Medicaid Expansion: Georgia's Access Problem

Within a day of retaking the Governor’s Mansion and the state House for the first time in over two decades, Georgia Democrats began discussing their plans to achieve a longstanding policy goal: full Medicaid expansion.

The only question that seemingly remains is how Senate Republicans will respond, given their narrow 29-27 majority, and the fact that five caucus members have previously backed some form of Medicaid expansion for low-income adults earning up to 138% of the federal poverty level.

The timing adds complications. Georgia Pathways, Gov. Brian Kemp’s alternative to full expansion, is set to expire Dec. 31. In October, the Kemp administration asked the federal government to extend the program and raise the federal share of Pathways costs from roughly 67% to 90%. The Trump administration denied the same request in 2019.

Gov.-elect Keisha Lance Bottoms has pledged to scrap Pathways altogether in favor of full expansion. That leaves the status of the program’s roughly 18,000 enrollees unresolved. Even if lawmakers pass a full Medicaid expansion bill early in the 2027 session, federal approval and new enrollment systems will take months, and turnover in Congress and an increasingly lame-duck presidency add their own uncertainty.

Scrapping Pathways, however, won’t scrap work requirements. The One Big Beautiful Bill Act kept the 90% federal match for the expansion population but attached new strings. Starting Jan. 1, 2027, able-bodied expansion adults nationwide must complete 80 hours a month of work or other qualifying activities.

The law also caps state financing mechanisms that have grown in scope and cost. For example, state-directed payments, which are supplemental Medicaid payments to hospitals and other providers, are capped at 100% of Medicare rates in expansion states, compared with 110% in nonexpansion states. Beginning in 2028, higher payments will be phased down. Expanding Medicaid would lower Georgia’s ceiling for these payments.

But even if Georgia finally expands Medicaid — more than 15 years after the Affordable Care Act made it possible — significant structural problems in the state’s healthcare system need to be addressed before hundreds of thousands of able-bodied Georgians are added to the Medicaid rolls.

Only 48% of Georgia’s roughly 28,000 practicing physicians report accepting new Medicaid patients, according to the Georgia Board of Health Care Workforce.

Low participation is most often attributed to Medicaid’s low reimbursement rates. With expansion expected to cost the state hundreds of millions of dollars, raising those rates enough to persuade more providers to accept Medicaid patients remains unlikely, especially as its undesignated budget surplus dwindles.

Of Georgia’s 159 counties, 151 are federally designated as medically underserved, a sign that the state’s healthcare provider shortage touches virtually every community.

Georgia ranks 38th among the 50 states in active patient care physicians, with just 218 physicians per 100,000 residents compared to the national average of 255; the state would need about 4,400 more physicians just to match the national average, according to the Georgia Higher Education Healthcare Initiative.

Georgia’s physicians are also unevenly distributed. According to the Georgia Board of Health Care Workforce’s most recent licensure data, 10 counties did not have a single practicing physician, 42 lacked an internal medicine physician, 63 had no pediatrician and 82 had no OB-GYN.

That means that before expanding Medicaid, lawmakers should consider two ways to increase access to healthcare.

Legislators should repeal certificate-of-need laws. The landmark Oregon Health Insurance Experiment found that Medicaid coverage increased emergency department use by about 40%, including for nonemergency care. New Medicaid patients will keep going to the ER; the difference is that taxpayers will foot more of the bill, for more visits than before.

Meeting that demand, and steering patients toward lower-cost settings, will require new healthcare facilities, from hospitals and freestanding emergency departments to urgent care centers and outpatient clinics. While lawmakers loosened the requirements for certain facilities and service lines in 2024, the program should be repealed entirely.

Legislators should also expand practice authority for nurse practitioners and physician assistants to deliver primary care. Reasonably expanding the scope of practice for advanced practice registered nurses, physician assistants and other medical professionals could improve access to care and help address physician shortages in many parts of Georgia.

Supporters of expansion may soon have the votes to change who receives a Medicaid card. Whether that card gets anyone through a doctor’s door depends on what lawmakers do first.