Category: Rehab News

A seemingly innocuous proposal to offer scholarships for mental health workers in California’s new court-ordered treatment program has sparked debate over whether the state should prioritize that program or tackle a wider labor shortage in behavioral health services.

Nine counties have begun rolling out the Community Assistance, Recovery, and Empowerment Act, which Gov. Gavin Newsom (D) signed into law in 2022 to get people with untreated schizophrenia or other psychotic disorders, many of them incarcerated or homeless, into treatment. But often those skilled clinicians have been pulled by counties from other understaffed behavioral health programs.

“There’s just so much change coming with a limited workforce, limited treatment resources, and high expectations for counties to solve things like homelessness,” said Scott Kennelly, director of the Butte County Behavioral Health Department. “It’s like I’m turning on a fire hose and saying, ‘Start drinking.’”

The bill by state Sen. Tom Umberg would create an annual scholarship fund for students who pursue a mental health profession provided they work for three years with CARE Court. Umberg had requested $10 million for the program, but it’s unclear how many students would receive the scholarship, said Jackie Koenig, a spokesperson for the senator. The bill sailed through the legislature without a single lawmaker voting against it.

Umberg, a Democrat from Santa Ana, said CARE Court deserves targeted funding because it’s a new program, and he noted other state scholarships are available for students pursuing a behavioral health degree. For instance, the state announced in March 2023 that it would issue $118 million in grants to support behavioral health providers at 134 nonprofit community-based organizations.

“CARE Court is new, and it is in a unique space that requires unique behavioral health skills, dealing with schizophrenics,” Umberg said. “So, we want to encourage folks to go into that space, because it is a challenge.”

But local behavioral health administrators say shifting experts into CARE Court may create shortages in other programs or thrust mental health specialists into multiple demanding programs.

The CARE Act allows patients or others, such as their relatives, behavioral health care providers, or roommates, to petition their county court for help. Individuals who agree to participate can receive up to 24 months of treatment, which can include outpatient substance use disorder treatment, stabilization medication, connection to social services, and housing. It is one of Newsom’s experimental initiatives intended to get some of the state’s 181,000 homeless people off the streets and into housing without resorting to mandatory conservatorships.

Only 7,000 to 12,000 Californians are estimated to be eligible for treatment, according to the Judicial Council, which helps oversee the program.

The state has allocated $251 million to staff and launch the CARE program through the current budget year, including $122 million in grants to counties, according to the state Legislative Analyst’s Office. At the same time, counties have been directed to implement a host of other behavioral health programs, such as mobile crisis teams, and boost mental health services for Medi-Cal patients. Last year, Newsom also signed legislation that broadened the number of Californians who could be involuntarily committed.

“As a high-profile mandate, counties are largely moving existing, skilled, experienced staff over to launch and staff the CARE Court teams,” said Michelle Cabrera, executive director of the County Behavioral Health Directors Association of California, which supports the bill.

It’s why critics, including ACLU California Action, Mental Health America of California, and some counties, say a CARE Court scholarship should also support other county programs that treat individuals with serious mental illness and housing instability.

“Restricting workforce development initiatives solely to one of the many new behavioral health initiatives will not solve the issues of staffing across the continuum of behavioral health services,” said Alexandra Pierce, an assistant director at the Merced County Behavioral Health and Recovery Services Department.

County behavioral health departments are in the midst of a massive behavioral health workforce shortage — running 25% to 30% below full staff capacity, on average, according to an internal 2023 survey conducted by the county behavioral health director association and the University of California-San Francisco’s Healthforce Center, Cabrera said.

More than a dozen rural and urban county behavioral health directors told California Healthline that hiring challenges are widespread and not unique to CARE Court, pointing to burnout since the start of the covid-19 pandemic and steep competition from schools, correctional facilities, and the private sector, which can offer skilled clinicians higher pay, work-from-home telehealth jobs, and generous vacation.

Michelle Funez, division director of Marin County Behavioral Health and Recovery Services, said a CARE Court scholarship could incentivize students to pursue county jobs that support vulnerable individuals in the community.

Finding the right clinician for CARE Court can be tricky because the job requires skilled individuals to work in homeless encampments and other nontraditional environments, Funez said.

“It can feel like we’re looking for the needle in the haystack,” Funez said, drawing from “an already smaller body of staff who have the requisite skills for this type of work, who are also up for the challenge.”

The nine counties that have launched the specialized courts have received more than 600 petitions in the first 10 months of the program, said Leah Myers, a spokesperson for the state Department of Health Care Services, which helps oversee the program. The remaining 49 counties are slated to launch their programs by Dec. 1.

There have been early successes with the program. A year in, San Diego County is already beginning to “graduate” patients, meaning they have received treatment and have made enough progress to transition out of the court system.

As more counties roll out CARE Courts, they will need more clinicians. A scholarship program, some counties said, could help. But the bill’s price tag could be its downfall. In June, Newsom signed a state budget closing an estimated $46.8 billion deficit, and last year he vetoed hundreds of bills, many of them over cost. Newsom spokesperson Elana Ross declined to comment on the measure.

Newsom has until the end of the month to sign or veto the bill.

SACRAMENTO — California Gov. Gavin Newsom will soon decide whether the most populous U.S. state will join 25 others in regulating the middlemen known as pharmacy benefit managers, or PBMs, whom many policymakers blame for the soaring cost of prescription drugs.

PBMs have been under fire for years for alleged profiteering and anticompetitive conduct, but efforts to regulate the industry at the federal level have stalled in Congress.

The three largest PBMs are owned by insurers and retail pharmacy chains, and about 80% of prescription drug sales in the United States are controlled by them: OptumRx, owned by UnitedHealth Group; CVS Caremark, owned by CVS Health, which also owns the insurer Aetna; and Express Scripts, owned by The Cigna Group.

The proposed law, spearheaded by state Sen. Scott Wiener of San Francisco, a Democrat, would require PBMs to apply for a license by 2027 and would mandate that licensed PBMs pass along 100% of pharmaceutical manufacturers’ rebates to health plans or insurers. Drug companies often offer substantial discounts on medications to boost demand, and one of the major criticisms of PBMs is that they pocket rebates rather than pass savings along to customers.

The law would also mostly bar PBMs from steering patients to pharmacies they own, which includes the major mail-order pharmacies. And it would prohibit them from giving independent pharmacies lower insurance reimbursements than they offer the big chains — a major issue for the dwindling number of independents around the country.

Wiener said the law aimed to rein in what he called “the worst abuses by PBMs.” Proponents of the legislation say the experiences in the 25 states that require PBM licensing and the 16 that ban steering of patients to preferred vendors show that regulations reduce costs for consumers.

“When they’re licensed like we’re looking at, the cost goes down. States without licensing saw costs go up,” said Assembly member Devon Mathis, one of two Republicans to co-author the bill, citing the National Community Pharmacists Association.

Health insurance premiums increased an average of 16.7% nationwide from 2015 to 2019, the association calculated, with premiums in states that license PBMs increasing 0.3 of a percentage point below the national average and those without, 0.4 above. The association claimed similar benefits from several other reforms affecting pharmacies.

The Pharmaceutical Care Management Association, which represents pharmacy benefit managers, said Wiener’s bill “blatantly” favors independent retail pharmacies over chains.

“This legislation does nothing to lower costs for patients; it simply seeks to financially promote one industry over another with no consumer benefit,” the group said.

Insurance companies argue that the California bill would reduce the PBMs’ ability to negotiate lower drug prices, resulting in higher coverage premiums for everyone. But drugmakers argue that reforms don’t raise premiums.

Supreme Court Decision Looms

States have stepped in to regulate PBMs in the absence of any federal action; Congress has been holding oversight hearings on PBMs, and the Federal Trade Commission in July said PBMs “may be profiting by inflating drug costs and squeezing Main Street pharmacies,” but there has been no new legislation or efforts to crack down based on existing laws barring anticompetitive conduct.

The U.S. Supreme Court could soon weigh in on whether states have the authority to regulate PBMs. A federal appellate court blocked Oklahoma regulations on PBMs on the grounds that federal law held sway, and a group of 35 state attorneys general, including California’s Rob Bonta, have asked the Supreme Court to overturn the ruling.

A central complaint about PBMs is that they take money from pharmaceutical companies, in the form of “rebates,” to give their drugs preferential treatment on health plans’ lists of medications that are covered by insurance, known as formularies. Those rebates may play a role in raising drug prices, found a 2020 paper by the University of Southern California’s Schaeffer Center for Health Policy & Economics.

Under the California bill, those rebates are to be used “for the sole purpose of lowering deductibles and out-of-pocket cost for consumers,” said Assembly member Jim Wood, a Democrat. “There is a perverse incentive by PBMs to choose for their formulary the drugs that will give them the biggest rebate, the largest rebate, even if there are other drugs just as effective and lower-cost. That alone should send shivers down your spine.”

Crackdown in California

California collected more than $215 million last year from the nation’s largest Medicaid insurer, Centene, after it failed to disclose or pass along drug discounts negotiated by its PBM to the state Medicaid agency.

Independent pharmacies say provisions in the proposed California law requiring PBMs to offer them the same pricing as the chains could be a lifeline.

Clint Hopkins, who has co-owned Pucci’s Pharmacy in Sacramento for eight years, said he’s forced to regularly turn away customers rather than lose hundreds of dollars each time he fills their high-cost prescriptions.

For instance, he said his cost for a monthly dose of Biktarvy, used to treat HIV, is $3,881.68. But he said pharmacy benefit managers short him up to $360 on the reimbursement.

“They dictate the rates to us, and they will not negotiate,” said Hopkins, who testified for the bill on behalf of the California Pharmacists Association. “Sometimes I have to say, ‘I’m sorry, I want to help you, but I can’t lose this much money on your prescription.’”

While the bill passed with unusual legislative support, it faces an uncertain future with the Democratic governor, who has until Sept. 30 to sign or veto it.

Newsom vetoed a 2021 bill that would have barred PBMs from steering patients to their own pharmacies, citing potential unintended consequences.

And his Department of Finance said administering the licensing and collecting the data required by the law would cost several million dollars. In vetoing other legislation, Newsom has repeatedly cited costs, as the state struggles with a massive budget deficit.

SIKESTON, Mo. — I wasn’t sure if visiting a cotton field was a good idea. Almost everyone in my family was antsy when we pulled up to the sea of white.

The cotton was beautiful but soggy. An autumn rain had drenched the dirt before we arrived, our shoes sinking into the ground with each step. I felt like a stranger to the soil.

My daughter, Lily, then 5, happily touched a cotton boil for the first time. She said it looked like mashed potatoes. My dad posed for a few photos while I tried to take it all in. We were standing there — three generations strong — on the edge of a cotton field 150 miles away from home and decades removed from our own past. I hoped this was an opportunity for us to understand our story.

As a journalist, I cover the ways racism — including the violence that can come with it — can impact our health. For the past few years, I’ve been working on a documentary film and podcast called “Silence in Sikeston.” The project is about two killings that happened decades apart in this Missouri city: a lynching in 1942 of a young Black man named Cleo Wright and a 2020 police shooting of another young Black man, Denzel Taylor. My reporting explored the trauma that festered in the silence around their killings.

While I interviewed Black families to learn more about the effect of these violent acts on this rural community of 16,000, I couldn’t stop thinking about my own family. Yet I didn’t know just how much of our story, and the silence surrounding it, echoed Sikeston’s trauma. My father revealed our family’s secret only after I delved into this reporting.

My daughter was too young to understand our family’s past. I was still trying to understand it, too. Instead of trying to explain it right away, I took everyone to a cotton field.

Cotton is complicated. White people got rich off cotton while my ancestors received nothing for their enslaved labor. My grandparents then worked hard in those fields for little money so we wouldn’t have to do the same. But my dad still smiled when he posed for a picture that day in the field.

“I see a lot of memories,” he said.

I’m the first generation to never live on a farm. Many Black Americans share that experience, having fled the South during the Great Migration of the last century. Our family left rural Tennessee for cities in the Midwest, but we rarely talked about it. Most of my cousins had seen cotton fields only in movies, never in real life. Our parents worked hard to keep things that way.

At the field that day, my mom never left the van. She didn’t need to see the cotton up close. She was around Lily’s age when her grandfather taught her how to pick cotton. He had a third-grade education and owned more than 100 acres in western Tennessee. Sometimes she had to stay home from school to help work that land while her peers were in class. She would watch the school bus pass by the field.

“I would just hide, lying underneath the cotton stalks, laying as close to the ground as I could, trying to make sure that no one would see me,” my mom said. “It was very embarrassing.”

She didn’t talk to me about that part of her life until we traveled to Sikeston. Our trip to the cotton field opened the door to a conversation that wasn’t easy but was necessary. My reporting sparked similar hard conversations with my dad.

As a child, I overheard adults in my family as they discussed racism and the art of holding their tongues when a white person mistreated them. On my mother’s side of the family, when we’d gather for the holidays, aunts and uncles discussed cross-burnings in the South and in the Midwest. Even in the 1990s, someone placed a burning cross outside a school in Dubuque, Iowa, where one of my relatives served as the city’s first Black principal.

On my father’s side of the family, I heard stories about a relative who died young, my great-uncle Leemon Anthony. For most of my dad’s life, people had said my great-uncle died in a wagon-and-mule accident.

“There was a hint there was something to do with it about the police,” my dad told me recently. “But it wasn’t much.”

So, years ago, my dad decided to investigate.

He called up family members, dug through online newspaper archives, and searched ancestry websites. Eventually, he found Leemon’s death certificate. But for more than a decade, he kept what he found to himself — until I started telling him about the stories from Sikeston.

“It says ‘shot by police,’ ‘resisting arrest,’” my dad explained to me in his home office as we looked at the death certificate. “I never heard this in my whole life. I thought he died in an accident.”

Leemon’s death in 1946 was listed as a homicide and the officers involved weren’t charged with any crime. Every detail mirrored modern-day police shootings and lynchings from the past.

This young Black man — whom my family remembered as fun-loving, outgoing, and handsome — was killed without any court trial, as Taylor was when police shot him and Wright was when a mob lynched him in Sikeston. Even if the men were guilty of the crimes that prompted the confrontations, those allegations would not have triggered the death penalty.

At a hearing in 1946, a police officer said that he shot my uncle in self-defense after Leemon took the officer’s gun away from him three times during a fight, according to a Jackson Sun newspaper article my dad found. In the article, my great-grandfather said that Leemon had been “restless,” “absent minded,” and “all out of shape” since he returned home from serving overseas in the Army during World War II.

Before I could ask any questions, my dad’s phone rang. While he looked to see who was calling, I tried to gather my thoughts. I was overwhelmed by the details.

My dad later gently reminded me that Leemon’s story wasn’t unique. “A lot of us have had these incidents in our families,” he said.

Our conversation took place when activists around the world were speaking out about racial violence, shouting names, and protesting for change. But no one had done that for my uncle. A painful piece of my family’s story had been filed away, silenced. My dad seemed to be the only one holding space for my great-uncle Leemon — a name that was no longer spoken. Yet my dad was doing it alone.

It seems like something we should have discussed as a family. I wondered how it shaped his view of the world and whether he saw himself in Leemon. I felt a sense of grief that was hard to process.

So, as part of my reporting on Sikeston, I spoke to Aiesha Lee, a licensed counselor and Penn State University assistant professor who studies intergenerational trauma.

“This pain has compounded over generations,” Lee said. “We’re going to have to deconstruct it or heal it over generations.”

Lee said that when Black families like mine and those in Sikeston talk about our wounds, it represents the first step toward healing. Not doing so, she said, can lead to mental and physical health problems.

In my family, breaking our silence feels scary. As a society, we’re still learning how to talk about the anxiety, stress, shame, and fear that come from the heavy burden of systemic racism. We all have a responsibility to confront it — not just Black families. I wish we didn’t have to deal with racism, but, in the meantime, my family has decided not to suffer in silence.

On that same trip to the cotton field, I introduced my dad to the families I’d interviewed in Sikeston. They talked to him about Cleo and Denzel. He talked to them about Leemon, too.

I wasn’t thinking about my great-uncle when I first packed my bags for rural Missouri to tell the stories about other Black families. But my dad was holding on to Leemon’s story. By keeping the file — and finally sharing it with me — he was making sure his uncle was remembered. Now I say each of their names: Cleo Wright. Denzel Taylor. Leemon Anthony.

The “Silence in Sikeston” podcast from KFF Health News and GBH’s WORLD is available on all major streaming platforms. A documentary film from KFF Health News, Retro Report, and GBH’s WORLD will air at 8 p.m. ET on Sept. 16 on WORLD’s YouTube channel, WORLDchannel.org, and the PBS app. Preview the trailer for the film and the podcast. More details about “Silence in Sikeston.”

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

WINDER, Ga. — About an hour after gunfire erupted at Apalachee High School, ambulances started arriving at nearby Northeast Georgia Medical Center Barrow with two students and two adults suffering from panic attacks and extreme anxiety, not bullet wounds.

A fifth patient with similar symptoms later arrived at another local facility, according to a health system spokesperson.

The day after the Sept. 4 school shooting that killed two students and two teachers, some 80 families showed up in a county office to receive counseling from volunteer therapists who converged from across the Atlanta metro area, according to one medical provider. That Sunday, nine people received free treatment at a local church for post-traumatic stress disorder from volunteering Atlanta-area providers. On Monday, the state opened a temporary recovery center to help locals find counseling, faith-based support, or other aid. The needs are still great.

“We don’t really know how we’re doing,” Amanda McKee — whose son, Asa Deslonde, is a senior at Apalachee — said two days after the shooting. “It’s second by second. It’s minute by minute. The last couple days have been unimaginable.”

When shootings of any magnitude occur, they often leave the survivors with invisible injuries that can create life-changing symptoms that sometimes paralyze them.But such problems can take time to emerge. Panic attacks and anxiety can spike across a community after a shooting and can be most intense when people return to the scene, said Howard Liu, chair of the Council on Communications for the American Psychiatric Association.

So health providers worry that in the coming days, months, and years the community will struggle to find help for their mental health needs. Barrow County, along a highway that connects Atlanta to the college town of Athens, is a community where agriculture is steadily giving way to development.

Prior to the shooting, the area had one stand-alone inpatient mental health facility, located in Gainesville, about 30 miles away from where the shooting occurred in Barrow County, that was “constantly overwhelmed,” said Sean Couch, a spokesperson for Northeast Georgia Health System. And, the latest federal data shows, Barrow would need to add at least 13 full-time providers to no longer be considered a mental health workforce shortage area.

“We put a band-aid on a chronic situation and that band-aid isn’t going to last,” said Roland Behm, a co-founder of the Georgia Mental Health Policy Partnership, an advocacy group that represents mental health organizations in the state. “What happens three months from now?”

The scarcity of mental health providers in Barrow County is emblematic of the state as a whole. Georgia ranks nearly last among states in access to mental health care resources, according to Mental Health America, a nonprofit that advocates for increased mental health spending. More than 5 million Georgians live in mental health care professional shortage areas like Barrow County.

Paying for mental health care to treat such trauma is difficult nationwide. But Georgia is one of the 10 states that have not fully expanded eligibility for Medicaid, the nation’s safety net insurance for those with low incomes and also the largest payer for mental health services. The state has an uninsured rate of 13.6%, which is 4.1 percentage points higher than the country as a whole, according to 2022 data from the U.S Census Bureau.

Even people with private health plans have trouble finding affordable, in-network mental health care because of a lack of providers willing to accept low insurance reimbursement rates, Behm said.

Tamara Conlin, CEO of Advantage Behavioral Health Systems, said the people who came to the initial counseling sessions that her group helped arrange in a county office showed a lot of sadness and anxiety.

“Some of them are still in shock and trying to wrap their heads around what happened,” she said.

Even before the shooting, students at Apalachee High School reported significant mental health challenges.

Nearly 200 of 1,725 student respondents reported that they had seriously considered attempting suicide one or more times in the prior year, according to the latest Georgia Student Health Survey. Top motivators included problems with peers, friends, or family. About half of the students from the school who answered said they felt sad, depressed, or withdrawn at least once in the prior 30 days.

County residents complained about having to travel for psychiatric care and said the “shortage of psychologists and counseling services led to untreated high anxiety and depression rates,” during a 2019 focus group about health care access.

The lack of mental health care remained a top concern in the region during a follow-up assessment in 2022. That year, the opioid overdose death rate in Barrow County was among the highest in Georgia, according to state data, and the five-year suicide rate was above the state average.

The Barrow County School System, which includes Apalachee High School, received a $1.8 million federal grant to boost mental health resources in schools from 2023 through 2028.

But immediately following the shooting, mental health providers across the region still had to cobble together free resources for area residents. Three volunteers helped with last Wednesday’s response at Northeast Georgia Medical Center Barrow. Advantage Behavioral Health Systems kept its Barrow clinic open on Sunday and is providing counselors to community events and local schools as they reopen.

William Smith, who heads the Atlanta Center for EMDR, is planning sessions using eye movement desensitization and reprocessing therapy to address PTSD — at least one for first responders and another for residents.

Over the weekend, Lutheran Church Charities brought nine golden retrievers as “comfort dogs” to help the grieving. The group’s dogs have been deployed in the wake of other school shootings, including the Uvalde, Texas, massacre.

“We can’t fix what they’re feeling,” said volunteer Paul Soost, as people gathered around a campus flagpole where they delivered flowers and messages. “We can provide comfort.”

Many health care providers expect the community’s needs to spike when students return to Apalachee High School and as the national attention on the shooting recedes.

“That’s when people start experiencing the trauma,” said Conlin, with Advantage Behavioral Health Systems, who compared the current crisis to the surge of patients she saw after the immediate threat of the covid-19 pandemic passed.

Her clinic in Barrow County already had about 750 active clients before the shooting, with about 120 under the age of 18.

McKee said she knows healing will be a long process for her son, Asa. One of his football coaches, Richard Aspinwall, was among the four killed. A key step came the day after the shooting, she said, when the school’s head football coach convened the team to share how much he was hurting.

“The coach validated that they were hurt, and encouraged them to embrace that they were injured,” McKee said. “They’re not the physical injuries that were incurred by the senseless act, but they are injuries nonetheless.”

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

ATLANTA — On a recent summer evening, Raymia Taylor wandered into a recreation center in a historical downtown neighborhood, the only enrollee to attend a nearly two-hour event for people who have signed up for Georgia’s experimental Medicaid expansion.

The state launched the program in July 2023, requiring participants to document that they’re working, studying, or doing other qualifying activities for 80 hours a month in exchange for health coverage. At the event, booths were set up to help people join the Marines or pursue a GED diploma.

Taylor, 20, already met the program’s requirements — she studies nursing and works at a fast-food restaurant. But she said it wasn’t clear what paperwork to submit or how to upload her documents. “I was struggling,” she said.

Georgia is the only state that requires certain Medicaid beneficiaries to work to get coverage. Republicans have long touted such programs, arguing they encourage participants to maintain employment. About 20 states have applied to enact Medicaid work requirements; 13 won approval under the Trump administration. The Biden administration has worked to block such initiatives.

The Georgia Pathways to Coverage program shows the hurdles ahead for states looking to follow its lead. Georgia’s GOP leaders have spent millions of dollars to launch Pathways. By July 29, nearly 4,500 people had enrolled, the state’s Medicaid agency told KFF Health News.

That’s well short of the state’s own goal of more than 25,000 in its first year, according to its application to the federal government, and a fraction of the 359,000 who might have been eligible had Georgia simply expanded Medicaid under the Affordable Care Act, as 40 other states did.

So far, the pricey endeavor has forced participants to navigate bureaucratic hurdles rather than support employment. The state would not confirm whether it could even verify if people in the program are working.

Research shows such red tape disproportionately affects Black and Hispanic people.

“The people that need access to health care coverage the most are going to struggle with that administrative burden because the process is so complicated,” said Leah Chan, director of health justice at the Georgia Budget and Policy Institute.

At an August press event, Georgia Republican Gov. Brian Kemp announced a $10.7 million ad campaign to boost enrollment in Pathways, one of his administration’s major health policy initiatives. The plan has cost more than $40 million in state and federal tax dollars through June, with nearly 80% going toward administration and consulting fees rather than paying for medical care, according to data the state Medicaid agency shared with KFF Health News.

Enrollment advisers, consumer advocates, and policy researchers largely blame a cumbersome enrollment process, complicated program design, and back-end technology flaws for Pathways’ flagging enrollment. They say that the online application is challenging to navigate and understand and lacks a way for people to receive immediate support, and that state staffers don’t respond to applicants in a timely manner.

“It’s just an administrative nightmare,” said Cynthia Gibson, director of the Georgia Legal Services Program’s Health Law Unit, who helps Pathways applicants appeal denials.

Administrative challenges have also undermined a key part of the program’s philosophy: that people maintain employment to keep coverage. As of July, the state was not removing enrollees for not meeting Pathways’ work requirement, according to Fiona Roberts, a spokesperson for Georgia’s Medicaid agency.

“We understand that people need to be held accountable to those 80 hours for the spirit of the program, and we intend to do that,” said Russel Carlson, the agency’s commissioner.

Pathways is set to expire Sept. 30, 2025, unless the state asks the Centers for Medicare & Medicaid Services for an extension. Georgia officials say they won’t have to make that request until next spring, well after November’s election. So the state could be asking for an extension from the Trump administration, which approved the program in the first place.

Georgia officials sued the Biden administration this year to keep Pathways running without going through the official extension process, which requires the state to conduct public comment sessions, gather extensive financial data, and prove that Pathways has met its goals. A federal judge ruled against Georgia.

A CMS spokesperson said the agency wouldn’t comment on the program.

During the August press event, Kemp said the Biden administration’s attempt to stop the program in 2021 delayed its rollout and stymied enrollment. A federal court blocked the administration and allowed Georgia to proceed.

People familiar with the enrollment process said Pathways has been mired in design flaws and system failures. As of the end of May, 13,702 applications were waiting to be processed, according to state documents.

The program’s lengthy questionnaires and technical language are confusing, guidance is opaque, and tools to upload documents are tricky to navigate, according to interviews with health insurance enrollment specialists conducted for the Georgia Budget and Policy Institute.

“It’s not an easy, ‘Oh, I want to apply for Pathways,’” said Deanna Williams, who helps people enroll in insurance plans at Georgians for a Healthy Future, a consumer advocacy group. People generally learn about the program after being denied other Medicaid coverage, she said.

In the online application, people click through pages of questions before they’re shown a screen with information about Pathways, Williams said. Then they must check a box and sign a form saying they understand the program’s requirements.

Sometimes the Pathways application doesn’t pop up, and she must start over. The process to apply is “not smooth,” she said.

Data shows that people who don’t earn enough to qualify for free ACA plans but also make too much for Medicaid are disproportionately people of color. Pathways offers Medicaid coverage to adults earning up to the federal poverty level: $15,060 for an individual or $31,200 for a family of four.

Some people eligible for Pathways who work in retail or restaurants with fluctuating hours are nervous they can’t meet requirements every month, Williams said.

Many current enrollees don’t know how to upload documents, and the website sometimes stops working, said Jahan Becham, an employment specialist for Pathways at Amerigroup Community Care. Or people just forget.

Every month Becham gets a list of 200 to 300 enrollees who haven’t submitted their hours. “It is something new, and not many people are used to this,” Becham said.

“I would get reminders,” said Taylor, who attended the event for enrollees in August. “I just didn’t know how.”

In a June 2023 meeting with Georgia Medicaid staffers weeks before the program launched, federal officials questioned why the state wasn’t automatically verifying eligibility with existing data sources, according to meeting minutes KFF Health News obtained through a state open-records request. Georgia officials said they were unsure when they’d be able to simplify the verification process.

Many potential participants face improper denials, advocates said. Gibson, at the Georgia Legal Services Program, said not enough workers are trained to properly evaluate applications.

Fewer than 1 in 5 people who have their Pathways applications processed had been accepted into the program as of May, according to a KFF Health News analysis of state data. Roberts, with the state, said people were denied because they earned too much, didn’t meet requirements, or didn’t complete the paperwork.

A full-time graduate student was wrongly blocked from the program, and in February a state administrative judge ordered her case be reconsidered. In another case, a different judge ruled a 64-year-old woman who couldn’t work because she was her disabled husband’s full-time caregiver would not qualify for Pathways.

Despite the challenges, state records from May show no individuals were removed from the program since it launched for failing to meet work requirements.

Georgia’s experiment comes after a 2018 effort in Arkansas to implement work requirements on an existing Medicaid expansion population led to 18,000 people losing coverage, many of whom either met requirements or would have been exempted.

Taylor found out about Pathways when she applied for food stamps last year. It wasn’t until August that she learned she could submit her school schedule to meet the qualifying hours requirement. With a full Medicaid expansion, Taylor would have been eligible for health coverage without the extra effort. But, for her, it’s still worth it.

“It’s important to have health insurance,” said Taylor, who has been to the dentist several times and plans to visit a doctor. “I’m glad I have it.”

The Host

As expected, the presidential debate between former President Donald Trump and Vice President Kamala Harris offered few new details of their positions on abortion, the Affordable Care Act, and other critical health issues. But it did underscore for voters dramatic differences between the two candidates.

Meanwhile, the Biden administration issued rules attempting to better enforce mental health parity — the federal government’s requirement that services for mental health care and substance use disorders be covered by insurance to the same extent as other medical services.

This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Stat, Riley Griffin of Bloomberg News, and Lauren Weber of The Washington Post.

Among the takeaways from this week’s episode:

• Trump declined to say during the debate whether he’d veto legislation implementing a nationwide abortion ban. But he could effectively ban the procedure without Congress passing anything because of the 150-year-old Comstock Act. And Project 2025, a policy blueprint by the conservative Heritage Foundation, calls for doing just that.
• There is a good chance that enhanced federal subsidies for ACA coverage that were introduced during the pandemic could expire next year, depending on which party controls Congress. The subsidies have helped more people secure zero-premium health coverage through the ACA exchanges, though Republicans say the subsidies cost too much to keep. Residents in states that haven’t expanded Medicaid coverage — including Florida and Texas — would be most affected.
• The Census Bureau reports that the uninsured rate didn’t change much last year after hitting a record low in the first quarter. But the report’s methodology prevented it from capturing the experiences of many people disenrolled and left uninsured after what’s known as the Medicaid “unwinding” began. Meanwhile, a Treasury Department report sheds light on just how many Americans have benefited from the ACA, as polls show the health law has also grown more popular.
• And Congress has yet to pass key government spending bills, meaning the nation (again) faces a possible federal government shutdown starting Oct. 1. It remains to be seen what could pass during a lame-duck session after the November elections. In 2020, the end-of-the-year spending package featured many health care priorities — and that could happen again.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: The Wall Street Journal’s “A Nurse Practitioner’s $25,000 in Student-Debt Relief Turned Into a $217,500 Bill From the Government,” by Rebecca Ballhaus.  

Lauren Weber: Stat’s “Youth Vaping Continues Its Tumble From a Juul-Fueled High,” by Lizzy Lawrence.  

Riley Griffin: Bloomberg News’ “Lilly Bulks Up Irish Operations in Obesity Drug Production Push,” by Madison Muller.  

Rachel Cohrs Zhang: ProPublica’s “‘I Don’t Want To Die’: Needing Mental Health Care, He Got Trapped in His Insurer’s Ghost Network,” by Max Blau.

Also mentioned on this week’s podcast:

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This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.