Georgia’s limited Medicaid expansion program is extended through 2026 despite concerns about cost

Georgia has received approval from the Trump administration to extend its Pathways to Coverage program, a partial Medicaid expansion with work requirement components, at least through the end of 2026. An approval letter from the U.S. Centers for Medicare and Medicaid Services that was sent this week to Georgia leaders noted that the temporary extension […]

Gov. Brian Kemp announces changes to Georgia Pathways during the first week of the 2025 legislative session. Ross Williams/Georgia Recorder

Georgia has received approval from the Trump administration to extend its Pathways to Coverage program, a partial Medicaid expansion with work requirement components, at least through the end of 2026.

An approval letter from the U.S. Centers for Medicare and Medicaid Services that was sent this week to Georgia leaders noted that the temporary extension and its amendments are designed to help the program accomplish its goals. 

The federal agency approved changes that were announced early this year, such as exempting caregivers of young children from the program’s work requirement. 

Currently, participants must complete 80 hours of work, job training, education or community service every month – and report that activity to the state. Under the new program rules, those qualifying activities would need to be reported annually instead of monthly as previously required. 

CMS noted that these changes are meant to “increase the number of potentially eligible beneficiaries under the demonstration who qualify for and maintain coverage.”

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Gov. Brian Kemp touted the approval as a collaboration with the Trump administration while criticizing former President Joe Biden administration’s efforts to prevent states from establishing work requirements in order to qualify for Medicaid coverage.

“Unlike the previous administration which chose to sue, obstruct, and delay, President Trump and his team have worked alongside us to improve Georgia Pathways and ultimately deliver a better program to Georgians who need it most. We look forward to continuing that partnership in the months ahead,” Kemp said in a statement Thursday.

The program was extended shortly after the U.S. Government Accountability Office released a report highlighting concerns about the program’s effectiveness and cost. The report was ordered by Georgia Democratic Sen. Raphael Warnock and Sen. Jon Ossoff, along with other lawmakers. The report found that the program came in “over budget and under delivered,” enrolling only 3,500 individuals in its first year, far short of the state’s projected goal of 25,028.

The GAO report found that the administrative spending for the program was substantial. Out of the $80.3 million spent on the program from fiscal year 2021 through the second quarter of 2025, approximately $54.2 million was allocated to administrative costs, with $26.1 million spent on health care benefits for recipients.

CMS’s approval letter acknowledged the low enrollment, noting that as of May 2025, enrollment was approximately 7,463 individuals, and attributes the shortfall to a “general lack of awareness and understanding of the program; a complex and administratively burdensome application process; and a limited set of exemptions and qualifying activities.”

Carter Chapman, a spokesperson for Kemp, said in a statement that Democrats are trying to “rewrite history after four years of inaction” while Georgia had “to fight in court for what was already promised.” The program was first unveiled in 2019, and a five-year agreement was approved in 2020 in the final months of the first Trump term, but it immediately faced scrutiny when Biden took office, leading to a two-year delay in implementation.

The GAO report indicates that administrative spending outpaced spending for medical assistance, but it was likely “driven by the up-front administrative changes needed to implement the demonstration, the delayed start date for enrollment, and any duplication in administrative spending due to the delay.”

“This report was requested by the same individuals who have no new or good ideas for addressing healthcare needs in Georgia. While they try to stand in the way of innovation and blame Republicans, the report itself details how the Biden administration put up roadblocks at every turn to try and stop this Georgia-centric approach to Medicaid coverage,” Chapman said.

Reaction to the program’s extension was mixed

The extension and its policy changes have been met with a mix of praise and criticism.

Natalie Crawford, executive director of Georgia First, a nonprofit think tank and policy advocacy group, said the changes are positive steps but called for a more comprehensive approach.

“More covered lives are always good but we know Georgia can do better,” said Crawford, a former Republican commissioner in Habersham County. Crawford criticized the program as “fiscally irresponsible.” 

In an interview Thursday, Crawford pointed to challenges Georgia will face in 2026 with the state managing two distinct work requirement policies: a less-frequent reporting schedule for the Pathways to Coverage population, while establishing the more frequent reporting requirements under the One Big, Beautiful Bill Act that will be implemented in 2027. That could increase administrative costs for the state, and it’s unclear whether the Pathways to Coverage population will be exempt from less frequent reporting requirements once work requirements under the new federal law are implemented.

“I think there’s still a lot of unknowns,” Crawford said.

The Georgia Hospital Association praised the extension, saying that it “will further strengthen the program and improve coverage and access to health care for Georgians.”

“This continuation further preserves access for the thousands of Georgians that are already benefiting and improves access for additional Georgians that will now find it more streamlined to qualify. We appreciate the Governor, the team at DCH, and CMS for continuing to champion and advance this program,” said Caylee Noggle, president and CEO of the Georgia Hospital Association.

Leah Chan, director of health justice at the Georgia Budget and Policy Institute, said that changing to annual reporting is an improvement for the program, but work requirements are still likely to be an impediment to coverage. She said that while the monthly reporting was burdensome for recipients, it did not account for Georgia’s low program enrollment because the state did not disenroll individuals who did not submit monthly reports to verify their qualifying hours and activities.

“Moving to annual reporting is a critical program pivot and will reduce the administrative burden on enrollees. However, it does not change the fundamental issues that are suppressing enrollment among potentially eligible Georgians and creating unnecessary costs for Georgia’s taxpayers: an outdated, confusing enrollment system; disinvestment in customer service and frontline caseworkers; and unnecessary bureaucratic red tape for low-income, uninsured Georgians that largely are already working, going to school, or caregiving,” Chan said in a statement.

During a recent Health Connect South conference in Atlanta, CMS Administrator Mehmet Oz addressed the Georgia program and defended the concept of work requirements in health coverage. He spoke about the national approach to Medicaid and the changes brought by recent federal legislation.

“I know a lot about the Georgia program. It’s actually known widely around the country, because it’s, I think, a very smart path for states who are not expanding Medicaid, and it might be a path for states that have expanded who want to go back. And it’s a clever and thoughtful and customized approach,” Oz said.

He went on to describe the philosophy behind the requirements, saying that without work requirements, Americans covered by Medicaid may be incentivized not to seek employment.

“The people don’t want to just stay at home. They actually do want to go work, but because of this bizarre compensation and almost bribe for you to stay home by giving you free health insurance, you incentivize people not to enter the workforce,” Oz said.

Crawford pushed back on that notion, saying that she has not seen any “compelling evidence” suggesting that people who would benefit from Medicaid expansion are incentivized to stay home when that coverage does not include a work reporting requirement.

“I think, honestly, when, for that specific population, more red tape is introduced, it can incentivize quite the opposite. These are folks who want to work. They want to work. They’re going to work. They’re trying to pay their bills and do what we so often say, ‘pull themselves up by their bootstraps,’” Crawford said.

Warnock, however, cast Georgia’s program as an example of bad policy.

“The only thing Pathways is incredibly effective at is barring working people from health coverage and making corporate consultants richer,” Warnock said in a statement Thursday. “If Republican politicians were serious about getting people to work, they would have closed the coverage gap nationwide and cut out the government bureaucracy. (Renewing the program) will continue to keep health care away from Georgians who need it most. It is wrong, it is immoral, and it only makes our country sicker and poorer.”