The 20-Year View
In 2004-2005, Georgia had the 8th highest uninsured rated in the nation, and in 2022, the 3rd highest. Over the last 20 years, GBPI has continued to advocate for health care access achieving incremental but meaningful wins like the 2023 elimination of the 5-year Medicaid waiting period for pregnant women and children who are lawful permanent residents. GBPI has also pursued larger strategic priorities like closing the coverage gap. In addition, GBPI has advocated for increasing state investments in the systems that support Georgians’ health.
Georgia’s 2025 Health Budget
The Departments of Behavioral Health and Developmental Disabilities (DBHDD), Community Health (DCH) and Public Health (DPH) are the primary agencies focused on the state’s health care and public health systems. Georgia plans to provide $7.3 billion in state funds for these three agencies in the fiscal year (FY) 2025 budget year, which accounts for about 1 in every 5 state dollars projected to be spent in the new fiscal year. General Fund appropriations account for $6.6 billion, or about 90%, of the state funds for these three agencies. Other sources, like Tobacco Settlement Funds, account for the remaining $740 million in state funds. Overall, general funds for these three agencies increased by $666 million, or about 11%, from the original FY 2024 budget. Although DCH accounts for the majority of state health spending, general fund appropriations at DCH, DBHDD, and DPH have more than doubled over time since FY 2005, 2010, and 2012, respectively.
Health Agencies’ Turnover Rates Improve, But Challenges Remain
Turnover rates for the state’s three health agencies have improved since the pandemic’s start; all three agencies’ turnover rates have decreased to levels that are about the same as or below the state average. Notably, the turnover rate at DBHDD decreased from a high of around 36% in 2021 to approximately 22% in 2023. These turnover rate decreases reflect, in part, sustained compensation adjustments over time, including the $5,000 cost-of-living (COLA) increases in amended fiscal year (AFY) 2023, the $2,000 COLA increases in FY 2024 and the one-time $1,000 bonuses in AFY 2024. Those increases will be further augmented by the 4% COLA increases (not to exceed $3,000) in FY 2025. Despite these gains, the higher-than-average percentage of employees eligible for full retirement within the next five years at all three health agencies presents additional challenges.
Investments Made in Increasing Pay for Health-Related Providers
The FY 2025 budget makes critical investments across the three health agencies by increasing Medicaid reimbursement rates for a range of community-based health care and behavioral health providers. Many of these rate increases are intended to improve pay, particularly wages for hourly workers. The rate increases may also improve access to care for Georgians with lower incomes.[1],[2]
Public Health
DPH operates programs focused on health promotion and health-related disaster response and preparedness as well as disease and injury prevention. The department receives around $400 million in General Funds and nearly $14 million in Tobacco Settlement funds. The largest state-funded programs support 159 county health departments, help prevent the spread of infectious diseases and provide services for children. Total DPH spending in FY 2025 represents an increase of 8% over the original 2024 budget. Notably, the budget includes about $1 million in new state funds to expand the maternal home visiting pilot launched in the prior fiscal year into additional counties.
Federal money makes up nearly half the department’s $835 million budget, while state and other funds comprise the remainder. Of those federal funds, more than half is accounted for by the Special Supplemental Nutrition Program for Women, Infants, and Children (or WIC), which provides low-income pregnant and postpartum people and children under age five with healthy food, nutrition information, breastfeeding support and other services.
Behavioral Health and Developmental Disabilities
DBHDD primarily serves uninsured and underinsured Georgians living with developmental disabilities, mental health conditions and substance use disorders. It also provides community-based services through contracted providers and operates state hospitals. The department also operates forensic evaluation and treatment programs under the court system’s jurisdiction. Georgia plans to allocate $1.6 billion in General Funds and $10 million in Tobacco Settlement Funds to DBHDD. Total state spending for DBHDD in FY 2025 represents a 10% increase over the original 2024 budget. More than half of that increase is dedicated to funding that will expand home- and community-based services for Georgians with intellectual and developmental disabilities and boost compensation for their providers.
Medicaid and PeachCare
DCH administers the state’s health care safety net, reimburses hospitals for services provided to uninsured and underinsured Georgians, manages health insurance coverage for state and school system employees and regulates health and long-term care facilities. The FY 2025 budget provides DCH with almost $4.6 billion in General Funds. State funding allocated to the Department of Community Health increased by $507 million, or 11%, above the original fiscal year 2024 budget. About 94% of the Department’s overall state funding is earmarked for Medicaid and PeachCare, which provide health care coverage to about 2 million Georgians with lower incomes. Most enrollees are children under the age of 18. More than half (56%) of FY 2025 state funds for Medicaid and PeachCare support coverage for older adults and individuals with disabilities. An encouraging addition to the FY 2025 budget is $10.5 million in state funding to expand dental coverage to Medicaid-eligible adults.
Medicaid Unwinding Brings Coverage Losses and Budget Changes
Like all states during the pandemic, Georgia received additional federal funding to keep Georgians continuously enrolled in the health care safety net without conducting regular eligibility checks. The Medicaid continuous eligibility policy started to ‘unwind’ in April 2023, and every child and adult enrolled in Georgia’s health care safety net was slated to have their eligibility redetermined before the end of May 2024. The FY 2025 budget includes shifts to reflect projected enrollment declines associated with the Medicaid unwinding (i.e., decreased projected utilization of both the Aged, Blind, and Disabled program and the Low-Income Medicaid program) and to reflect the return to the standard federal match rate (a decrease from 72% to 66%).
As of January 2024, about 18% of the adults and children who had Medicaid and PeachCare at the start of the Medicaid unwinding in April 2023 have lost their coverage. For those who have lost coverage, there are three paths depending on household income, employment status, and other variables: Enroll in an alternate form of health insurance coverage (e.g., individual health insurance marketplace), re-apply to Medicaid or PeachCare, or fall into the health insurance coverage gap and remain uninsured.
Procedural Denials During Unwinding Likely Impacted Children’s Coverage Losses
Most Georgians who have lost coverage during the Medicaid unwinding have lost it for procedural reasons, which means they may still be eligible but are denied coverage due to a human or technological error in the renewal process.[3] These temporary losses in coverage can wreak havoc on Georgians’ health and financial security. Additionally, these procedural denials can negatively impact the state’s budget. Georgians who remain eligible for Medicaid but lose coverage are likely to re-enroll, which creates extra work for the state’s eligibility caseworkers and results in variable state expenditures.[4]
State data on procedural denials by age or by race/ethnicity are not publicly available; however, based on the available information, there is cause for concern. Children represent most of the population covered under Medicaid and PeachCare in Georgia, and child eligibility criteria are more expansive than adult eligibility criteria. For various reasons, children would theoretically be less likely than adults to become ineligible and more likely to lose coverage for procedural reasons. Children of color and children living in rural communities are overrepresented in Medicaid and PeachCare. Due to inequitable access to economic security for their parents and families, about 1 in every 2 Black and Latinx children under 18 years old in Georgia are covered by Medicaid and PeachCare compared to about 1 in every 4 white children.[5] Similarly, about half of children in small towns and rural areas of Georgia are covered by Medicaid and PeachCare compared to about 40% in metro areas of the state.[6] These same children may also be more likely to get caught up in the complexity of the bureaucracy. For example, children in rural Georgia whose families lack access to high-speed internet or children whose parents speak a non-English language may have a harder time with the already complicated renewal process—resulting in a coverage loss even if their child is still eligible.
Georgians Face Significant Barriers to Healthcare Coverage
Unequal access to affordable, high-quality health care continues to impact Georgians across the state. Georgia ranks third nationally in the number of Georgians without health insurance coverage. Almost 1-in-6 non-elderly adults and 1-in-16 children in the state are uninsured across income levels.[7] The burden is heaviest on Georgians living in rural communities and Georgians of color—particularly Latinx Georgians. Across states, Georgia’s healthcare system ranks 45th overall based on measures like healthcare access, cost, avoidable hospital use, reproductive care and women’s health, as well as prevention and treatment.[8]
Endnotes
[1] Saulsberry, L., Seo, V., & Fung, V. (2019). The impact of changes in Medicaid provider fees on provider participation and enrollees’ care: A systematic literature review. Journal of General Internal Medicine, 34(10), 2200-2209. https://pubmed.ncbi.nlm.nih.gov/31388912/
[2] Alexander, D., & Schnell, M. (2020). The impacts of physician payments on access, use, and health (NBER working paper 26095). National Bureau of Economic Research. http://www.nber.org/papers/w26095
[3] GBPI analysis of: Georgia Department of Community Health (2024). 2023-2024 Medicaid Redetermination Information (March 2024 version) [Data Set].
[4] Sugar, S., Peters, C., De Lew, N., & Sommers, B.D. (2021). Medicaid churning and continuity of care: Evidence and policy considerations before and after the COVID-19 pandemic [Issue Brief]. Assistant Secretary for Planning and Evaluation. https://aspe.hhs.gov/reports/medicaid-churning-continuity-care
[5] KFF (2022). Medicaid coverage rates for children by race/ethnicity [Data Set]. https://www.kff.org/
[6] Osorio, A., Alker, J., & Park, E. (2023). Medicaid’s coverage role in small towns and rural areas. Georgetown University Center for Children and Families. https://ccf.georgetown.edu/
[7] GBPI analysis of: KFF. (2022). Health insurance coverage of children 0-18 and of adults 19-64. https://www.kff.org/state-category/health-coverage-uninsured/health-insurance-status/
[8] Radley, D.C., Baumgartner, J.C., Collins, S.R., & Zephyrin, L.C. (2023). Scorecard on state health system performance. The Commonwealth Fund. https://www.commonwealthfund.org/publications/scorecard/2023/jun/2023-scorecard-state-health-system-performance
