JOHN YANG: Since Medicaid was created nearly 60 years ago, it's been expanded many times, and it's now the government's biggest public health insurance program.

Tonight, a look at the efforts to expand it even further, with a visit to the only state with a work requirement for Medicaid.

It's part of our ongoing series, America's Safety Net.

SHANAN ALLISON: Can we walk?

Come on.

JOHN YANG: For Shanan Allison, taking her emotional support dog, Wolf, for a walk in her Atlanta neighborhood can feel like an ordeal.

SHANAN ALLISON: You were inpatient for mama?

JOHN YANG: The 48-year-old has limited mobility because of hip dysplasia and degenerative disc disease.

SHANAN ALLISON: Come, come.

JOHN YANG: Her biggest health challenge came in 2018, when she was diagnosed with breast cancer.

She didn't have health insurance at the time, but the diagnosis qualified her for Medicaid's Women's Health Program for breast and cervical cancer.

SHANAN ALLISON: As an adult never having had private insurance, I mean, it was like it was a miracle.

It was like, wow, finally, somebody can see about this symptom, and somebody can treat that, and I can, you know, and maybe I can get back to work.

JOHN YANG: The coverage also paid for a hip replacement in 2020 and for medication to treat a heart condition and bipolar disorder.

So, now your cancer's in remission?

SHANAN ALLISON: Yes, thank God.

Yeah.

JOHN YANG: Well, thank God the cancer's in remission.

SHANAN ALLISON: Yes.

JOHN YANG: But what does that mean for your Medicaid?

SHANAN ALLISON: Well, it means, since I'm no longer seeing an oncologist, that it's been five years, and if you're not continuing to see an oncologist, you're not qualified for Women's Health Medicaid anymore.

JOHN YANG: The only other time Allison had health insurance was when her pregnancies qualified her for Medicaid.

Physical limitations have kept her from holding a job since 2012, and before that, she'd never had one that gave her coverage.

And despite having no income, she does not qualify for Georgia's traditional Medicaid program, which requires a participant to not only have a low income, but also be pregnant, have a child or have a disability.

SHANAN ALLISON: See here, it's got where I was approved, but there's a termination, and then denial for the regular Medicaid.

JOHN YANG: No eligible people in your household.

Not having Medicaid, how does that make you feel?

SHANAN ALLISON: Well, I'm scared, really.

I need a continuation of care for my hip, you know, and my psych meds, for instance, you know, a lot of things.

It's just like you fall -- I fall in a gap.

I don't know.

It's scary.

JOHN YANG: Georgia is one of 10 states that has not used the Affordable Care Act to expand Medicaid to cover all adults earning less than 138% of the federal poverty line, or about $20,800 a year for an individual.

Under the act, the federal government pays a generous subsidy for the additional cost.

LEAH CHAN, Director of Health Justice, Georgia Budget and Policy Institute: There's been a lot of momentum in our surrounding neighbor states.

And I think that legislators are seeing how it is a good deal for Georgia.

JOHN YANG: Leah Chan is Director of Health Justice at Georgia Budget and Policy Institute, a nonpartisan research group and a proponent of full Medicaid expansion.

She says it would benefit the estimated 400,000 uninsured Georgians in what's called the coverage gap.

Earning too little to qualify for federal subsidies in the ACA insurance marketplace, but not qualifying for Medicaid in the state because they're adults without a qualifying disability.

LEAH CHAN: This is just an economic imperative.

We can no longer ignore the financial benefits that we would get from closing the coverage gap.

And I think we can no longer ignore the mounting pressure that many communities are feeling as hospitals close and as more people fall into the coverage gap.

JOHN YANG: Since 2013, 12 hospitals across Georgia have shut their doors, including Atlanta Medical Center here in the heart of the city, which closed in 2022.

One reason for the financial squeeze, unreimbursed care for people with low incomes and no insurance.

Earlier this year, Georgia lawmakers signaled a willingness to consider Medicaid expansion.

But in February, legislative leaders said the issue needed more study.

Instead, Georgia has a new program called Pathways to Coverage.

NO NAME GIVEN: Georgia Pathways provides a hand up and a way for our citizens to thrive.

JOHN YANG: Pathways provides Medicaid to adults who are in less than 100% of the federal poverty line or about $15,000 a year for an individual and spend at least 80 hours a month either working, going to school, participating in job training or doing volunteer service.

Georgia is the only state with a Medicaid work requirement currently in place.

State officials estimated that 50,000 people would enroll in Pathways in its first two years.

But since it launched last July, only about 3,500 have signed up.

Georgia's Department of Community Health, which administers Pathways, declined an interview request.

But in a statement said the program puts Georgia at the forefront of innovation in health care and serves as a new way to increase access to affordable health care coverage.

CHRIS DENSON, Director of Policy and Research, Georgia Public Policy Foundation: And I would hope that the critics, those who are calling for full Medicaid expansion, would actually choose to embrace this program and help raise awareness, because it does provide a pathway to health care coverage for the recipients.

JOHN YANG: Chris Denson is the Director of Policy and Research at the Georgia Public Policy Foundation, a conservative free market think tank.

The fact that you're asking people in order to get the coverage, you have to put in something.

Is that -- do you think that's an important factor?

CHRIS DENSON: We believe it's an important factor because these are able-bodied working age individuals.

And so, in order to not only receive the program, we think it's important for them to have some skin in the game.

This is also a pathway to receiving private insurance.

And we want more patients on more private health insurance plans, where it's easier to see a physician because a physician or the hospital is paid more for seeing those patients.

JOHN YANG: Nationwide, about 30% of physicians don't accept new Medicaid patients.

In Georgia, according to one survey, it's 40%.

But Leah Chan says research on Medicaid, including from states that use the ACA to expand, shows that those on the program have better health outcomes.

What's more, she says, Georgia taxpayers pay more for each pathways participant than they would under full Medicaid expansion, because the federal subsidy is smaller.

You say that Pathways isn't as good as Medicaid expansion, but is it better than nothing?

LEAH CHAN: So we have the opportunity before us to bring billions of dollars to our state, create tens of thousands of new jobs, shore up the financial stability of our rural hospitals, and get access to health care for hundreds of thousands of Georgians.

And, instead, we have chosen this other path that is more expensive and covers fewer people.

JOHN YANG: In addition, Chan says the existing Pathways program has a big barrier.

Every month, participants must submit documentation to certify that they're meeting the requirements.

That's impossible for people like Donald Crawford in rural Toccoa, Georgia, northeast of Atlanta, near the South Carolina border.

Uninsured, he relies on the free Open Arms Clinic for all his health care needs, including prescriptions.

DONALD CRAWFORD: I have high blood pressure, diabetes, breathing problems.

JOHN YANG: Crawford hasn't had full-time employment since the threadmill where he worked shut down nearly a decade ago.

Now he does odd jobs, just a couple of hours a month.

The 58-year-old says, even if he had the hours to qualify for Pathways, there's no way he could do the reporting.

DONALD CRAWFORD: But this phone right here, I was old school.

I had to flip phone.

My daughter got this phone right here, been working with me and working with me and everything, you know, all this technology.

There ain't no way.

There ain't no way.

JOHN YANG: Clinic Executive Director, Sherry Beavers, is one of only two paid employees.

Everyone else, including the doctors, are volunteers.

SHERRY BEAVERS: You know that little room in your doctor's office that they take you to, and they give you a little sample?

This is our sample room.

JOHN YANG: Beavers says that in the absence of full Medicaid expansion, clinics like hers fill a vital need for low-income adults in Georgia, helping them manage chronic conditions like diabetes.

SHERRY BEAVERS: That's over a million dollars' worth of insulin right there, the difference between life and death for a person with diabetes.

JOHN YANG: Pathways is aimed at some of the people who use the Open Arms Clinic.

But Beavers says not a single one of the clinic's patients has enrolled in the program.

SHERRY BEAVERS: The qualifications are just too steep.

You know, I have patients that I have to put A on the pill bottles if they take them in the morning, and P on the pill bottles if they take them at night.

And you expect these people to be able to upload documents and renew their health insurance monthly?

It's not going to work.

JOHN YANG: For Shanan Allison in Atlanta, the documentation isn't the problem.

The problem, she says, is actually doing the required activities.

SHANAN ALLISON: If I could do a part-time job, I would do it for money.

JOHN YANG: Right.

SHANAN ALLISON: -- or Medicaid, either one.

JOHN YANG: Right.

SHANAN ALLISON: I would love to have the Medicaid over the money.

But the point is, I can't do it.

JOHN YANG: Recently, she was turned down for Social Security disability benefits.

But a recent mammogram spotted something that requires additional testing.

It could be another serious health challenge.

But, ironically, it could also give her coverage again, qualifying her for Women's Health Medicaid.

How does this make you feel about this whole system?

SHANAN ALLISON: Well, I feel cheated.

It's almost like, in a way, I feel discriminated against.

I'm just confused as to why Georgia did this, and some places didn't.

You know, it's almost making me want to move, you know, because I need the care that badly.