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Georgia’s Medicaid waivers

October 19, 2020

Topics: Quote of the Day

CMS.gov, October 15, 2020

Today, the Centers for Medicare & Medicaid Services (CMS), under the leadership of President Trump, announced action it has taken to advance an innovative package of state-led reforms that were crafted in response to the guidance and unprecedented flexibility offered by the Trump Administration.

Specifically, CMS announced the approval of Georgia’s new Medicaid section 1115 demonstration called “Pathways to Coverage.” The demonstration is designed to create a pathway for working-age Georgia adults who are ineligible for Medicaid to opt into Medicaid coverage by participating in qualifying activities like work and education, as well as meeting premium and income requirements.

Georgia’s Medicaid section 1115 demonstration “Pathways to Coverage” applies to individuals who are between the age of 19 through 64, with income up to and including 100 percent of the federal poverty level (FPL) and is effective today through September 30, 2025, with implementation beginning July 1, 2021. Those who already qualify for Medicaid today will not be directly affected, and it is estimated that over 30,000 individuals will receive Medicaid coverage during the first year of the demonstration and nearly 65,000 Georgians will enroll in Medicaid or receive Medicaid premium assistance for coverage through Employer Sponsored Insurance (ESI) over the five-year demonstration.

In order to qualify for this program, individuals must comply with specific requirements, including participating in 80 hours a month of work or other qualifying activities. Most individuals with income between 50 and 100 percent of the FPL will be required to make initial and ongoing monthly premium payments. Applicants and beneficiaries with disabilities requiring reasonable accommodation will have options available to complete and report their qualifying activities and hours. The state is providing support to those not already working to encourage and enable those beneficiaries to obtain employment and take part in other education and job-supporting activities.

Georgia is also pursuing complementary reforms of its individual health insurance market through a section 1332 State Relief and Empowerment Waiver, also referred to as a section 1332 waiver. This waiver is designed to put Georgia on a path to change the systemic issues with the state’s individual health insurance market—with the goal of reducing premiums, providing greater access and promoting a more competitive private insurance marketplace.

Under the Georgia Access Model, consumers will shop for and compare available plans through private sector partners, including web brokers, health insurance companies, and traditional agents and brokers.


CMS details of “Georgia Pathways to Coverage” (51 pages):


By Don McCanne, M.D.

CMS administrator Seema Verma worked with Vice President Mike Pence when he was governor of Indiana to attempt to convert their Medicaid program into a consumer-directed program with phony health savings accounts. She brought with her to CMS her ideology aimed at privatizing the government health programs.

Under a section 1115 waiver, she has granted Georgia changes that will allow qualified individuals with incomes between 50 and 100 percent of the federal poverty level to enroll in Medicaid providing they meet an 80 hour per month work/education requirement and “pay” a premium for their Medicaid coverage (a complicated process described in the 51 page CMS document – link above). Failure to meet the requirements can result in expulsion from the program.

They are also in the process of privatizing the ACA exchange function by allowing private insurance brokers to provide that function.

Seema Verma says, “I’m thrilled to support this comprehensive state-led reform that will help thousands of working adults in Georgia gain access to coverage for the first time in a way that addresses both their health and socio-economic needs.” “Socio-economic needs” means finding and holding jobs in a depressed economy that has caused many to lose their employment.

These people have incomes below the federal poverty level. How can Verma expect them to function on a socio-economic level comparable to individuals with average incomes?

We have tremendous problems – many of them being due to ever widening income and wealth inequality. These problems cry out for public solutions. In health care, the solution is easy – simply enact and implement a well designed, single payer model of an improved Medicare for All. Each person can meet their individual responsibility that Verma demands by paying their equitable share of progressive taxes that would fund the system (though solidarity-based responsibility is not what Verma has in mind).

In a couple of months there should be new management at HHS/CMS. Let’s just hope that they do not put in charge more neoliberals who would maintain a dominant role for the private insurers that keep shifting responsibility (risk) to patients. We can get this right if we all join together and work on it.

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About the Commentator, Don McCanne

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Don McCanne is a retired family practitioner who dedicated the 2nd phase of his career to speaking and writing extensively on single payer and related issues. He served as Physicians for a National Health Program president in 2002 and 2003, then as Senior Health Policy Fellow. For two decades, Don wrote "Quote of the Day", a daily health policy update which inspired HJM.

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