When the Mississippi Legislature during the 2024 session could not agree on the terms by which the state might expand Medicaid, it was because the Senate had a much more crimped version of what expansion should look like.
Senators said they wanted to model it on Georgia, the only state whose work requirement has survived the objections of the Biden administration.
So far, though, the Georgia model is not much of a model — that is unless your goal is to have Medicaid expansion in name only and not really help many of those who are uninsured.
Georgia calls its plan Pathways to Coverage. It requires beneficiaries to work at least 80 hours a month, or to spend that much time on volunteer activity, schooling or vocational rehabilitation. It also limits coverage to those earning no more than 100% of the federal poverty level, rather than the 138% threshold that the federal government encourages and for which it is willing to generously pay.
This week, an Associated Press article took a look at how many poor Georgians the program was helping at the one-year mark since Pathways took effect. The numbers are even less than the modest figures Georgia projected.
According to the AP article, 4,300 people have received Medicaid coverage as a result of the limited expansion, a tiny fraction of the roughly half-million residents who could be covered if Georgia fully expanded the government insurance program in the manner that most of the 40 expansion states have. Even with the restrictions, Georgia officials had projected first-year sign-up could cover up to 100,000 people.
Why hasn’t it come anywhere close?
Mostly because of the work requirement, according to critics of the setup. Pathways makes no exception for people who are caring for young children or other family members or who have transportation difficulties in getting to work. It does not take into account the “cash economy,” in which people get paid under the table for their work. And even for those who have regular jobs for which they draw a paycheck, the requirement that they prove it every month causes some to conclude that the benefit is not worth the hassle.
The reality is that most of those who fall in the insurance gap — making too much to qualify for traditional Medicaid and too little to afford private insurance — are working. Otherwise they would already be covered. To impose a system to document what’s largely a given mostly benefits those who get the government contract to handle the verification. According to the reporting of KFF Health News earlier this year, more than 90% of Georgia’s outlays for Pathways went to administration and consulting costs.
In theory, what the Mississippi Senate insisted on made sense. If Medicaid expansion is supposed to help the working poor, why not be sure that the beneficiaries are really working?
Georgia’s experience shows, however, that the theory doesn’t translate well into practice. The cost of verifying employment is not worth the benefit of potentially weeding out a few slackers. And the verification process discourages people from utilizing a benefit for which they qualify.
The reasons to expand Medicaid are to help the uninsured, help the hospitals that are burdened with too much uncompensated care, and help the state’s economy by getting an extra billion dollars a year or so from the federal government. If, however, Mississippi creates a program that only helps a few of the uninsured, the other two objectives don’t happen.
The state should expand Medicaid, but it needs to do so in a manner that produces the best results.
