Georgia helped inspire Medicaid work rules. Its own rules could soon end.

After years of searching for affordable health insurance, Trey Wright discovered Georgia Pathways to Coverage.

The state’s limited Medicaid expansion program allowed the 27-year-old living in the rural city of Jesup in southeastern Georgia to finally visit a primary care doctor regularly. It also covered weekly shots to manage an array of allergies, saving him more than $1,700 a year in out-of-pocket costs, he said.

Gov. Brian Kemp pursued Pathways as an alternative to full Medicaid expansion, which 40 other states and Washington, D.C., adopted as part of the Affordable Care Act to make more low-income people eligible for healthcare coverage.

Launched in 2023, Georgia’s program currently provides health coverage through Medicaid, the federal-state insurance program, to more than 20,000 people. It requires those enrolled to prove they’re working or doing other qualifying activities such as workforce training or community service — and it served, in part, as a model for the Medicaid work requirements that will roll out across most of the country starting Jan. 1.

Now Pathways, one of Kemp’s main health policy initiatives, is slated to expire at the end of the year unless it’s renewed. That would coincide with the Republican’s term ending, leaving his successor with big decisions about the program and challenges delivering on promises for Medicaid.

It was a tight race between Democrat Keisha Lance Bottoms, a former Atlanta mayor who wants to fully expand Medicaid eligibility, and Republican Rick Jackson, a healthcare staffing executive and billionaire who has pitched “intelligent Medicaid expansion” but has provided few details.

Now Bottoms must decide whether the state can afford to bring Pathways in line with new federal Medicaid work rules established under President Donald Trump’s signature One Big Beautiful Bill Act. The federal rules include more exemptions than Georgia’s, and state officials said that would make the program fiscally unsustainable, by expanding coverage to an estimated 100,000 more people.

Joining the states that have expanded Medicaid coverage under the ACA could open the program to an estimated 347,000 uninsured Georgians, according to the Center on Budget and Policy Priorities.

“There’s a lot of opportunity for the next governor 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,” said Leah Chan, director of health justice at the left-leaning Georgia Budget and Policy Institute.

Midterm elections, a looming federal decision

Georgians whose incomes are at or under the federal poverty level — $33,000 per year for a family of four in 2026 — and who complete up to 80 hours of qualifying activities a month are eligible for Pathways.

The future of the program rests heavily with the next governor, who will have to determine whether it’s fiscally sustainable past the end of the year.

Bottoms would “restructure” Pathways to cut through bureaucracy until Georgia fully expands Medicaid, said TaNisha Cameron, a spokesperson for her campaign.

“As governor, she will make meaningful improvements to Georgia’s eligibility and enrollment systems to ensure people can get enrolled and prevent people from being denied simply because of paperwork barriers,” Cameron said.

Bringing the program in line with federal law requires Georgia to offer exemptions to its work rules that it doesn’t now. For example, under the new federal Medicaid work rules as outlined, those who prove they are too sick to work wouldn’t be subject to the reporting requirements. Other groups can get exemptions, too, such as people with substance use disorder or caretakers for people with disabilities.

Georgia officials want the federal government to chip in more to pay for this expanded group of people who would qualify for an exemption. The state made a similar request for additional federal funding when it applied to create Pathways, but it was denied.

A state estimate projects an additional $1.4 billion in spending for this group by mid-2028. And state officials have signaled they may let the program expire at the end of the year if they don’t get the extra cash.

“The state will have no alternative but to make decisions that imperil health policy goals around personal responsibility and healthy choices,” state Medicaid agency officials wrote in their funding request to the Centers for Medicare & Medicaid Services.

CMS said it doesn’t comment on pending requests.

Carter Chapman, a spokesperson for Kemp, said the governor supports the request by the Department of Community Health, Georgia’s Medicaid agency, for enhanced funding and remains “committed, as he always has been, to ensuring Georgians have access to quality healthcare while maintaining fiscal discipline for the state.”

If the federal government grants the request, it could set a precedent for other states to draw down more federal money for limited Medicaid expansions, like Georgia’s, potentially putting the federal government on the hook for additional spending.

“It’s an attractive fiscal offer for states,” said Joan Alker, a health policy researcher and executive director at the Georgetown University Center for Children and Families.

That would reduce the incentives for states to fully expand Medicaid and might even encourage some to roll theirs back, policy researchers said.

But with Georgia’s work requirements serving as a model for the nation’s work rules, the chance of full Medicaid expansion in the state isn’t so far out of reach, said Laura Colbert, executive director of the consumer advocacy group Georgians for a Healthy Future.

“It’s almost kind of silly that our lawmakers continue to hold it at arm’s length when really the federal version is shaped or has been shaped by the Georgia model,” Colbert said.

In the states that fully expanded Medicaid, to keep their coverage enrollees must show they’re working, volunteering, or attending school for 80 hours a month, starting Jan. 1. Some states, such as Nebraska, have already started enforcing the rules. The states that did not expand their Medicaid programs to cover additional low-income adults won’t have to implement the work rules.

Enrollment issues

Full Medicaid expansion would cover people with incomes of up to 138% of the federal poverty level — amounting to $45,540 a year for a family of four using the 2026 figure. But that would require support from Georgia’s legislature, where Republicans in power have held firm against such an expansion for years. If Bottoms were to win the governor’s race, the Democrat couldn’t do the expansion alone: Under a 2014 law, it would require the approval of state lawmakers.

Full expansion would also move hundreds of thousands of Georgians from subsidized Affordable Care Act plans into Medicaid, something opponents have long warned about. Those who make too much to qualify for Georgia Pathways but still make up to 150% of the federal poverty level can qualify for federal ACA subsidies that don’t cost states anything.

But even skimpy private coverage beats being on Medicaid, said Chris Denson, director of policy and research with the right-leaning Georgia Public Policy Foundation.

“It still hopefully gives them better access to see a primary care physician and other specialists than being on Medicaid,” he said.

Former gubernatorial candidate Rick Jackson’s proposal to find an alternative to full expansion would probably have required tinkering with some of Medicaid’s rules, which would need federal signoff. Denson said that would probably take time. Georgia submitted its application for Pathways in 2019, but a protracted legal fight kept it from launching until more than three years later.

But policy researchers worry the state simply doesn’t have the capacity to sign people up if Georgia fully expands Medicaid. They point to the low participation in Georgia Pathways, which has an enrollment process that many have found difficult to navigate. Georgia Gateway, the state’s online portal to apply for social services such as Medicaid and Supplemental Nutrition Assistance Program benefits, has a documented history of glitches, errors, and slow processing times.

Combined, the state and federal government have spent more than $128 million on the Pathways program, according to state data obtained through a public records request. As of Oct. 9, more than three years into the program, 20,606 people were enrolled. The state originally projected more than 25,000 people would be signed up after just one year.

Georgia’s Department of Community Health declined to make any officials available for interviews for this report and did not respond to specific questions about Pathways.

All of this means uncertainty for Pathways enrollees like Trey Wright.

As a part-time worker at a law enforcement training facility, Wright would probably be able to meet the work requirements under full Medicaid expansion, but a transition might not be seamless. He was unaware that he might lose his coverage through Pathways by the end of the year. Getting taken off Medicaid “would suck,” he said. He hopes the new governor can work out some way to help him maintain coverage, he added.

Wright said he cast an early ballot for Bottoms.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF. This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-