Conditional Medicaid Expansion and Mental Health Outcomes in Georgia.

Importance: 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. Objective: To evaluate changes in mental health outcomes following implementation of Georgia's Pathways to Coverage program. Design, Setting, and Participants: 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-Medicaid 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. Exposure: Implementation of Georgia's Pathways to Coverage Medicaid expansion program. Main Outcomes and Measures: 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. Results: 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; P < .001) when mental health was not good and an increase of 7.2 percentage points (95% CI, 2.4-12.0 percentage points; P = .003) in the probability of ever being told they had a depressive disorder, compared with adults in neighboring non-Medicaid expansion states. Conclusions and Relevance: In this difference-in-differences analysis of national surveillance data, Georgia's 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.