Georgia is about to grow to be the one state to have work requirements for Medicaid coverage.

Republican Gov. Brian Kemp’s reelection — and a surprising Biden administration decision to not appeal a federal court ruling — have freed the state to introduce its plan that may allow for a limited increase within the pool of low-income residents eligible for Medicaid.

Questions remain in regards to the rollout of Kemp’s plan. Nevertheless it would arrange Georgia as a test case for a piece provision that has been proposed by several states and struck down in federal courts and by the Biden administration.

Meanwhile, advocacy groups are concerned about barriers to obtaining and maintaining the coverage. Additionally they indicate that the Kemp plan could be costlier per enrollee and canopy a fraction of the individuals who would get Medicaid under a full expansion. The brand new Georgia eligibility program would require a minimum of 80 hours of labor or volunteering a month.

“The perfect-case scenario is that some uninsured Georgians would get coverage for some period of time,” said Laura Colbert, executive director of the buyer advocacy group Georgians for a Healthy Future. “It should be a giant headache for the state and for individuals who enroll or attempt to enroll.”

The Trump administration approved Medicaid work requirements for Georgia and 12 other states. Georgia got approval under a “waiver,” or a federal permission that lets states run programs that differ from standard rules on Medicaid, the federal government insurance that covers the poor and the disabled.

However the Biden White House rejected the Georgia plan.

In August, though, a federal judge in Georgia ruled the Biden administration overstepped its authority, clearing the best way for the Kemp plan to proceed. The federal government allowed the 60-day appeal window to lapse without making a move.

The rationale behind the White House decision to not appeal the court decision stays murky. A Centers for Medicare & Medicaid Services spokesperson, Bruce Alexander, said “as a matter of policy, CMS doesn’t comment on matters of litigation.”

CMS’ reluctance to appeal could also be connected to where the case would head next, said Leonardo Cuello, a research professor on the Georgetown University McCourt School of Public Policy’s Center for Children and Families. If appealed, the case would go to a conservative federal court that could be favorable to the lower-court decision — and establish it as a stronger precedent.

“The choice to not appeal can have been based on fear that the result would get confirmed on appeal, since a lot of the appellate judges within the eleventh Circuit are Republican-appointed,” he said.

Biden administration officials is also waiting for the plan to play out before they step in, said Catherine McKee, a senior attorney with the National Health Law Program, a nonprofit advocacy program. Federal health officials “could let the state go forward and monitor it, and take motion in the long run,” she said.

Kemp’s office didn’t reply to KHN’s requests for comment on the status of the plan, however the governor celebrated the federal court’s August ruling in a series of tweets.

“Despite the Left’s efforts to claw back good policy for partisan politics, this week the judiciary … Ruled the Biden Admin erred in striking down our progressive healthcare waiver which might higher serve Georgians than a one-size-fits all Medicaid expansion,” the tweets said.

The Georgia Department of Community Health, which oversees the Medicaid program within the state, declined an interview to reply questions on the work requirement plan.

However the agency recently posted on its website two pages related to the “Georgia Pathways” program: one with information on how you can join, the opposite with details on the plan’s requirements. Each pages were taken down after KHN asked the agency about them.

“Pathways will not be yet going live so the links were disabled to avoid confusion,” said Fiona Roberts, an agency spokesperson.

Work requirements for Medicaid have a brief history of implementation nationally.

The one state to run a full-fledged work requirement program was Arkansas, which launched the rule in 2018. It led to about 18,000 people losing Medicaid coverage. A federal court suspended the requirement the subsequent 12 months.

Kemp’s victory over Democrat Stacey Abrams on this month’s midterm election also stymied — not less than for now — Georgia Democrats’ long-standing push for full Medicaid expansion, projected to cover an estimated 450,000, versus about 50,000 under the Kemp plan. On Nov. 8, South Dakota voters approved a ballot measure for full expansion, which might cover greater than 40,000 additional people in that state.

Georgia’s per-enrollee cost for the work requirement program is anticipated to be not less than thrice higher than it could be under a daily Medicaid expansion, said Colbert.

The federal government would have paid for not less than 90% of the prices of insuring a whole bunch of 1000’s of Georgians under a full expansion. That compares with the expected 67% matching rate from the feds under the slimmer Kemp plan. And that difference doesn’t account for a Biden administration incentive for expansion that may net Georgia $710 million, in line with a KFF estimate.

The executive barriers to the Kemp work plan could be significant, consumer advocates say. Full-time caregivers, individuals with mental health conditions or substance use disorders, and folks unable to work but who haven’t yet qualified for disability coverage would find it hard to qualify, Colbert said.

Other challenges could include an absence of transportation that makes it hard for enrollees to get to work and, for potential enrollees, limited access to computers to enroll.

Besides volunteering, other qualifying activities for coverage within the Kemp plan include education and job training.

Many individuals fighting homelessness in Georgia would likely not meet the work or volunteer thresholds, said Kathryn Lawler, CEO of Saint Joseph’s Health System, an Atlanta-based nonprofit. Sixty percent of patients at its Mercy Care community health centers are homeless, she said. Coverage through Medicaid expansion would let patients afford health care, address chronic conditions, and relieve the stress of medical bills, she said.

Individuals who need medical care often are too sick to go to work, Lawler said, adding that a single mother with three babies could possibly be deemed ineligible. Full Medicaid expansion, through increased payments to providers, would ultimately allow Mercy Care to serve more people in need, she said.

The choice by CMS to not appeal “was a bit surprising,” Colbert said, but she added that one other unfavorable court ruling could pose a risk to other states’ Medicaid programs, by clearing the best way for other work requirements.

The CMS inaction could encourage similar bids for work requirements in other GOP-led states, McKee said.

The Georgia plan, meanwhile, would probably not start until the tip of the covid-19 public health emergency, which has provided continuous coverage for a lot of Medicaid enrollees throughout the pandemic, and appears set to proceed into early next 12 months.