Insurance coverage and employment after Medicaid expansion with work requirements: quasi-experimental difference-in-differences study

Abstract Objective To understand how health insurance coverage and employment changed among working age adults with low incomes in Georgia, the first state to implement Medicaid expansion with work requirements under the Pathways to Coverage program. Design Quasi-experimental difference-in-differences study. Setting Georgia, which expanded Medicaid with work requirements on 1 July 2023; Alabama, Florida, Mississippi, South Carolina, and Tennessee, which neighbor Georgia and did not expand Medicaid; and South Dakota, which simultaneously expanded Medicaid without work requirements. Participants Adults aged 19-64 years with low incomes defined as ≤100% of the federal poverty level who completed the US Census Bureau’s household pulse survey between 2021 and 2024. Main outcome measures Medicaid coverage, uninsured rate, and employment. Results The study population consisted of 3303 adults in Georgia (intervention state) and 14 148 in neighboring states that did not expand Medicaid (controls). After the implementation of Pathways to Coverage, Medicaid coverage did not change in Georgia (35.5% to 32.4%) or in neighboring control states (39.6% to 39.3%), resulting in no differential change in Medicaid coverage between these states (adjusted difference-in-differences −3.0 percentage points, 95% confidence interval −7.6 to 1.6). These patterns were similar for the uninsured rate (−2.3 percentage points, −6.9 to 2.3). Additionally, employment did not increase in Georgia compared with control states (−1.6 percentage points, −8.7 to 5.4). In a secondary analysis that aimed to isolate the effects of work requirements, Medicaid coverage did not change in Georgia (35.5% to 32.4%) but increased in South Dakota (36.6% to 44.6%)—a state that expanded Medicaid without work requirements—resulting in a differential decrease in coverage in Georgia relative to South Dakota (−11.7 percentage points, −19.5 to −3.9). There was no differential change in employment (−0.1 percentage points, −9.8 to 9.6) between these states. Conclusions The implementation of work requirements with Medicaid expansion in Georgia did not increase health insurance coverage or employment during the first 15 months of the program. These findings have important implications as US policy makers recently enacted legislation that will mandate work requirements in Medicaid programs across all US states beginning in 2026.