Current law in Georgia reveals clues to how the new work requirements in the bill to enact Trump’s agenda could play out for struggling households
Senate Republicans approved one of the steepest-ever cuts to publicly funded health insurance today, a move expected to result in millions of Americans losing coverage if they can’t properly complete cumbersome applications or prove they’re employed.
If the bill meets full congressional approval, in order to qualify for Medicaid, parents, guardians and relatives caring for youth 14 and older would be among those subjected to new reporting requirements. A section of the 887-page bill titled “Increasing Personal Accountability” states that every six months until they turn 65, those caregivers and other non-disabled adults will have to prove they’ve been working, attending college or a training program, or performing community service for 80 hours a month.
The broader package delivers on many of President Donald Trump’s campaign promises, legislation he’s dubbed the “big, beautiful bill.” The sweeping agenda includes $4.4 trillion in new and extended tax cuts, and increased spending on immigration enforcement and the military. To cover part of the cost, the plan relies on more than $1 trillion in reductions to health care, food aid, higher education and renewable energy investments.
Republican lawmakers have described the legislation as an overdue crackdown on waste, fraud and abuse in government, and a historic victory for working-class families.
House Speaker Mike Johnson of Louisiana hailed the Senate’s razor-thin 51-50 vote and pledged to work quickly to take their final vote on the measure. He added that they intend to deliver the package to Trump’s desk by July 4.
“Republicans were elected to do exactly what this bill achieves,” Johnson stated in a press release today, “secure the border, make tax cuts permanent, unleash American energy dominance, restore peace through strength, cut wasteful spending, and return to a government that puts Americans first.”
Democrats vigorously denied that framing, as did a growing number of economic analysts. Some who voted against the bill have described it as one of the largest transfers of wealth from the poor to the rich in this country’s history.
In interviews, child welfare leaders across the country expressed alarm about how many vulnerable parents and families at risk of CPS involvement could lose health insurance, with possible cascading consequences for their children.
A June analysis produced by Cornell University health policy experts emphasizes that when parents lose their Medicaid coverage or have to incur higher co-pays, “we expect fewer Medicaid eligible kids to be enrolled and fewer Medicaid-covered kids to access healthcare services.”
“The work requirements don’t account for the realities of parenting in poverty,” said Mike Leach, a consultant who led South Carolina’s Department of Social Services from 2019 until January. With a shortage of affordable child care and reliable transportation, “stripping Medicaid for non-compliance could be devastating,” he added.
“The contrary [of] being on government programs is the life of poverty, and if you want to get out of poverty, you’ve got to be in the world of work — and that’s what we’re trying to accomplish through this legislation.”
—Sen. Chuck Grassley of Iowa
If signed by Trump on July 4 as he has pledged, states would be required to start collecting proof of work from Medicaid recipients and applicants at the end of 2026. The provision would apply to those earning up to 138% of the federal poverty line in the 41 states that opted to expand Medicaid under the Affordable Care Act. The poorest families would be exempt, along with disabled or pregnant caregivers, or those over age 64.
Trump has attempted to deflect concerns about millions losing health care coverage, promising Americans last week that “you’re not gonna feel any of it, and your Medicaid is left alone.” In press releases, the White House has also emphasized that the tax cuts include large reductions for low-income families.
The nonpartisan Congressional Budget Office reports the contrary, that wealthy families will see their after-tax income rise dramatically under the proposed tax cuts, and poor families will have less each year due to reductions in Medicaid, nutritional assistance and other social safety net programs.
The Budget Office also estimates the Senate’s version of the so-called megabill will result in nearly 12 million adults losing Medicaid coverage over the next decade, while the liberal Center on Budget Policy and Priorities puts the figure at roughly 16 million, in what would be a historic rollback of Obamacare’s expansion of the six-decade old War on Poverty program.
“The work requirements don’t account for the realities of parenting in poverty.”
—Mike Leach, former leader of South Carolina Department of Social Services
The cuts could also drive more kids into foster care, child welfare experts say.
Several studies have shown steep declines in child maltreatment reports in states that expanded Medicaid last decade, including one that found a nearly 19% decline in cases involving parents of teenagers.
The loss of health coverage would be particularly difficult for low-income households where Medicaid benefits that treat acute mental illness and behavioral health challenges are critical to keeping kids safely home. Even now, those benefits are stretched too thin, with the federal government reporting that 5% of all entries into foster care involve parents “relinquishing” their children to the state because they can’t afford or access adequate care.
Noting those challenges, Leach said the Senate-approved budget that requires caregivers to work for health care benefits and jump through more hoops to apply and stay enrolled “may mean more teens coming into care.”
Family law expert Vivek Sankaran, a frequent contributor to The Imprint’s op-ed section, agreed.
“These work requirements sound so benign on paper,” Sankaran said, “but the bureaucracy of demonstrating that you are working or have an exemption is so complicated.”
Jaia Peterson Lent with the Washington, D.C.-based Generations United, a national nonprofit advocating for relative caregivers, said grandparents raising children will also be at particular risk.
Grandparents often become caregivers outside of the formal child welfare system, so the children coming into their home don’t receive the automatic Medicaid enrollments they would receive in a licensed foster home. More complex applications, and stepped-up work and reporting requirements could leave these extended families uninsured.
Even under current Medicaid rules, Lent said her organization often hears from grandparent caregivers across the country who are forgoing their own health care, or cutting meds in half to ration them, so they can save sparse resources for rent, groceries and basic needs for kids who’ve ended up in their homes. Lent worries the additional burden of the new work requirements and more frequent reporting will further strain these families.
“These caregivers are already facing extremely stressful situations, because many are applying for benefits shortly after the children unexpectedly come into their care,” she said. “We’re concerned that this will leave many overwhelmed and result in leaving children uninsured or at least without the necessary medical care that they may need.”
Republicans call work-for-health care ‘common sense’
Requiring work in exchange for government benefits is a popular and long-standing conservative policy goal. The America First Policy Institute, one of the most influential think tanks in President Trump’s movement, made Medicaid work requirements a cornerstone of his pre-election agenda.
Iowa’s Republican Sen. Chuck Grassley, cofounder of the Senate’s Caucus on Foster Youth, called the work requirements “common sense” in a floor speech last Tuesday. He added that the bill included “reasonable exceptions” for former foster youth up to age 26, parents with children younger than 14, and many other groups.
“The contrary [of] being on government programs is the life of poverty, and if you want to get out of poverty, you’ve got to be in the world of work — and that’s what we’re trying to accomplish through this legislation,” Grassley stated, according to a transcript posted to the Senate website.
“It’s devastating to think if we wouldn’t have had Medicaid, how would we have gotten through that? Would I have been reported? Would my children have been removed from me if I wasn’t able to get them the help they need? … Medicaid is so major and critical in the lives of parents and families.”
—Christina Simmons, Mississippi mother
Yet evidence that SNAP work requirements push people into jobs is thin and inconclusive, and there is even less evidence for Medicaid work requirements. In a New York Times op-ed Friday, leaders of the right-leaning Alaska State Legislature argued “most Alaskans on Medicaid are already working, and these provisions just create more barriers and bureaucracy.”
In a webinar hosted by Georgetown University in March, Christina Simmons, a Mississippi single mother living “at the poverty level” with six children ages 2 to 19, described access to Medicaid as a “safety issue.”
The benefit covers her non-verbal and autistic 19-year-old son’s visits to specialists, and medications that cost more than $500 per month. With such care, he’s graduated from high school. The program also covered her prenatal care, Type-2 diabetes treatment and the “major trauma” of domestic violence, including weekly therapy appointments for herself and her children, which helped them avoid CPS involvement.
“It’s devastating to think if we wouldn’t have had Medicaid, how would we have gotten through that? Would I have been reported? Would my children have been removed from me if I wasn’t able to get them the help they need?” she said. “Medicaid is so major and critical in the lives of parents and families. We wouldn’t have been able to get through that time.”
Georgia’s 2023 law already requires work for some parents’ coverage
As the only state with Medicaid work requirements currently in place, Georgia may offer a preview into what’s to come for other states.
Launched in 2023, Georgia’s Pathways to Coverage was designed to extend Medicaid coverage to people who earn up to 100% of the federal poverty level and did not previously qualify for the state’s Medicaid program. But, unlike any other state, those eligible must also document 80 hours of work or other “qualifying activities” every month.
Gov. Brian Kemp has touted Pathways as one of his key priorities. Pathways covers many of the same services as Medicaid, including doctor visits, hospital stays and prescriptions, without co-pays.
But Leah Chan, director of health justice at the Georgia Budget and Policy Institute, said bureaucratic paperwork barriers and complex requirements have prevented Georgia’s Medicaid program from reaching the low-income populations it is intended to serve.
Although the state initially estimated that around 345,000 people would be eligible for Pathways to Coverage, less than 8,000 are enrolled, Chan said. Gov. Kemp in January announced a proposal to exempt parents of young children from the work requirements.
“This is not filling the gap we have, which means we have Georgians out there who are not getting access to the life-saving coverage they need,” Chan said.
In this way, Chan said Georgia’s Medicaid experiment has already exposed some critical pitfalls in restricting access to basic health coverage — a particular irony since nearly everyone on Medicaid is already working, disabled or in school.
“Georgia really has a lot of lessons learned for other states to understand what the real impact of this is,” she said.
Has Medicaid – or the lack of it – impacted your family? We want to hear from you. Email mfitzgerald@imprintnews.org or stiano@imprintnews.org. And if you’re in Georgia and have experience with Pathways to Coverage, we want to hear from you, too. Email janderson@imprintnews.org.
