As federal changes drive up the cost of Affordable Care Act health insurance plans for next year, about 190,000 fewer people in Georgia had enrolled ahead of the Dec. 15 open enrollment deadline than last year, data show.
While about 1.5 million people had enrolled by the deadline in 2024, this year about 1.3 million people had, according to data from the federal Centers for Medicare & Medicaid Services and the Georgia Department of Insurance.
More than two-thirds of current enrollees were automatically enrolled into the same or similar plan for 2026, meaning they took no action to select a plan for next year, spokesperson Bryce Rawson said. Those customers could face sticker shock as higher premiums come due in January.
Some may decide not to pay and eventually be disenrolled, Rawson said, adding it will take a few months to figure out the impact of the higher rates.
Georgians had to enroll by Dec. 15 to ensure coverage started Jan. 1. Those who missed the deadline have until Jan. 15 to enroll for coverage to start Feb. 1.
The higher ACA prices for next year are due to the expiration of enhanced premium subsidies first enacted in 2021. Congress has not renewed the subsidies, though four House Republicans have joined with Democrats to force a vote on the issue next year.
Other federal policy changes to ACA and Medicaid policies are also expected to drive up the number of uninsured Georgians in the coming years. An estimate from the Georgia Health Initiative found that those and other federal changes could result in close to a half-million people losing health insurance between 2025 and 2034.
Those would be added to 1 million Georgians under age 65 who are already uninsured.
Public health advocates say the increase in uninsured Georgians could result in greater pressure on local health departments, charity clinics, and hospitals, as uninsured people seek health care they can’t pay for. Those pressures will be made more acute by cuts in funding for safety-net hospitals and potentially dramatic public health funding reductions.
How insurance coverage changes can impact public health
Local health departments often provide low-cost or free basic health services to uninsured people. They rely on revenue from insurance for services they provide to patients on Medicaid, Medicare, the Affordable Care Act, and employer-sponsored insurance plans.
How much local public health departments bring in from insurance varies widely, however.
For example, only about 5% of DeKalb Public Health’s $46 million budget comes from fees patients pay out-of-pocket or through insurance for services. That’s nearly evenly split between out-of-pocket payments and payments from Medicaid, Medicare, and private insurers.
Of the $3.3 million the county health department received for these services, $2.6 million came from patients paying out of pocket, with the remainder coming from services provided to Medicaid, Medicare, and private insurance.
In rural Miller County, in southwest Georgia, 15%, or nearly $60,000, of the county’s public health budget comes from fees for services provided to patients. The vast majority of that came from patients with insurance, whether private insurance, Medicaid, or Medicare, with only about 9% of that revenue coming from patients who paid out of pocket.
“We’ve relied on Medicaid reimbursement, private insurance reimbursement, to make health departments run well and to fund their work, and some of that money is going to go away, and there’s no funds there to immediately replace it,” said Scott Thorpe, executive director of nonprofit Southern Alliance for Public Health Leadership.
“What we know is that in particular, for rural communities and underserved communities, when people lose access to care, they tend to rely more on safety-net services like those provided at their county health department,” said Leah Chan, director of health justice at the Georgia Budget and Policy Institute.
Thorpe said he doesn’t expect health departments to have to close their doors if funding decreases and demand for services increases. Instead, agencies will spread staffers out to provide services on an increasingly thin basis. That could detract from other important preventive programs like lead testing.
“They’re a customer-facing organization, and they want to do everything they can to continue to offer the services that they offer because they … want to do the best job they can,” Thorpe said.
Charity clinics and hospitals are also anticipating an increase in demand for their services, though with federal funding up in the air, they aren’t sure what the impact will be.
Dr. Theresa Jacobs of the Georgia Primary Care Association, which represents the state’s federally qualified health centers, said those clinics are not yet seeing an impact, but the organization will be watching what happens at the federal level in January.
Jeremy Cole, executive director of the Mosaic Clinic in Clarkston, which serves uninsured people, said there is a lot of uncertainty about how federal changes will affect his team’s work, but they are planning for a “significant increase” in uninsured patients seeking their services.
“What we are currently anticipating and planning for, unless things change, is a domino effect in the years ahead, each one causing more people to lose their health insurance: first, the lapsing of the enhanced subsidies on Jan. 1 (again, unless Congress acts before then); second, the cutting of federal benefits for refugees and asylees who have been here less than 5 years (this is at least how we understand it, although it is all a bit confusing) starting next October; and finally, the Medicaid cuts that we understand go into effect in 2027,” Cole said.
Georgia hospitals are also concerned, said Anna Adams, senior vice president of government relations at the Georgia Hospital Association. Hospitals will continue to provide care to patients but may not be compensated for that care if people are uninsured, forcing them to “stretch already scarce resources.”
Federal funding for public health in jeopardy
Meanwhile, it’s unclear exactly how public health will be funded in fiscal 2026. About half of Georgia’s public health funding comes from the government – much of it funneled through grants administered by the Centers for Disease Control and Prevention. Congress has not yet decided on a budget for fiscal 2026, but President Donald Trump’s proposal would dramatically cut the agency’s funding. If adopted, that would have downstream effects on state and local public health funding.
That’s left a question mark hanging over planning for Georgia’s budget process, which will start when the legislature opens in January.
The state public health department has presented a mostly flat budget request that assumes federal funding will continue and provides state funding at current levels. Commissioner Kathleen Toomey did not address potential federal cuts during a preliminary December budget hearing at the state Capitol.
Once the session starts on Jan. 12, the legislature will first take up the current year’s budget and make any adjustments needed, said Rep. Darlene Taylor, a Republican from Thomasville who is chairwoman of the House appropriations health subcommittee. After that, legislators will work on the budget for next year.
Taylor said she anticipates Congress enacting the fiscal 2026 budget by the time the state legislature gets to that budget, which would resolve many questions about how much money the state will have for public health and other programs.
She is concerned about Georgians’ access to health care and the burden hospitals and health departments could face, but emphasized that there are resources for Georgians seeking care.
One area Taylor wants to ensure continues to get funded is public health education, she said, pointing to the work public health departments do in educating people about “everything from stop smoking to diabetes control.”
She said she’d work to plug holes in funding for such educational efforts if needed.
“Until I see that budget, I really can’t say, let’s plug the hole here,” Taylor said.
She cited resources for Georgians who lack insurance, including public health departments, charity clinics, and hospitals.
But those entities could be crunched by a change enacted in the One Big Beautiful Bill signed by Trump in July to payments Georgia uses to supplement rural hospital funding. Those cuts will be phased in beginning in 2028 and, along with other changes, will reduce funding for safety-net and rural hospitals, according to a Georgia Health Initiative analysis.
“If you go to the hospital, and you don’t have insurance, they’re still going to treat you,” Taylor said. “What concerns me there is the cost and the burden for the hospital to be able to treat patients when they’re not being compensated for it.”
Rebecca Grapevine is a reporter covering public health in Atlanta for Healthbeat. Contact Rebecca at rgrapevine@healthbeat.org.
