Background Information
In 2010, the Affordable Care Act (ACA), expanded Medicaid coverage for people from low-income backgrounds who were previously uninsured due to Medicaid’s previous eligibility requirements. The Medicaid expansion addressed a phenomenon known as the coverage gap, which occurs when an individual’s income is too high to qualify for their state’s Medicaid program but too low to qualify for marketplace plan subsidies. All states except the following ten accepted the Medicaid expansion plan: Texas, Wyoming, Kansas, Wisconsin, Tennessee, Mississippi, Alabama, Georgia, South Carolina, and Florida. Still, in 2022, one in five uninsured adults did not have access to medical care due to the costs. Additionally, uninsured people compared to people with insurance are less likely to receive access to preventative care and services for chronic diseases.
Since the ten non-expansion states have a high population of rural residents who are more likely to die prematurely from chronic illnesses, state governments have developed chronic disease management programs that are distinct from those in Medicaid-expanded states. Chronic disease management programs are structured health treatment plans for people who have chronic diseases such as asthma, breast cancer, or coronary artery disease. These programs provide coverage for regular check-ups and treatments and offer guidance on how to navigate certain diseases. Programs for chronic illness in New York and Georgia provide important insights into how states with differing Medicaid policies tackle chronic disease management.
New York Medicaid Health Homes: Comprehensive Care Management
Under the ACA Section 2703, states have the authority to develop and receive federal reimbursement if they have a set of health home services for their state’s Medicaid populations with chronic illness. In 2012, New York State (NYS) launched its Medicaid Health Homes program. The program was created to reduce inpatient utilization costs, remove social and economic barriers to care, and provide general behavioral and medical care.
When the program initially launched, almost 1 million people met the eligibility criteria. To be eligible for the Home Health Program, an individual must: 1) be enrolled in Medicaid, 2) have two or more chronic conditions, or 3) have one single qualifying chronic condition such as HIV/AIDS, Serious Mental Illness, Sickle Cell Disease, or Serious Emotional Disturbance. However, at the start of the program, NYS prioritized enrolling 500,000 adults who had mental health and substance use conditions over those with other conditions. In early 2020, over 180,000 people were enrolled in the Health Homes program. When a member enrolls in the program, the health homes receive per-member-per-month payments from NYS. These payments are dependent on the member’s health and social needs which include comprehensive care management, care coordination, individual and family support, referral to community and social support services, and the use of health information technology to link services.
The program fell short of the initial three-year target of 240,000 enrollments due to problems with the top-down enrollment process. For instance, the care management agency outreach team relied on Department of Health information to reach people with the most pressing needs, but the information was often outdated and inaccurate. Additionally, it was often difficult for outreach workers to explain the Health Homes’ benefits because the term ‘home’ suggested that patients would have to go to a particular place. Moreover, many of the eligible participants were unstably housed and were difficult to locate and inform. Overall, the New York Medicaid Health Homes program provides a robust system to assist people with chronic illnesses. Nonetheless, it is important to acknowledge that the program is not a one-step solution in addressing chronic illnesses among NYS populations, as chronic condition disparities continue to persist.
Georgia Pathways: A State Care Program
Georgia is among the ten non-Medicaid-expansion states and ties with Oklahoma for the second-highest proportion of residents without health insurance in the nation. The state’s health care system ranks 45th based on measures of health care access, cost, avoidable hospital use, reproductive care, and women’s health. Georgia has an approximate rural population of 1.5 million people. Due to the state’s denial of Medicare expansion, people with chronic illnesses in Georgia cannot access Medicaid expansion-supported chronic illness programs. Instead, Georgia launched a state program called Georgia Pathways in July 2023 that aims to provide health coverage to certain low-income people. The program covers the cost of many of the same medical services as traditional Medicaid such as doctor visits, hospital stays, and prescriptions. Georgia Pathways requires enrollees to sign a program contract and submit documentation to prove they have completed 80 hours of work or other qualifying activities in a recent month. Since the program’s approval, an average of $13,000 was spent per enrollee in combined state and federal funds.
When the program initially launched, it expected 100,000 enrollments. As of January 2, 2025, the program is underperforming with only 6,503 active enrollments. Between July and October of 2024, 29% of the applicants were denied because they could not meet the eligibility requirements for the documentation, specifically the need to prove they were working, in school, or volunteering for at least 80 hours per month. One reason for this gap could be that people with chronic illnesses and disabilities cannot find enough hours to work because employers often fail to provide adequate work accommodations for people with disabilities. Additionally, many people face long bureaucratic processes that prevent them from reporting their work hours monthly. Moreover, people with low-income jobs often have employers who can reduce their work hours without notice. Therefore, the hurdles associated with Georgia Pathways’ 80-hour work requirement have been a barrier for some Georgians in need of care.
In January 2025, state Senators introduced a bill to fully adopt Medicaid Expansion, as the state program has not been efficient enough to address people’s healthcare needs. The bill has garnered bipartisan support, with a handful of Republicans from rural districts joining Democrats as co-sponsors on the bill. However, Georgia Governor Brian Kemp stated that he would push back against attempts to adopt Medicaid expansion in the state. Instead, he signaled support for a bill to establish a Comprehensive Health Care Commission to explore health coverage options. Since the Pathways program could expire in 2025, Georgia House Speaker Jon Burns emphasized the need to gather information, hear from policy experts and stakeholders, and create an effective policy solution to support the low-income and uninsured people of Georgia.
Conclusion
Even in the aftermath of the Affordable Care Act and Medicaid Expansion, significant coverage gaps exist across the country. These gaps include identifying people with the most pressing clinical and social needs, expanding access to care for people with chronic disabilities, and financing state-based healthcare expenditures for chronic disease management programs. New York’s robust system of chronic disease management, Healthy Homes, offers a centralized system of clinical care, social care, and essential services such as food. Despite the program’s benefits, it faces challenges including reliance on old data to identify high-need individuals, difficulty locating unhoused people with chronic illnesses, and trouble communicating the program’s requirements. On the other hand, Georgia’s Pathways program provides health coverage to low-income individuals if they sign a program contract and submit documentation to prove they have completed 80 hours of work or other qualifying activities in a recent month. The program fell significantly short of its projected enrollment numbers, spurring debate on other potential policy interventions for chronically ill Georgians.
In February 2025, the 119th Congress proposed H.R.919 to codify Internal Revenue Service (IRS) guidance relating to the treatment of certain services and items for chronic conditions. The recent bill could impact two different kinds of health insurance coverage: High Deductible Health Plans (HDHP) and Health Savings Accounts (HSA). The proposed bill would expand coverage for health insurance plans; these health insurances would treat chronic care as preventable and cover chronic illness care that might not have been originally covered. If passed, federal bills like H.R. 919 are likely to impact state-level care programs.
