South Dakota’s traditional Medicaid expansion without work requirements resulted in significantly higher coverage gains than Georgia’s Pathways to Coverage program with mandatory work requirements during the first 15 months of implementation, according to a study published Monday, October 6, 2025 in The BMJ.
The research compared Georgia’s approach with South Dakota, which expanded Medicaid on the same date — July 1, 2023 — but without imposing work mandates. Medicaid coverage increased in South Dakota from 36.6 percent to 44.6 percent among low-income adults, while Georgia’s coverage decreased from 35.5 percent to 32.4 percent, resulting in an 11.7 percentage point differential decrease in Georgia relative to South Dakota, according to the study.
South Dakota voters approved Medicaid expansion through a 2022 ballot measure by a 56 percent to 44 percent margin, extending coverage to adults with incomes up to 138 percent of the federal poverty level, according to HealthInsurance.org, which tracks state Medicaid programs. By October 2024, almost 28,000 people had enrolled under the expanded eligibility guidelines, the site reported.
The findings carry particular significance for the Northern Plains region as South Dakota navigates complex healthcare policy decisions. In 2024, voters approved Constitutional Amendment F with 56 percent support, authorizing state officials to seek federal approval for work requirements on able-bodied adults receiving expanded Medicaid, according to Ballotpedia. However, no work requirements have been implemented to date, South Dakota Searchlight reported.
In November 2026, South Dakota voters will decide on Constitutional Amendment I, which would condition Medicaid expansion on federal funding remaining at or above 90 percent, according to Ballotpedia. If federal support falls below that threshold, the constitutional requirement for Medicaid expansion would no longer apply. The South Dakota Legislature approved the measure for the ballot by 31-3 in the Senate and 59-7 in the House, according to South Dakota Searchlight.
Researchers from Beth Israel Deaconess Medical Center and Harvard Medical School found that Georgia’s work requirements — mandating at least 80 hours monthly of qualifying activities such as employment, community service or higher education — created administrative barriers that prevented coverage gains.
Of more than 110,000 people who elected to be considered for Pathways to Coverage during Georgia’s Medicaid application process, only 5 percent ultimately enrolled, while approximately 50 percent were denied coverage owing to failure to report qualifying activities or not meeting activities requirements, according to the study.
Neither Georgia nor South Dakota showed employment increases compared to control states, with no differential change in employment between the two states, challenging the premise that work requirements promote job participation, the researchers found.
The research arrives at a critical juncture for Medicaid policy nationwide. Congress recently enacted legislation that will mandate work requirements in Medicaid programs across all U.S. states beginning in 2026.
At the federal level, proposed Medicaid work requirements would mandate those between 19 and 65 who rely on the state-federal health program to work, participate in community service or attend an educational program for at least 80 hours each month, according to South Dakota Searchlight.
South Dakota’s Medicaid enrollment stood at almost 147,000 by late 2024, after experiencing initial disenrollments during the post-pandemic “unwinding” period when states resumed eligibility redeterminations, according to HealthInsurance.org.
Ben Hanson, North and South Dakota government relations director for the American Cancer Society Cancer Action Network, said barriers to accessible and affordable health care hurt South Dakotans in the long run, according to South Dakota Searchlight. He said he worries work requirements at the state or federal level will burden employees and small business owners with paperwork.
Despite the 2024 voter authorization, South Dakota has not yet applied for federal permission to impose work requirements, South Dakota Searchlight reported.
The study analyzed U.S. Census Bureau Household Pulse Survey data from 17,451 working-age adults with low incomes across multiple states between 2021 and 2024.
