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Georgia's program has been closely watched because Republicans throughout the country as part of the tax and budget overhaul signed into law by Trump. Starting in 2027, some adults who seek Medicaid coverage must first show they are working, taking classes or performing community service for at least 80 hours a month.

The Georgia program, which has similar work or activity requirements, has enrolled far fewer people than originally projected, covering 9,175 people as of August. on administrative costs than on providing actual health care. The Kemp administration had projected it would cover 25,000 people in its first year and up to 100,000 eventually.

Critics warn the Georgia experience shows that millions will lose coverage under the Trump law because the administrative process will make it too difficult for them to document their work. Republicans have defended the low enrollment, saying Medicaid should be temporary for people who can get insurance through an employer.

Pathways is Kemp's answer to pressure to expand Medicaid to cover all adults who earn less than 138% of federal poverty line wages, as originally envisioned under President Barack Obama's healthcare overhaul. Georgia is one of 10 Republican-led states that refused to expand coverage. Instead, Kemp launched Pathways, offering coverage to people who earn up to the poverty line — $15,650 a year. Georgia’s traditional Medicaid program still covers poorer children, disabled adults, poor people in nursing homes and a few other very poor adults.

Under the extension, Georgia will offer health coverage of children younger than six without any additional work requirement. The state will also let beneficiaries report qualifying work or activity hours only once a yearly, instead of monthly. Some beneficiaries had said the monthly reporting process was glitchy and hard to use. Insurance will also start on the first day of the month that an application is received, meaning hospitals and doctors will have an incentive to help uninsured patients apply in hopes of getting paid for care already delivered. Right now, coverage doesn't start until after someone is approved.

“Unlike the previous administration which chose to sue, obstruct, and delay, President Trump and his team have worked alongside us to improve Georgia Pathways and ultimately deliver a better program to Georgians who need it most," Kemp said in a statement.

A federal watchdog reported earlier this month that Georgia spent $54.2 million in administrative spending and $26.2 million on health care from 2021 through the middle of 2025. The administrative portion declined more recently, from 96.5% in fiscal year 2023 to 58.8% in fiscal year 2024. It is expected to drop more in 2025.

Nearly 90% of spending has been federal money, and Georgia used $20 million in other federal grants to help implement the program.

Opponents, including Democratic U.S. Sens. Raphael Warnock and Jon Ossoff, deride Pathways as festooned in red tape while funneling money to the private consulting firm that runs it. In a Thursday statement, Warnock said that “the only thing Pathways is incredibly effective at is barring working people from health coverage and making corporate consultants richer."

“Today’s decision will continue to keep health care away from Georgians who need it most. It is wrong, it is immoral, and it only makes our country sicker and poorer,� Warnock continued.