Part I: Georgia Pathways 1115 Waiver Requires Sick People To Work For Healthcare

Almost one half million Georgians don’t have health coverage because elected officials and the Governor of Georgia have refused to accept resources from the federal government to pay for Medicaid Expansion.  

Georgia’s uninsured rate of 12.9% is the fifth-worst in the country and could climb higher.   Currently, Medicaid in Georgia only covers pregnant women, children under 19, people who are legally blind or disabled and retirees 65 and older.

Originally Medicaid Expansion was intended to be national but the Supreme Court in 2012 made it optional for states.  Georgia and 14 other states (92% in the South) have not expanded the program leaving millions of Americans in a coverage gap without any health care.

In March 2019, Governor Brian Kemp and the Georgia General Assembly passed the Patients First Act (SB 106) to develop federal waivers to change healthcare in Georgia. They created two waiver plans. One plan will change the Georgia Medicaid program and the other will change how private insurance works.

Click to access 185957.pdf

The State claims that Medicaid Expansion will undermine access to care and cost Georgia taxpayers over a billion and a half dollars in the first five years. 

Georgia continues to lose $3 billion in federal funding every year that elected officials don’t expand Medicaid and that money could cover all Georgians with Medicaid.  Other states that have expanded Medicaid see their tax dollars come back into the state to benefit their citizens – but not Georgia.   

The State claims that the Georgia Pathways Waiver will enhance eligibility for thousands of working Georgians and will honor hard work, protect families, and champion individual responsibility.

The State’s 1115 Waiver plan will cover about 80,000 Georgians and will cost the state $215 million.  But if the state expanded Medicaid it would cover 500,000 Georgians and would cost the state $213 million, according to the Georgia Budget and Policy Institute.  

Advocates of Medicaid Expansion believes it is insane for Georgia to not expand Medicaid which will cover more people for less money than the State waiver.

Seven rural hospitals have closed since 2013 and many other Georgia hospitals treat patients who don’t have health insurance and now they are vulnerable to closure and this impacts rural areas in Georgia the most.  


The Georgia Medicaid 1115 waiver allows an individual with an annual income below $12,000 or $26,000 for a family of four to enroll in Medicaid.  People with incomes above the poverty line but not making enough to afford private health insurance will not qualify.

Enrollment begins on July 1, 2021, and you must not currently be eligible for Medicaid in Georgia. 

This proposal requires people to file paperwork on how many hours they work, attend a school or college, community service, or vocational education training, along with supporting documentation.  They are required to work or go to school 80 hours a month. If they don’t file the paperwork each month, they will be suspended and after three months they are kicked off their health coverage.  

It requires people making between 50 and 100% of the federal poverty line to pay monthly premiums from $7 to $11 a month.  If they fail to pay for three months, they are kicked off of their health coverage.  

It requires copayments that range from $0 to $30 per visit for non-emergency use of the emergency department.  

 This plan does not include non-emergency transportation which would impact Georgians who live in rural areas far away from doctors and hospitals.  

This complicated plan erects barriers and is difficult to navigate which makes it hard for low-income and sick people to get covered and stay covered. 

It creates a state bureaucracy to keep track of all the paperwork and its limited expansion will reduce federal funding of Medicaid.  


Public Hearing for both waivers opened on November 4 and closed on November 22.  The Georgia Department of Community Health (DCH) held six public hearings where the public gave comments on the Waivers.   The meetings were in Savannah, Macon, Bainbridge, Gainesville, Rome, and Kennesaw. Additional public comments will be accepted on-line at  until December 3, 2019. 

It was noted that none of the meetings were in Atlanta where more people, without cars, could attend using public transportation.

The Streets of Atlanta attended the last meeting on November 22 in Kennesaw and here is what people said about the Georgia Medicaid Waiver 1115.


There was a lot of concern about the work requirements which many believe puts the cart before the horse.   It’s like telling a student – when you learn Algebra then you can go to school. Sick people need healthcare in order to get better so they can get a job.  

Also, if they don’t file a work report each month they will be dropped from the healthcare coverage after three months.   Federal Medicaid receipts are not dropped from healthcare and are not required to fill out work forms. 

It is the chronically ill and mentally ill that have the greatest need for ongoing care and with good healthcare they may be able to gain employment, it’s not the other way around.  

 “My son has hemophilia and because we had good healthcare he is now a productive member of society.  Without good healthcare, he would be disabled and the State would have to support him,” Julia Conde, told DCH.  

“The State is trying to combine two very difficult and complicated programs – a jobs programs and an affordable healthcare program – this will be extremely expensive and difficult to do, ” Michael Firmen said and added “I don’t think it is possible to do.” 

The work requirements have been put on hold in other states and are the subject of federal lawsuits.  The courts find that while employment is a goal – it is not the goal of the Medicaid program. Medicaid’s goal is to ensure healthcare coverage for the most vulnerable and work requirements doesn’t advance that goal.

“A Harvard Study documented the negative results in Arkansas where seventeen thousand lost their healthcare because of the burden of reporting requirements with no real gains in employment,” Janet Grant, a former healthcare executive responsible for Medicaid across 16 states, testified to DCH. 

As people lose coverage, it can lead to more expensive hospitalizations and higher uncompensated care costs for hospitals. Some hospitals are just barely hanging on financially. 

This program appears to mostly benefit young, healthy individuals who don’t have any pre-existing conditions who can work or attend school 80 hours a month.   This plan may not serve the needs of poor, sick people with pre-existing conditions who need healthcare the most. 


There are premiums and copayments with the Georgia Medicaid Waiver plan that can be an additional burden and cause people to drop the plan.

“We looked at three states with premiums attached and even as low as 1% there was a reduction of 15% in enrollment.   Wisconsin only charged premiums on people making above the poverty line but they saw a 24% reduction in enrollment,” Laura Harker, with the Georgia Budget & Policy Institute, said.

“I believe the reporting requirements for the work and cost-sharing will be an obstacle for the very people who this waiver is supposed to help,” Susan Marling said.   

People who fail to pay premiums for three months will be kicked off of the State health coverage.  

This proposal forgoes funding opportunities.  The federal government pays for 90% of the cost of full Medicaid Expansion, but will pay only about 67% of the State’s limited expansion. 


There is no information about how much it will cost for an expensive administrative department to manage the work reports from State Medicaid recipients.  

 “In Kentucky, those work requirements were put on hold by court order and yet our company had invested $9 million dollars getting ready to provide the administrative requirement necessary.   That had to be reimbursed by the state across the five health care plans,” Janet Grant told DHS.  


Several people expressed concerns about citizens not going to the hospital because they can’t afford the huge hospital bill and an Emory doctor worries about people he has to turn away who may later die. 

“I saw my mother show signs of having a stroke and she debated if she should go to the hospital because of the medical bill she would receive.  There is money left on the table for Georgia to receive Medicaid Expansion but that is not happening,” Tori Ladipo, with New Georgia Project, said. 

“People with asthma should not be discouraged to go to the emergency room for trouble breathing for fear their condition will be judged as non-emergency,” June Deen, with the American Lung Association of Georgia, said. 

The American Lung Association of Georgia opposes the proposal as it currently stands.  

“I don’t want to tell 5 out of every 6 patients, below the federal poverty line, that there is not much we can do for them when they show up at the emergency room,” Dr. Anurag Sahu, Cardiologist at Emory University, said to DCH.

“There are 320 research studies in states that have expanded Medicaid on the positive impact by the Kaiser Foundation.   States with expanded Medicaid have seen decreases in the number of uninsured, improved health outcomes, and saving for the State government and taxpayers,” Janet Grant reported.  

Because of the length and complexity of the changes to Georgia’s healthcare, Part II: Georgia Access 1332 Private Insurance Waiver will be published later.  

By Gloria Tatum

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