Georgia’s Medicaid Expansion Leaves Many Behind

Medicaid was originally designed to give health insurance to the poorest and most vulnerable Americans: children, pregnant women, poor parents, and people with disabilities. But in this model, low-income adults without kids were left with few options for health insurance if they were unemployed or their employer did not offer coverage. The Affordable Care Act of 2010 changed that by giving states the option to expand Medicaid eligibility. Most states opted in, but several declined.

Georgia was one state that initially did not expand Medicaid. When it finally did in 2023, the state legislature tied Medicaid eligibility to work requirements. Its Pathways to Coverage program made all low-income adults eligible for Medicaid, but only if they could prove they worked 80 hours a month. State policymakers hoped this would reduce the number of people without health insurance, promote employment, and ultimately transition Georgians off of Medicaid and onto employer-sponsored insurance. But in practice, work requirements in public benefit programs often do the opposite, creating administrative hurdles that make it harder for people who qualify to maintain coverage without increasing employment.

A new study by Daniel Johnson and colleagues shows that the work requirement in Georgia did not improve insurance coverage or employment. The researchers used data from the U.S. Census Household Pulse Survey to compare insurance and employment rates among low-income adults in Georgia with those in neighboring states that did not expand Medicaid (Alabama, Florida, Mississippi, South Carolina, and Tennessee). They also compared Georgia to South Dakota, which expanded Medicaid at the same time as Georgia, but did not include work requirements.

What happened in Georgia may be a preview of what’s coming nationwide.

A year after Georgia expanded Medicaid to include working low-income adults, the proportion of low-income people with health insurance had not changed in the state or its neighboring states. In contrast, Medicaid coverage increased in South Dakota, from 36.6% to 44.6%. Meanwhile, employment rates stayed roughly the same in Georgia, the non-expansion states, and South Dakota, suggesting that employment was not associated with Medicaid, regardless of work requirements.

Previous research shows that work requirements reduce participation in government benefit programs, even among those who meet all the qualifications. History also tells us this. In 1996, welfare reform made employment a condition for aid. This drastically reduced the number of people receiving benefits, but didn’t lift families out of poverty through work. And in 2018, Arkansas implemented a Medicaid work requirement similar to Georgia’s. This program kicked 18,000 people off Medicaid while failing to have any effect on employment rates. The program was in effect for only 6 months before it was halted by a federal judge.

Work requirements don’t automatically increase employment or Medicaid access for several reasons. One is that the process of proving eligibility is arduous. More than 110,000 Georgians applied for Medicaid as part of Pathways to Coverage, but only 5% ultimately enrolled. Roughly half were denied for failing to report qualifying work activities. Additionally, most low-income adults who qualify for Medicaid are already employed, meaning they won’t affect the unemployment rate. Others face barriers to working, such as illness, caregiving, or lack of transportation. While Pathways to Coverage does offer resources on how to find qualifying employment opportunities, it doesn’t address these barriers.

What happened in Georgia may be a preview of what’s coming nationwide. The One Big Beautiful Bill Act, passed by Congress earlier this year, will require all states to impose similar 80-hour-per-month work mandates by 2027. Supporters argue the bills will support job growth and drive down unemployment, but this framing obscures the real purpose. The national law is designed not to expand opportunity, but to limit enrollment in Medicaid and decrease public spending on social safety-net programs. The results in Georgia and Arkansas indicate that the Big Beautiful Bill will likely succeed at what it was built to do.