Case Study: Georgia

In July 2023, Georgia began a highly touted, but very limited, expansion of its traditional Medicaid program to cover individuals earning up to 100 percent of the FPL who reached a similar 80-hour monthly threshold of work, volunteer activity, study, or vocational rehabilitation. The Georgia work requirement did not have exemptions for parents or other full-time caregivers. Although the state estimated that nearly 240,000 people would qualify for Medicaid and that nearly 75,000 people would enroll in the first two years, the actual numbers have been much lower. In its first two years, the Georgia Pathways to Coverage Section 1115 waiver enrolled fewer than 12,000 people.^10,11

Within its first year, the program’s administrators had a backlog of more than 16,000 cases. Like Arkansas’ burdensome approach, Georgia initially required enrollees to submit monthly work hours with monthly certification but then switched to only recertifying or checking the submitted hours annually, citing administrative burden. Had the state pursued the Affordable Care Act’s Medicaid expansion to cover individuals up to 138 percent of the FPL without work requirments, Georgia would have received $1 billion in federal funds for two years which would have offset cost increases associated with expansion, drawn a 90 percent federal match for newly eligible enrollees, and cost the state less than $500 per new enrollee. Instead, Pathways has cost Georgia more than $86.9 million in combined state and federal funds and costs nearly $13,000 per person.^12,13

Traditional Medicaid versus Medicaid Expansion

Medicaid generally covers individuals who quality for Supplemental Security Income, individuals with disabilities, pregnant women, and low-income children and parents. The federal minimum eligibility levels for children and pregnant individuals are effectively set at 138% of the federal poverty level (FPL), but in the 10 states that did not expand Medicaid, adults without dependent coverage are not eligible for Medicaid coverage regardless of their income level. In the 40 states that expanded Medicaid following the passage of the Affordable Care Act in 2010, the median coverage level for parents and adults without dependent children is 138% FPL, compared to states have not adopted the ACA expansion, the median eligibility for parents was 33% FPL.^14,15

Implications for Federal Implementation

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By implementing Medicaid work requirements nationwide, there may be real short-term cost savings accrued to the U.S. federal government. However, the long-term cost of limiting access to coverage may outweigh these short-term gains. The Congressional Budget Office projected work requirements would reduce federal spending by $326 billion over 10 years.^3,16 The bulk of these potential savings results from an additional 4.8 million people losing Medicaid coverage by 2034 because of work requirements.^3,16 These potential savings must be weighed against the harms of decreased access to insurance and loss of preventive medical care that will affect those individuals unable to comply with the actual work or with the administrative burden of submitting documentation under Medicaid work requirements.