What Three Years of Georgia's Medicaid Work Requirement Show as the Policy Goes National

In 2023, Georgia launched Pathways to Coverage, currently the nation's only Medicaid program that conditions coverage on work. The program operates under a special federal waiver, which allows states to test their own approaches for Medicaid programs. Adults can qualify only by documenting at least 80 hours a month of work, school, or volunteering.  

The state projected 25,000 enrollees in the first year. After two years, about 8,077 Georgians were actively enrolled in Pathways to Coverage as of June 2025—which represents no more than 7% of uninsured, low-income adults from working households in Georgia. Pathways is designed to reach the 180,000–200,000 Georgians who are in a health insurance "coverage gap," which means they are not eligible for traditional Medicaid but also do not earn enough to qualify for the health insurance marketplace under the Affordable Care Act (ACA).

Next year, a version of Georgia’s work requirement is becoming federal law—largely in states that expanded under the ACA. Beginning January 1, 2027, the federal law requires 43 states and the District of Columbia to verify that certain adults covered under the ACA Medicaid expansion and in selected waiver programs, including Georgia’s, are working or engaging in qualifying activities for at least 80 hours a month. Supporters argue that the requirement will encourage employment and keep the program focused on people working toward self-sufficiency.  

Research to date has not found that effect. The Kaiser Family Foundation estimates that 92% of working-age adults on Medicaid are already working or report a reason they cannot, such as caregiving, illness, or school attendance. The Congressional Budget Office projects the requirement will leave around 5 million people losing health insurance coverage over the next decade without meaningfully increasing employment.

Because congressional Republicans cited Georgia's program as a model for the federal law, its results have drawn attention as the rest of the country prepares to newly implement a Medicaid work requirement. 

Rising Administrative Costs for Georgia’s Pathways

Kathleen Adams, PhD, a health economist in the Department of Health Policy and Management at Emory University's Rollins School of Public Health, says the enrollment gap in Georgia likely reflects administrative barriers rather than eligibility.

"You’ve got people in poverty working part time or hourly who now have to take time documenting all of it," Adams said. "Georgia spent enormous amounts of money building the system to verify that, and yet far fewer people than expected have been able to enroll.”

A Government Accountability Office review found the state spent more than twice as much administering Pathways as it did on health care for enrollees, with over $54 million going to administration and roughly $26 million to benefits. However, due to the difficulty confirming the employment of those who work in the informal economy such as house cleaners and landscapers, Georgia has loosened its work verification protocols from monthly to an annual check.

"States have to balance their budgets, and Medicaid is a large part of that," Adams said. "But Georgia's experience suggests the work requirement isn't functioning well as a strategy to reduce preventable health expenses for low-income workers or moving people to self-sufficiency. The state is spending considerable money while eligible people remain unenrolled or ‘churn’ in and out of the program." 

Does Medicaid Policy Translate to Economic Outcomes?  

The policy's central rationale is that work requirements move people into jobs. But an analysis comparing Georgia with neighboring states found no measurable increase in employment during the program's first 15 months. The findings echo Arkansas's brief 2018 trial of work requirements, in which researchers found that 18,000 people lost coverage with no significant short- or long-term change in employment.

Adams says the pattern is consistent with what economists would expect.

"If the goal is more people working, that's a question for economic policy, not Medicaid," she said. "Increases in states’ employment levels are influenced by broader factors such as tax policy—for example, those that brought the film industry to Georgia—and industry investment. Eligibility rules for health coverage are not designed to do that. Companies look for a workforce with the education and skills needed for their businesses, but they also need workers to stay healthy.” 

States Are Watching Georgia  

As the rest of the country prepares for 2027, the questions raised in Georgia are relevant to further policy implementation. States must set up administrative structures to confirm eligibility at application and six-month renewals, as well as to ensure they are providing exemptions appropriately.  

Last month, a coalition of states sued the Centers for Medicare and Medicaid Services over a rule narrowing which "medically frail" enrollees—people with serious illnesses or disabilities—can be exempted from the requirement. And if clinician attestation for medical frailty is necessary, states may need to fund administrative capacity to handle exemption cases.

Adams says the consequences of coverage losses reach beyond those directly enrolled.

"It's your neighbor, your coworker, the person ringing you up at the store," she said. "When people lose coverage, they don't stop getting sick. They show up in the emergency rooms instead, and those costs are shared. A health system works better when the people in it can get care."