Medicaid Waiver Principles for Georgia’s Health Crisis

The Medicaid program is a state-federal partnership in which states contribute and receive federal matching dollars to provide health coverage to low-income residents. States run their programs according to broad federal regulations, but there are a number of options to give states flexibility in how they operate their programs. One of these options is a Section 1115 waiver that allows states to try new policy approaches to further the objectives of the Medicaid program. In 2011, Georgia received one of these waivers to provide additional coverage for family planning services. Some states are using 1115 waivers to expand eligibility for health coverage at a higher federal matching rate.

Georgia is facing a rural health crisis with seven hospitals closing since 2013 and several others deemed to be financially struggling based on negative operating margins. Rising rates of drug overdose deaths and suicide have created an urgent need for enhanced prevention and behavioral health treatment in the state. Below are five key strategies for creating an effective Medicaid waiver that will effectively respond to these needs.

Put a health insurance card in the pockets of more Georgians in 2019

About 240,000 Georgians have no health coverage options through their employer or the health insurance marketplace.[1] These Georgians are veterans, parents, and low‐wage workers with no health coverage through their employer. Georgia is losing $8 million in federal funds every day the coverage gap remains. The need is urgent to provide an affordable health coverage option for these Georgians and help rural hospitals who are struggling under the burden of high uncompensated care costs and the changing health care financing landscape.

Recommendation: Submit to the U.S. Department of Health and Human Services an 1115 waiver proposal that will be implemented in 2019.

Extend coverage to all Georgians up to 138% of the Federal Poverty Level (FPL)

An additional 220,000 working poor Georgians make between 100% FPL and 138% FPL, or about $16,750 for an individual and $28,670 for a family of three.  While some are eligible for financial help through the health insurance marketplace, for many the costs of health care coverage (e.g. high deductibles) are still unaffordable, effectively leaving them with no affordable coverage option. These Georgians would be eligible for coverage if the state expanded Medicaid at an enhanced federal match. Georgia Medicaid brings in about $2.17 of federal money for each dollar the state spends. The expansion program would be funded at a rate of about $8 or $9 of federal money for every dollar the state spends. This is a strong return on an investment in working Georgians and the state’s health care system.

Recommendation: Georgia’s 1115 waiver proposal provides coverage for all Georgians up to 138% FPL.

Facilitate comprehensive access to health care services

Extending comprehensive health coverage to uninsured Georgians can help improve health outcomes and the financial sustainability of health systems. People with health insurance are much more likely than the uninsured to utilize preventive health services, to seek medical care when they need it and to report better overall health.[2] They are also better able to manage their finances and less likely to have medical debt. When more patients are meaningfully insured, health care providers are better able to collect reimbursement for the services they provide.

Recommendations: Georgia’s waiver proposal should include provisions that:
  1. Ensure enrollment remains open year-round and enrollees are notified of eligibility or enrollment status in a timely manner.
  2. Foster care coordination and promote continuity of care
  3. Don’t overly limit enrollees ability to use their coverage for the important and timely services they need
  4. Set provider reimbursement rates at competitive and fair levels and retain retroactive eligibility to enhance provider participation and reduce uncompensated care

Maintain stable and affordable coverage for newly eligible Georgians

Putting restrictions on eligibility and enrollment through cost-sharing and work requirements impedes the goals of reducing the uninsured rate and reducing hospital uncompensated care costs. Requiring low-income people to pay premiums, co-payments and required health savings accounts contributions led to reduced enrollment in other states.[3] This results in more uninsured people, unmet health care needs and less payments to hospitals. About 76 percent of nonelderly Georgians in the Medicaid program are in a family with a worker.[4] People who are not working are mostly students, caregivers or people with chronic health conditions.[5] Chronically ill people need health coverage to work, and losing coverage through a work requirement would impede their future employment. These requirements also add significant administrative costs and put further strain on the state’s budget. Georgia would have to come up with all of the additional funds for services that help people find work because federal dollars can’t be used for this purpose.

Recommendation: Georgia’s waiver proposal does not place restrictions on eligibility and enrollment that are shown to interfere with or jeopardize access to care.
  1. Ensure provisions such as work requirements, premiums and co-payments, required health savings accounts, limited enrollment periods, lock-out periods and penalties are not included in Georgia’s waiver

Provide comprehensive benefits to newly-eligible enrollees and preserve coverage for currently enrolled.

The Medicaid benefit package is structured to provide over 2 million Georgians with health care coverage that facilitates their ability to access preventive, diagnostic, and treatment services. Some benefits such as dental and vision coverage and non-emergency medical transportation are optional in 1115 waivers, but important for the state to include. Transportation to health appointments is critical to ensuring access to health care for rural Georgians and can help avoid more expensive emergency room visits. Some states have used waivers to extend additional benefits to support enrollees in maintaining housing and work.[6] Georgia has seen success in supported housing and employment services and can use a waiver to extend these services to new enrollees.

Recommendations: Georgia’s waiver proposal should maintain or enhance coverage for people already enrolled in Medicaid and extend comprehensive benefits to people who are newly eligible.

I. Dental/vision coverage and non-emergency medical transportation are included in the benefit package

II. Provide support services such as supported housing and employment, but do not make participation a condition of keeping health coverage


[1] Garfield R and Damico A. “The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid.” November 2017.

[2] Robert Wood Johnson Foundation. “What is the link between having health insurance and getting adequate health care?”. August 2011.

[3] Suzanne Wikle. “Work Requirements in Medicaid Would Add More Red-Tape and Barriers to Health Coverage.” Georgetown University Center for Children and Families. November 2017.

[4] Kaiser Family Foundation. “Distribution of the Nonelderly with Medicaid by Family Work Status”. 2016.

[5] Garfield R, Rudowitz R, Damico A. “Understanding the Intersection of Medicaid and Work”. January 2018.

[6] Peggy Bailey. “Washington Waiver Shows How Medicaid Can Support Work”. Center on Budget and Policy Priorities. January 2018.

Support GBPI Today

The Georgia Budget & Policy Institute is a 501(c)3 organization. We depend on the support of donors like you. Your contribution makes the work that we do possible.

Related Posts

Leave a Comment

Your email address will not be published. Required fields are marked *

Subscribe to our Newsletter