During the first Trump presidency, 13 states enacted requirements for people on Medicaid to work, though rules varied per state. All 13 states’ rules were struck down by either the Centers for Medicare and Medicaid Services under Biden or individually by judges, but Georgia created a new work-requirement Medicaid program, Georgia Pathways, in 2023. It hasn’t been going so well: only 4,000 people have enrolled as of October 2024. States like Georgia, and others that have embraced such requirements, have also rejected Medicaid expansions in the past. That’s led to people who are low-income—but do not have certain disabilities, are pregnant, or are youths—to not qualify. States like South Dakota and Mississippi are expected to add work requirements back during Trump’s second term. GOP members of Congress are mulling over mandating work requirements nationally.
There are wide-ranging reasons why work requirements do harm. For instance, it’s often impossible for caregivers to both work and support their sick loved ones. I spoke with Alton F., a self-described hillbilly who lives in rural northwest Georgia, about the challenges he faced in trying to join Georgia Pathways. Alton works as a mason contractor and previously struggled with methamphetamine addiction for two decades.
This interview has been edited for length and clarity.
I was diagnosed with prostate cancer three months ago. My wife had been fussing me to go in, because I’d never been to the doctor before, that I needed to go get my blood pressure checked. So I went to one of our local quick care clinics. The doctor, he said, “Yeah, I’ll get you some blood pressure medication. But I want to do blood work, make sure nothing’s wrong.” I said, “I don’t know. I don’t want to do that. Just give me the blood pressure pill.” So he did. Then I went back next time, he said, “We need to do tests today.” He, just a simple country doctor who only charges $40 a visit, found my panel came back that my prostate, the PSA score—which is your prostate score—for a man my age, normal is 2.5, and mine was 14.1. He said, I’ve never seen anythin’ that high and not be cancer. So, he got me in with another doctor, and they got a CAT scan, and the CAT scan showed a large lesion. They put me up for a biopsy: four spots were cancer, with three of them bad, progressive. He said something needs to be done about it.
“I know there’s gonna come a point where I’m gonna die because I can’t afford any more doctors.”
A friend of mine who works for the government tried to get me in with the Georgia [Pathways] program. They wanted tax returns, which I didn’t have. I got out of prison in 2018. I hadn’t filed taxes. I don’t have pay stubs. I was getting back on my feet. So then she said, “Can you make something up?” So I said, “Yeah, I’ll get my wife to make a spreadsheet and show them what I make each month [as a masonry contractor].” Well, that wasn’t good enough. She was a very nice lady and very apologetic, but there was nothing more I can do because I don’t have tax returns. I could file taxes this year, but it’s too late [for this year] to get health insurance [through the Marketplace].
We got this plan two or three months ago, and the lady said it’s like $378 a month. I thought for $378 a month, I would be getting some great insurance. Apparently, I got the sorry crap that you can get and am on a limited plan. When I went and had the procedure done [to test for cancer], I walked into the lady’s office and she said, she spun her paper message, “Here’s what you owe, $15,000.”I said, “I might as well go on home, because I don’t have $15,000 to give you.” She said, “No, your insurance paid $4,000 of it, and you owe the other $10,000, almost $11,000.” She said, “But I need you to make a down payment today.” So, I had to put $1,000 on my credit card to get that done.
The doctor said [I could get] what is called a full prostatectomy. The other option is chemo, he said, but that’s five days a week for eight weeks. I can’t do that. He said, “You’re not gonna be able to go to work because you’ll be too sick.” No, I can’t do that. I can’t afford to miss eight weeks of work. I know there’s gonna come a point where I’m gonna die because I can’t afford any more doctors. I’m not going to leave my wife homeless. I’m not going to leave my wife with hundreds of thousands of dollars in medical bills trying to save my life.
