Annual Performance Review — Georgia Pathways to Coverage Pilot
Compliance Infrastructure Assessment, FY2021–Q2 FY2025
Prepared by: Bureau of Eligibility Verification, Cost Containment Division
PROGRAM: Georgia Pathways to Coverage REVIEW PERIOD: Federal Fiscal Year 2021 through Q2 FY2025 ASSESSMENT BASIS: GAO Report GAO-25-108160, publicly released September 18, 2025 PROGRAM STATUS: Extended through December 31, 2026
Section 1 — Program Objectives and Measured Outcomes
The Georgia Pathways to Coverage program was established to reduce Medicaid costs by ensuring that only working-age adults who meet a monthly work-reporting requirement may access healthcare coverage. The program's stated purpose is cost containment through eligibility verification.
The Bureau is pleased to report that the program's eligibility verification infrastructure performed at scale.
Total program expenditure over the review period: $80.3 million.
Of this amount, $54.2 million was directed to administration — the systems, contractors, and compliance personnel required to verify that enrolled participants are, in fact, eligible to be enrolled participants. The remaining $26.1 million was directed to healthcare: the coverage the program exists to gate.
The ratio of administrative expenditure to healthcare expenditure is 2.08:1.
The Bureau records this as a compliance outcome. The gatekeeper is funded. The gate is operational.
BUREAU NOTE: The $54.2 million figure does not represent the full administrative investment. An additional $6 million in CMS-approved administrative costs was not yet reflected at the time of the GAO audit. Consulting fees — primarily from Deloitte, totaling approximately $27 million, plus approximately $10 million in other consulting and legal expenditures — bring total program investment to approximately $86.9 million. The Bureau notes that thorough eligibility verification is a thorough operation. The thoroughness is documented. The healthcare expenditure is $26.1 million. These two figures are in the same report.
Section 2 — Enrollment Performance
As of August 31, 2025, 9,175 individuals were enrolled in Georgia Pathways.
The eligible population is approximately 250,000 low-income Georgians.
Enrollment rate: 3.7 percent.
The Bureau calculates administrative expenditure per enrolled participant at approximately $5,907. This figure represents only the administrative cost column. It does not include the cost of healthcare provided to enrolled participants.
The Bureau presents this figure as evidence that each enrolled participant was verified with exceptional rigor. An eligibility confirmation process costing $5,907 per confirmed person is not a casual process. It is thorough.
The program was extended through December 31, 2026.
Section 3 — The Federal Expansion Initiative
The 2025 budget reconciliation law requires all Medicaid expansion states to implement work reporting requirements by January 1, 2027. Forty-one states will need to build the compliance infrastructure that Georgia has piloted.
To support this effort, the federal government allocated $100 million equally among all 50 states as implementation funding.
This is $2 million per state. Before any systems are built, any staff are hired, or any outreach is conducted.
The Bureau notes that Georgia spent $80.3 million on a single-state pilot. The Bureau further notes that New York has estimated it will require 80 new employees at a cost of $6.2 million for processing alone — which exceeds the full equal-split federal allocation by more than 3:1, before any system is built, before outreach begins, and before the first eligibility check is filed.
The Bureau records no inconsistency here. The Bureau records a federal investment and a demonstrated per-state cost. The reader may perform the arithmetic at their own pace.
BUREAU NOTE: Idaho currently has 40 eligibility worker vacancies. Pennsylvania has nearly 400 open positions. Indiana has 94. Missouri has 1,000 fewer front-line workers than it did a decade ago, managing twice as many enrollees. The Bureau notes that a $2 million implementation grant will not close these gaps. The Bureau further notes that this has been reviewed and the program has been extended.
Section 4 — Implementation Sequencing
States must begin outreach to Medicaid enrollees between June 30 and August 31, 2026. HHS is required to issue implementation guidance by June 1, 2026.
The Bureau presents this sequence without revision: guidance arrives June 1. Outreach begins June 30. States have, at most, 91 days between receiving the rules and beginning mandatory enrollment communications. In practice, depending on guidance publication timing, potentially fewer.
Initial guidance issued in December 2025 was described by independent policy researchers as leaving states without key implementation details.
The Bureau records this as a streamlined launch sequence in which states will contact enrollees about requirements that are, at the time of contact, still being defined. The Bureau regards early communication as a sign of institutional enthusiasm.
Section 5 — Cost Containment Outcomes
The program was designed to contain Medicaid costs. The Bureau documents the mechanism by which this containment is projected to occur.
The Congressional Budget Office projects that 5.2 million adults will lose Medicaid coverage by 2034 as a direct result of work requirements. The CBO found that work requirements would not have any meaningful impact on the number of Medicaid enrollees who are working.
The coverage losses and the employment outcomes are therefore distinct. The mechanism of savings is not the movement of non-working adults off the rolls. The mechanism is documentation failure.
In Arkansas — the only prior state to implement and operate a work requirement before federal courts blocked it — more than 95 percent of the adults who lost coverage under the program either met the work requirement or qualified for a statutory exemption. They lost coverage because they could not document compliance with a monthly online reporting system. More than 85 percent of respondents preferred a reporting method other than the state's computer-only portal. Coverage loss was not a function of working. It was a function of filing.
The Brookings Institution identified the arithmetic consequence of this mechanism: to achieve the projected $44.5 billion in annual savings by 2030, the program must disenroll people it explicitly designates as exempt. Workers who meet the 80-hour monthly threshold. People with disabilities. Caregivers. These populations must be captured by the administrative friction to close the savings gap. The actual population choosing not to work numbers approximately 300,000 adults — generating at most one-third of projected savings at approximately $3,400 per person per year in healthcare costs.
The savings are consistent with the coverage losses. The coverage losses are distributed primarily among the compliant.
BUREAU NOTE: The Bureau is aware that this section describes a cost-containment mechanism that contains costs by removing people who qualify for coverage. The Bureau files this observation as a factual summary of the CBO projection and the peer-reviewed Arkansas evidence, not as an editorial position. The Bureau does not take editorial positions. The Bureau notes that the program generated $54.2 million in administrative expenditure and $26.1 million in healthcare expenditure, and that on September 25, 2025 — seven days after GAO published this finding — the Centers for Medicare and Medicaid Services approved the program's extension through December 31, 2026. The Bureau records the date.
Performance Rating
The Bureau of Eligibility Verification, Cost Containment Division, submits the following assessment for the record.
Georgia Pathways to Coverage has demonstrated that a work-requirement eligibility apparatus, once built, can successfully verify that 9,175 of approximately 250,000 eligible participants are enrolled. The verification cost per enrolled participant exceeds $5,900. The ratio of administrative expenditure to healthcare expenditure is greater than 2:1.
The program has been extended.
The performance review is complete. The eligibility check is funded. The question of what it was checking for is noted in the record and referred to the appropriate division.
Bureau of Eligibility Verification, Cost Containment Division — a sub-bureau of the Bureau of Public Agreement™. The Bureau's cost-containment portfolio was established when the cost of containing costs became worth documenting.