Official Public Comments Submitted to Centers for Medicare & Medicaid Services (CMS)

State of Georgia Department of Community Health

Georgia Section 1115 Demonstration Waiver Extension Request

Submitted Via CMS Portal: June 1, 2025

My name is Natalie Crawford, Founder and Executive Director of Georgia First, a Georgia-based 501(c)(4) nonprofit think tank and policy advocacy organization. One of our three policy priorities is ensuring access to quality, affordable healthcare. In 2023, I established the BRIDGE Georgia healthcare coalition to advocate for closing Georgia’s health insurance coverage gap. Currently, nearly 300,000 Georgians fall in the gap, earning too much for traditional Medicaid but too little to afford private insurance through the open marketplace with Georgia Access. Additionally, these Georgians face barriers to enrollment in the Georgia Pathways Program.  

As a fiscally responsible, lifelong Republican who previously served as an elected official in Georgia, I cannot support the continuation of Georgia Pathways to Coverage as originally designed under the 1115 Waiver program, nor can my organization support the 2025 waiver application as submitted to CMS. Listed below are the reasons we do not support Pathways, followed by the elements of the current application that we do support and finally Georgia First’s recommendations for improving the Georgia application. 

We do not support the Georgia Pathways waiver application as submitted because Pathways is  

• Not an efficient use of taxpayer dollars – It cost more than $86 million to date to implement with the majority of those tax dollars, approximately 75%, attributed to administrative and consulting costs not actual healthcare services rendered; 

• Not addressing Georgia’s high uninsured rates – Georgia consistently ranks among the top five states annually for highest uninsured rates with more than 1.2 million uninsured residents; Pathways has enrolled a mere 7,000 Georgians in more than a year since initial implementation.* That is a cost of $12,285 per enrollee.  

* Pathways initially projected 30,000 enrollees in its first year but had only 6,500 by July 2024. Revised estimates now suggest only 30,000 enrollees by 2030—six years after initial implementation. 

The elements of the current Pathways waiver application we support include:  

• Expansion of eligibility to parents and legal guardians of young children (ages 0-6), supporting growing families. 

• Less frequent eligibility checks, shifting from monthly reporting requirements to every six months. 

It’s important to note that over 800,000 Georgians are currently receiving fully subsidized premiums through the Georgia Access marketplace tax credits, but these federal Enhanced Premium Tax Credits (EPTCs) are set to expire in 2025. Without renewal, Georgia’s uninsured rate will undoubtedly increase and the need for quality, affordable healthcare will be greater than ever. At the end of the day, all US residents pay for high uninsured rates in our communities. 

Georgia’s answer is not Pathways—expanding Georgia’s Medicaid eligibility to 138% of the federal poverty level (FPL), as 40 other states and D.C. have done, is essential for addressing high uninsured rates and strengthening Georgia’s middle class and economy. Georgia First is disappointed that Georgia’s current 1115 Medicaid waiver application does not include this expansion, despite its cost-effectiveness compared to Pathways at full enrollment. As detailed above, Georgia Pathways remains inefficient, with high administrative and consulting costs. 

The Pathways program provides limited Medicaid expansion with work and activity requirements but suffers from low actual and projected enrollment, excessive bureaucracy, and high administrative expenses. This is the antithesis of what our current administration is working so hard to address with the efforts of DOGE.  

In fact, a 2024 economic impact study by REMI (Regional Economic Modeling, Inc.), commissioned by a BRIDGE Georgia coalition member, projected that full expansion would create over 150,000 jobs within three years, increase economic output by $9.4 billion annually, boost GDP by $5.5 billion per year, and raise Georgians’ aggregate personal income by $3.6 billion annually. These state-level economic benefits of Medicaid expansion also benefit the overall US economy. 

Georgia First acknowledges the programmatic impacts, including delayed implementation, caused by the litigation between the federal government and the former administration. However, Georgia taxpayers continue to bear the cost of a hyper partisan healthcare debate at home and in D.C., paying with their personal health impacts and their tax dollars going to fund 138% FPL Medicaid expansion in 40 other states and D.C. It’s time to prioritize people and make sound fiscal decisions that maximize public benefit. 

Without full expansion, Georgia First recommends key reforms to improve Pathways’ efficiency, reduce bureaucracy, and support family caregivers: 

• Expand work exemptions to include caregivers of any child, elderly, or disabled relative—not just children under six. 

• Reduce reporting burdens, cut government red tape, and maximize tax dollars by further reducing reporting requirements to an annual l certification schedule and allowing enrollees to report annualized qualifying hours. The proposed six-month reporting is an improvement over monthly certification, but we believe more can be done. 

• Expand auto-enrollment for eligible populations, including automatic transition to Pathways for postpartum Medicaid recipients and low-income caregivers above 35% FPL, and by using SNAP, TANF, or workforce program data for auto-enrollment. 

• Support older workers (ages 60-64) by exempting them from qualifying activity requirements, recognizing their employment barriers. 

Expanding Medicaid without unnecessary restrictions is a strategic investment in Georgia’s healthcare system, workforce, and economy. Georgia needs to address the 300,000 Georgians—farmers, veterans, older adults (60-64 years), gig workers, and caregivers for family members with chronic illnesses or disabilities—who remain in the coverage gap by fully expanding eligibility to 138% of FPL. (If federal healthcare EPTCs expire, even more Georgians will fall into this gap, increasing our already high uninsured rates and escalating uncompensated care.) We cannot continue applying short-term fixes to a long-term problem. It is time to close Georgia’s healthcare coverage gap and fully utilize available federal tax dollars, regardless of anticipated or future changes to Medicaid under a new administration. 

~Natalie Crawford, Founder & Executive Director