ATLANTA – Georgia Republicans have sought to go their own way in expanding Medicaid coverage for more than a decade since a U.S. Supreme Court ruling on the Affordable Care Act (ACA) passed by a Democratic Congress gave states that right.

Now, the “Georgia-centric” version of Medicaid expansion is about to take flight. The new Georgia Pathways program, a more limited expansion of Medicaid than its federal counterpart, is taking effect this weekend.

But Democrats in the General Assembly and health-care advocates say the state is missing an opportunity both to save taxpayer dollars and serve more low-income Georgians by not adopting a full-blown expansion of Medicaid coverage under the ACA, as 40 other states have done. Opponents are particularly critical of Georgia Pathways’ first-in-the-nation work requirement for Medicaid recipients.

Under Georgia Pathways, Georgia residents between the ages of 19 and 64 with household incomes up to 100% of the Federal Poverty Level will be eligible for Medicaid coverage. The program will not apply to low-income elderly Georgians or the disabled.

The federal program covers Americans with household incomes up to 138% of the poverty level, which is $30,000 a year for a family of four.

Recipients of Georgia Pathways coverage also must participate in at least 80 hours per month of “qualifying” activities, including work but also education, job training, or community service.

“This is not a work requirement,” said Caylee Noggle, commissioner of the state Department of Community Health (DCH), which oversees Georgia’s Medicaid program. “Work is one way to meet the requirement.”

Republican Gov. Brian Kemp first proposed a limited Medical expansion back in 2019, his first year in office. The administration of then-President Donald Trump approved Georgia Pathways in 2020 as a waiver from the requirement that states fully expand Medicaid coverage only to have the Biden administration reject the plan in 2021.

Georgia took the decision to federal court last year and won the right to move forward with the waiver.

The state estimates about 345,000 Georgians will potentially be eligible to enroll in Georgia Pathways, including about 200,000 current Medicaid recipients.

As the program ramps up, it will serve an estimated 100,000 during the first year. The DCH has budgeted $117 million in state dollars to cover the program initially, along with $227 million in federal matching funds.

Critics of Georgia Pathways say even if the program ultimately reaches that peak enrollment, it won’t cover all Georgians who are uninsured.

“Any program that doesn’t cover all 400,000 to 450,000 [uninsured] Georgians falls short of what Georgia needs,” said Laura Colbert, executive director of Georgians for a Healthy Future.

Supporters of full Medicaid expansion say Georgia would gain access to a much larger federal match than Georgia Pathways – with the feds providing 90 cents of every dollar spent on expansion through the ACA compared to 66 cents on the dollar Georgia’s Medicaid program currently gets.

In fact, full Medicaid expansion comes at no cost to states for the first two years, thanks in part to a one-time bonus of up to $1.2 billion the American Rescue Plan offers states that choose to expand coverage through the ACA. Congress passed the legislation in 2021 as a pandemic relief measure.

“It’s past time for us to bring home those federal funds,” said Leah Chan, senior health policy analyst with the Georgia Budget and Policy Institute, an Atlanta-based nonprofit.

But Garrison Douglas, a spokesman for Kemp, said Georgia Pathways offers a “sustainable solution” to Medicaid coverage that the ACA can’t guarantee would continue indefinitely.

“When you rely on the federal government, you don’t know who’s going to be in office,” Douglas said.

Chan said North Carolina resolved those concerns when it adopted full Medicaid expansion by including a provision in the legislation stating the Tar Heel State would pull out of the federal program if the federal match is significantly reduced.

Advocates for full Medicaid expansion say it also would provide an economic boost to Georgia, creating thousands of jobs and stabilizing rural hospitals.

“Our rural hospitals are in trouble,” said Dr. Len Lichtenfeld, an Atlanta oncologist and internist. “We’re losing their services and the employment and income they bring.”

Georgia Pathways’ supporters counter that many of the Georgians who would sign up for Medicaid under a full expansion already have health insurance coverage through their employers.

“The added cost of covering those already-covered Georgians pushes the price tag of Medicaid expansion far higher than proponents usually allow,” Kyle Wingfield, president of the Georgia Public Policy Foundation, a think tank that advocates free-market approaches to public policy, wrote in a column last winter.

Opponents of the new program also raise the issue of timing. The federal government stopped doing the usual eligibility screening of Medicaid enrollees during the pandemic but resumed that “redetermination” process in April.

“It’s a very turbulent time for tens of thousands of Georgians,” said Joe Binns, Georgia state director of Protect Our Care, a nonprofit health-care advocacy group. “This is a terrible time to be conducting an experiment on the health-care system in Georgia.”

Noggle turned that argument on its head.

“This is a perfect time for this,” she said. “This is more coverage. This is another option.”

Noggle said Georgia Pathways will begin with a “soft launch” this weekend. The DCH expects to have application forms on the agency’s website by Sunday morning, she said. A mobile application will be launched later in July.