On Thursday, December 23, 2021, Centers for Medicare & Medicaid Services (CMS) formally rejected the state of Georgia’s Medicaid waiver to impose work requirements on people as a condition of Medicaid coverage.  CMS had given the state a waiver approval near in end of the Trump Administration in October 2020.

In part the 79 page rejection letter, that includes various addenda and instructions on the appeal process, indicated that the worsening coronavirus pandemic, and the emergence of the Omicron variant, had made Georgia’s work requirement “infeasible under the current circumstances” as Covid cases surged. The letter points out that “a similar work requirement in other states has been referred to as a “community engagement requirement,” but this policy is called the “qualifying hours and activities requirement under the Georgia Pathways to Coverage demonstration.”

According to CMS, Georgia indicated in July that it was delaying implementation of the demonstration until the end of 2021, as it assessed options to resolve issues raised by the Biden Administration.  The state did not submit a waiver amendment.

The Trump Administration issued the waivers under CMS Administrator Seema Verma. In 2018 CMS issued guidance to let states implement work rules for the very first time. Some of the first states efforts to create new work requirements were stopped or placed on hold by the courts, and as a result, the work rules weren’t in effect in any states when the Biden Administration started.

CMS indicates that they raised concerns regarding the work requirements especially in light of the COVID-19, a concern raised with other state-Medicaid waivers.  CMS explained that Georgia’s qualifying hours and activities requirements significantly compromises the demonstration’s effectiveness in promoting health care coverage but that they did not take action because the state had voluntarily delayed implementation.

CMS points out that, “…despite various mitigation efforts underway, the emergence of the newer Delta and Omicron variants of the SARS-CoV-2 virus that causes COVID- 19 are proving difficult, especially for the low -income populations across the country, including in Georgia, to make a complete recovery.

This is part of ongoing actions by CMS to reject work requirements under Medicaid. Last August 10, 2021, the CMS sent letters to the states of Ohio, South Carolina, and Utah that followed up on February 12 letters, rejecting those state Medicaid waivers that attempted to impose work requirements for people seeking health care coverage under Medicaid.

The August letter to the state of South Carolina pointed out that despite the state submitting additional information, “…information that South Carolina submitted did not address the concerns we raised in the February 12, 2021, letter. Specifically, the state did not dispute that the COVID-19 pandemic has had a significant impact on the health of Medicaid beneficiaries, including a discernible uptick in substance use disorder and mental health crises in the state, or that there is uncertainty about the lingering health effects of COVID-19. The state did not provide information to demonstrate how it would minimize coverage losses of at least 7,100 individuals (5,100 for non-completion of required hours of qualifying activities and another 2,000 for lack of timely documentation) by the end of the first full year of implementation….”

According to the CMS letter to Utah, “…the Commonwealth Fund estimated that Medicaid coverage losses could be between 10,000 and 17,000 beneficiaries within the first 12 months of full implementation of the community engagement requirement in Utah, representing a coverage loss of 15–20 percent out of the estimated total population of 67,000–87,000 beneficiaries who could be subject to the requirement in the state.”

In Ohio, citing the same source, the estimates were that Medicaid coverage losses could be between 121,000 and 163,000 beneficiaries within the first 12 months, a coverage loss of 26–35 percent of the projected 466,000 beneficiaries subject to the requirement in the state.

In Georgia, the most current data available on employment rates show that, in August 2021, employment rates for low-wage earners (i.e., annual wages under $ 27,000) in the state were still 21.6 percent lower compared to the corresponding pre-pandemic rates in January 2020.  Critics point out that the impacts of the pandemic and the economic fallout continue to remain particularly prevalent among Black and Latino populations, and other people of color, as well as in households with children.