The South

The South’s Medicare story is the most politically complex and equity-relevant in the country. Three states illustrate three different trajectories for health policy in the post-ACA, post-OBBBA environment. Georgia ran the nation’s only Medicaid work requirements program and produced the cautionary tale that congressional Republicans cited as a model for the federal mandate enacted in July 2025. North Carolina expanded Medicaid in December 2023 after a decade of legislative resistance and is building an SDOH integration infrastructure that is generating national attention. Louisiana has the highest dual eligible rate of any state and the lowest-income Medicare population in the country, and it faces the most severe OBBBA-driven Medicaid pressure of any state in the region. What unites all three is the rural-urban equity fracture: urban centers with functional MA markets and some integration infrastructure, and rural areas where Black Belt counties, Delta parishes, and Appalachian communities face simultaneous provider shortages, MA plan absence, limited SHIP counseling, and concentrated disadvantage that the policy architecture has not reached.

Georgia: Work Requirements and the Cautionary Tale

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Georgia Pathways to Coverage launched in July 2023 as the nation’s first and only Medicaid work requirement program. The program requires eligible adults ages 19-64 with household income up to 100 percent of FPL to document at least 80 hours per month of work, job training, or volunteer activity to receive Medicaid coverage. Georgia promoted Pathways as an alternative to ACA Medicaid expansion, arguing that it would promote personal responsibility and reduce reliance on government programs.

The results have been extensively documented. As of August 2025, approximately 9,175 Georgians were actively enrolled, out of an estimated 240,000 eligible. Only 8,077 had maintained continuous enrollment through the program’s first two years. The GAO reported in September 2025 that the program had spent $54.2 million on administrative costs compared to $26.1 million on actual health care services, with nearly 90 percent of administrative expenditures coming from the federal budget. Total federal and state spending exceeded $86.9 million through the end of 2024, three-quarters of which went to consultants. The per-enrollee cost in the first year was approximately $13,360, more than five times the initial estimate of $2,490 and dramatically more expensive per person than ACA expansion would have been.

The enrollment barriers were predictable. Forty-two percent of people who expressed interest in applying did not complete the application because they could not document qualifying activity hours. Among those who did complete applications, 19 percent were denied for reporting fewer than 80 hours or insufficient verification. Digital platform glitches, chronic understaffing at the state enrollment agency, and bureaucratic complexity combined to produce a program that spent more on proving people were working than on providing them healthcare. The state quietly rolled back monthly work verification, moving to verification only at enrollment and annual renewal, effectively conceding that the monthly reporting requirement was administratively unworkable.

Congressional Republicans cited Georgia Pathways as the model for the federal Medicaid work requirement enacted under OBBBA in July 2025, which takes effect in 2027. CMS extended the Georgia program through December 2026. The Georgia experience is now the primary empirical reference point for what federal work requirements will produce when implemented across all states.

The Georgia MA market operates independently of the Pathways story but intersects through the dual eligible pipeline. Atlanta is a competitive, growing MA market with national plan concentration. Anthem (Elevance) has historically been the dominant MA insurer in the metro area. Rural Georgia, particularly the southwest Black Belt counties and the coastal communities, has very limited MA plan availability. The dual eligible rate in rural Georgia counties is among the highest in the Southeast, but D-SNP availability outside the Atlanta metro area is minimal.

Georgia has one of the highest concentrations of Black Medicare beneficiaries of any state, concentrated in Atlanta, the Black Belt, and coastal communities. The HCC coding gap and supplemental benefit access disparities documented in MCR-10.02 apply with particular force in a state where the Black Medicare population is large, geographically concentrated, and disproportionately in rural markets with the fewest plan options and the weakest coding infrastructure.

North Carolina: The Health Policy Acceleration

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North Carolina expanded Medicaid in December 2023 after a decade of legislative resistance, among the last large states to expand. The enrollment surge was immediate: over 600,000 new Medicaid enrollees in the first year of expansion. The dual eligible pipeline is expanding rapidly as newly eligible adults with chronic conditions and disabilities gain Medicaid coverage that creates D-SNP eligibility.

North Carolina’s Medicaid managed care transformation, implemented through the NC Medicaid Managed Care program, is among the most ambitious in the country. The state incorporated SDOH screening requirements, community health worker integration, and advanced medical home standards into its managed care contracts. The Healthy Opportunities Pilots (HOPs), operating under a Section 1115 waiver, became the first Medicaid program in the country to pay for non-medical SDOH interventions at scale: housing support, food assistance, transportation, and interpersonal safety services delivered through community-based organizations and reimbursed through Medicaid managed care. The evidence base from HOPs is generating national attention as the primary demonstration of whether paying for social determinants produces measurable health outcomes and cost savings.

The implications for Medicare are indirect but significant. If the HOPs evidence demonstrates that SDOH investment reduces utilization and improves outcomes for the Medicaid population, the same logic applies to the dual eligible population and, by extension, to Medicare beneficiaries with similar social risk profiles. North Carolina’s SDOH infrastructure creates a policy laboratory whose results will inform how CMS, MA plans, and ACOs think about non-medical benefit investment. The state is also building data infrastructure connecting health and social services that could eventually support SDOH-informed care management for Medicare beneficiaries.

The NC MA market has moderate competition in Charlotte, Raleigh-Durham, and Greensboro. Rural western North Carolina and the eastern Black Belt counties are significantly underserved. The Medicaid expansion is changing the economics of the rural market by bringing Medicaid revenue into facilities that were previously uncompensated care providers, stabilizing the rural health infrastructure that Medicare beneficiaries also depend on.

Louisiana: The Highest Dual Eligible Rate and the OBBBA Crisis

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Louisiana has the highest dual eligible rate of any state, approximately 25 percent of Medicare beneficiaries also enrolled in Medicaid. The income profile of Louisiana’s Medicare population is among the lowest in the country, with heavy dependence on QMB, SLMB, and LIS for cost-sharing protection. Healthy Louisiana, the state’s Medicaid managed care program, has significant dual eligible enrollment, and the D-SNP market is concentrated in the New Orleans and Baton Rouge metro areas.

OBBBA creates existential risk for Louisiana’s Medicaid program. The state’s Medicaid enrollment is large relative to its population, its reliance on federal FMAP is high, and its state fiscal capacity to absorb federal funding reductions is among the lowest in the country. The dual eligible cascade is the most severe in Louisiana of any state: if Medicaid coverage disruptions disenroll beneficiaries from Medicaid, they lose D-SNP eligibility, Part D cost-sharing protection through LIS, MSP coverage, and access to the LTSS services that Medicaid funds. For a state where one in four Medicare beneficiaries depends on Medicaid for cost-sharing and LTSS coverage, the OBBBA-driven fiscal pressure is not a policy abstraction. It is a direct threat to the coverage architecture that makes Medicare affordable for Louisiana’s poorest seniors.

Rural Louisiana compounds the crisis. The Delta parishes, the Cajun parishes, and the Florida parishes (the rural areas north and east of Baton Rouge) have among the most acute primary care deserts in the South. Louisiana has experienced significant rural hospital closures. The remaining Critical Access Hospitals are often the only Medicare providers in their parishes. When a CAH closes, the nearest hospital may be 45 minutes or more away, in a state where the elderly population has limited transportation access and where the road infrastructure in rural parishes does not support the travel times that urban policy assumes.

The Rural-Urban Equity Fracture Across the South

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The shared pattern across all three states is consistent and severe. Urban centers have functional MA markets, some D-SNP availability, and basic navigation infrastructure through SHIPs and AAAs. Rural areas, particularly the Black Belt counties stretching from southwest Georgia through eastern North Carolina and into the Mississippi Delta corridor, face simultaneous provider shortages, MA plan absence, limited SHIP counseling, and high dual eligible rates. The seniors with the highest health needs, the greatest benefit complexity, and the least navigation support are concentrated in the same rural Southern counties.

The ACO coverage gap is widest in the rural South. The 511 MSSP ACOs cover 53 percent of Traditional Medicare beneficiaries nationally, but coverage is concentrated in markets where physicians have the organizational infrastructure to form ACOs. Rural Southern counties, where primary care physicians are scarce and practice independently, are where the ACO coverage gap is most acute and where the potential impact of ACO expansion would be greatest. A rural Louisiana parish or rural Georgia county without an ACO, without an MA plan, and without D-SNP availability is a Medicare market in name only. The beneficiaries living there have coverage on paper and a delivery system that cannot execute on what that coverage promises.

The racial dimension is inescapable. The Black Belt, named for its soil but defined by its demographics, contains the highest concentrations of Black Medicare beneficiaries in the country. These counties also have the highest rates of diabetes, hypertension, and heart disease, the lowest HCC capture rates, the fewest MA supplemental benefits, and the least access to the primary care relationships that drive both health outcomes and accurate risk adjustment. The equity infrastructure being dismantled at the federal level was never adequate for these counties. Its removal does not create a new crisis. It removes the last remaining institutional acknowledgment that the crisis exists.

Related Reading

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MCR-09_01 Medicaid Work Requirements: The Dual Eligible Blind Spot MCR-10_02 Racial and Ethnic Health Equity in Medicare: HCC Coding Gaps, Benefit Disparities, and What the Data Shows MCR-05_13 Rural Medicare: Critical Access Hospitals, Ground Ambulance, and the Geographic Equity Problem