Georgia faces a fiscal dilemma because work requirements that served as a national model for Medicaid now threaten the state’s limited expansion program. Pathways to Coverage, which covers more than 20,000 people, expires at the end of 2026 unless the next governor renews it. The program requires 80 hours of work, training, or community service monthly to maintain eligibility. Federal rules established under the One Big Beautiful Bill Act mandate more exemptions for people who are too sick to work, people with substance use disorder, or caretakers for people with disabilities. State officials say complying with these federal exemptions would expand coverage to 100,000 more people and cost an additional $1.4 billion by mid-2028.
| Metric | Pathways to Coverage | Full Medicaid Expansion |
|---|---|---|
| Income Limit (Family of 4) | $33,000 | $45,540 |
| Monthly Work Requirement | 80 hours | 80 hours |
| Additional Costs (by 2028) | $1.4 billion | N/A |
The election and program expiration
The expiration of Pathways arrives as Georgia prepares for a gubernatorial election between Democrat Keisha Lance Bottoms and Republican Rick Jackson. Bottoms wants to restructure the program to eliminate paperwork barriers before the state moves to full Medicaid expansion. Jackson, a healthcare staffing executive, proposed "intelligent Medicaid expansion" but provided few details. The Republican-controlled legislature must approve any full expansion that would cover an estimated 347,000 uninsured Georgians. Because of a 2014 law, Democrat Bottoms cannot expand eligibility alone as the state legislature must approve such changes.
Enrollment and administrative hurdles
Enrollment in the current program remains lower than the state anticipated. As of October 9, 2026, the program has 20,606 enrollees, while the state originally projected more than 25,000 people would sign up after just one year. The state and federal governments spent more than $128 million on the program since its launch in 2023. Many applicants found the Georgia Gateway online portal difficult to use because of documented glitches and slow processing times. Trey Wright, a 27-year-old in Jesup, uses Pathways to manage his allergies and save more than $1,700 annually in out-of-pocket costs. He said getting taken off Medicaid "would suck" and hopes the next governor maintains his coverage.
Federal funding and expansion costs
The state Medicaid agency officials told the Centers for Medicare & Medicaid Services that the state would have no alternative but to make decisions that imperil health policy goals around personal responsibility and healthy choices if they do not receive more federal funding. The federal government denied the request for more money to cover these new exemptions. The state made a similar request for additional federal funding when it applied to create Pathways, but the federal government denied it. Policy researcher Joan Alker noted that federal funding for limited expansions is an "attractive fiscal offer for states."
Full expansion would move many people from subsidized Affordable Care Act plans into Medicaid. Opponents warn that these changes could displace people who currently qualify for federal subsidies by making too much for Pathways but earning under 150% of the federal poverty level. Chris Denson, a director with the Georgia Public Policy Foundation, said even limited private coverage provides better access to physicians than Medicaid. The current work requirements in Georgia provided a model for the national rules that will roll out across the country starting January 1. Laura Colbert, executive director of Georgians for a Healthy Future, said it is "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."
