.ga.gov/legislation/54962
[5] The State of Georgia and Georgia Department of Community Health v. Chiquita Brooks Lasure, No. 2:2022cv00006 (S.D. Ga. Aug, 19, 2022). https://cases.justia.com/federal/district-courts/georgia/gasdce/2:2022cv00006/86202/52/0.pdf?ts=1660998390
[6] CMS (2024). Monthly monitoring report – June 2024 [Data Set]. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/81441
[7] Grapevine, R. (2022, December 23). How Georgia’s new Medicaid work requirement program will work. Capitol Beat. https://capitol-beat.org/2022/12/how-georgias-new-medicaid-work-requirement-program-will-work/
[8] U.S. Department of Health and Human Services. (2020). Georgia “Pathways to Coverage” 1115 demonstration waiver approval. https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ga/ga-pathways-to-coverage-ca.pdf
[9] Georgia Department of Community Health. (2019). Georgia “Pathways to Coverage” 1115 demonstration waiver application. https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ga-pathways-to-coverage-pa1.pdf
[10] U.S. Department of Health and Human Services. (2020). Georgia “Pathways to Coverage” 1115 demonstration waiver approval. https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ga/ga-pathways-to-coverage-ca.pdf
[11] Georgia Department of Community Health. (2019). Georgia “Pathways to Coverage” 1115 demonstration waiver application. https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ga-pathways-to-coverage-pa1.pdf
[12] Kemp, B. (2023). 2023 State of the state address [Speech transcript]. Office of the Governor, https://gov.georgia.gov/press-releases/2023-01-25/governor-brian-p-kemps-2023-state-state-address
[13] Thomas, G. (2024, September 5). Georgia Pathways to Coverage [PowerPoint slides]. Georgia Department of Community Health. https://dch.georgia.gov/document/document/comprehensive-health-coverage-meeting-slide-deckdch-presentation-002/download
[14] GBPI analysis of Department of Health and Human Services’ data on county estimates of the uninsured population in the U.S. using the Census Bureau’s 2022 American Community Survey. https://aspe.hhs.gov/reports/state-local-estimates-uninsured-population-2022
[15] Ibid.
[16] Chan, L. (2023). 2023 Georgia Medicaid unwinding: Grassroots advocacy toolkit. Georgia Budget and Policy Institute. https://gbpi.org/2023-georgia-medicaid-unwinding-grassroots-advocacy-toolkit/
[17] Georgetown University’s Center on Children and Families. (2024). How many people are applying or reapplying for Medicaid. https://ccf.georgetown.edu/2024/01/26/medicaid-application-data/
[18] Finch Floyd, I. (2024). Georgia Human Services budget primer for state fiscal year 2025. Georgia Budget and Policy Institute. https://gbpi.org/georgia-human-services-budget-primer-for-state-fiscal-year-2025/
[19] Herd, P., & Moynihan, D. (2020). How administrative burdens can harm health. Health Affairs Health Policy Brief. https://www.healthaffairs.org/do/10.1377/hpb20200904.405159/
[20] Guth, M., Ammula, M., & Hinton, E. (2021). Understanding the impact of Medicaid premium and cost-sharing: Updated evidence from the literature and Section 1115 waivers. KFF. https://www.kff.org/medicaid/issue-brief/understanding-the-impact-of-medicaid-premiums-cost-sharing-updated-evidence-from-the-literature-and-section-1115-waivers/
[21] Corallo, B., & Tolbert, J. (2023). Understanding Medicaid ex parte renewals during the unwinding. KFF. https://www.kff.org/policy-watch/understanding-medicaid-ex-parte-renewals-during-the-unwinding/
[22] Medicaid and CHIP Payment and Access Commission. (2023). Increasing the rate of ex parte renewals. https://www.macpac.gov/wp-content/uploads/2023/09/Increasing-the-Rate-of-Ex-Parte-Renewals-Brief.pdf
[23] Harker, L. (2023). Pain but no gain: Arkansas’ failed Medicaid work-reporting requirements should not be a model. Center on Budget and Policy Priorities. https://www.cbpp.org/research/health/pain-but-no-gain-arkansas-failed-medicaid-work-reporting-requirements-should-not-be
[24] Georgia Department of Human Services (2024, September 19). Percentage of call center inquiries on Pathways to Coverage. (Obtained through an Open Records Request; requested percentage of calls to the call center about Pathways to Coverage; received September 2024).
[25] Wikle, S., Wagner, J., Erzouki, F., & Sullivan, J. (2022). States can reduce Medicaid’s administrative burdens to advance health and racial equity. Center on Budget and Policy Priorities. https://www.cbpp.org/research/health/states-can-reduce-medicaids-administrative-burdens-to-advance-health-and-racial
[26] Code for America. Blueprint for a human-centered safety net. https://www.codeforamerica.org/explore/safety-net-blueprint/
[27] Chan, L. (2024). Understanding the Pathways to Coverage program: An initial review of the enrollment process. https://gbpi.org/wp-content/uploads/2024/04/C4ABrief-202404.pdf
[28] Liss, S., & Pradhan, R. (2024, September 5). Errors in Deloitte-run Medicaid systems can cost millions and take years to fix. KFF Health News. https://kffhealthnews.org/news/article/deloitte-run-medicaid-systems-errors-cost-millions-take-years-to-fix/
[29] Pradhan, R., & Liss, S. (2024, June 24). Medicaid for millions in America hinges on Deloitte-run systems plagued by errors. KFF Health News. https://kffhealthnews.org/news/article/medicaid-deloitte-run-eligibility-systems-plagued-by-errors/
[30] Georgia Department of Human Services (2024, September 19). Gateway defects. (Obtained through an Open Records Request; requested Gateway defects from July 2023 – August 2024; received September 2024).
[31] Landergan, K. (2023, February 3). DFCS caseworkers in Georgia: ‘It’s like being in an emergency room’. Atlanta Journal-Constitution. https://www.ajc.com/news/atlanta-news/dfcs-caseworkers-in-georgia-confront-chaos-its-like-being-in-an-emergency-room/M6VEWIPZZFGJ5BAX2F264UVKAA/
[32] Finch Floyd, I. (2024). Georgia Human Services budget primer for state fiscal year 2025. Georgia Budget and Policy Institute. https://gbpi.org/georgia-human-services-budget-primer-for-state-fiscal-year-2025/
[33] Finch Floyd, I. (2024). Overview: 2025 fiscal year budget for Department of Human Services. Georgia Budget and Policy Institute. https://gbpi.org/overview-2025-fiscal-year-budget-for-human-services/
[34] Atske, S., & Perrin, A. (2021). Home broadband adoption, computer ownership vary by race, ethnicity in the U.S. Pew Research Center. https://www.pewresearch.org/short-reads/2021/07/16/home-broadband-adoption-computer-ownership-vary-by-race-ethnicity-in-the-u-s/
[35] Code for America. The benefits enrollment field guide: What the online enrollment experience for safety net benefits looks like across America. https://codeforamerica.org/explore/benefits-enrollment-field-guide/
[36] Artiga, S., Rudowitz, R., & Tolbert, J. (2016). Outreach and enrollment strategies for reaching the Medicaid eligible but uninsured population. KFF. https://www.kff.org/medicaid/issue-brief/outreach-and-enrollment-strategies-for-reaching-the-medicaid-eligible-but-uninsured-population/
[37] Greene, J., Gibson, D., Quincy, L. & Rappaport, J. (XX). A guide to monitoring Medicaid using lived experience. Center on Budget and Policy Priorities. https://www.cbpp.org/sites/default/files/Monitoring%20Medicaid%20Lived%20Experience%20Report.pdf
[38] Robert Wood Johnson Foundation. (2023). Work requirements: What are they? Do they work? https://www.rwjf.org/en/insights/our-research/2023/05/work-requirements-what-are-they-do-they-work.html
[38] Pavetti, L., Bolen, E., Harker, L., Orris, A., & Mazzara, A. (2023). Expanding work requirements would make it harder for people to meet basic needs. Center on Budget and Policy Priorities. https://www.cbpp.org/research/poverty-and-inequality/expanding-work-requirements-would-make-it-harder-for-people-to-meet
[40] Drake, P., Tolbert, J. Rudowitz, R., & Damico, A. How many uninsured are in the coverage gap and how many could be eligible if all state adopted Medicaid expansion? KFF. https://www.kff.org/medicaid/issue-brief/how-many-uninsured-are-in-the-coverage-gap-and-how-many-could-be-eligible-if-all-states-adopted-the-medicaid-expansion/
[41] Pavetti, L., Bolen, E., Harker, L., Orris, A., & Mazzara, A. (2023). Expanding work requirements would make it harder for people to meet basic needs. Center on Budget and Policy Priorities. https://www.cbpp.org/research/poverty-and-inequality/expanding-work-requirements-would-make-it-harder-for-people-to-meet
[42] Drake, P., Tolbert, J. Rudowitz, R., & Damico, A. How many uninsured are in the coverage gap and how many could be eligible if all state adopted Medicaid expansion? KFF. https://www.kff.org/medicaid/issue-brief/how-many-uninsured-are-in-the-coverage-gap-and-how-many-could-be-eligible-if-all-states-adopted-the-medicaid-expansion/
[43] Center on Budget and Policy Priorities. (2024). The Medicaid coverage gap in Georgia. https://www.cbpp.org/sites/default/files/4-3-24health-factsheet-ga.pdf
[44] Bhattacharya, J., Brumfield, C., Finch Floyd, I., Price, A., & Van Winkle, S. (2024). Work requirements are trash. The Maven Collaborative and the Center for Law and Social Policy. https://www.mavencollaborative.org/work-requirements-are-trash/
[45] Congressional Budget Office. (2022). Work requirements and work supports for recipients of means-tested benefits. https://www.cbo.gov/publication/58199
[46] Griffin, G. (2024, February 22). Fiscal note on House Bill 62 (LC 33 9274). Georgia Department of Audits & Accounts. https://opb.georgia.gov/document/fiscal-notes-2024/lc-33-9274/download
[47] Ibid.
[48] Evangelakis, P., & Paulhus, L. (2024). Economic impacts of Medicaid expansion in Georgia. Regional Economic Models, Inc. https://www.remi.com/wp-content/uploads/2024/03/Georgia-Medicaid-Expansion-Economic-Impact-Report-REMI-March-2024-.pdf
[49] Simpson, M., & Banthin, J. (2024). Expanding Medicaid in Georgia would help uninsured people gain coverage. Urban Institute. https://www.urban.org/research/publication/expanding-medicaid-georgia-would-help-uninsured-people-gain-coverage
