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Thomas Simonetti

On Capitol Hill this spring, House Republicans — who were engaged in ferocious negotiations over the national <a href="https://www.washingtonpost.com/politics/2023/04/26/debt-ceiling-explained/" target="_blank" class="contextual_link">debt ceiling</a> — wanted to purge many poor adults from Medicaid rolls unless they held a job, trained for work or helped in their community.

More than 600 miles to the south, Georgia’s GOP governor prepared to do something similar, allowing impoverished adults in the state who had never qualified for Medicaid to join — but only if they prove every month they meet the same kind of requirements.

The Medicaid changes sought in Congress did not survive a debt ceiling compromise. But Georgia’s plan — called Georgia Pathways to Coverage — has proceeded and is beginning in July. Despite their disparate outcomes, the moves in Washington and Atlanta reflect a renewed determination among conservatives in various parts of the country to tie eligibility for the largest form of public health insurance to work.

The moves are striking because a few years ago, federal courts struck down other states’ efforts to impose Medicaid work requirements. The Biden administration then blocked a batch of state requirements on the runway. These actions appeared to forestall the possibility of compelling certain poor Americans to work, study or volunteer in exchange for Medicaid, a program run jointly by the federal government and states, which can set their own eligibility rules.

The renewed push among Republicans is reigniting an ideological dispute over the role and nature of the social safety net, opening a new chapter in an old debate about the fundamental compact between the government and the nation’s poor.

The GOP argument is that imposing requirements to qualify for Medicaid will enable people to rise out of poverty, eventually weaning them from public insurance because they will attain jobs that provide health benefits. Democrats counter that health care is a basic right that should not be conditioned on any obligations — and that having insurance is necessary to help some people become healthy enough to work.

According to the Congressional Budget Office, the House’s short-lived work requirements plan would have caused perhaps 1.5 million Americans to lose Medicaid coverage, while the rules would have resulted in few people joining the nation’s workforce because 9 in 10 people who would face the new measures already have jobs or cannot work because of disabilities or emergencies.

But it is difficult to know what really would happen. “At this point, we’re relying on theory and economics,” said Chris Denson, policy and research director for the Georgia Public Policy Foundation, a libertarian group that favors making Medicaid eligibility contingent on work and other requirements.

In a few places — including Arkansas and Georgia — state officials have been refashioning Medicaid work rules to try to circumvent legal arguments wielded against such plans in the past.

Legislatures in a few states are taking a stand without expecting quick results. A new North Carolina law poised to expand Medicaid says that, if a federal administration ever would allow requirements, then the state must pursue federal approval to force recipients to work.

As a conservative push for work requirements crops up again, it is too soon to know how much will wind up mere rhetoric and how much reality — and what happens when the change is put in place. Georgia is about to offer the best glimpse.

Joshua L. Jones

The governor’s race in Georgia was among the most expensive and bitter of 2018. Stacey Abrams, the Democratic candidate and former Democratic leader in the state House of Representatives, argued passionately that her state — with the country’s third-highest uninsured rate at the time — should expand Medicaid under the Affordable Care Act, as three dozen states already had done. Republican Brian Kemp, then Georgia’s secretary of state, steadfastly opposed the idea, arguing for making private health insurance more affordable and available.

It was a bad year for the GOP nationally. Republicans lost their House majority, in part because the chamber had voted dozens of times to dismantle core aspects of the ACA, to voters’ chagrin. Still, Kemp won — by 1.4 percentage points.

Kemp’s campaign “had realized they needed a rebuttal” to Abrams’s fervor for expansion, according to Denson, who said the libertarian group coached the candidate on the idea of work or other requirements for Medicaid.

Historically, Georgia’s Medicaid eligibility rules have been among the nation’s most restrictive. They allow parents to enroll if they are new mothers or have incomes of no more than $8,000 a year for a family of three, roughly 30 percent of the federal poverty level. Adults without children cannot join, no matter how poor.

Weeks after Kemp was sworn in, his allies in the legislature began working on a plan. It envisioned a more limited Medicaid expansion for able-bodied adults — with or without children — than is called for under the ACA. Georgia residents could qualify if they had incomes up to the federal poverty line, translating into just under $25,000 for a family of three — instead of about $34,000 for such a family in full-expansion states. Georgia would be the first state to expand Medicaid partway and the first to compel work or other requirements at the same time, meaning that everyone facing the rules would be new to the program.

Georgia Pathways to Coverage became ensnared in the ideological warring that surrounds such requirements. Three weeks before the 2020 election, with President Donald Trump’s appointees still in power, the federal Centers for Medicare and Medicaid Services approved Georgia’s plan. But weeks after <a href="https://www.washingtonpost.com/elections/candidates/joe-biden-2024/" target="_blank" class="contextual_link">President Biden</a> moved into the White House in 2021, the agency told the state it was reconsidering. And two days before Christmas in 2021, the federal government rescinded two important parts of the Pathways plan: the work requirements and small monthly insurance premiums.

Georgia was one of 10 states whose plans for work requirements were revoked under Biden. It was the only state that sued. “An unlawful regulatory bait and switch,” Kemp said of the Medicaid agency’s back and forth.

In August 2022, U.S. District Judge Lisa Godbey Wood sided with the state. “[R]escinding would mean less Medicaid coverage in Georgia,” the judge wrote in her opinion. Georgia, she reasoned, was unlike other states that would remove people from Medicaid if they failed to adhere to added requirements. Anyone covered through Pathways would increase Medicaid’s availability.

Most observers expected the Biden administration to appeal. It did not. CMS officials have refused to discuss their reasons.

Sara Rosenbaum, a health law and policy professor at George Washington University, said the Biden administration doubtlessly realized the case would be far trickier to win than earlier legal fights over such requirements. Even if a partial expansion added “unbelievably low numbers,” Rosenbaum said, “any whiff of an expansion is part of the core objective of Medicaid.”

Other experts said an appeal would have placed the case before a conservative appellate court and perhaps the Supreme Court, risking for the Biden administration a broader precedent supporting work requirements.

Appeal or no appeal, it wasn’t clear right away whether Pathways would ever happen. The judge’s ruling arrived amid a rematch last year between Kemp and Abrams, who was again campaigning in favor of full Medicaid expansion. Kemp again won, this time by 7.5 percentage points.

In its basic contours, Georgia’s Medicaid plan resembles ones drafted by other states. People in the partial-expansion group will need to report that they work, go to college, pursue job training or volunteer at least 80 hours a month.

In other ways, Pathways’ rules are more stringent. They apply to adults through age 64, a year before people qualify for Medicare and older than all but three other states had proposed. People caring full-time for young children or other relatives will not be exempt.

Unlike other states, which would have given beneficiaries a few months grace period to fulfill requirements or report compliance, the Georgia Department of Community Health said people will have a matter of weeks before losing coverage.

And to apply, people will need to prove they already meet the 80-hour requirement.

“The governor is hoping that Georgia Pathways will reach all low-income and able-bodied Georgians aged 19 to 64 who wish to opt in to Medicaid coverage,” said Garrison Douglas, Kemp’s press secretary.

Many health-care advocates are less optimistic. Laura Harker, a senior policy analyst for the left-leaning Center on Budget and Policy Priorities who worked in Georgia, said the work requirements “don’t acknowledge the … fluctuation in hours in low-pay work. Some months, they might meet the hours, other months not.”

In Quitman, a rural Georgia community of 4,000 just above the Florida line, Belinda Sherley recognizes that her life and the state’s Medicaid offer are not going to mesh.

While she was single, Sherley worked as a ticket seller at a theme park, Wild Adventures. She has not had a job since she married 19 years ago. Her husband, David, suffers from severe agoraphobia and anxiety, she said, so she cannot leave him alone.

They live on her husband’s $914-a-month disability payments and rent-free in a house on her in-laws’ land. His disability qualifies him for Medicare. She is exempt from work requirements for food stamps because of a doctor’s letter explaining that her husband needs her at home — an exemption Pathways will not allow.

At 42, Sherley has not had health insurance since she was a girl on the health benefits provided by her father’s job as a fire inspector.

Around the time Kemp became governor, her period became nonstop. She was so anemic it was hard even to get into a shower. “I would start gasping for breath,” Sherley said. “I put it off and off, because I couldn’t afford to go to a doctor.”

After a year, her husband drove her to a clinic in town that charged $25, its lowest fee for the poorest patients. A doctor discovered her hemoglobin was dangerously low and insisted she go to a small hospital.

She filed for indigent care at Archbold Brooks County Hospital. It covered two blood transfusions but not the emergency room bills.

She went on birth control pills, which stopped the bleeding. But she can’t afford treatment for depression. She knows the depression contributes to her weight, just under 400 pounds, but she doesn’t have money for weight-loss surgery or recent medications to control obesity.

Sherley has heard about the state’s plan to partially expand Medicaid. She is poor enough to qualify. “But I’m not going to be able to work,” she said. She couldn’t get an online job or take virtual classes at home, she said, because their rural area lacks reliable high-speed internet.

“That’s what’s so frustrating,” she said. “I need help and can’t get the help I need.”

Republican fervor for work requirements represents a recalibration of a compact between the government and its neediest citizens that began when Congress created Medicaid in the 1960s as part of President Lyndon B. Johnson’s War on Poverty. Three decades later, the notion that the needy should be required to work in exchange for help was braided into federal policy, when the nation’s welfare system was converted to temporary cash assistance for people who had — or prepared for — jobs. Such requirements were also added for food stamps.

Access to health insurance, many policy experts believed, should not be restricted in that way. That was always the view of top federal health officials — until the Trump administration pivoted. The CMS administrator at the time, Seema Verma, invited states to draft work requirements and ask for federal permission to impose them. CMS approved 13 such plans under Trump. Arkansas was the first to put the requirement into effect, in 2018.

The following spring, a <a href="https://www.washingtonpost.com/national/health-science/federal-judge-blocks-medicaid-work-requirements-in-kentucky-and-arkansas/2019/03/27/34dab2c8-50a8-11e9-a3f7-78b7525a8d5f_story.html" target=_blank>federal district judge struck down</a> HHS’s approval of the Arkansas plan and one in Kentucky that had not begun. HHS had been “arbitrary and capricious” in granting permission, U.S. District Judge James E. Boasberg ruled, because the department had not addressed how the experiment squared with Medicaid’s basic purpose of expanding coverage. By the time Boasberg’s decision stopped Arkansas’s experiment, about 18,000 residents had lost Medicaid.

The U.S. Court of Appeals for the D.C. Circuit in 2020 <a href="https://www.washingtonpost.com/health/appeals-court-unanimously-strikes-down-medicaid-work-requirements/2020/02/14/2fe1007a-4f43-11ea-b721-9f4cdc90bc1c_story.html" target=_blank>upheld Boasberg’s ruling</a>.

Three years later, the new Republican governor of Arkansas, Sarah Huckabee Sanders, who had been one of Trump’s White House press secretaries, has made the revival of Medicaid work requirements a priority, contending they would “address our state’s workforce challenges and empower thousands of Arkansans to escape the trap of government dependency.”

Rather than requiring the old 80 hours a month, the latest draft takes a different tack, assigning “success coaches” to beneficiaries in the expansion group, if they are unemployed or underemployed. And if they still do not work enough, they would not lose Medicaid outright; they would be moved to an older, less generous version.

The state submitted its plan to CMS in June, with Sanders saying she would like it to begin in January. The agency would not discuss whether it might approve this version. CMS also will monitor Georgia Pathways now that it is beginning.

In a letter last fall to Georgia’s Democratic members of Congress, Kemp explained his opposition to full Medicaid expansion, writing that about 200,000 Georgians who buy private health plans with federal subsidies through the ACA marketplace would “be forced into Medicaid coverage. It would hurt both patients and providers.”

Georgia, the governor said, already has a shortage of health-care practitioners willing to treat Medicaid patients because the program pays so little.

It is unclear how many Georgians are expected to benefit from Pathways. When Kemp first broached the idea, state officials predicted 50,000 people would join the first year. His most recent forecast: 345,000 eventually eligible — about 1 in 4 uninsured Georgians.

Nearly half a million of the state’s 1.3 million uninsured adults would be eligible if the state fully expanded Medicaid, according to Leah Chan, a senior health analyst for the Georgia Budget and Policy Institute.

Pathways “will cost more and cover fewer people,” Chan said, noting that, without a full expansion, the state will not get as much federal money.

With sign-ups expected to start within days, conservatives laud Pathways’ potential. The requirements will prompt the poor “to shoot higher in terms of work aspirations,” said Denson of the Georgia Public Policy Foundation.

Others with firsthand views of the health-care needs of Georgia’s poor remain wary. They point out the program will not provide people with mental illnesses or addictions the treatment that would enable them to work.

Cynthia Gibson, a health law specialist at Georgia Legal Services Program, said most people she sees who work 80 hours a month — in fast-food jobs or other low-wage work — earn slightly above the poverty line, so won’t qualify. She expects college students not on parents’ insurance may be the biggest group to benefit.

Many of those who do qualify, Gibson predicted, may end up being removed because reporting their hours will be complex. “Most people don’t get paychecks anymore, because it’s done electronically,” she said. “To get a pay stub, you have to log on and print out, and what if you don’t have a printer?” And though the state will allow people to provide proof online, by phone or at the state’s Department of Family and Children Services, that agency has limited hours in smaller counties, Gibson said.

Deep in Southern Georgia, Sherley wishes the state would open the door to Medicaid wider. “This is going to help some people,” she said, “but there are many people who cannot work, and it’s still leaving them without anything.”

Part of Washington Post team that won the 2002 Pulitzer Prize for national reporting for coverage of 9-11 and the government's response to the attacks

2009 Pulitzer Prize finalist for national reporting for series co-wrote on the medical treatment of immigrants detained by the federal government.

Janesville: An American Story

Brown University, AB in American civilization, magna cum laude

Fellowships at the Nieman Foundation for Journalism and the Radcliffe Institute for Advanced Study, Harvard University.

Amy Goldstein is The Washington Post’s national health-care policy writer. During her three decades at The Post, her stories have taken her from homeless shelters to Air Force One, often focused on the intersection of politics and public policy. She is the author of "Janesville: An American Story."

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The push to link Medicaid to jobs is returning

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