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On December 7th, the Georgia Department of Community Health (DCH) held a public forum about the Georgia Pathways to Coverage program. The forum included an opportunity for Georgians to provide feedback about the program’s implementation. DCH also allowed stakeholders to submit written comments through December 14th. 

GHF verbally commented during the forum, but because of time constraints, followed up with these written comments. 

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December 14, 2023

Commissioner Carlson
Georgia Department of Community Health

Re: Comments on Pathways to Coverage program implementation

Dear Commissioner Carlson,

Thank you for the opportunity to provide the Department of Community Health with feedback about the Pathways to Coverage program. Georgians for a Healthy Future (GHF) is a consumer health policy and advocacy organization. We have actively engaged with DCH and other stakeholders on Medicaid issues for Georgia children, families, people with disabilities, and others since our founding in 2008.

GHF employs two enrollment assisters who have helped Georgians apply for and enroll in the program. We also meet with a working group of assisters across the state to collaborate and help each other during the Medicaid unwinding and the Pathways rollout. Their experiences have informed our comments below.

We celebrate any progress made towards reducing Georgia’s very high uninsured rate. While the Pathways program is more limited than we have advocated for, we celebrate the 1800 Georgians who have successfully enrolled in the program and will benefit from having quality, affordable health coverage.

We have learned from the application and enrollment experiences of some of these Georgians. We offer the following feedback for your consideration:

Very few Georgians are aware of the Pathways program. For a decade, low-income Georgia adults have been turned away from any coverage option by our state agencies and leaders; it will require meaningful investment to help them unlearn the message they’ve heard so consistently for so long. DCH should consider investing in an outreach, education, and assistance campaign to reach low-income adults with information about the program and provide help for enrolling.

Based on the notices that we have seen, likely-eligible Georgians who are being procedurally disenrolled from other Medicaid eligibility classes are not receiving information about Pathways in their termination notices. Young adults who are aging out of children’s Medicaid and parents who are losing pregnancy Medicaid are two of the largest likely-eligible groups of Pathways applicants. Our enrollment assisters have observed that these groups are not receiving Pathways information or referrals in their termination notices. Their termination notices point them to the ACA marketplace at healthcare.gov. The marketplace does not recognize the Pathways program and thus advises these consumers that they live in a state that has not expanded Medicaid and likely have no coverage options. This feels like a missed opportunity for thousands of potential Pathways members. We recommend that DCH consider how to include information about Pathways with these termination notices, or follow-up separately with procedurally terminated adults to let them know about the program.

The Gateway website and system continues to be a barrier for Georgians. We collected this anecdotal feedback from the assister working group mentioned earlier:

• Gateway is not particularly mobile friendly. Younger adults were trying to use this method but they were getting stuck. Most low-income families are primarily operating off of their phones.
  Applicants have tried to upload documents or complete their applications but the Gateway member portal prevented them from doing so. Even though they were technologically capable of completing it themselves, these Georgians had to find a Gateway partner or provider with “back-end access” to complete their applications or upload materials.
• While this issue doesn’t seem to be a problem for every applicant, its wide-spread enough that we’ve received it anecdotally from several assisters. One assister shared the following:
  • “I recently tried enrolling a college student in the program, but their application was denied due to challenges within the Gateway system. Higher education is one of the demographics that are expected to be eligible for the program. As a navigator expected to help enroll people in coverage, provide them with resources, and understand the needs of my community, it feels disappointing to not be able to provide people access to health coverage that they should be eligible for, due to issues in the Gateway consumer portal.”
• The application fields for requesting a “Good Cause Exception” are confusing, if not contradictory. When an applicant selects the option indicating that they need a good cause exemption, they are still required to enter an employer’s information, number of qualifying hours, and other information that is irrelevant to a person in need of an exception. This causes enough confusion that it may prompt applicants to abandon their applications.
• The initial Pathways screen (and other Gateway screens) uses language that requires an 11th grade reading level to understand. Most US adults read at a 7th or 8th grade reading level. We hope that DCH may consider revising this language so that it is simpler and more understandable to applicants.

We are pleased to see a note in the Pathways data reports that indicated DCH has postponed suspensions and terminations until early 2024 for not reporting qualifying activities. If true, we encourage the Department to maintain this policy through the remainder of the demonstration period. Consistent coverage is key to successfully supporting and improving the health of Pathways members.

We are disappointed that less than two percent (2%) of the 100,000 adults that DCH estimated may be eligible for Pathways coverage have been able to do so thus far. In the same period of time (July 1st to Nov. 1st), 12,600 South Dakotans have been able to enroll in their state’s traditional Medicaid expansion. Based on our observations, two of the biggest barriers to enrollment and program success may be:

1. The inability to automatically transition Medicaid members from another eligibility category into the Pathways program. Medicaid members auto transfer between other categories regularly (like pregnancy Medicaid to low-income parent Medicaid). This strategy has not been applied to Pathways. The requirement for members to actively opt into Pathways leaves many likely-eligible Georgians unenrolled and thus uninsured. If the option exists to eliminate the program’s active opt-in for existing Medicaid members, we recommend that course of action.
2. The program’s requirement to complete and document work or other qualifying activities. Six in ten (60%) low-income Georgia households are working, going to school, or doing other valuable work like caregiving. Georgians are very likely fulfilling the program requirements but may not understand the notice about monthly attestation, be able to log into Gateway or get help to provide their paperwork, or experience another barrier to enrollment. Not only does this requirement prevent likely-eligible Georgians from enrolling in coverage, it has a disproportionate impact on Georgians who experience systemic barriers to work. For example, Georgians living in rural areas and communities of color are more likely to live in areas where decent jobs with consistent hours are harder to come by because of long-term disinvestment (not to mention job supports like good child care and public transportation).

DCH has the authority to pause or postpone certain program components and we recommend that DCH exercise that authority for the proof of work or school requirement. We appreciate that DCH has delayed the requirement for Pathways enrollees to pay monthly premiums and encourage the Department to do the same with this program component.

We hope our input helps the Department improve the Pathways program so that as many hard-working Georgians as possible can get covered and stay covered.

We additionally urge that the Department will share this input and your own lessons learned with Governor Kemp and the General Assembly. It is important for our state’s decision makers to understand the administrative complexities that Pathways poses for your agency and the number of Georgia families and workers who remain uninsured. The Department’s time and resources would be better spent on a simpler, more cost-effective option that would benefit many more Georgians: expanding Medicaid to low-income adults making less than 138 percent of the poverty line without onerous monthly paperwork requirements.

Thank you for the opportunity to weigh in on this important program. We are happy to respond to any questions or feedback you have about our comments.