Now that Republicans' big tax-and-spending bill has become law, there will be new bureaucratic hurdles for millions of Americans who rely on Medicaid.
The new law contains a provision that in most states, for the first time, low-income adults will have to start meeting work requirements to keep their health coverage.
Some states have already tried this, but Georgia is the only state that currently has an active system using work requirements to establish Medicaid eligibility — and recipients must report to the system once a month.
When she first started using the system, Tanisha Corporal, a social worker in Atlanta, wasn't opposed to work requirements — in principle.
But then she left her job at a faith-based nonprofit to start her own project, called the Be Well Black Girl Initiative. While she got that up and running, she needed health coverage. She soon came face-to-face with the daunting bureaucratic hurdles involved in meeting Georgia's work requirements.
"I would have never thought that I was going to run into the challenges that I did, with trying to get approved, because I'm like, I know the process," Corporal said. "I'm a social worker. I've been in human service."
Georgia's system: a win for other states, or a warning?
Corporal was familiar with the state's social service programs. She had spent many years helping other Georgians sign up for benefit programs.
But the challenges Corporal ran into, with paperwork and the process, were unexpectedly severe. Other Georgians have also struggled to comply with the work requirements.
That's why health advocates are concerned about other states having to set up their own systems, given Georgia's experience. They say the eligibility verification involves excessive red tape, leading to improper denials and loss of health coverage.
As early as 2027, the law will require adults on Medicaid who are under 65 to report how they are using their time: to be eligible for coverage, they will have to spend at least 80 hours every month at work, in school, or in volunteer activities.
Alternatively, these adults could submit documentation showing they qualify for an exemption, such as being a full-time caregiver.
Verification systems like Georgia's can be expensive to implement and run. In the two years since launching its program, Georgia has spent more than $91 million in state and federal funds, according to state data.
More than $50 million of that was spent on building and operating the eligibility reporting system.
Currently, 8,078 people are enrolled in Georgia as of June 30.
Denials, appeals and confusion
For Corporal, 48, forgoing health insurance wasn't an option. She had pre-diabetes as well as other medical concerns.
"I have breast cancer in my family history," she said. "I gotta get my mammograms."
On paper, it looked like she qualified for Georgia's program, called Pathways to Coverage, for adults who wouldn't otherwise qualify for traditional Medicaid in Georgia.
To be eligible, adults must have an income below the federal poverty level, which is $15,650 per year for an individual, or $26,650 per year for a family of three. They also must show they're working at least part time, attending school, training for a job, or volunteering at least 80 hours a month.
Corporal was already volunteering at least that much, including with the nonprofit Focused Community Strategies, and helping with other South Atlanta community improvement efforts.
She gathered up the various documents and forms needed to verify her volunteer duties and hours, then submitted it all through Georgia's online portal.
"And we were denied. I was like, this makes no sense," said Corporal, who has a master's degree in social work. "I did everything right."
In the end, it took eight months fighting to prove that she, and her son, a full-time college student in Georgia, both qualified for Medicaid.
She repeatedly uploaded their documents, only for them to bounce back or seemingly disappear into the portal. She went through numerous rounds of denials and appeals.
Corporal pulled up one of the denial letters on her cell phone, and read it out loud.
"Your case was denied because you didn't submit the correct documents. And you didn't meet the qualifying activity requirement," she read from the email.
When she tried to call the state Medicaid agency, it was difficult to reach anyone who could explain what was wrong with her application paperwork, she said.
"Or, they'll say they called you and we look at our call log. Nobody called me," she said. "And the letter will say, you missed your appointment and it'll come on the same day."
Georgia promises tech fixes
Corporal's application was finally approved in March after she spoke about her experience at a state public hearing about Pathways to Coverage, covered by Atlanta news outlets.
When asked about the delays and difficulties Corporal experienced, Ellen Brown, a spokesperson for Georgia's Department of Human Services, emailed this statement: "Due to state and federal privacy laws, we cannot confirm or deny our involvement with any person related to a benefits case."
Brown added that Georgia is implementing a number of tech fixes to streamline the uploading and processing of participants' documents. They include, "rolling out a refresh to the Gateway Customer Portal in late July that will include easier navigation and training videos for users as well as built-in prompts to ask customers to upload required documents."
Now that Corporal has Medicaid coverage, she has to recertify her volunteer hours every month using the same glitchy reporting system.
"It's still a nightmare. Even once I got through the red tape and got approved," Corporal said. "Now maintaining it is bringing another level of anxiety."
But she wonders how anyone without her professional background manages to get into the program at all.
"I think the system has to be simplified," she said.
Because Georgia set up its work requirement before the recently-passed law, it had to get permission from the federal government through a special waiver.
It is now seeking an extension of that waiver to continue the Pathways to Coverage program beyond its current expiration of September 2025. In the application, officials said they would reduce the frequency by which participants needed to re-verify their hours from once a month, to once per year.
What happened in Arkansas
But for now, Corporal's experience remains typical. And many health advocates fear it will be replicated elsewhere.
"In Georgia, we have seen that people just can't get enrolled in the first place. And some folks who do get enrolled lose their coverage because the system thinks they didn't file their paperwork or there's been some other glitch," said Laura Colbert, who leads the advocacy group Georgians for a Healthy Future.
Another state, Arkansas, also tried work requirements in 2018.
But it didn't go any better for Arkansas, said Joan Alker, who leads the Center for Children and Families at Georgetown University.
"A lot of the problems were similar to Georgia," she said, "in terms of the website closed at night, people couldn't get a hold of people."
Some Republicans who backed the legislation known as the "One Big, Beautiful Bill" said the idea behind the national Medicaid work mandate is to ensure that as many people as possible who can work, do work.
Another benefit is it will help eliminate what the Trump administration deems waste, fraud and abuse.
"What we're doing is restoring common sense to the programs in order to preserve them because Medicaid is intended to be a temporary safety net for people who desperately need it," said Speaker Mike Johnson during a June appearance on the Megyn Kelly Show.
Medicaid was meant for certain populations, Johnson argued, such as people with disabilities and "young, single, pregnant moms who are down on their luck."
"But it's not being used for those purposes because it's been expanded under the last two Democrat presidents, and to cover everybody. So, you've got a bunch of able-bodied young men, for example, who are on Medicaid and not working. So what we're doing is restoring work requirements to Medicaid, okay? This is common sense," Johnson said.
National work requirements are unlikely to actually boost employment, Alker said, because more than two-thirds of Medicaid recipients already have jobs. The remainder includes students, or those who are too sick or disabled to work.
"Work requirements don't work, except to cut people off of health insurance," she said.
The logistical steps required to report one's activities assume that a recipient has reliable internet or transportation to travel to an agency — both things that low-income Georgians may not be able to access, Alker said.
The paperwork requirements to gain coverage via is time consuming, said Georgia resident Paul Mikell, who has Medicaid.
Mikell is a licensed truck driver, but does not have coverage through that job. He's also an electrician who currently does property maintenance in exchange for free housing.
Mikell has had Medicaid through Pathways for nearly two years. He had problems navigating the Pathways web portal.
"And I know it wasn't my device because I would go to the library and use the computer, I would try different devices, and I've had the same issues," he said. "Regardless of the device, it's something with the website."
Another time, he said, his attempt to recertify his work hours got delayed for paperwork issues.
"They said I was ineligible for everything because of a typo in the system or something, I don't know what it was. I eventually was able to speak to someone and she fixed it," he said.
This story comes from NPR's health reporting partnership with WABE and KFF Health News.
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