Daphne Young, 61, was recovering from cervical cancer and managing a complex heart condition when she arrived late last month at an Atlanta job fair desperate to regain health coverage through Medicaid.
In July, Ms. Young, a journalist, has moved from California to Georgia, a state with strict Medicaid eligibility limits and one of only 10 that did not expand the program to adults under the Affordable Care Act. The monthly income listed for herself and her son was too high for her to qualify, she said.
Instead, Ms. Young was guided to the table with a potential alternative: the new Medicaid program called Georgia Pathways to Coverage, which requires enrollees with incomes up to 100 percent of the federal poverty level to work, study or do community service for at least. 80 hours a month to secure coverage.
The line, which has drawn anemic enrollment ahead of its scheduled expiration next year, is the subject of an intense legal and philosophical battle over the future of Medicaid, a joint state-federal program that accounts for about 10 percent of the federal budget and covers around. 75 million Americans, mostly low income.
Health policy experts say Georgia has operated as a conservative laboratory for Medicaid, eyeing potentially dramatic changes that could occur if former President Donald J. Trump wins the White House in November.
Democrats have seized on the program’s future at a crucial time in the campaign.
“Let’s finally expand Medicaid in Georgia so people can take their children to the doctor or go to the emergency room without going into medical debt,” said Vice President Kamala Harris in a recent campaign speech in Savannah, Ga.
Mr. Trump, who as president called for major cuts to Medicaid in his budget proposal, has said little about how he might reshape the safety net program. In this week’s presidential debate, he suggested he has a “concept plan” to overhaul the Affordable Care Act that he will soon share, which he could use to call for big reductions in Medicaid spending.
Edwin Park, a Medicaid expert at Georgetown University, said that a fight in Congress next year over the expired tax measure signed into law by Mr. Trump in 2017 could lead lawmakers to hunt for big cuts from the federal health program.
“And where would you go but Medicaid?” Mr. Park said. “If we take former President Trump’s claims about protecting Medicare and Social Security, Medicaid will be the largest source of savings.”
Republican lawmakers and policy experts, some of whom work in the Trump administration, are busy trying to convince themselves that recent Medicaid growth is putting unsustainable pressure on federal and state budgets.
The House Republican budget proposal, along with the Project 2025 initiative and a conservative think tank paper, say the program’s growth to cover more adults has diverted resources from other Medicaid recipients who need it, such as children, pregnant women and people with disabilities.
The authors of Project 2025, which was accepted by the Trump campaign, called Medicaid “a complicated, complicated and incalculable burden in almost every state.”
The Pathways program is central to the Republican vision for rethinking Medicaid. About a dozen states received permission from the Trump administration to implement work requirements in their Medicaid programs, but were halted by the Biden administration.
Republicans have also called for limiting federal funding that states receive for the Medicaid program or its recipients, a practice known as block granting or per capita caps. The Trump administration in 2020 began to allow such plans.
And they have proposed reducing the share of Medicaid spending borne by the federal government, or the so-called matching rate. In the expansion of Medicaid, which covers poor adults, the federal government takes 90 percent of the cost, making the option attractive even to Republican-led states.
States that lose a larger share of federal funding in Medicaid may have to increase their own spending to make up for it, or make big cuts to Medicaid.
A major change in the matching rate could also prompt states to reverse expansion of the program, something Republicans sought during Mr. Trump’s first term. Some Republican state lawmakers, including in Idaho, have begun considering such a move.
Pathways, which typically uses federal funds, was created as a backlash against Medicaid expansion, reflecting Republicans’ emphasis on personal responsibility as a condition of publicly subsidized health care.
But health policy experts say that approach essentially penalizes people like Ms. Young, putting low-income people who manage complicated lives in limbo unless they can pocket their pay stubs.
The program has become a warning sign about how the reforms are being implemented. By July, a year into the Pathways program, fewer than 4,500 people had signed up — a fraction of the roughly 168,000 that state officials estimated would be eligible to sign up.
A spokeswoman for Georgia’s Medicaid agency did not respond to follow-up questions about Pathways’ more recent enrollment figures.
“The goal of Georgia Pathways is not — and never has been — to keep hundreds of thousands of Georgians in government-run health care forever,” said Brian Kemp, the state’s Republican governor, at a recent health roundtable event. He said the coverage is meant to be “a pathway to education, employment, career and a better life without government assistance.”
Critics of the route have pointed to the contradictions in the program: To reduce the role of the federal government in health care, the state orchestrated a federally funded expensive government program that spent little on health care. As of March 31, about $25 million of the $32.5 million spent on the program was for administrative costs.
Leah Chan, a health policy expert at the Georgia Budget and Policy Institute, a nonprofit research firm, said those administrative costs mean the state is spending more to insure others in Pathways than through traditional Medicaid expansion.
“The most fiscally responsible decision is to close the coverage gap,” he said, referring to the roughly 175,000 people in Georgia who earn too much to qualify for the state’s Medicaid program but not enough for highly subsidized plans in the Affordable Care Act marketplace.
As with the Pathways model, some conservative health policy experts have suggested that states could adopt an in-between position: allowing adults with incomes up to 100 percent of the federal poverty level into Medicaid, and those above that receive significant financial assistance to plan purchases . Affordable Care Act market.
With the help of those subsidies, about 1.3 million people in Georgia signed up for plans in the marketplace this year. About 400,000 people already on Medicaid now have plans on the market that provide “better coverage, with more options, while saving taxpayer dollars,” Kemp said at the roundtable event.
State officials have stood by the Pathways program, announcing a marketing campaign of more than $10 million last month in an effort to juice enrollment.
In a recent registration event at the government building next to the State Capitol, a small group of contractors recruiting people into the program handed out Pathways-branded hand sanitizer, first aid kits, umbrellas and ponchos.
The coverage often gives recipients access to other safety net programs. Diamond Carter, a 23-year-old Pathways recipient from Atlanta who is raising a daughter, said her enrollment has given her access to the Special Supplemental Nutrition Program for Women, Infants and Children, a federally funded program known as WIC that covers the cost. of groceries.
“I can log in anytime and apply for anything I need,” Ms. Carter said, referring to the web portal used for Pathways.
Ms. Young, a Pathways recipient candidate, said she racked up a roughly $30,000 bill at a private Atlanta hospital before being transferred to a public hospital that typically treats the uninsured. He stayed there last week, and plans to finish his Pathways application as soon as he can, he said.
The part-time job she started probably wouldn’t have health insurance, Ms. Young said. He expects to work about 80 hours a month while juggling his health issues, leaving him barely on the threshold for Pathways eligibility.
“How are you supposed to survive?” she asked.
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