Democrats have long tried to persuade red states to expand the federal Medicaid program and bring health insurance to more of their most vulnerable residents. The Biden administration sweetened the pot in 2021 with additional federal money, but GOP officials, including Kemp, have been reluctant to take the offer unless they can tie benefits to employment.

The slow uptake in the Georgia program has done little to change the state’s double-digit uninsured rate, one of the highest in the U.S. And it could dissuade other red states that have yet to expand Medicaid — including nearby Alabama, Mississippi and South Carolina — from following in Georgia’s footsteps even as they come under increasing pressure from the health care industry to expand the government-run health insurance program.

Some in Georgia, however, maintain it’s too early to draw conclusions about the program and that many people may still be unaware the program exists.

“I’ve got my fingers crossed it’s going to be a good solution,” said Georgia state Rep. Lee Hawkins, a Republican who chairs the House health committee. “Getting the word out is always difficult with any new program.”

Georgia is the only state that has a Medicaid work requirement, though Kansas Gov. Laura Kelly, a Democrat, recently proposed one to entice the Republican legislature. Arkansas Republican Gov. Sarah Huckabee Sanders is awaiting federal approval for a similar idea.

Work requirements were a feature of the Trump administration’s plans to overhaul Medicaid, and the Centers for Medicare and Medicaid Services approved them in 13 states. But court rulings and the Covid-19 pandemic snarled implementation, and the Biden administration subsequently rescinded the approvals. Georgia, however, won a federal court challenge in 2022 allowing it to implement the policy while partially expanding Medicaid.

The move followed years of public debate over whether to expand the low-income health insurance program, with Democrats making it the centerpiece of gubernatorial campaigns in 2018 and 2022.

Kemp, who won both those elections, opted instead to limit expanded coverage to adults earning up to the federal poverty line — $14,580 for a single person or $30,000 for a family of four. But coverage for this new group is available only to those who document they are working, studying or volunteering 80 hours a month.

“It feels like a political compromise between people who wanted an expansion and people who didn’t want an expansion,” Pope said. “And it ended up being a fairly slight expansion.”

Republicans in Georgia urge patience and note that the state Medicaid agency has been busy reviewing eligibility for millions of people for the first time since the pandemic.

“As with any newly launched program, we expect enrollment to build over time,” a health department spokesperson said.

Kemp’s office did not respond to a request for comment.

For those on the right who have long wanted to limit Medicaid, the low enrollment numbers are proof that too many people are content to rely on government help that they don’t need instead of finding employment or going to school.

“As so few able-bodied adults are willing to work, train or volunteer even part time to qualify for the Pathways program, it’s clear that a full expansion would discourage employment for those who can work and risk resources meant for the truly needy — low-income children and people with disabilities,” said Jonathan Ingram, vice president of policy and research at the Foundation for Government Accountability.

There is bipartisan agreement that the lack of awareness about the program is also likely contributing to the low enrollment.

“It’s still early, and I think people need to be educated,” said Rep. Buddy Carter (R-Ga.). “I wouldn’t read too much into that at this point.”

For opponents of the limited expansion, the slow start has led to renewed calls for the state to adopt full Medicaid expansion, covering people who earn up to 138 percent of the poverty level without work requirements.

“Pathways to Coverage has cost Georgia more money and covers far fewer people than if the state simply joined 40 other states in expanding Medicaid,” Sen. Raphael Warnock (D-Ga.) said in a statement to POLITICO. “While state politicians continue playing games with people’s lives, Georgians are dying because they can’t afford the health care they need.”

The final judgment on Georgia’s program could determine whether red states try again to impose Medicaid work requirements, especially if a Republican wins the White House.

“Making sure that the path is cleared, and states like Georgia taking the lead, might help create a new pathway that is seen as less full of barriers and obstacles,” said Nina Owcharenko Schaefer, director of the Center for Health and Welfare Policy at the Heritage Foundation. “It’s important to have these kinds of experiments. We have to learn from them. They’re not intended to be, hit it out of the ballpark in one hit.”

In Kansas, Kelly’s proposal — to add a work requirement that is reported once a year — is a concession that comes after five failed attempts to convince the Republican-dominated legislature to expand Medicaid.

The governor’s office rejected the idea that its program will face a similar fate to Georgia’s.

“The reason they’ve struggled to get few enrollees is because of the bureaucratic hurdles people have to jump through to prove they’re working,” said Kelly spokesperson Brianna Johnson.

Arkansas has an application pending before CMS to reinstall work requirements, but beneficiaries won’t lose coverage for not complying. Instead, beneficiaries will receive more care coordination, services and outreach.

The state imposed requirements in 2018, and more than 18,000 people lost coverage over seven months. A federal judge struck down the program in 2019, ruling that work requirements undermine Medicaid’s primary mission to provide health care.

Courts also struck down work requirement programs in New Hampshire and Kentucky. Other states like Arizona and Indiana paused their programs due in part to actions in other states.

Liberals hope the Georgia program’s slow uptake gives states pause before trying anything similar under a future Republican administration.

“Given where we are with the enrollment, it seems that would be extraordinarily foolish,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families. “Never say never, but … the fact that nobody is getting covered doesn’t address the pressures that states are feeling.”