What Georgia’s Medicaid work requirement tells us about costs of ‘Big Beautiful Bill’

This article was produced for ProPublica’s Local Reporting Network in partnership with The Current. Sign up for Dispatches to get stories like this one as soon as they are published.

Congressional Republicans, looking for ways to offset their proposed tax cuts, are seeking to mandate that millions of Americans work in order to receive federally subsidized health insurance. The GOP tax and budget bill passed the House in May, and Senate Republicans are working feverishly to advance their draft of federal spending cuts in the coming days.

Georgia, the only state with a Medicaid work mandate, started experimenting with the requirement on July 1, 2023. As the Medicaid program’s two-year anniversary approaches, Georgia has enrolled just a fraction of those eligible, a result health policy researchers largely attribute to bureaucratic hurdles in the state’s work verification system. As of May 2025, approximately 7,500 of the nearly 250,000 eligible Georgians were enrolled, even though state statistics show 64% of that group is working.

Gov. Brian Kemp has long advocated for Medicaid reform, arguing that the country should move away from government-run health care. His spokesperson also told The Current and ProPublica that the program, known as Georgia Pathways to Coverage, was never designed to maximize enrollment.

Health care analysts and former state Medicaid officials say Georgia’s experience shows that the congressional bill, if it becomes law, would cost taxpayers hundreds of millions of dollars in administrative costs as it is implemented while threatening health care for nearly 16 million people.

Here’s how proposed federal work requirements compare to Georgia’s — and how they may impact your state:

How will states determine who is eligible?

What Congress proposes:

The House bill, H.R. 1, and draft Senate proposal require all states to verify that Americans ages 19 through 64 who are receiving Medicaid-funded health coverage are spending 80 hours a month working, training for a job, studying or volunteering. These new verification systems would need to be in place by Dec. 31, 2026, and would have to check on enrolled residents’ work status twice a year. That means people who already receive coverage based on their income level would need to routinely prove their eligibility — or lose their insurance.

The federal work requirements would apply to more than 10 million low-income adults with Medicaid coverage as well as approximately 5 million residents of the 40 states that have accepted federal subsidies for people to purchase private health coverage through what’s commonly known as Obamacare.

The House bill exempts parents with children under 18 from the new requirements, while the Senate version exempts parents with children under 15. Neither bill exempts people who look after elderly relatives.

Georgia’s experience:

Georgia’s mandate applies to fewer categories of people than the proposed federal legislation would. Even so, officials failed to meet the state’s tough monthly verification requirement for Pathways enrollees due to technical glitches and difficulty confirming the employment of those who work in the informal economy such as house cleaners and landscapers because they may not have pay stubs or tax records. The challenges were steep enough that Georgia has decided to loosen its work verification protocols from monthly to once a year.

What this means for your state:

The Congressional Budget Office estimates that H.R. 1 would result in at least 10 million low-income Americans losing health insurance. Health care advocates say that’s not because they aren’t working, but because of the bureaucratic hoops they would need to jump through to prove employment. Research from KFF, a health policy think tank, shows that the vast majority of people who would be subject to the new law already work, are enrolled in school or are unpaid stay-at-home caregivers, duties that restrict their ability to earn a salary elsewhere.

Arkansas is the only state other than Georgia to have implemented work requirements. Republican state lawmakers later changed their minds after data showed that red tape associated with verifying eligibility resulted in more than 18,000 people losing coverage within the first few months of the policy. A federal judge halted the program in 2019, ruling that it increased the state’s uninsured rate without any evidence of increased employment.

House Speaker Mike Johnson, a Louisiana Republican, says Medicaid work requirements in H.R. 1 are “common sense.” He says the policy won’t result in health coverage losses for the Americans whom Medicaid was originally designed to help because the work requirements won’t apply to these groups: children, pregnant women and elderly people living in poverty. He points to the $344 billion in a decade’s worth of projected cost savings resulting from Medicaid work requirements as beneficial to the nation’s fiscal health. “You find dignity in work, and the people that are not doing that, we’re going to try to get their attention,” he said earlier this year.

Who will pay for work verification system in each state?

What Congress proposes:

The House bill allocates $100 million to help states pay for verification systems that determine someone’s eligibility. The grants would be distributed in proportion to each state’s share of Medicaid enrollees subject to the new requirements — an amount health policy experts say will not be nearly enough. States, they say, will be on the hook for the difference.

Georgia’s experience:

In the two years since launching its experiment with work requirements, Georgia has spent nearly $100 million in mostly federal funds to implement Pathways. Of that, $55 million went toward building a digital system to verify participants’ eligibility — more than half the amount House Republicans allocated for the entire country to do the same thing.

Like other states, Georgia already had a work verification system in place for food stamp programs, but it contracted with Deloitte Consulting to handle its new Medicaid requirements. Georgia officials said the state has spent 30% more than they had expected to create its digital platform for Pathways due to rising consultant and IT costs. Deloitte previously declined to answer questions about its Pathways work.

What this means for your state:

All states already verify work requirements for food stamp recipients, but many existing systems would need upgrades to conform to proposed federal legislation, according to three former state Medicaid officials. In 2019, when states last considered work requirements, a survey by the nonpartisan Government Accountability Office showed that Kentucky expected administrative costs to top $200 million — double what H.R. 1 has allocated for the country.

Rep. Buddy Carter, the Republican who represents coastal Georgia and chairs the health subcommittee of the House Energy and Commerce Committee, which had recommended Medicaid cuts in H.R. 1, said that upfront costs borne by states would be offset by longer-term savings promised in the House bill. Some congressional Republicans concede that the cost savings will come from fewer people enrolling in Medicaid due to the new requirements. Savings from work mandates amount to 43% of the $793 billion in proposed Medicaid cuts, according to the Congressional Budget Office.

How will states staff the program?

What Congress proposes:

Medicaid is a federal social safety net program that is administered differently in each state. Neither H.R. 1 nor the Senate legislative proposal provides a blueprint for how states should verify eligibility or how the costs of overseeing the new requirements will be paid.

Georgia’s experience:

Georgia’s experience shows that state caseworkers are key to managing applications and work requirement verifications for residents eligible for Medicaid. The agency that handles enrollment in federal benefits had a staff vacancy rate of approximately 20% when Georgia launched its work requirement policy in 2023. Georgia at the time had one of the longest wait times for approving federal benefits. As of March, the agency had a backlog of more than 5,000 Pathways applications. The agency has said it will need 300 more caseworkers and IT upgrades to better manage the backlog, according to a report submitted to state lawmakers in June.

What this means for your state:

Former state Medicaid officials and health policy experts say Georgia’s staffing struggles are not unique. In 2023, near the end of the COVID-19 public health emergency, KFF surveyed states about staffing levels for caseworkers who verify eligibility for federal benefits, including Medicaid. Worker vacancy rates exceeded 10% in 16 of the 26 states that responded; rates exceeded 20% in seven of those states.

Adding caseworkers will mean higher costs for states. Currently, 41 states require a balanced budget, meaning that those state legislators would either need to increase taxes and revenues to verify Medicaid enrollees are working or lower enrollment to reduce costs, said Joan Alker, executive director of Georgetown University’s Center for Children and Families.

In about half a dozen large states where county governments administer federal safety net programs, the costs of training caseworkers on the new verification protocols could trickle from states to counties.

“There are provisions in there that are very, very, very challenging, if not impossible, for us to implement,” Sen. Lisa Murkowski, an Alaska Republican, told reporters in June of the costs facing her state to meet the House bill requirements.

Related