{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,2]],"date-time":"2026-06-02T19:04:33Z","timestamp":1780427073221,"version":"3.54.1"},"reference-count":29,"publisher":"American Medical Association (AMA)","issue":"6","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"\n Importance<\/jats:title>\n The continuous Medicaid enrollment provision adopted during the COVID-19 pandemic ended in March 2023, after which approximately 24 million individuals were disenrolled. This unwinding was associated with worsening mental and behavioral health, an urgent public health concern in the US. On July 1, 2023, Georgia implemented Pathways to Coverage, a limited Medicaid expansion program that conditions eligibility on meeting monthly work or community engagement requirements.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n To evaluate changes in mental health outcomes following implementation of Georgia\u2019s Pathways to Coverage program.<\/jats:p>\n <\/jats:sec>\n \n Design, Setting, and Participants<\/jats:title>\n This cross-sectional study with a difference-in-differences design used survey data from the national Behavioral Risk Factor Surveillance System. The analysis compared the survey responses of adults residing in Georgia with those of adults residing in neighboring non\u2013Medicaid expansion states (Alabama, Mississippi, Tennessee, and South Carolina). The sample included adults aged 18 to 64 years with household income at or below 100% of the federal poverty level. The preintervention period spanned January 2, 2017, through March 28, 2023, and the postintervention period spanned July 11, 2023, through December 31, 2024. To account for potential confounding related to the end of pandemic-era continuous enrollment, observations from March 29 through July 10, 2023, were excluded.<\/jats:p>\n <\/jats:sec>\n \n Exposure<\/jats:title>\n Implementation of Georgia\u2019s Pathways to Coverage Medicaid expansion program.<\/jats:p>\n <\/jats:sec>\n \n Main Outcomes and Measures<\/jats:title>\n Self-reported number of days in the past 30 days when mental health was not good and self-report of ever having been told that one had a depressive disorder.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n The analytic sample ranged from 7071 to 7259 observations, depending on the outcome, with a total of 8138 observations in all 5 states. The mean respondent age was 46.4 years (95% CI, 46.1-46.7 years). Most respondents (6155 of 8084 [76.1%]) were single, and 1756 (21.6%) resided in Georgia. Among income-eligible adults, implementation of Pathways to Coverage was associated with an increase of 4.0 days per month (95% CI, 2.0-6.0 days per month;\n P<\/jats:italic>\n &amp;lt; .001) when mental health was not good and an increase of 7.2 percentage points (95% CI, 2.4-12.0 percentage points;\n P<\/jats:italic>\n \u2009=\u2009.003) in the probability of ever being told they had a depressive disorder, compared with adults in neighboring non\u2013Medicaid expansion states.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions and Relevance<\/jats:title>\n In this difference-in-differences analysis of national surveillance data, Georgia\u2019s Pathways to Coverage program was associated with worsening mental health among low-income adults. These findings suggest that conditioning Medicaid eligibility on work or community engagement requirements may create additional barriers to coverage and mental health care access, with potential implications for population health and equity.<\/jats:p>\n <\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2026.13934","type":"journal-article","created":{"date-parts":[[2026,6,2]],"date-time":"2026-06-02T18:30:16Z","timestamp":1780425016000},"page":"e2613934","source":"Crossref","is-referenced-by-count":0,"title":["Conditional Medicaid Expansion and Mental Health Outcomes in Georgia"],"prefix":"10.1001","volume":"9","author":[{"given":"Sezen O.","family":"Onal","sequence":"first","affiliation":[{"name":"Department of Health Policy and Management, School of Public Health, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Seth J.","family":"Prins","sequence":"additional","affiliation":[{"name":"Department of Community Health Sciences, School of Public Health, SUNY Downstate Health Sciences University, Brooklyn"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joanne","family":"Constantin","sequence":"additional","affiliation":[{"name":"Department of Health Policy and Management, School of Public Health, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","published-online":{"date-parts":[[2026,6,2]]},"reference":[{"issue":"1","key":"zoi260410r8","doi-asserted-by":"publisher","first-page":"129","DOI":"10.1257\/jep.20231394","article-title":"Administrative burdens in the social safety net.","volume":"39","author":"Herd","year":"2025","journal-title":"J Econ Perspect"},{"issue":"2","key":"zoi260410r9","doi-asserted-by":"publisher","first-page":"367","DOI":"10.1111\/puar.13497","article-title":"The effect of administrative burden on state safety-net participation: evidence from food assistance, cash assistance, and Medicaid.","volume":"83","author":"Fox","year":"2023","journal-title":"Public Adm Rev"},{"issue":"3","key":"zoi260410r15","doi-asserted-by":"publisher","DOI":"10.1001\/jamahealthforum.2025.0092","article-title":"Health characteristics of adults unable to complete Medicaid renewal during the unwinding period.","volume":"6","author":"Soni","year":"2025","journal-title":"JAMA Health Forum"},{"issue":"5","key":"zoi260410r16","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2025.8469","article-title":"Medicaid unwinding and changes in buprenorphine dispensing.","volume":"8","author":"Constantin","year":"2025","journal-title":"JAMA Netw Open"},{"issue":"6","key":"zoi260410r18","doi-asserted-by":"publisher","first-page":"e181","DOI":"10.1016\/j.amepre.2020.01.025","article-title":"Comparisons of estimates from the Behavioral Risk Factor Surveillance System and other national health surveys, 2011-2016.","volume":"58","author":"Hsia","year":"2020","journal-title":"Am J Prev Med"},{"key":"zoi260410r22","doi-asserted-by":"publisher","DOI":"10.1136\/bmj-2025-086792","article-title":"Insurance coverage and employment after Medicaid expansion with work requirements: quasi-experimental difference-in-differences study.","volume":"390","author":"Johnson","year":"2025","journal-title":"BMJ"},{"issue":"7","key":"zoi260410r23","doi-asserted-by":"publisher","first-page":"1057","DOI":"10.7326\/ANNALS-24-03261","article-title":"Insurance coverage among working-age U.S. adults after the end of the Medicaid continuous enrollment provision.","volume":"178","author":"Marinacci","year":"2025","journal-title":"Ann Intern Med"},{"issue":"2","key":"zoi260410r24","doi-asserted-by":"publisher","first-page":"498","DOI":"10.1007\/s11606-024-08886-5","article-title":"Medicaid disenrollment by race and ethnicity in the United States: a national cross-sectional analysis.","volume":"40","author":"Marinacci","year":"2025","journal-title":"J Gen Intern Med"},{"issue":"5","key":"zoi260410r25","doi-asserted-by":"publisher","DOI":"10.1111\/1475-6773.14624","article-title":"The impact of Arkansas Medicaid work requirements on coverage and employment: estimating effects using national survey data.","volume":"60","author":"Gangopadhyaya","year":"2025","journal-title":"Health Serv Res"},{"issue":"8","key":"zoi260410r27","doi-asserted-by":"publisher","first-page":"1208","DOI":"10.2105\/AJPH.2020.305697","article-title":"Work requirements and Medicaid disenrollment in Arkansas, Kentucky, Louisiana, and Texas, 2018.","volume":"110","author":"Chen","year":"2020","journal-title":"Am J Public Health"},{"issue":"6","key":"zoi260410r29","doi-asserted-by":"publisher","first-page":"657","DOI":"10.1177\/1077558710369911","article-title":"Patterns of Medicaid disenrollment for youth with mental health problems.","volume":"67","author":"Pullmann","year":"2010","journal-title":"Med Care Res Rev"},{"key":"zoi260410r1","unstructured":"Coleman? A, Federman? S. Work requirements for Medicaid enrollees. Commonwealth Fund. September 30, 2025. Accessed March 17, 2026. https:\/\/www.commonwealthfund.org\/publications\/explainer\/2025\/sep\/work-requirements-medicaid-enrollees"},{"key":"zoi260410r2","unstructured":"Hinton? E, Rudowitz? R. 5 Key facts about Medicaid work requirements. February 18, 2025. Accessed March 10, 2026. https:\/\/www.kff.org\/medicaid\/5-key-facts-about-medicaid-work-requirements\/"},{"key":"zoi260410r3","unstructured":"Eligibility criteria. Georgia Pathways to Coverage. Accessed March 5, 2026. https:\/\/pathways.georgia.gov\/eligibility"},{"key":"zoi260410r4","unstructured":"Medicaid eligibility and enrollment in Georgia. HealthInsurance.org. Accessed March 1, 2026. https:\/\/www.healthinsurance.org\/medicaid\/georgia\/"},{"key":"zoi260410r5","unstructured":"Gardner? A, Alker? J, Cuello? L. An analysis of Georgia\u2019s Section 1115 Medicaid Pathways to Coverage program. Georgetown University Center for Children and Families. June 27, 2023. Accessed February 20, 2026. https:\/\/ccf.georgetown.edu\/wp-content\/uploads\/2023\/06\/GA-1115-final.pdf"},{"key":"zoi260410r6","unstructured":"Chan? L. Georgia\u2019s Pathways to Coverage Program: the first year in review. Georgia Budget and Policy Institute. October 29, 2024. Accessed February 10, 2026. https:\/\/gbpi.org\/georgias-pathways-to-coverage-program-the-first-year-in-review\/"},{"key":"zoi260410r7","unstructured":"Herd? P, Moynihan? D. How administrative burdens can harm health. Health Affairs Health Policy Brief. October 21, 2020. Accessed December 10, 2025. https:\/\/www.healthaffairs.org\/content\/briefs\/administrative-burdens-can-harm-health-1773889203949"},{"key":"zoi260410r10","unstructured":"Counts? N. Medicaid\u2019s role in mental health and substance use care. The Commonwealth Fund. May 7, 2025. Accessed April 28, 2026. https:\/\/www.commonwealthfund.org\/publications\/explainer\/2025\/may\/medicaids-role-mental-health-and-substance-use-care"},{"key":"zoi260410r11","unstructured":"Zur? J, Musumeci? M, Garfield? R. Medicaid\u2019s role in financing behavioral health services for low-income individuals. Henry J Kaiser Family Foundation. June 29, 2017. Accessed November 10, 2025. https:\/\/www.kff.org\/mental-health\/medicaids-role-in-financing-behavioral-health-services-for-low-income-individuals\/"},{"key":"zoi260410r12","unstructured":"Saunders? H, Euhus? R, Burns? A, Rudowitz? R. 5 Key facts about Medicaid coverage for adults with mental illness. Kaiser Family Foundation. February 21, 2025. Accessed November 10, 2025. https:\/\/www.kff.org\/mental-health\/5-key-facts-about-medicaid-coverage-for-adults-with-mental-illness\/"},{"key":"zoi260410r13","unstructured":"Jennifer? T, Meghana? A. 10 Things to know about the unwinding of the Medicaid continuous enrollment provision. Kaiser Family Foundation. June 9, 2023. Accessed Month\/day\/year. https:\/\/www.kff.org\/medicaid\/10-things-to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-provision\/"},{"key":"zoi260410r14","unstructured":"Medicaid enrollment and unwinding tracker. Kaiser Family Foundation. March 26, 2026. Accessed March 30, 2026. https:\/\/www.kff.org\/medicaid\/medicaid-enrollment-and-unwinding-tracker\/"},{"key":"zoi260410r17","unstructured":"An act to provide for reconciliation pursuant to title II of H. Con. Res. 14. HR 1, 119th Congress (2025-2026). Accessed March 10, 2026. https:\/\/www.congress.gov\/bill\/119th-congress\/house-bill\/1\/text"},{"key":"zoi260410r19","unstructured":"Georgia Medicaid. Accessed December 21, 2015. https:\/\/medicaid.georgia.gov\/"},{"key":"zoi260410r20","unstructured":"Status of state Medicaid expansion decisions. Kaiser Family Foundation. March 30, 2026. 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