At nearly every campaign stop, former Atlanta mayor and current Democratic candidate for governor Keisha Lance Bottoms returns to the same topic: expanding Medicaid, the federal program that sends states billions of dollars to provide healthcare to low-income residents. “Even if people don’t need Medicaid, they do need Medicaid to be expanded in the state,” Bottoms said at a recent event.
Georgia is one of only 10 states that has declined the funding since the program’s inception in 2010, forgoing billions of dollars that could have gone toward healthcare. In states that have expanded Medicaid, research shows increased coverage, lower rates of people avoiding care, and more preventive visits.
But Bottoms cannot expand Medicaid on her own. In 2014, the state Legislature passed a law stripping the governor of the unilateral authority to do so. That means control of the state House and Senate will determine whether expansion happens at all—and Democratic candidates say it could be their first priority if they take the majority.
“If the Democrats can win the House of Representatives, that’s probably one of the first things we will do—is pass expanded Medicaid,” said Eric Gisler, who is running for re-election in House District 121.
Republicans, who have been in power in the state Legislature since Medicaid funding became available in 2010, have consistently rejected legislation that would expand the program. Billionaire health care executive Rick Jackson, who is running as the Republican nominee for governor, has similarly rejected calls for Medicaid expansion. He has said the private sector is a better solution, despite the fact his company has received more than a billion dollars in public contracts.
The costs of not expanding Medicaid in Georgia
The price of Georgia’s refusal to expand Medicaid has been steep, both financially and in terms of public health.
Georgia currently ranks 49th out of 50 states in rates of uninsured residents, according to the United Health Foundation.
“We have 12% of our population that is uninsured,” said Beth Fuller, the Democratic nominee for State House District 53.She added that the effect ripples outward to emergency rooms across the state. “People don’t have access to a hospital when they need it or access to a doctor… it ends up flooding the emergency rooms.”
Those costs are ultimately absorbed by hospitals that go unreimbursed—a dynamic that has contributed to the closure of rural hospitals across South Georgia.
Dr. Michelle Schreiner, a former psychologist now running in the competitive House District 45 race in East Cobb, said she saw the consequences firsthand: low-income, uninsured patients delaying treatment until their conditions worsened and became more expensive to treat.
Schreiner, who previously worked at the Department of Health and Human Services with access to extensive healthcare data, framed the choice starkly: “We can either invest in helping people get the care they need earlier and ensuring that it’s affordable, or we can continue absorbing those costs downstream. So to me, expanding Medicaid is both a compassionate choice and the fiscally responsible one to pursue.”
The federal government covers 90% of Medicaid expansion costs, funded in part by taxes Georgians already pay. Because state Republicans have declined to expand the program, those dollars are effectively lost to the state.
“Essentially all of our taxes that go toward Medicaid go out of the state, but our refusal to expand the program here means we don’t get the benefit of them coming back to the state in the places we need them,” said Adam Cleveland, a candidate for State House District 48.
With fewer people in the insurance pool, costs usually rise across the board. Expanding Medicaid “would have almost certainly lowered everyone’s costs,” said Gisler, who also runs an insurance startup. He argued the toll goes beyond dollars and cents.
“How many people stay in bad marriages, violent marriages, because if they leave, they can’t get health insurance?” he asked.
Rather than expand Medicaid, Georgia pursued a narrower program called “Pathways” that had stringent work requirements to qualify for healthcare. But reporting from ProPublica found the state spent roughly twice as much on administrative costs and consultants as it did on actually providing care to enrollees.
“Pathways has been an unmitigated failure and disaster,” Gisler said.
Candidates on both sides of the aisle say private support for expanding Medicaid is growing as Pathways is recognized as a failure, even as some lawmakers oppose expansion publicly.
“Behind closed doors and away from the press, there’s actually more acceptance of the benefit to Georgia of expanding Medicaid,” Fuller said. “People understand that we’re leaving a lot of federal dollars on the table.”
Gisler echoed that sentiment: “Some of them are starting to come around because at the end of the day they’ve got constituents that are suffering too and there are not really any other solutions out there.”
How a Democratic governor could shift the calculus
Even without unilateral authority over Medicaid, Georgia’s governor wields significant power through the office’s line-item veto, which allows the governor to strike individual items from the state budget. Democrats argue that power could give Bottoms leverage to pressure Republican legislators who resist expansion.
It could also create political cover for Republican lawmakers who privately support expansion but have been wary of breaking with Gov. Brian Kemp, a vocal opponent of Medicaid expansion.
“I think that the leadership change in the governor’s office will open so many doors, and it may give Republicans at the Legislature some space to navigate maybe in a different way,” Fuller said.
Schreiner framed the stakes in terms of the broader legislative map: “When we flip these 10 seats, we fundamentally change the discourse that is happening at the state capital.”
If that happens, candidates and legislators said Georgia could take steps toward becoming a place where everyone can readily access preventive care, mental health resources, and comprehensive pregnancy support.
“People deserve to be able to be taken care of when they’re sick,” Fuller said, “and they deserve to be able to access care for their family.”
