The numbers tell an inconvenient story. When Georgia became the first state to tie Medicaid coverage to work requirements in 2023, officials predicted up to 345,000 people would qualify and roughly 64,000 would enroll. Instead, insurance coverage stalled and employment stayed put, raising questions about a policy model that Congress just mandated for the entire nation starting in 2026.
A new study in The BMJ tracked 17,451 low-income adults across Georgia and neighboring states from 2021 through 2024, comparing outcomes before and after Georgia’s Pathways to Coverage program launched. The results suggest the administrative burden of proving you work each month may do more harm than the expansion does good.
The Coverage That Wasn’t
Medicaid coverage in Georgia drifted from 35.5% to 32.4% among eligible adults during the program’s first 15 months. Meanwhile, five neighboring states that didn’t expand Medicaid at all (Alabama, Florida, Mississippi, South Carolina, and Tennessee) saw their rates hold essentially steady at around 39%. The statistical difference between these trends? Effectively zero.
Employment numbers showed a similar lack of movement. Despite work requirements mandating 80 hours monthly of job activity, community service, or education, the percentage of low-income Georgians reporting employment didn’t budge compared to control states.
“In this study, we found that Pathways to Coverage did not change Medicaid coverage or the uninsured rate during its first year compared with states that did not expand Medicaid to adults with low incomes, suggesting the program’s goal of increasing insurance coverage [and employment] has not yet been met.”
Perhaps more revealing was what happened when researchers compared Georgia to South Dakota, which expanded Medicaid the same month without work requirements. South Dakota’s Medicaid coverage jumped from 36.6% to 44.6%. Georgia’s stayed flat. That’s an 11.7 percentage point difference, and still no employment gains to show for it.
The mechanics of failure are buried in the enrollment data. Of the 110,000 people who started Georgia’s application process, only 5% made it through to coverage. Half were denied for failing to report their work hours properly or not meeting activity requirements: an administrative gauntlet that seems to trip up even people who actually qualify.
When Requirements Become Barriers
The policy rests on a premise that research keeps questioning: that people on Medicaid aren’t working and need incentives to start. Multiple studies suggest most working-age Medicaid beneficiaries either already hold jobs (often without employer insurance) or face genuine barriers to employment that a reporting requirement won’t solve. Childcare. Transportation. Disabilities that don’t quite meet exemption criteria.
Arkansas tried this approach from 2018 until a federal judge halted it. Coverage dropped 13 percentage points in six months among the affected age group. Employment? No change. Georgia’s 15-month experiment is producing eerily similar results, though state officials have requested a five-year extension and some lawmakers argue the program encourages self-sufficiency.
The timing makes these findings particularly consequential. The One Big Beautiful Bill Act doesn’t just allow work requirements; it mandates them across all 50 states by the end of 2026. Several non-expansion states were already pursuing similar programs through federal waivers. Georgia was supposed to be the proof of concept.
The study authors acknowledge limitations. The Census Bureau’s Household Pulse Survey has a response rate of just 5 to 7%, though weighting adjusts for non-response. Outcomes were self-reported. The 15-month window may not capture longer-term effects, and state-level variation in how Medicaid unwinding was handled after pandemic protections ended could muddy the picture.
Still, the pattern holds across multiple sensitivity analyses. When researchers looked at adults over 65 (ineligible for the program but subject to other policy changes like Medicaid unwinding) there was no differential change in coverage between Georgia and control states. The effect appears specific to the work requirement itself.
“These findings have important policy implications given US policymakers’ recent decision to mandate Medicaid work requirements nationwide beginning in 2026.”
Health policy tends to move slowly, which makes natural experiments like Georgia’s valuable even when the results are disappointing. Medicaid now covers roughly one in five Americans, making it the country’s largest health insurance program. What happens when you add a monthly paperwork hurdle to coverage matters at scale.
For now, Georgia’s data suggests that requiring proof of work doesn’t increase working; it just decreases insuring. Whether that finding will influence the nationwide rollout remains unclear. The policy is already law. The evidence is still arriving.
The BMJ: 10.1136/bmj-2025-086792
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