Georgia spent $54 million proving people work, and $26 million on their actual care

Georgia has been running this experiment for four and a half years, so nobody has to guess how it turns out.▸ Pathways to Coverage — the country's only live Medicaid work-requirement program — was supposed to prove that conditioning coverage on an 80-hour-a-month work, school, or volunteer requirement was administratively workable. Instead it produced a paper trail showing the opposite: the state has spent more money proving people qualify than it has spent on their actual health care, according to a GAO review released in September 2025. Now that same machinery is being built in every other state. Nebraska switched it on May 1, the first state in the country to do so. Montana followed on July 1. The rest of the country is required to follow by January 2027, under Section 44141 of the 2025 reconciliation law.

Georgia's demonstration didn't start paying for anyone's health care until July 2023 — enrollment was delayed two years past its original 2021 start date.▸ But the state had already been spending on eligibility systems, staff training, and marketing since fiscal year 2021. By the time enrollment began, administrative costs had a two-year head start medical spending never closed.

Of the $80.3 million Georgia has spent on the demonstration, 67.5% — $54.2 million — paid for administering it, not for anyone's medical care.▸ GAO's analysis found that $50.8 million of that went to rebuilding the state's eligibility and enrollment system alone. The federal government picked up 87.6% of the administrative tab, at a matching rate of up to 90% for IT changes — meaning Washington's contribution to Georgia's paperwork exceeded what the state spent on care outright.

Georgia's 2019 application to CMS projected first-year enrollment above 25,000 people, on a full-year-equivalent basis.▸ What the state actually got, per data it reported to CMS and GAO reviewed, was under 3,500 in the first 15 months — later climbing to 7,463 people enrolled as of May 2025. Georgia attributes the shortfall to the delayed launch colliding with the post-pandemic Medicaid "unwinding," when the state was simultaneously redetermining eligibility for its entire caseload. Whatever the cause, the state spent nine-figure sums building a system that, by its own projections, is still enrolling well under a third of the people it expected.

None of this stayed a Georgia problem.▸ Section 44141 of H.R. 1, the One Big Beautiful Bill Act, requires nearly every state to condition Medicaid expansion eligibility on the same 80-hour-a-month work, training, or community-service requirement, with states required to be live by January 1, 2027. The Congressional Budget Office estimates that once fully phased in, about 18.5 million people a year will be subject to the requirement nationwide. By 2034, CBO projects federal Medicaid coverage will fall by 5.2 million adults as a direct result — and because "few of those disenrolled... would have access to and enroll in employment-based coverage," 4.8 million of them are projected to end up uninsured outright, not just off Medicaid.

Georgia is the only state with a multi-year track record, and it is not a flattering one: a program built to filter out people who supposedly shouldn't be on Medicaid instead filtered out people who should have been — the state's own officials confirmed the shortfall wasn't from beneficiaries failing to report their hours, but from the system itself failing to enroll them.▸ CBO's national numbers describe the same mechanism at fifty times the scale.

Georgia figures cover fiscal year 2021 through the second quarter of fiscal year 2025 (ended March 31, 2025), as reported to CMS by May 20, 2025; they do not capture all downstream administrative spending, per GAO. National figures are CBO's 2034 projections for full nationwide implementation and will differ from the eventual state-by-state rollout.