Georgia's Pathways to Coverage program was associated with worsening mental health among low-income adults, suggesting that conditioning Medicaid eligibility on work or community engagement requirements may create additional barriers to coverage and mental health care access.
Key Findings
Results
Implementation of Georgia's Pathways to Coverage was associated with a significant increase in the number of days per month when mental health was not good among income-eligible adults.
The program was associated with an increase of 4.0 days per month (95% CI, 2.0-6.0 days per month; P < .001) when mental health was not good
Comparison was made against adults in neighboring non-Medicaid expansion states (Alabama, Mississippi, Tennessee, and South Carolina)
The analytic sample for this outcome ranged from 7071 to 7259 observations depending on the outcome
The sample was restricted to adults aged 18 to 64 years with household income at or below 100% of the federal poverty level
Results
Implementation of Georgia's Pathways to Coverage was associated with a significant increase in the probability of ever being told one had a depressive disorder.
The program was associated with an increase of 7.2 percentage points (95% CI, 2.4-12.0 percentage points; P = .003) in the probability of ever being told they had a depressive disorder
This outcome was measured as self-report of ever having been told by a provider that one had a depressive disorder
The total analytic sample across all 5 states was 8138 observations
1756 respondents (21.6%) resided in Georgia
Background
Georgia's Pathways to Coverage is a conditional Medicaid expansion program that launched July 1, 2023, requiring monthly work or community engagement requirements for eligibility.
The program was implemented on July 1, 2023, following the end of the COVID-19 pandemic continuous Medicaid enrollment provision in March 2023
Approximately 24 million individuals were disenrolled nationally following the end of continuous enrollment
The unwinding of continuous enrollment was itself associated with worsening mental and behavioral health
To account for potential confounding related to the end of pandemic-era continuous enrollment, observations from March 29 through July 10, 2023 were excluded from the analysis
Methods
The study used a difference-in-differences design comparing Georgia residents to residents in neighboring non-expansion states across pre- and post-intervention periods.
Data were drawn from the national Behavioral Risk Factor Surveillance System (BRFSS)
The preintervention period spanned January 2, 2017, through March 28, 2023
The postintervention period spanned July 11, 2023, through December 31, 2024
Comparison states were Alabama, Mississippi, Tennessee, and South Carolina, all non-Medicaid expansion states
The mean respondent age was 46.4 years (95% CI, 46.1-46.7 years), and most respondents (76.1%) were single
Conclusions
The authors conclude that conditioning Medicaid eligibility on work or community engagement requirements may create additional barriers to coverage and mental health care access.
The findings suggest potential implications for population health and equity
The study design was cross-sectional with a difference-in-differences analytic approach
Outcomes were self-reported mental health days and self-reported diagnosis of depressive disorder
The income-eligible population studied had household income at or below 100% of the federal poverty level
What This Means
This research suggests that Georgia's 'Pathways to Coverage' Medicaid program, which requires low-income adults to meet monthly work or community engagement requirements to qualify for health insurance, was associated with worse mental health outcomes compared to similar low-income adults living in neighboring states without Medicaid expansion. Specifically, adults eligible for the program in Georgia reported about 4 more days per month of poor mental health, and were about 7 percentage points more likely to report ever having been diagnosed with depression, after the program launched in July 2023. The researchers used a statistical method called difference-in-differences, which compares changes over time in Georgia against changes in comparable states (Alabama, Mississippi, Tennessee, and South Carolina), to try to isolate the effect of the policy.
The study took place in a complicated context: just before Georgia launched its program, a national policy that had kept millions of Americans continuously enrolled in Medicaid during the COVID-19 pandemic came to an end, causing roughly 24 million people to lose coverage nationally. The researchers excluded data from the transition period to try to separate the effects of that national disenrollment from the specific effects of Georgia's new conditional program. The analytic sample included over 8,000 low-income adults across the five states.
This research suggests that attaching conditions like work requirements to Medicaid eligibility may make it harder for low-income people to obtain and keep health insurance, potentially reducing access to mental health care and worsening mental health at the population level. The findings have potential relevance for ongoing policy debates about whether and how to structure eligibility requirements for public health insurance programs, particularly for vulnerable low-income populations.
Onal S, Prins S, Constantin J. (2026). Conditional Medicaid Expansion and Mental Health Outcomes in Georgia.. JAMA network open. https://doi.org/10.1001/jamanetworkopen.2026.13934