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Background

On May 22, the U.S. House passed a sweeping budget bill, known as the “One Big Beautiful Bill” Act. The budget bill proposes significant changes to the Affordable Care Act (ACA) Health Insurance Marketplace, which is known as Georgia Access in our state. Proponents say these changes will cut costs, but they would also make it harder for many Georgians to enroll in or keep their health coverage.

The Senate is now making its changes to the bill, but what those changes will look like is unclear. As currently written, projections from the non-partisan Congressional Budget Office (CBO) show the House’s changes would reduce overall Marketplace enrollment and increase the uninsured rate nationally and in Georgia. If the budget bill passes as currently written, the combination of Marketplace (including allowing the expiration of the enhanced premium tax credits) and Medicaid changes could lead to an estimated 560,000-940,000 Georgians becoming uninsured.^[1] (Notably, some of the marketplace changes presently in the bill are also under consideration by the Centers for Medicare & Medicaid Services (CMS), meaning they could be authorized through federal regulation even without new legislation.)

Georgia Access’s Record-Setting Success Is at Risk

Georgia Access (the state’s new state-based marketplace (SBM)) celebrated record-setting enrollment in its first year of operation. Over 1.5 million Georgians enrolled in plans through Georgia Access (including ~225,000 new consumers), making it the second largest SBM in the country.^[2] These historic gains rest on two pillars:

• Streamlined renewals: 72% of 2024 enrollees automatically kept their coverage.^[3]
• Extra-generous federal financial assistance: the discounts from the enhanced premium tax credits (ePTCs) pushed average net premiums down to $74 a month, with half of enrollees paying less than $10.^[4]

The budget bill would take a wrecking ball to both pillars and create additional costs and administrative barriers to enrollment. Below is a look at the current Marketplace regulations, what the bill would change, and the potential impacts to Georgia.

Georgia-Specific Impacts of ACA Marketplace Provisions in Federal Budget Bill (As of May 22, 2025)

Marketplace Component	Current Law[5]	House Budget Proposal[6]	Impacts on Georgia
Automatic re-enrollment	Georgia Access renews your plan and recalculates your subsidy if you do nothing.	Ends passive renewal: everyone must reapply between Aug 1 and Dec 15 or lose all subsidies.	927,000 Georgians relied on auto-renewal for 2025.[7] The end of automatic renewals will likely be the single largest source of coverage loss among all the proposed changes.
Open-Enrollment window & Low-income Special Enrollment Period (SEP)	Open Enrollment (OE) runs Nov 1 – Jan 15; adults with incomes of 100-150% FPL can sign up any time.	OE ends Dec 15 (one month earlier); ends the year-round low-income SEP.	81% of GA sign-ups occurred after Dec. 15th of OE.[8] Shortening the window and ending the low-income Special Enrollment Period (SEP) could lock out tens of thousands of Georgians from coverage for a full year.
“Provisional” subsidies during data checks	When a consumer experiences a data matching issue (DMI), such as a change in income, the Marketplace gives applicants 90 days of tax credits to allow them to enroll in coverage at the same time they upload documents and resolve the data issue.	Applicants can’t receive tax credits until the marketplace addresses/reviews any mismatched data. Applicants with DMIs must pay the plan’s full cost if they want coverage while the DMI is addressed.	Georgians with unpredictable incomes or life events such as a birth or divorce often face income or identification DMIs. The full cost of the premium will be unaffordable for most, meaning they’ll choose to be uninsured while the DMI is reviewed. Combined with the new premium payment lockout provision and the end of the low-income SEP, many could also lose coverage for the entire year.
First-month & past-due premiums	Coverage starts if enrollees pay 95 % of the first premium; insurers consider the monthly premium fully paid if the enrollee pays 98%; insurers cannot deny an applicant having past-due premiums on a previous plan.	Before enrolling again, you must pay the full premium upfront and clear any prior-year debt.	About 9% of enrollees underpaid their first premium in 2022.[9] That percentage would likely increase under this new rule, which impacts Georgians who experience financial hiccups. This affordability barrier could keep tens of thousands of Georgians from enrolling in coverage.
Repayment caps at tax time	Low- and middle-income families who underestimated their yearly income pay back a limited portion (not all) of the extra financial help they received to lower their premiums.	Families who under-estimate their incomes must repay 100% of any excess subsidy.	Seasonal workers in tourism, farming, & logistics (big industries in Georgia) could face surprise tax bills, be unable to pay back the subsidy they owe, and drop coverage.
Cost-sharing reduction (CSR) payments and “silver-loading”	The first Trump administration ended the practice of reimbursing insurers for CSRs. In response, insurers added CSR costs into the premiums of silver-level plans, which boosts tax-credit amounts for everyone (referred to as “silver loading”).	Restores direct federal CSR payments to insurers and adds a new stipulation that plans providing abortion coverage are ineligible for CSR payments. In turn, insurers would lower the cost of silver premiums. Because the cost of Silver plans determines the size of tax credits, decreases in Silver premiums would cause tax credits to shrink.	Consumers will receive less financial assistance to lower their premiums. Silver premiums would also be modestly lower, so Silver plan enrollees with subsidies wouldn’t feel much of a change. Most GA enrollees choose Silver plans, so the net effect is modest. However, enrollees who received the larger tax credits and used them to buy Gold plans will pay more, as will some in subsidized bronze plans.
Exclusion of gender-affirming care from essential benefits	ACA rules bar plans from excluding medically necessary gender-affirming care.	Amends the ACA to exclude “gender transition procedures” from the definition of EHB. Puberty blockers, hormone therapies, gender-affirming surgeries, and related services would no longer be required coverage in Marketplace plans (and could be outright denied by insurers without violating ACA rules).	Georgia’s state insurance mandates do not require private plans to cover gender-affirming care, but many ACA plans do under federal nondiscrimination regulations. With this change, Georgia Access plans could outright exclude transgender health services. This policy would mean transgender Georgians would have to pay out of pocket for these medications and services, increasing affordability barriers to care.
Enhanced premium tax credits (ARPA/IRA) after 2025	The enhanced subsidies cap premiums at ≤ 8.5 % of income and allow middle-income families (over 400 % FPL) to receive subsidies (before the ARPA/IRA enhanced subsidies). Before the ARPA/IRA enhanced subsidies, applicants with incomes over 400% FPL were ineligible for subsidies. The enhanced subsidies expire at the end of 2025 unless Congress takes action to extend them.	The budget bill does not contain a provision to extend the subsidies past 2025.	The premium spikes caused by the expiration of the enhanced tax credits would be significant. For example, a 60-year-old couple in Georgia making $82,800 yearly would see their annual premiums increase by over $18,000 (a 265% increase). See how costs could rise in your Congressional district or use the calculator to estimate cost increases based on your income information.

Sources: Georgia Access enrollment data and projections compiled from CMS 2025 Open Enrollment Public Use Files^[10] and GHF policy analyses.

The Marketplace changes in the federal budget bill present an outsized risk to Georgia.

1. Heavy reliance on subsidies. 93% of Georgia Access customers get premium discounts through advanced premium tax credits (APTCs), and 66% receive financial assistance to lower out-of-pocket costs like deductibles and co-pays.^[11] Any policy that cuts or complicates subsidies will significantly impact Georgia Access enrollment because low-income enrollees who can suddenly no longer afford their coverage will drop altogether.

2. Low-income Georgians make up a significant portion of Georgia Access enrollment. Nearly 60% of Georgia Access enrollees live at or below 150% FPL. Those enrolled are the same ones losing the year-round SEP, facing the steepest paperwork hurdles, and experiencing the most jarring premium increases. When these changes are combined, they are most likely to become uninsured.
3. Georgia does not have the backstop of full Medicaid expansion. If Georgia had fully expanded Medicaid, all adults below 138% FPL would be eligible for Medicaid. Currently, Georgians between 100-138% FPL can enroll in coverage through Georgia Access with little to no monthly premium. However, if premiums become unaffordable for this group (the most sensitive group to cost increases), they have no alternative coverage option. Losing marketplace coverage would mean they would go uninsured without affordable access to medical care or medicines.
4. Already a high rate of uninsured. Georgia has the 5th-highest uninsured rate in the country (13.6%); in some rural counties, it tops 21%.^[12] Using the most recent CBO estimates, the Kaiser Family Foundation estimates 690,000 additional uninsured Georgians if enhanced subsidies lapse and new red-tape rules take hold.^[13]
5. Rural health stakes. Many rural hospitals and doctors’ offices already operate on razor-thin margins. More uninsured patients mean more uncompensated care and higher risks of closure. Rural hospitals facing additional financial challenges due to an influx of uninsured patients would exacerbate Georgia’s health care access crisis in rural and under-resourced areas, and strain remaining hospitals and doctors.

A note about reinsurance

In 2022, Georgia launched a reinsurance program to lower health insurance premiums. Reinsurance—insurance for insurers—covers a portion of high-cost medical claims, lowering individual-market premiums for everyone.

For 2024–2025, Georgia’s program reimburses 15% to 80% of claims between $35,000 and $500,000.^[14] The federal government funds the program, based on federal savings on premium tax credits due to the state’s lower premiums. In 2025, Georgia received over $1 billion from this “pass-through” funding.^[15]

However, if cost-sharing reduction (CSR) payments return or the enhanced premium tax credits expire, federal reinsurance funding to Georgia could drop. Reduced pass-through funding would shrink Georgia’s reinsurance budget just as the risk pool gets smaller and sicker due to the expiration of the enhanced tax credits. (Healthier people are likelier to drop their coverage if premiums rise.) Without enough federal funding, the state must invest significant amounts of its own funding to maintain current reinsurance levels. If Georgia doesn’t, insurers will raise premiums to cover more of the cost of large claims.

Bottom Line

Georgia Access’s success story proves that people sign up when coverage is affordable and paperwork is light. However, the ACA Marketplace provisions in the House-passed budget bill represent a move in the opposite direction–from maximizing coverage and enrollment ease toward imposing new paperwork requirements and cost containment. At home, these changes could push well over half a million Georgians^[16] off their health insurance plans and into more medical debt, increase the state’s uninsured rate, and destabilize an already strained health care system.

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[1] Alice Burns et al., How Will the 2025 Reconciliation Bill Affect the Uninsured Rate in Each State? Allocating CBO’s Estimates of Coverage Loss | KFF, June 12, 2025.

[2] Bryce Rawson, “Georgia’s First Open Enrollment Period as the State-Based Exchange Ends With Record-Breaking Results,” Office of the Commissioner of Insurance and Safety Fire, February 17, 2025.

[3] 2025 Marketplace Open Enrollment Period Public Use Files | CMS, n.d.

[4] 2025 Marketplace Open Enrollment Period Public Use Files | CMS

[5] KFF. Tracking the Affordable Care Act Provisions in the 2025 Reconciliation Bill. May 22, 2025

[6] Text – H.R.1 – 119th Congress (2025-2026): One Big Beautiful Bill Act,” Congress.gov | Library of Congress, n.d.

[7] 2025 Marketplace Open Enrollment Period Public Use Files | CMS

[8] 2025 Marketplace Open Enrollment Period Public Use Files | CMS

[9] Centers for Medicare and Medicaid Services, Effectuated Enrollment: Early 2023 Snapshot and Full Year 2022 Average, 2023.

[10] 2025 Marketplace Open Enrollment Period Public Use Files | CMS

[11]  2025 Marketplace Open Enrollment Period Public Use Files | CMS

[12] Kristal Dixon, Alex Fitzpatrick, and Kavya Beheraj, Georgia Has Fifth-highest Share of Residents With No

Health Insurance, Axios, August 16, 2024.

[13] Burns et al., “How Will the 2025 Reconciliation Bill Affect the Uninsured Rate in Each State? Allocating CBO’s Estimates of Coverage Loss | KFF.”

[14] Office of the Commissioner of Insurance and Safety Fire, 1332 Waiver, March 19, 2025.

[15] Notification to Georgia of their Section 1332 State Innovation Waiver estimated pass-through funding amounts for Plan Year (PY) 2025,” |  CMS, May 8, 2025.

[16] Burns et al., How Will the 2025 Reconciliation Bill Affect the Uninsured Rate in Each State? Allocating CBO’s Estimates of Coverage Loss | KFF.