By Rebecca Gaunt

For Georgia’s Medicaid expansion advocates, the federal spending bill President Donald Trump signed into law July 4 was another blow.

The bill, referred to as “One Big Beautiful Bill” by Trump, cuts more than $1 trillion in healthcare spending over the next decade that could force individual states to cut and reduce programs, reports KFF, a non-profit health policy and research organization.

It also imposes restrictions on the 40 states that expanded Medicaid under the 2010 Affordable Care Act, one of which is the implementation of a work requirement.

Georgia, one of 10 states that did not pass Medicaid expansion, instead implemented an alternative program called Pathways to Coverage. It has been heavily criticized for being overly expensive and ineffective.

According to 2022 Census data, Georgia has the fifth-highest uninsured rate for people under 65, with 13.6 % of the population–that’s 1.2 million residents–having no coverage. That’s above the national rate of 9.5%

Disability advocacy groups are sounding the alarm because, although the bill isn’t expressly written to remove funding from disabled populations, the loss of funds could seriously impede how the states administer their Medicaid programs. Nor are states required to offer home and community-based Medicaid disability waivers. Optional programs are often the first to see cuts under budget constraints.

Stephanie Meredith, a disability advocate with a doctorate in Public Health, is worried about how the cuts could affect her adult son Andy, who has Down syndrome. He has a thriving life in his Georgia community thanks to the NOW/COMP Medicaid waiver, she told the Courier, but they sat on the waiting list for 17 years.

Georgia’s NOW (New Options Waiver) and COMP (Comprehensive Support Waiver) can be used for medical equipment, employment supports, residential, and day programs.

“I think it shocks people, to be honest, because I think they assume people with disabilities, of course have access to Medicaid…but the issue is that while we may be able to get some healthcare coverage in Georgia…what it doesn’t cover is those additional services people with disabilities need, like our direct support providers,” Meredith said.

In Andy’s case, his direct support providers help him get to his jobs in a grocery store and coaching lacrosse while his parents are at work.

What is medicaid expansion? 

The expansion of Medicaid eligibility to adults under age 65 with household incomes up to 138% of the federal poverty level (FPL) was a cornerstone of the Affordable Care Act. However, the Supreme Court ruled that states could not be forced to expand their programs. The following states, most of which are in the south, have not passed expansion in their state legislatures: Georgia, Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wyoming, and Wisconsin.

The federal government covers 90% of the cost for those eligible under expansion.

To qualify for Medicaid in Georgia without the expansion in place, a citizen must meet the low-income requirements, plus one of the following: be pregnant, be a child or teenager, be 65 years or older, be legally blind or disabled, or require nursing home care.

According to a 2024 report by the Center for Policy and Budget Priorities, 1.6 million people between the ages of 19 and 64 are in the coverage gap, meaning their income is too high to qualify for Medicaid, but still under the poverty level and not eligible for healthcare subsidies in the Marketplace. 192,000 of them are in Georgia. 61% of those Georgians are people of color.

Problems with Pathways

As an alternative to expanding Medicaid, Georgia launched Gov. Brian Kemp’s initiative Pathways to Coverage in 2023.

To be eligible for Pathways, applicants must be a citizen or legal resident, aged 19-64, not qualify for any other type of Medicaid, not be incarcerated, have an income up to 100% of the federal poverty rate, and complete 80 hours a month of work, volunteering, or education credits.

In 2025, the 100% FPL income requirement in Georgia equaled $15,650 for an individual or $26,650 for a family of three.

In June, the Southern Poverty Law Center released a study on the need for Medicaid expansion in the Deep South. It said Georgia’s Pathways program “does not create meaningful and responsive health care access for people in need of care.” 

It also cited studies that show work requirements are ineffective.

Policy analyst Gina Azito Thompson wrote, “These work requirements are based, in part, on racist narratives about Black people’s unwillingness to work and have historically been used to create needless barriers to cash assistance during times of financial crises. Additionally, the requirements funnel people with low incomes into the most available job opening — even if the role does not improve their financial outcomes and long-term goals.”

Two other studies of the Pathways program also revealed problems.

The Georgia Budget & Policy Institute completed a study of the program’s first year that found that more than 40% of Georgia’s counties had fewer than 10 enrollees despite the state having one of the highest rates of uninsured people in the country. It called the enrollment process “cumbersome” with a “steep paperwork burden.” The program only reached 17% of the projected enrollment.

GBPI also found that the first year resulted in a backlog of 14,000 applications. While applicants who managed to successfully enroll reported positive healthcare outcomes, many applicants reported serious technical problems using the website and the difficulty of getting someone on the phone.

The state’s spending on upgrades to the online enrollment system was five times higher than the spending on healthcare benefits for enrollees.

The Current and Propublica released a joint investigative series showing that the state awarded Deloitte Consulting tens of millions of dollars in taxpayer funds to promote Georgia Pathways, but has not linked the consultants’ work to enrollment goals. When a $10.7 million publicity contract started last summer, enrollment in Georgia Pathways was about 2% — when it ended in February, enrollment was still under 3% of 240,000 potentially eligible Georgians.

An independent evaluation by Public Consulting Group was commissioned by the state but not released. It was obtained by ProPublica and The Current through an open records request.

According to the evaluation, Pathways had only enrolled 6,500 people, about 75% short of the projections. The investigation by Propublica and The Current found that more than 75% of the $86.9 million in taxpayer money spent on the program went to consultants.

Due to a lack of staff and technical glitches, Georgia rolled back the monthly requirement to report hours worked to once a year.

Trump’s federal spending bill includes a requirement that the states implement similar work requirements for those who qualified for Medicaid expansion under the ACA. 

Cobb legislators

State Sen. Kay Kirkpatrick (R-Marietta) does not regard Medicaid expansion as the answer to the problem.

“I support getting insurance for all Georgians, but Medicaid is a broken program that gets people a card but does not necessarily get them care. The only group currently not covered by Medicaid is comprised of able-bodied adults between 18-65. Kids, people with disabilities, pregnant and postpartum women are already covered. Seniors are covered by Medicare,” she told the Courier in an email.  

Kirkpatrick also said that the Department of Community Health has increased its outreach to assist Georgians with the enrollment process for the programs offered.

“I support making it easier for people to participate in the programs available to them,” she said.

State Rep. Lisa Campbell (D-Kennesaw), however, called Pathways to Coverage a disaster.

“We all heard the governor talk about what a great success it was, but behind the scenes, we know the facts do not add up,” she said. “Even if it worked perfectly, it still would be more expensive to cover each individual Georgian through this Pathways program, than it would have been through Medicaid expansion, because without Medicaid expansion, we weren’t getting all those federal dollars.”

Campbell said that the healthcare costs of the uninsured still ultimately end up falling on the taxpayer when people are left with no option but to go to the emergency room–the most expensive kind of care.

Kemp has often touted Georgia’s ranking as the number one state for business. Campbell sees keeping citizens healthy as key to maintaining healthy businesses.

“If I’m sick, I can’t show up to work. If my child is sick, I can’t show up to work,” she said.

Campbell introduced House Bill 751 during the 2025 legislative session to add caregiving as a qualifying activity for Medicaid. If it passes in a future session, it would make parents caring for their children in the home eligible for Medicaid coverage, as well as family members caring for disabled adult children or aging parents. 

“Being an elected..I am eligible for state health insurance. The amount of savings for me –my monthly bill went from $700 to $70. It’s disingenuous for all the legislators, myself included, to get up there and talk about pulling yourself up by the bootstraps,” she said.

Gov. Kemp’s office did not respond to the Courier’s questions about Medicaid or Pathways to Coverage.

Concerns from the disability community

The Georgia Council on Developmental Disabilities, the Arc of the United States, the National Down Syndrome Congress, the National Disability Rights Network, the Muscular Dystrophy Association, the Spina Bifida Association, and the Cystic Fibrosis are just a few of the organizations that opposed the cuts to Medicaid.

“This bill makes massive cuts and substantial changes to Medicaid, a program on which most people with Down syndrome rely. It will also weaken our healthcare system, cut millions of dollars of Medicaid funding to schools, and further strain state budgets, jeopardizing state-based Home-and Community-Based waiver services (HCBS) that enable people with Down syndrome and other disabilities to live, work, and thrive in their communities. This bill will have significant unintended negative consequences for people with Down syndrome, their families, and those who provide supports,” the NDSC wrote on its Facebook page.

Without those supports, families like Andy’s could face significant challenges. 

“I think there is an assumption that all of those things are normally covered by Medicaid, but the fact is that they really are not, they are an optional service,” Meredith said. “If the state ends up saying we’re going to have to cut the number of Medicaid waivers, or we’re just not going to add anymore, then you leave people in real crisis.”

About 7,000 people are currently on the NOW/COMP waiver waiting list, according to the Georgia Council on Developmental Disabilities.

Meredith and her husband both work 60 hours per week. Without the waiver, they would face a choice to dramatically decrease their hours, which would affect their retirement savings–Meredith pointed out that they must save enough for three people to live on–or their son loses his meaningful role in the community. Additionally, many of the young people Meredith has hired to work with Andy go on to pursue careers in special education or therapy, motivated by the experience.

“He has a lot to contribute to the world, but he has to have support to do it. I think you either lose the work capacity that my husband and I are giving, plus the taxes we pay, if you’re looking at it from a strictly conservative perspective. If we end up continuing to work, and we just let him stay at home, the community is losing out on having him be a meaningful part of it.”

Georgia also offers the TEFRA or Katie Beckett waiver for disabled children under 19 whose parents have an income too high to qualify for Medicaid. Though it can be used as the child’s primary insurance, families often have it as a secondary insurance to private healthcare coverage. It’s essential for many families that wouldn’t otherwise be able to cover the bills of their child’s high healthcare and therapy needs.

The program was established under Ronald Reagan’s administration and named for a ventilator-dependent three-year-old who had to live in the hospital so Medicaid would pay for her care. In 1982, Reagan signed the law that allowed her to go home, have treatment, and maintain her Medicaid coverage at about a sixth of the cost.

Meredith’s son had Katie Beckett when he was eligible and it provided access to enough therapy to help him meet his milestones.

Many private policies limit the number of speech, physical, and occupational therapy visits each year. Medicaid picks up the costs when those visits run out.

But the waiver programs and how they operate already vary widely by state, meaning it’s unknown exactly what lies ahead for those relying on them.

Florida does not have a Katie Beckett waiver. Its alternative, called the Model waiver, only has 20 slots.

Tennessee didn’t offer a Katie Beckett waiver until 2020, 38 years after the program was signed into law. The state offers Part A for the most significant disabilities and medically complex, but only has 300 slots.

Brittany Schwaigert’s son Greyson, who was born with tuberous sclerosis complex, a genetic disorder that causes noncancerous tumors to grow throughout the body, and has diagnoses of epilepsy and autism, qualified for Part B, which is considered a Medicaid diversion program. Instead of Medicaid services, Part B recipients receive a maximum of $10,000 per year to help with out-of-pocket costs.

“We burn through that by summer usually,” Schwaigert said. 

Since she’s self-employed, she has insurance through the ACA Marketplace. The premium for Schwaigert’s family is roughly $2,000 per month.

The money they receive through Katie Beckett part B goes to help Greyson’s portion of the premium ($450), a monthly $250 co-pay on one of his medications, and this year, $3,000 for orthotics to help him walk because their primary insurance won’t cover it until they meet their deductible.

“Not affordable at all,” she said. 

There is a light at the end of the tunnel though. With his upcoming 18th birthday, Greyson will qualify for full Medicaid and supplemental security income (SSI) in Tennessee, which would significantly help with the family’s premiums–assuming the spending bill doesn’t affect the program. It’s a thought that keeps her up at night.

The ripple effect

“It’s going to exponentially exacerbate the desperate situation that the people who are lacking health insurance today are feeling, but will trickle down to everyone else,” Rep. Campbell said of the spending cuts.

According to KFF, 310,000 Georgians are estimated to lose their healthcare by 2034 under Trump’s bill. If Congress allows enhanced ACA tax credits to expire this year, that number could reach 750,000.

Rural hospitals, senior care facilities, and other providers that rely on Medicaid funding are all facing major shortfalls. If they close, people who live in those areas either go without, or make the drive to other areas, which creates longer waits for everyone.

The Center for Healthcare Quality and Payment Reform released a report that said 700 rural hospitals are at risk of closing nationally. 20 are in Georgia, and nine of those are classified as an immediate risk. 

The state is already grappling with maternal care deserts, which disproportionately impacts Black mothers and babies, Meredith told the Courier.

Georgia is one of the worst-ranked states for maternal and infant deaths.

“If we continue to have them close, we are going to continue to see a rise in those infant mortality numbers,” Meredith said.