Work Requirements and Red Tape Ahead for Millions on Medicaid

Now that the Republicans’ big tax-and-spending bill has become law, new bureaucratic hurdles have emerged for millions of Americans who rely on Medicaid for health coverage. A provision in the new law dictates that, in most states, for the first time, low-income adults must start meeting work requirements to keep their coverage.

Some states have already tried doing this, but Georgia is the only state that has an active system using work requirements to establish Medicaid eligibility — and recipients must report to the system once a month.

When she first started using the system, Tanisha Corporal, a social worker in Atlanta, wasn’t opposed to work requirements — in principle.

But when she left her job at a faith-based nonprofit to start her own project, the Be Well Black Girl Initiative, she needed health coverage. She soon came face-to-face with how daunting it can be to prove you are meeting the state’s work requirements.

“I would have never thought that I was going to run into the challenges that I did, with trying to get approved, because I’m like, I know the process,” Corporal said. “I’ve been in human services.”

Corporal has been a social worker for more than two decades in Georgia and was familiar with the state’s social service programs. For years, it had been her job to help others access benefit programs.

But her challenges with paperwork and the process had only begun.

Health advocates point to Georgia’s system as a sign that the new law will lead to excessive red tape, improper denials, and lost health coverage.

Beginning in 2027, the law will require adults on Medicaid who are under 65 to report how they engaged in at least 80 hours per month of work, education, or volunteer activities. Alternatively, these adults could submit documentation showing they qualify for an exemption, such as being a full-time caregiver.

Most states will have to set up verification systems similar to Georgia’s, which can be expensive to implement and run. In the two years since launching its program, Georgia has spent more than $91 million in state and federal funds, according to state data. More than $50 million of that was spent on building and operating the eligibility reporting system. Right now, just under 7,500 people are enrolled in Georgia.

For Corporal, 48, forgoing coverage wasn’t an option. She had been diagnosed with pre-diabetes and had other medical concerns.

“I have breast cancer in my family history,” she said. “So it was like, I gotta get my mammograms.”

On paper, it looked as if she qualified for Georgia’s program, called Georgia Pathways to Coverage.

It offers Medicaid to adults — who otherwise wouldn’t qualify for traditional Medicaid in Georgia — with incomes up to the federal poverty level ($15,650 per year for an individual, or $26,650 per year for a family of three), as long as they can show that for at least 80 hours a month they’re working, attending school, training for a job, or volunteering.

Corporal was eager to apply. She was already volunteering at least that much, including with the nonprofit Focused Community Strategies, and helping with other South Atlanta community improvement efforts.

She gathered up the various documents and forms needed to verify her duties and volunteer hours, then submitted them through Georgia’s online portal.

“And we were denied. I was like, this makes no sense,” said Corporal, who has a master’s degree in social work. “I did everything right.”

In the end, it took eight months fighting to prove that she and her son, a full-time college student in Georgia, qualified for Medicaid. She repeatedly uploaded their documents, only for them to bounce back or seemingly disappear into the portal. She went through numerous rounds of denials and appeals.

Corporal recently pulled up one of the denial notices on her cellphone to read aloud: “Your case was denied because you didn’t submit the correct documents. And you didn’t meet the qualifying activity requirement,” she read from the email.

When she tried to call the state Medicaid agency for answers, it was difficult reaching anyone who could explain what was wrong with her application paperwork, she said.

“Or, they’ll say they called you, and we look at our call log. Nobody called me,” she said. “And the letter will say, you missed your appointment, and it’ll come on the same day” as it was scheduled.

Corporal’s Pathways to Coverage application was finally approved in March after she spoke about her experience at a public hearing covered by Atlanta news outlets.

When asked about the delays and difficulties Corporal experienced, Ellen Brown, a spokesperson for Georgia’s Department of Human Services, emailed this statement: “Due to state and federal privacy laws, we cannot confirm or deny our involvement with any person related to a benefits case.”

Brown added that Georgia is implementing tech fixes to streamline the uploading and processing of participants’ documents. They include “rolling out a refresh to the Gateway Customer Portal in late July that will include easier navigation and training videos for users as well as built-in prompts to ask customers to upload required documents.”

Now that Corporal has coverage, she is having to recertify her volunteer hours every month using the same glitchy reporting system. It’s stressful, she said.

“It’s still a nightmare, even once I got through the red tape and got approved,” Corporal said. “Now maintaining it is bringing another level of anxiety.”

But she wonders how anyone without her professional background manages to get into the program at all.

“I think the system has to be simplified,” she said.

Because Georgia set up its work requirement before the recently passed law, it needed permission from the federal government through a special waiver.

It is now seeking an extension of that waiver to continue the Pathways program beyond its current expiration of September 2025. In the application, officials said they would reduce the frequency by which participants needed to reverify their hours from once a month to once per year.

But for now, Corporal’s experience remains typical. And many health advocates fear it will be replicated under Trump’s budget law with its new national Medicaid work mandate.

“In Georgia, we have seen that people just can’t get enrolled in the first place. And some folks who do get enrolled lose their coverage because the system thinks they didn’t file their paperwork or there’s been some other glitch,” said Laura Colbert, who leads the advocacy group Georgians for a Healthy Future.

Another state, Arkansas, tried work requirements in 2018.

But it didn’t go any better there, said Joan Alker, who leads the Center for Children and Families at Georgetown University.

“A lot of the problems were similar to Georgia,” she said, “in terms of the website closed at night, people couldn’t get a hold of people.”

Some Republicans who backed the spending and tax legislation said the idea behind the national Medicaid work mandate was to ensure that as many people as possible who can work, do work. And to eliminate what the Trump administration deems waste, fraud, and abuse.

“What we’re doing is restoring common sense to the programs in order to preserve them because Medicaid is intended to be a temporary safety net for people who desperately need it,” U.S. House Speaker Mike Johnson said during a June appearance on “The Megyn Kelly Show.” “You’re talking about the elderly, disabled, you know, young single pregnant moms who are down on their luck, right? But it’s not being used for those purposes because it’s been expanded under the last two Democrat presidents and to cover everybody. So, you’ve got a bunch of able-bodied young men, for example, who are on Medicaid and not working. So what we’re doing is restoring work requirements to Medicaid. OK, this is common sense.”

National work requirements are unlikely to actually boost employment, Alker said, because more than two-thirds of Medicaid recipients ages 19-64 already have jobs. The remainder includes students, or those who are too sick or disabled to work.

“Work requirements don’t work, except to cut people off of health insurance,” she said.

The logistical steps required to report one’s activities assume that a recipient has reliable internet or transportation to travel to an agency — things that low-income Georgians may not have.

The paperwork requirements to gain coverage are time-consuming, said one Medicaid recipient, Paul Mikell.

Mikell is a licensed truck driver but does not have coverage through that job. He’s also an electrician who currently does property maintenance in exchange for free housing.

Mikell has had Medicaid through Pathways for nearly two years and has had problems navigating the Pathways web portal.

“And I know it wasn’t my device because I would go to the library and use the computer, I would try different devices, and I’ve had the same issues,” he said. “Regardless of the device, it’s something with the website.”

Another time, he said, his attempt to recertify his work hours was delayed because of paperwork issues.

“They said I was ineligible for everything because of a typo in the system or something, I don’t know what it was. I eventually was able to speak to someone and she fixed it,” he said.

This article is from a partnership with WABE and NPR.