Insurance And Employment After Medicaid Expansion Work Rules

Researchers conducted a quasi-experimental difference-in-differences study to evaluate how Medicaid expansion with work requirements affected insurance coverage and employment among low-income adults in Georgia.

The policy under study—Georgia’s Pathways to Coverage program—was implemented on July 1, 2023, making Georgia the first US state to expand Medicaid while simultaneously imposing work requirements. The analysis focused on adults aged 19 to 64 years with incomes at or below 100% of the federal poverty level.

The study used data from the US Census Bureau’s Household Pulse Survey collected between 2021 and 2024. Investigators compared outcomes in Georgia (the intervention state) with two control groups: neighboring states that did not expand Medicaid (Alabama, Florida, Mississippi, South Carolina, and Tennessee) and, in a secondary analysis, South Dakota, which expanded Medicaid at the same time as Georgia but without work requirements. This design allowed researchers to evaluate both the combined effect of expansion with work requirements and the specific contribution of work requirements relative to expansion alone.

The primary outcomes were self-reported Medicaid coverage, uninsured status, and employment (defined as working for pay or profit within the previous seven days). Multivariable linear regression models were used to estimate adjusted difference-in-differences effects, controlling for demographic characteristics and incorporating time and state fixed effects. In the primary comparison with neighboring non-expansion states, Medicaid coverage in Georgia did not significantly change after implementation (from 35.5% to 32.4%), while coverage in control states also remained stable (39.6% to 39.3%). The adjusted difference-in-differences estimate showed no significant change in Medicaid coverage (−3.0 percentage points; 95% CI, −7.6 to 1.6). Similarly, there was no significant differential change in uninsured rates (−2.3 percentage points; 95% CI, −6.9 to 2.3) or employment (−1.6 percentage points; 95% CI, −8.7 to 5.4) between Georgia and non-expansion states.

In the secondary analysis comparing Georgia with South Dakota, which expanded Medicaid without work requirements, Medicaid coverage increased in South Dakota (36.6% to 44.6%) but did not change in Georgia. This resulted in a significant relative decrease in Medicaid coverage in Georgia compared with South Dakota (−11.7 percentage points; 95% CI, −19.5 to −3.9). There was no significant differential change in employment between the two states (−0.1 percentage points; 95% CI, −9.8 to 9.6).

Sensitivity analyses—including falsification tests in adults aged 65 years or older, leave-one-out analyses of control states, and replication using an alternative national dataset (Current Population Survey Annual Social and Economic Supplement)—produced consistent findings, supporting the robustness of the results.

Overall, the study found that Medicaid expansion with work requirements in Georgia did not increase insurance coverage, reduce uninsured rates, or improve employment during the first 15 months of implementation. Compared with expansion without work requirements, the policy was associated with lower gains in Medicaid coverage without corresponding improvements in employment. These findings suggest that adding work requirements to Medicaid expansion may limit coverage gains without achieving intended labor-market effects.