Georgia Weighs Letting Its Work-Requirement Medicaid Program Expire

Georgia's limited Medicaid expansion expires Dec. 31 unless the state renews it, and state Medicaid officials have told the federal government they may let it lapse because the program's work rules do not match the ones Washington is about to impose on the rest of the country.

The program, Georgia Pathways to Coverage, was launched in 2023 as Gov. Brian Kemp's alternative to full Medicaid expansion. It covers just over 20,600 people as of Oct. 9, according to state data obtained by KFF Health News through a public records request, and it requires enrollees to document up to 80 hours a month of work, job training or community service to stay covered. State and federal governments have spent more than $128 million on it, and the state originally projected more than 25,000 enrollees after a single year.

Pathways also served as a template for the Medicaid work requirements that begin rolling out in most states on Jan. 1. That timing is the problem. The federal rules, written into the One Big Beautiful Bill Act, grant exemptions Georgia's version does not — including for people with a substance use disorder, caretakers of people with disabilities and people too sick to work.

Why the state says it can't afford the federal version

Georgia's Department of Community Health has asked the Centers for Medicare & Medicaid Services for extra federal matching money to cover the broader exemption list. Without it, the agency wrote in its funding request, the state "will have no alternative but to make decisions that imperil health policy goals around personal responsibility and healthy choices." The state estimates bringing Pathways into line would add roughly 100,000 people to the program and cost $1.4 billion more by mid-2028.

CMS declined to discuss a pending request. Georgia made a similar ask when it first applied to create Pathways in 2019 and was turned down. If the current request succeeds, it would set a precedent for other states running limited expansions to draw more federal money, according to Joan Alker, executive director of Georgetown University's Center for Children and Families, who said it is "an attractive fiscal offer for states."

Whether Pathways survives past New Year's is now a question for the next governor. Kemp is term-limited, and the race between Democrat Keisha Lance Bottoms, a former Atlanta mayor, and Republican Rick Jackson, a healthcare staffing executive, has not been settled. Bottoms wants full Medicaid expansion, which her spokesperson TaNisha Cameron said would come after she "restructure" Pathways to cut through bureaucracy and paperwork barriers. Jackson's campaign did not answer KFF's questions; his website promises to "use better technology" to "transform healthcare," and he has described his approach as "intelligent Medicaid expansion" without details.

Full expansion would still need approval from the Legislature, where Republicans have blocked it for a decade, and state law requires legislative sign-off. The Center on Budget and Policy Priorities estimates 347,000 uninsured Georgians would gain coverage if the state expanded.

What the January rules mean for people in treatment

The federal requirement applies in the 40 states and Washington, D.C., that expanded Medicaid. Enrollees there must show 80 hours a month of work, volunteering or school starting Jan. 1. Nebraska has already begun enforcing it.

For addiction providers, the relevant change is the exemption list. Under the federal rules, a person with a substance use disorder is not supposed to face the reporting requirement — a protection that matters for a population that reaches addiction treatment largely through Medicaid. Georgia's current program offers no equivalent carve-out, and the state's own estimate of 100,000 additional enrollees under the federal version turns on exactly those exclusions.

Georgia officials have argued the federal timetable leaves them exposed either way. If they let Pathways expire and the next governor does not expand Medicaid, roughly 20,600 people would lose coverage without a replacement.

Enrollment that never reached the projection

Policy researchers told KFF that Georgia's enrollment numbers reflect the design of the program rather than demand. Georgia Gateway, the state portal used to apply for Medicaid and food assistance, has a documented history of glitches and slow processing, and Pathways requires enrollees to document qualifying activity month to month. Leah Chan, director of health justice at the Georgia Budget and Policy Institute, said the next governor has "a lot of opportunity to implement changes that are rooted in the realities of Georgians who for so long have been locked out of the ability to achieve optimal health."

Laura Colbert of the consumer group Georgians for a Healthy Future made the opposite case from the same numbers: if Georgia's model shaped the federal rule, she said, it is "almost kind of silly" for state lawmakers to keep full expansion at arm's length. Chris Denson of the right-leaning Georgia Public Policy Foundation countered that even narrow private coverage can give people better access to primary care than Medicaid does.

Twenty-seven-year-old Trey Wright, who lives in Jesup in southeastern Georgia, told KFF that Pathways let him see a primary care doctor and cover weekly allergy shots, saving him more than $1,700 a year. He did not know the program might end in December, and he cast an early ballot for Bottoms.

Other states have already published compliance estimates for the January rollout, among them Indiana, which counted about 58,000 enrollees not yet showing compliance. A federal judge in Boston separately blocked part of the administration's definition of medical frailty on Oct. 29, a ruling that bears on how states must treat people whose conditions make an 80-hour threshold hard to meet — the exemption Georgia says it cannot afford to widen without more federal money.