By now, Georgia officials expected their new Medicaid plan, the only one in the nation with a work requirement, to provide health insurance to 25,000 low-income residents and possibly tens of thousands more.
But a year since its launch, Pathways to Coverage has roughly 4,300 members, much lower than what state officials projected and a tiny fraction of the roughly half-million state residents who could be covered if Georgia, like 40 other states, agreed to a full Medicaid expansion.
Georgia Gov. Brian Kemp's office has presented Pathways as a compromise that would add people to Medicaid while also helping them transition off it. Blaming the Biden administration for delaying the program's start, Kemp's office said it's redoubling efforts to sign people up.
Health and public policy experts believe the enrollment numbers, dismal even compared to what Kemp's office had said Pathways could achieve, reflect a fundamental flaw: The work requirement is just too burdensome.
"It's clear that the Georgia Pathways experiment is a huge failure," said Leo Cuello, JD, a research professor at the Georgetown University McCourt School of Public Policy.
Pathways requires all recipients to show at least 80 hours of work monthly, volunteer activity, schooling, or vocational rehabilitation. It also limits coverage to able-bodied adults earning no more than the federal poverty line, which is $15,060 for a single person and $31,200 for a family of four.
Cuello noted the program makes no exceptions for people who are caring for children or other family, lack transportation, suffer from drug addiction, or face myriad other barriers to employment. Then there are people with informal jobs that make documenting their hours impossible.
In rural Clay County in southwest Georgia, Karen Kinsell, MD, said many of her patients are too sick to work. Over the last year, Kinsell has suggested Pathways to about 30 patients who might meet its requirements, but none have signed up.
"I think the general idea is it would be too much work and too complicated for little benefit," she said.
Just going online each month to submit proof of work can be a significant obstacle, said Harry Heiman, MD, MPH, a health policy professor at Georgia State University.
"For low-income people who are worried about staying housed and putting food on the table, one more thing to do is often one thing too many," he said.
The program's poor showing so far may have implications beyond Georgia. Republicans in other states in recent months also have proposed requiring work to get Medicaid. In Mississippi, Lt. Gov. Delbert Hosemann i cited Georgia's Pathways program as a model.
A second term for former President Donald Trump would significantly boost the prospects for such programs. The Trump administration approved Medicaid work requirement plans in 13 states, only to have the Biden administration in 2021. Pathways survived after a court fight.
Georgia launched the program on July 1, 2023 with , and public health experts said they have seen scant effort to promote it or sign people up.
The launch coincided with a federally mandated review of the eligibility of all 2.7 million Medicaid recipients in the state following the end of the COVID-19 public health emergency, another challenging task for Georgia officials.
Still, they did not scale back their enrollment expectations. Days before the launch, then-Georgia Department of Community Health Commissioner the Associated Press that Pathways could cover up to 100,000 people in year one. The 25,000 estimate had been in the state's 2019 application for Pathways.
Garrison Douglas, a spokesman for Kemp, said in a statement that Pathways had received "extraordinary interest from thousands of low-income, able-bodied Georgians," and the state was "still fighting to reclaim the time stolen" from it by the Biden administration.
The program was supposed to launch in 2021, but the Centers for Medicare and Medicaid Services objected to the work requirement that February and later revoked it. Georgia sued and a federal judge reinstated the work mandate in 2022.
As of June 7, Pathways had 4,318 members, according to the Georgia Department of Community Health. The agency said in an email that promotion efforts have included social media content and streaming ads on TV and radio, while a "robust" outreach campaign was being planned.
"Pathways deserves more time to see if it reaches its potential," said Chris Denson, director of policy and research at the conservative Georgia Public Policy Foundation.
Denson said there is general agreement even among Pathways' supporters that the state could have done a better marketing job. But he said a fundamental tenet of Pathways -- transitioning people through employment, job training, or other qualifying activities to private insurance -- is sound, particularly given that many primary care physicians in the state are not accepting new Medicaid patients.
To critics, the actual first-year figure is all the more galling given how many people full Medicaid expansion could cover at no extra cost to the state, at least initially.
An analysis by the left-leaning Georgia Budget and Policy Institute found Georgia's Medicaid program would receive so much more federal funding under full expansion that in its first year the program could cover 482,000 residents for the same cost as 100,000 Pathways' recipients.
North Carolina, which fully expanded Medicaid in December 2023, has enrolled nearly 500,000 people in about half the time Pathways has been in effect.
That broader Medicaid expansion was a key part of President Barack Obama's healthcare overhaul in 2010. In exchange for offering Medicaid to nearly all adults with incomes up to 138% of the federal poverty level, states would get more federal funding for the new enrollees.
The higher eligibility limit is $20,783 annually for a single person and $43,056 for a family of four. None of the 40 states that have accepted the deal require recipients to work in order to qualify.
But Kemp, like many other Republican governors, rejected full expansion, arguing that the state's long-term costs would end up being too high.
Republicans in the Georgia Legislature floated the possibility of full expansion in 2024 before .
For now, Georgia officials show no sign of giving up on Pathways. The program is set to expire at the end of September 2025. But in February, the state the Biden administration to try to extend it to 2028. A federal judge heard arguments last month.