Georgia Medicaid Expansion vs. Private-Plan Options: What Comes Next?

2027 will almost certainly bring substantial change for Georgia Medicaid, the state’s health insurance program for the poor and disabled.

Georgia Pathways to Coverage, Gov. Brian Kemp’s alternative to full Medicaid expansion under the Affordable Care Act, is set to expire at the end of 2026. The Georgia Department of Community Health (DCH) announced a proposed extension in August 2026, asking the federal government to raise its share of Pathways costs from about 67%, the state’s traditional Medicaid match, to 90%.

At the time of this publication, DCH was accepting public comments and had not yet officially submitted its extension request to the Centers for Medicare & Medicaid Services (CMS). Neither nominee to succeed Gov. Kemp has committed to extending Pathways. Democrat Keisha Lance Bottoms supports full Medicaid expansion, while Republican Rick Jackson has proposed an “intelligent Medicaid expansion” that would rely on enhanced federal funding and flexibility.

This policy brief examines the current data and costs associated with Georgia Medicaid and provides an analysis of the landscape moving forward.

Who is Covered by Georgia Medicaid?

There are two “traditional” groups covered by Georgia Medicaid: the aged, blind, disabled (ABD) population and the low-income population. According to the most recent data from the Georgia Board of Healthcare Workforce, fewer than 50% of Georgia physicians accept new Medicaid patients. 

The ABD population consists of Georgians with limited income and resources who are aged 65 or older, legally blind, and/or totally disabled; individuals in a nursing home; individuals in hospice; and children enrolled in the Georgia Pediatric Program (GAPP). The low-income population covers women who are pregnant, including labor and delivery and for up to 12 months after giving birth; children under 19; parents/caretakers with children; women with breast/cervical cancer; and most children who are wards of the state.

Income limits vary by group. Children under 1 qualify up to 210% of the federal poverty level (FPL), children ages 1–5 up to 154%, children ages 6–18 up to 138%, and pregnant women up to 225%, while parents and caretakers qualify only up to 36% FPL.

Following the Supreme Court’s 2012 decision in NFIB v. Sebelius, which made the ACA’s Medicaid expansion optional, states could choose to expand Medicaid coverage to able-bodied, working age adults at 138% FPL or below. The federal government covers 90% of this cost, while the state covers the remaining 10% (commonly referred to as 90/10). This was a significant inducement because it represented a higher cost share than what the federal government provides for the traditional Medicaid population, which is about 67% in Georgia. Forty states and the District of Columbia have adopted Medicaid expansion.

Even without expansion, Georgia’s Medicaid enrollment has continued to grow. Between 2000-2019, total Medicaid enrollment in Georgia doubled from 947,000 recipients to more than 1.9 million. This was an increase from 12% of the state population in 2000 to over 18% by 2019. Total spending on Georgia Medicaid during this time also grew from $3.5 billion to $10.3 billion, not including PeachCare for Kids.

According to DCH, Medicaid enrollment in July 2025 totaled 2,185,620 Georgians: 1,587,559 in managed care (Georgia Families, which mainly serves the low-income population) and 598,061 in fee-for-service (mainly the ABD population). Another 477,203 children were enrolled in PeachCare for Kids. In the current state budget (FY27), total federal and state spending on the ABD population ($9,781,068,939) and low-income population ($8,533,825,451) was projected to be over $18.3 billion.

Georgia Pathways (“1115 Waiver”) and Georgia Access (“1332 Waiver”) 

In 2019, Gov. Kemp announced the state would pursue an 1115 Medicaid waiver for low-income Georgians as an alternative to Medicaid expansion. In conjunction with the 1115 waiver, his administration would also pursue a 1332 waiver for Georgia’s health insurance marketplace. This would include reinsurance and the creation of a state-based exchange for Georgians shopping for health insurance on the individual marketplace, replacing healthcare.gov.

Georgia Pathways officially launched in July 2023, covering Georgians aged 19-64 with household incomes up to 100% FPL, and who complete 80 hours per month of qualifying activities, including employment, job training, enrollment in postsecondary education, community service and, since October 2025, participating in SNAP Works or caring for a Medicaid-enrolled child under six.

Low-income Georgians are also eligible to receive subsidized private health insurance through Georgia Access, the state’s marketplace. Georgians at 100–150% FPL qualify for premium tax credits and, if they choose a Silver plan, a 94% cost-sharing reduction (CSR) that lowers their deductibles and copays. Under the 2027 premium tax credit schedule, the benchmark premium is capped at 2.15% of income for those between 100–133% FPL, and there is a tiered cap for those with incomes between 133–150% FPL (3.23% to 4.3%). For a single Georgian at 100% FPL, this means a maximum expected contribution of about $29 a month for the benchmark Silver plan, and approximately $65 a month at 138% FPL.

These figures reflect the end of the enhanced federal premium subsidies, which expired at the end of 2025 and had allowed enrollees at 100–150% FPL to buy a benchmark Silver plan with no premium. After they expired, Georgia’s effectuated marketplace enrollment fell 8% across all income levels, from 1,298,071 in 2025 to 1,188,140 in 2026, according to KFF’s analysis of CMS data.

Premium tax credits can be applied to any plan. For example, in Georgia, a low-income enrollee’s premium tax credit can often cover the full cost of a Bronze plan, making it free. However, Bronze plans have high deductibles, which often exceed $7,000, and out-of-pocket maximums of up to $12,000 in 2027. A 94% CSR Silver plan charges a modest premium, roughly $29–$65 a month for the benchmark plan at 100–138% FPL, but typically has a $0 to low deductible, small copays, and an out-of-pocket maximum of no more than $4,000 for an individual in 2027. For single enrollees earning between $16,000–$22,000 a year, Silver represents better protection against recurring medical costs, while Bronze mainly guards against catastrophic expenses and offers health insurance (if not necessarily care) without monthly premium costs to the beneficiary. While some states provide additional funding for premium tax credits, in Georgia, state tax funds do not cover or supplement individual health insurance premium tax credits.

Recent Federal Changes to Medicaid Financing

While the One Big Beautiful Bill Act (OBBBA) did not eliminate the ACA’s 90/10 match for Medicaid expansion, it enacted stricter limitations for expansion states. It also eliminated the incentive for non-expansion states that was included in the American Rescue Plan Act of 2021: a two-year, 5-percentage-point increase in federal matching funds for traditional Medicaid.

Effective January 1, 2027, community engagement requirements similar to Georgia Pathways will apply to able-bodied expansion adults nationwide. Then, beginning October 1, 2028, expansion adults between 100–138% FPL will also face new cost sharing of up to $35 per service. Primary care, mental health care, substance use disorder treatment and services at federally qualified health centers and rural health clinics are exempt, and prescription drug cost sharing is limited to nominal amounts.

The OBBBA also implemented limits on many of the Medicaid financing mechanisms at the state level, including provider fees and state-directed payments. Many states, including Georgia, fund their share of Medicaid by taxing hospitals and other providers and then using that money to draw federal funds. The cap on provider fee rates in expansion states is being phased down. The limit, which was capped at no more than 6% of patient revenue, will decrease to 3.5% by 2032, starting in fiscal year 2028. Non-expansion states may keep existing provider fees at their current rates, but new provider fees and increases to existing ones are barred in all states. State-directed payments, which are supplemental payments from the federal government often totaling billions of dollars that states send to providers, are now capped at 100% of Medicare rates in expansion states, and 110% of Medicare rates in non-expansion states.

The Expansion Population and Estimated Cost

KFF estimates roughly 450,000 uninsured Georgia adults would become eligible under expansion, though estimates of how many would actually enroll vary. KFF’s more recent May 2025 fact sheet counts about 184,000 Georgia adults in the “coverage gap,” those who currently qualify for neither Medicaid nor marketplace subsidies.

The state’s February 2026 fiscal note on Medicaid expansion also counted about 741,000 Georgia Access enrollees with incomes of 100–138% FPL, who would move from marketplace coverage to Medicaid under expansion, though state auditors could not reconcile that figure with Census data. That number has likely fallen since the enhanced subsidies expired. But any Georgia Access enrollees who switch to Medicaid would represent a new expense to the state for people who are already insured and have better access to a network of providers, including primary care physicians. 

According to DCH’s FY2025 annual report, low-income Medicaid costs $358.29 per member per month, or about $4,300 per member per year, in total state and federal spending. At that rate, enrolling all of the about 1.2 million eligible Georgians, the roughly 450,000 uninsured plus 741,000 Georgia Access enrollees, would cost about $5.1 billion a year, with the state’s 10% share around $510 million. Because not every eligible person would actually enroll, the Urban Institute’s projection of 671,000 new enrollees implies a more likely cost of about $2.9 billion, with a state share of about $290 million. These estimates use the low-income average, which includes children; costs for adults are likely higher. Unlike the state fiscal note, these estimates include Georgians below 100% FPL, most of whom are not enrolled in Pathways.

The state’s most recent fiscal note, issued in February 2026, estimates the net state cost of expanding Medicaid to adults at 100–138% FPL at $154.8 million to $317.0 million in year three. Total Medicaid spending, state and federal combined, would reach $2 billion to $3.8 billion by year three, with the federal government covering 90% of benefit costs.

With Pathways set to expire, federal approval of the 90% match uncertain and a new governor taking office in January, Georgia’s next administration will face a choice between extending a modified Pathways, pursuing full expansion or neither. Each path carries significant costs, and the OBBBA’s new financing limits mean those costs will look different than they did even two years ago.

Ultimately, Medicaid expansion would add hundreds of thousands of Georgians to a program into which fewer than half of the state’s physicians are accepting new patients, and would impose a net cost on the state. Coverage on paper is not the same as access to care, and expanding enrollment without addressing the ability to see a physician risks giving new enrollees a card that few doctors will accept.