A high-stakes mystery is unfolding in the Georgia governor’s race, potentially affecting health insurance for hundreds of thousands of Georgians.
Republican gubernatorial nominee Rick Jackson released a major policy announcement last week supporting “intelligent Medicaid expansion.” But Medicaid expansion to all a state’s poor is no longer possible under President Donald Trump’s new One Big, Beautiful Bill law, and Jackson’s team says details are still undetermined. So what exactly will this do?
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“We haven’t seen a detailed proposal yet; it’s not 100% clear how this is going to work,” said Leo Cuello, an expert in Medicaid expansion law at Georgetown University. He said that after viewing Jackson’s list of bullet points on the issue and some remarks by Jackson at the event sent to him by a reporter.
From what Jackson said, there is a range of possibilities, though, and they could help or hurt hundreds of thousands of Georgians trying to get or renew coverage.
It is clear that his plan will seek more federal money. In the process, will it seek to close the coverage gap of perhaps 200,000 poor Georgia adults who lack health insurance? Jackson said he would close the coverage gap, but federal law now makes the full scope of that impossible.
So, just a portion of those people? How big a portion?
Importantly, will his plan fix Georgia’s defective paperwork systems that help keep many poor adults who work from getting Medicaid?
Or – potentially a huge concern for coverage advocates – will it turn Georgia’s current work verification bureaucracy on hundreds of thousands of other Georgians, potentially knocking many off their private health insurance if their paperwork falls through the cracks?
Reporters for the Georgia Recorder drilled down on those questions in several exchanges with Jackson’s campaign spokesman, Garrison Douglas. Douglas replied in a text message, “The details of this will be worked out through the waiver negotiation process (with the Trump administration) and with the General Assembly.”
The Jackson Action Plan
Jackson named his policies the “Jackson Action Plan,” and sketched them out at a campaign event last week at a Perimeter hotel conference room. The Jackson Action Plan included principles on taxes, housing, jobs, education, government, public safety, and three pages of goals on health care.
A headline moment came midway through his speech: “On day one, I will close the coverage gap with intelligent Medicaid expansion.”
Trump’s first Secretary of Health and Human Services, Tom Price, was in the audience, and afterwards called Jackson’s plan “exciting.”
“He believes he can close the coverage gap right away, and with a (state-specific plan), and I believe that that’s possible as well,” Price said.
Traditionally, that would mean Jackson would offer health insurance to all uninsured poor people who fall in a gap between other programs. It comes with a big extra federal check to pay for it. It’s been the quest of Democrats from Stacey Abrams, who ran against Gov. Brian Kemp on expanding Medicaid, to Keisha Lance Bottoms, Jackson’s opponent.
If she’s elected governor, Bottoms says she will fully expand Medicaid to cover Georgians earning up to about $22,000 a year for a household of one, or 138% of the federal poverty level.
Jackson did say he is requesting the extra check.
But there’s a snag. The One Big, Beautiful Bill law passed last year by Congress and President Donald Trump says that Medicaid expansion and the extra federal money that comes with it now must include work and activity requirements, similar to the ones Georgia already has in place under Gov. Brian Kemp. And in Georgia, history shows that requirement – as well as the mere paperwork it takes – is a barrier even for eligible people.
Under Kemp’s Pathways to Coverage Medicaid expansion with work and activity requirements, compared to perhaps 100,000 Georgians that Kemp aides thought would be eligible, 18,000 are actually enrolled.
People who navigate the Georgia system suspect a major culprit is the bureaucracy of the eligibility checking itself, with its glitchy computer system and swamped customer assistance.
“It’s important for people to understand how suppressive the Georgia Pathways model has been,” Cuello said. “It’s an abysmal failure at covering people in poverty, by any measure. To say that we are going to bring that to somewhere else? That does not seem like a good idea.”
Could ACA policyholders be subject to work verification requirements?
The “somewhere else” Cuello referred to concerns another big group of Georgians, these ones on private insurance plans.
There are currently about 500,000 or so low-income Georgians on Affordable Care Act plans, private insurance subsidized by the government under the Georgia Access ACA marketplace. If Kemp had expanded Medicaid, they would have gotten Medicaid instead.
Those subsidized plans proved wildly popular as they got cheaper under pandemic-era subsidies. Even after the subsidies expired and low-income enrollment in the plans slid from 700,000 Georgians, it’s still substantial at 500,000.
Kemp and his aides have long pushed back at criticisms like Cuello’s by changing the focus to that group. Kemp points to those people getting federal help for private plans as part of the benefit he delivered with his restraint.
Those 500,000 ACA policyholders are not below the poverty line like the Pathways recipients, but just barely above it. That means making, for example, more than about $16,000 per year but less than about $22,000 per year, for a household of one.
In the 40 states that expanded Medicaid, people in that income group are about to have to meet Trump’s work requirements to keep their Medicaid.
Not in Georgia. But would that change if Jackson got the Trump administration to call that group covered as part of Georgia’s Medicaid expansion strategy? Jackson is asking for the federal government to put Medicaid dollars toward some private insurance plans. “Medicaid resources should help Georgians keep or obtain private coverage,” his proposal says.
Garrison, the spokesman for Jackson, did not say whether the ACA policyholders could be subject to filing work eligibility paperwork with the system.
“It is not something Rick has announced. Rick laid out a vision of closing the coverage gap, eliminat(ing) burdens that inhibit successful enrollment and ensuring that we do so in a way that does not remove access to private coverage for half a million Georgians in the 100-138% FPL window,” Douglas said.
He noted that Bottoms’ plan to fully expand Medicaid would do exactly that, though, shifting them to Medicaid.
Plenty of room for improvement to current system
Leah Chan, who closely follows Medicaid expansion rules and Pathways as director of health justice at the Georgia Budget and Policy Institute, echoed Cuello’s concerns with the functioning of the eligibility system.
But Chan, an advocate for Medicaid expansion, also cheered another possibility in Jackson’s plan. What if the notorious Georgia Medicaid computer portal and eligibility bureaucracy actually worked like a charm?
Chan homed in on a line deep in the Jackson Action Plan reading “Reduce paperwork barriers that keep eligible Georgians from care. Enrollment and renewal should be clear, modern, and accountable, not a maze that causes eligible people to lose coverage because a form was missed.” The problems with the system are well known.
“When we talk about day one priorities, that should be top of the list,” she said.
Chan said the current outdated system works to undermine Pathways and other Georgia public assistance programs.
For eligible people who are trying to enroll or renew, “it’s basically like having a part-time job to navigate,” Chan noted, from faulty technology to overburdened caseworkers who never call back, to rural offices that aren’t even staffed with on-site caseworkers but with people who take messages.
“We still don’t have, I think, a clear explanation for why everybody was kicked off the (Georgia disabled children category) at Medicaid earlier this year. Just some sort of technology glitch,” she said.
When it comes to renewing paperwork to show a person met the work requirement for the Pathways Medicaid program, Chan said, “a high proportion of them are being denied because of, like, a missing form.”
“A win for anyone coming into office would be modernizing that system,” she said. “It would help everyone,” the entire Georgia Medicaid population and the workers who deal with them, she said.
Leaders have chipped away at fixes to the system, and allocated some money to starting. But a replacement technology system to manage the 1.8 million-strong Medicaid population could be hugely expensive.
Chan stressed that she can’t be sure which level of fix Jackson is proposing – until more information comes out.
Georgia Recorder is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity.
