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On January 21, 2025, the Georgia Department of Community Health (DCH) announced its intent to submit a Section 1115 Demonstration Waiver Extension Application to the Centers for Medicare & Medicaid Services (CMS) for Georgia Pathways to Coverage® (Georgia Pathways). As part of the waiver extension process, DCH accepted public comments through February 20, 2025.

GHF submitted written comments during the public comment period to ensure that Georgians’ needs and experiences are reflected in the future of the Pathways program.

Our full letter to DCH is included below:

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February 19, 2025

Stuart Portman
Executive Director, Division of Medical Assistance Plans
Georgia Department of Community Health
2 Martin Luther King Jr. Drive, SE
East Tower, 18th Floor
Atlanta, Georgia 30303

Re: Comments on Georgia Pathways to Coverage 1115 Demonstration Waiver Notice

Dear Executive Director Portman,

Thank you for the opportunity to provide comments on the proposed extension of Georgia’s Pathways to Coverage 1115 Demonstration Waiver. Georgians for a Healthy Future (GHF) is a non-profit consumer health advocacy organization dedicated to ensuring all Georgians have access to high-quality, affordable health care and coverage. Through policy research, community education and assistance, and advocacy, we work to improve health outcomes, expand coverage, and reduce barriers to care for Georgia’s uninsured and under-insured populations.

GHF has engaged with the Georgia Department of Community Health (DCH) about the Georgia Pathways to Coverage program since the introduction of the Patients First Act in 2019 and employs two full-time enrollment assisters who help Georgians enroll, renew, and troubleshoot their Medicaid applications and coverage, including for Pathways. Our comments are informed by the experiences of our enrollment assisters and their clients, as well as our history of engagement with DCH regarding the Pathways program.

We appreciate the efforts to improve the Pathways program but remain deeply
concerned that the waiver remains an inadequate and costly approach to addressing Georgia’s coverage gap, even with the proposed modifications.

The Pathways Program Remains Too Limited

The waiver extension proposal estimates that only 30,271 Georgians will enroll in the Pathways program by 2030—just 12% of the estimated 240,000 low-income adults in the coverage gap.[1] This projection underscores the fundamental shortcomings of the program: it remains an overly restrictive, administratively burdensome, and costly alternative to full Medicaid expansion. Rather than continuing to layer modifications onto an inherently flawed structure, DCH should maximize the authority it has under the Patients First Act to extend coverage to Georgians based solely on age and income with no qualifying activity requirements). Doing so would enable approximately 240,000 Georgians aged 19-64 and with incomes up to 100% of the federal poverty level (FPL) to qualify and enroll in coverage.[2] 

GHF Supports Some Proposed Changes, But More Are Needed  

GHF supports several of the proposed modifications that would make it marginally easier for eligible Georgians to gain and maintain coverage through Pathways, including: 

• Removing the monthly qualifying activity reporting requirement will reduce paperwork burdens that have kept some eligible individuals from enrolling.[3] While GHF urges DCH to eliminate all qualifying activity requirements and related reporting, this proposed change will ease the reporting burden for currently enrolled participants and could enable some new individuals to enroll as well. 
• Adding caregiving for children under six as a qualifying activity, recognizing the valuable and unpaid work parents and caregivers perform. GHF appreciates that DCH has considered and responded to input that it has received from stakeholders during program implementation with this change, and we encourage DCH to add other types of caregiving to the list of qualifying activities as well.
• Adding compliance with the Supplemental Nutrition Assistance Program (SNAP) Able-Bodied Adults Without Dependents (ABAWD) program as a qualifying activity type for program eligibility. While the SNAP ABAWD program is not particularly easy to enroll in, this change will help reduce confusion and time spent on paperwork and reporting among adults who can successfully effectuate enrollment in both SNAP ABAWD, so they benefit from both food assistance and health insurance. 
• Adopting retroactive coverage, which allows coverage to begin on the first day of the month in which an application is submitted. This is a particularly beneficial change because Georgia has among the slowest Medicaid application processing times in the U.S., leading to big delays between application and effective enrollment. Many likely-eligible Georgians will apply for coverage as they seek emergency or urgent care, so retroactive coverage ensures that they are financially protected as they receive care and limits the burden of uncompensated care for providers. 

GHF recognizes that these changes will modestly improve the Pathways program and enable several thousand more Georgians to gain health insurance; however, the scale of these changes is insufficient to meaningfully address the coverage needs of low-income Georgians, and the goals laid out by DCH in the proposed waiver extension. The Pathways program continues to exclude thousands of uninsured adults due to ineffective and expensive paperwork and activity requirements.  

Pathways Should Expand Eligibility to More Georgians in Need  

Despite the proposed improvements, the qualifying activity requirements leave many low-income Georgians uninsured. While we continue to urge DCH to eliminate qualifying activity requirements to maximize eligibility and enrollment in the Pathways program, we also share the following more-limited opportunities to expand eligibility to more Georgians:

• Including family caregivers of individuals beyond young children, such as caregivers of adults with disabilities, chronic illnesses, or seniors. Many Georgians provide unpaid care to family members, which limits their ability to work full-time and meet the current Pathways requirements.[4] DCH heard from one such caregiver during the February 10, 2025 public hearing. That caregiver shared that she cares for her parent with Alzheimer’s and that the level of care her parent needs precludes her from working. She and caregivers like her should not go uninsured while they are supporting their family members in need. 
• Expanding eligibility to people with severe health conditions that prevent consistent work participation but do not qualify them to be deemed “disabled” by the federal government. This group includes individuals undergoing cancer treatment, those recovering from a stroke, or those with mental health conditions that impact their ability to maintain stable employment.[5] GHF’s enrollment assisters have helped clients who meet these criteria. In one such case, an independent computer programmer lost feeling and mobility in his hands suddenly, which prevented him from working. He newly met the Pathways income requirements but could not meet the work requirements while his condition persisted. Health coverage was essential for this individual to be able to recover from his condition, return to work, and avoid major financial consequences, but Pathways was unavailable to him.
• Automatically enrolling low-income Georgians transitioning from other Medicaid coverage, such as postpartum Medicaid enrollees and low-income parents who lose traditional Medicaid due to modest income increases.[6] This will reduce the administrative burden for the Department of Family and Children’s Services and increase Medicaid application processing times by removing unnecessary applications from the pipeline. 
• Eliminating barriers for older adults (ages 50-64) who face significant challenges in meeting qualifying activity requirements, as evidenced by data showing lower approval rates for older applicants.[7] GHF’s enrollment assisters have helped several older adults who have been laid off from jobs and are now informally working by providing childcare to family members or cleaning the houses of neighbors and friends. They often cannot provide the kind of documentation that Pathways requires to meet the qualifying activities requirements despite wanting to work and picking up informal work as they are able.

Work and Qualifying Activity Requirements will prevent the Pathways program from meeting its stated goals  

Pathways’ continued reliance on work and qualifying activity requirements undercuts its stated goal of increasing access to health care. Extensive research from other states has shown that such requirements do not increase employment or economic stability; instead, they result in eligible individuals losing coverage due to administrative hurdles.[8] Most Georgians in the coverage gap already work or are in families where someone works. They are often working in low-wage jobs that do not offer employer-sponsored health insurance.[9] The added burden of proving work or other qualifying activities creates an unnecessary and counterproductive barrier to coverage. 

Additionally, Pathways has proven to be a costly administrative experiment. As of September 2024, the program had spent over $79 million in combined state and federal funds, with the vast majority going to system upgrades and administrative expenses rather than health care services.[10] Georgia taxpayers deserve a more efficient and effective solution that maximizes coverage while minimizing bureaucracy. 

Monthly reporting should not be discontinued

GHF does not support the proposed elimination of monthly reporting by the Department of Community Health (DCH) to the federal government. DCH’s monthly reports offer important transparency and accountability for a program that is the only one of its kind in the country; has proven to be administratively complex and expensive; and has not met its stated enrollment metrics or overarching demonstration goals. Each of these factors should justify continued monthly reporting, and when combined, monthly reporting is imperative.

Reports should continue to be submitted to the federal government on a monthly basis and made available to the public as soon as possible following submission.

Medicaid Expansion Is the Best Path Forward for Georgia  

Rather than continuing to prop up an ineffective and exclusionary program, DCH should work with Georgia leaders to take the fiscally responsible approach of fully closing the coverage gap by extending Medicaid eligibility to all adults earning below 138% FPL. Under the current federal policy, expanding Medicaid would:  

• Cover between 881,199 and 1.2 million Georgians within three years of implementation[11]; 
• Draw down a 90% federal match for newly eligible enrollees, significantly reducing state costs; 
• Provide an additional $1 billion in federal funds for Georgia’s traditional Medicaid program over two years, offsetting state costs entirely for the initial years of implementation;¹² and

• Support economic growth by creating over 51,000 jobs and adding $5.5 billion to the state’s GDP.[12]  

Instead of investing further in Pathways’ restrictive, expensive, and inefficient structure, Georgia should take advantage of the proven benefits of Medicaid expansion. Expanding Medicaid would reduce uncompensated care costs for hospitals, stabilize rural health care systems, and ensure that Georgians can access care without arbitrary barriers.  

Conclusion  

While GHF supports some of the proposed modifications to the Pathways waiver, the changes do not go far enough to meaningfully address Georgia’s health coverage crisis. Georgia leaders, with DCH’s support and expertise, should take bold action to remove unnecessary eligibility restrictions, reduce administrative burdens, and, ultimately, transition to a full Medicaid expansion. Georgians deserve a health coverage system that prioritizes access, efficiency, and economic responsibility rather than an underperforming and exclusionary alternative.  

Thank you for considering our comments. We welcome further dialogue on how Georgia can best meet its residents’ health coverage and care needs.  

Sincerely,  

Laura Colbert

Executive Director

Georgians for a Healthy Future  

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[1] Georgia Department of Community Health (2025). Public Notice on Pathways Waiver Extension

[2] Georgia Dept. of Community Health. (Sept. 5, 2024.) Georgia Uninsured and Marketplace Data, August 2024

[3] Public Consulting Group. (2024, December 16). Georgia Pathways demonstration program interim evaluation report. (Obtained through an Open Records Request; requested interim evaluation report prepared by Public Consulting Group; received January 2025).

[4] Reinhard, S.C., Caldera, S., Houser, A., & Choula R.B. (2023). Valuing the invaluable: Strengthening supports for family caregivers. AARP.  

[5] American Cancer Society. (April 25, 2023). Medicaid Work or Community Engagement Requirements Could Harm People with Cancer and Cancer Survivors. 

[6] Chan, L. (2023). Georgia’s Pathways to Coverage Program: The First Year in Review. Georgia Budget and Policy Institute. https://gbpi.org/georgias–pathways–to–coverage–program–the–first–year–in–review/

[7] Public Consulting Group. (2024, December 16). Georgia Pathways demonstration program interim evaluation report. (Obtained through an Open Records Request; requested interim evaluation report prepared by Public Consulting Group; received January 2025).

[8] Kaiser Family Foundation. (2025, February 4). Understanding the Intersection of Medicaid and Work: An Update.

[9] Kaiser Family Foundation (2024, February 26.) How Many Uninsured Are in the Coverage Gap and How Many Could be Eligible if All States Adopted the Medicaid Expansion?

[10] Georgia Budget and Policy Insitute. (2025, January). Data Tracker. Georgia Pathways.

[11] Griffin, G. (2024, February 22). Fiscal note on House Bill 62 (LC 33 9274). Georgia Department of Audits & Accounts. https://opb.georgia.gov/document/fiscal-notes-2024/lc-33-9274/download ¹² Ibid.

[12] Evangelakis, P., & Paulhus, L. (2024). Economic impacts of Medicaid expansion in Georgia. Regional Economic Models, Inc.

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