Work Requirements, Surveillance, and the Street: How Conditional Medicaid Expansion Reshapes Drug-Related Arrest Patterns

• In Event: Medicaid Policy and Access to Care: Evidence on Utilization, Outcomes, and System Design

Abstract

Background: Georgia Pathways to Coverage – the only active conditional Medicaid expansion in the United States, requiring monthly work verification as a condition of eligibility – represents a novel and consequential policy experiment with implications that extend well beyond the health system. By imposing administrative burdens that disproportionately screen out individuals with unstable employment, behavioral health conditions, and substance use disorders, conditional Medicaid may alter patterns of community-level policing and criminal justice contact in ways that have received no empirical attention. As federal proposals advance to nationalize Medicaid work requirements beginning in 2027, understanding the full societal consequences of conditionality – including its effects on arrest patterns – is of urgent policy importance.

Purpose: This study estimates the causal effects of Georgia Pathways to Coverage on drug-related arrest rates, drug equipment and paraphernalia arrests, DUI arrests, and liquor violation arrests, providing the first empirical evidence on how conditional Medicaid expansion shapes criminal justice contact related to substance use.

Data: We use 2021-2024 incident-level data from the National Incident-Based Reporting System (NIBRS), aggregated to the state-month level. The analytic sample includes Georgia and nine never-expansion comparison states.
Research Design and Methods: We estimate state-month Poisson difference-in-differences models with state and month fixed effects, using state population as an offset so that coefficients are interpretable as proportional changes in arrest rates. The exposure of interest is Georgia Pathways to Coverage, implemented July 2023. Event-study specifications assess pre-trend parallel assumptions and characterize the dynamic trajectory of effects. Analyses are stratified by arrest type to capture heterogeneity across the spectrum of substance-related criminal justice contact.

Results: Findings reveal a striking and heterogeneous pattern. Conditional Medicaid expansion was associated with a significant decline in broad drug-related arrests (-8.5%; p=0.002) – a counterintuitive finding consistent with reduced community-level drug market activity or shifts in enforcement priorities following partial coverage expansion. In sharp contrast, drug equipment and paraphernalia arrests increased substantially (25.7%; p<0.001), suggesting a shift toward heightened surveillance and enforcement of lower-level possession offenses. DUI arrests also increased markedly (46.3%; p<0.001). Liquor violation arrests trended upward (12.2%) but did not reach statistical significance (p=0.418). Event-study plots support the validity of the parallel trends assumption in the pre-period.

Conclusion and Implications: Conditional Medicaid expansion in Georgia is associated with a complex, heterogeneous reshaping of drug-related arrest patterns – reducing broad drug arrests while simultaneously intensifying paraphernalia and DUI enforcement. These findings are consistent with a surveillance and administrative burden mechanism, whereby individuals excluded from or unable to navigate conditional coverage face greater exposure to punitive systems. At a moment when work requirements are poised to restructure Medicaid eligibility for millions of low-income adults nationwide, this evidence illuminates a dimension of policy harm that extends far beyond the clinic: conditional coverage may deepen the entanglement of marginalized populations with the criminal justice system.

Author

• Joanne Constantin, State University of New York (SUNY) Downstate Health Sciences University
  Presenting Author