The introduction of work requirements for certain adults enrolled in the US health insurance program Medicaid has so far failed to boost insurance coverage or employment rates, finds a study published by The BMJ today.
It shows that health insurance coverage and employment did not increase after Georgia implemented Medicaid expansion with work requirements. Work requirements are due to be rolled out across the US in 2026 as part of the "One Big Beautiful Bill Act."
Georgia was the first state to expand Medicaid with work requirements under the Pathways to Coverage program in 2023, but little is known about the impact of this approach on insurance coverage rates and employment.
To find out, researchers drew on data for 17,451 working-age adults (aged 19-64 years) with low incomes who completed the US Census Bureau's Household Pulse Survey between 2021 and 2024.
They included 3,303 adults in Georgia (intervention state) and 14,148 in five neighboring states – Alabama, Florida, Mississippi, South Carolina, and Tennessee – that did not expand Medicaid (controls) in the analysis.
The results show that 15 months after the implementation of Pathways to Coverage, Medicaid coverage did not change substantially in Georgia (35.5% to 32.4%) when compared with neighboring control states (39.6% to 39.3%), resulting in no differential change in Medicaid coverage between these states.
There was also no significant change in employment among adults with low incomes in Georgia compared with those in control states.
In an additional analysis that aimed to isolate the effects of work requirements, Medicaid coverage decreased in Georgia by almost 12 percentage points compared with South Dakota – a state that expanded Medicaid without work requirements – and there was no change in employment between these states.
Possible explanations include the fact that many working-age Medicaid beneficiaries either already work or are unable to work, explain the authors, and a burdensome eligibility and enrollment process.
They acknowledge several limitations, such as relying on self-reported outcomes, a low survey response rate, and a focus on changes in outcomes during the program's first 15 months, so further research is needed to understand the long term implications.
Nevertheless, they conclude: "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."
These findings have important policy implications given US policymakers' recent decision to mandate Medicaid work requirements nationwide beginning in 2026, they add.
