Kaitlin Cooke of Cartersville, Georgia, was contemplating suicide when she started calling a statewide mental health crisis line in 2018. She said she would sneak outside and call the hotline behind her car, where her boyfriend would not hear her.

The counselors who answered her calls were there for her when no one else was, she said. Each time she called, they spoke to her for at least 45 minutes. And they told her that life “does get better.”

“If it weren’t for this resource, I might have been a statistic,” said Cooke, now 31, who found a local therapist.

Starting in March, the call response record for that resource, the Georgia Crisis and Access Line, and its newer national counterpart, the 988 Suicide & Crisis Lifeline, plummeted in the state. The 988 line was created during President Donald Trump’s first term.

National data shows Georgia is one of several states that have struggled to keep their rates of disconnected or rerouted 988 calls low. Disconnected calls typically involve the caller hanging up, possibly after a long wait time. States are largely responsible for funding and staffing their 988 systems, with some money from the federal government. Mental health experts said proper funding for the 988 system in a state, through a well-staffed response network, can influence whether a caller is connected to a local counselor — or chooses to hang up.

The future of mental health services appears uncertain amid massive changes from the Trump administration, including Medicaid cuts that could limit access to care. The cuts could also lead states to consider reducing their allocations to crisis lines, said Heather Saunders, senior research manager for the Program on Medicaid and the Uninsured at Â鶹ŮÓÅ, a health information nonprofit that includes Â鶹ŮÓÅ Health News.

The stakes couldn’t be higher for callers experiencing severe mental health crises.

“Some of the callers are actively experiencing suicidal thoughts,” Saunders said. “Sometimes they actively have a suicide plan and it’s a very urgent situation.”

Alarm About Call Abandonment Rate

Georgia has contracted with Carelon Behavioral Health, a unit of insurance giant Elevance Health, to run its crisis lines. When Carelon dropped a subcontractor that managed staffing the lines, performance plunged. Abandoned calls spiked, which means more callers were hanging up or disconnecting before a counselor answered the phone, Kevin Tanner, commissioner of the state Department of Behavioral Health and Developmental Disabilities, pointed out in a letter to Carelon.

The state requires a call abandonment rate of 3% or less, and, Tanner wrote, the current rate was 18%. After sending the letter, the state narrowed its definition of abandoned calls, lowering the current rate. The state now counts only calls disconnected after being on hold for more than 30 seconds and not those rerouted to backup centers.

Carelon officials have acknowledged the dip in performance. They said it reflected a “necessary” transition from the company’s vendor and that they were hiring more staff to ensure the crisis lines could handle the demand. Carelon spokesperson Hieu Nguyen said the company is “committed to ensuring that every Georgian in crisis can access help through 988,” noting that calls not answered locally are routed to national backup centers.

With the help of some federal funding, Georgia is paying Carelon $17 million annually to manage 988 and its predecessor, the Georgia Crisis and Access Line, which is still operating. Crisis calls go to the same response team, whether someone calls 988 or the original state line. Carelon and state officials declined to disclose how much of the money went to the subcontractor, Behavioral Health Link, with Carelon saying it is proprietary information. The state can extend its contract with Carelon to 2032.

Camille Taylor, a spokesperson for the state Department of Behavioral Health and Developmental Disabilities, said in December that Carelon had improved its call response performance but that the state continues to monitor the company’s answer rates.

‘Enormous’ Staffing Challenges

Launched in 2022, the national 988 Suicide & Crisis Lifeline connects people experiencing mental health problems, emotional distress, or alcohol or drug use concerns to trained counselors. The free hotline, with the three-digit number mirroring the ease of dialing 911, aims to help avert mental health crises and reduce suicide risk. It also supports people who call for someone they care about.

“All behavioral health is having enormous challenges in terms of staffing,” said Margie Balfour, an Arizona psychiatrist and a member of a national 988 advisory committee. Being a crisis line counselor “is a very stressful job,” she said. “You’re talking to people at the peak of their crisis.”

In December, Georgia ranked near the bottom of the 50 states in percentage of calls answered that it kept in state, according to Vibrant Emotional Health, which administers the 988 line nationally. A high number of Georgia calls were routed to national call centers, data showed.

The latest national data also showed how different the response times to a 988 call can be. In December, it took one second on average if someone called from Mississippi. It took 74 seconds for a caller from Virginia.

While the unofficial industry target rate for answering in-state calls is 90%, more than half the states fell below that mark in December, according to the . In Georgia, the tracking data for 988 showed that more than 80% of crisis calls were answered within the state — until March, when the number dropped to 73%. Then it fell again in April, to 62%. The rate rose to 72% in October and reached 79% in December.

Local counselors “should be more familiar with the state infrastructure, mental health system, and resources that are available to people who live in the state,” said Saunders of Â鶹ŮÓÅ.

Pierluigi Mancini, interim president and CEO of Mental Health America, said it’s unlikely that an out-of-state counselor would know much about that state’s mental health system and providers. The service also sends many predominantly Spanish-speaking callers to out-of-state call centers, possibly hindering their connection to local help, Mancini said.

Since the 988 rollout, the volume of calls, texts, and chats to the crisis line by November, from killing themselves.

More than 49,000 Americans died by suicide in 2023. Nearly 17 million Americans ages 12 and older said in 2024 they had in the previous year, according to the National Survey on Drug Use and Health.

For Generation Z adults, the oldest of whom are now reaching their late 20s, suicide is taking more lives than a decade ago when millennials were the same age, according to a of federal death statistics. The largest increase in suicide rates for the age group was in Georgia, which jumped 65% from 2014 to 2024.

Mike Hogan, a consultant who ran mental health systems in three states, said recent Georgia data reflects “a bungled transition. It looks like performance fell off a cliff.”

For people calling a crisis line, he said, “counselors, with the right training, can talk people down and away from the suicidal crisis.”

Balfour noted that 988 has bipartisan support. The system can be improved, she said, emphasizing that it’s still an important resource that’s effectively helping people in crisis.

“988 is a success,” Balfour said. “And it’s work in progress.”

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Now at least 20 states have settled with Centene over its pharmacy benefit manager operation that coordinated the medications for Medicaid patients. Arizona was among the most recent to join the ranks, settling for an undisclosed payout, Richie Taylor, a spokesperson for the state’s attorney general, told Â鶹ŮÓÅ Health News in December.

All told, Centene has agreed to pay more than $1 billion in settlements, according to , one of the law firms representing states in the agreements. Meanwhile, St. Louis-based Centene reported $163 billion in revenue in 2024, largely proceeds from government health programs for Medicaid, Medicare, and the Affordable Care Act. The health care company has admitted no wrongdoing in the settlements.

Two state holdouts appear to remain: Georgia has yet to settle with Centene, even though the administration of Gov. Brian Kemp in 2019 to investigate state pharmacy benefit operations.

Florida hired the same law firm in 2021 to pursue overbilling allegations involving Centene, but state officials declined to answer a reporter’s questions about whether Florida has dropped the case, reached an undisclosed settlement, or is still discussing the issue.

Neither state has publicly disclosed what’s standing in the way of potentially tens of millions of dollars in Centene payouts, or whether negotiations are taking place. Because the deals are largely , the process between the private law firms hired by states and Centene remains generally out of public view.

Centene spokespeople did not return multiple phone calls and emails asking for updates. In 2022, the company said it was working on settlements with Georgia and eight other states, having reached deals with 13 others. And in a Securities and Exchange Commission , Centene said it had reached settlements with “the vast majority of states impacted” over the operations of its former pharmacy benefits manager.

Georgia has “taken disproportionately long compared to other states,” said Greg Reybold, a vice president of the , which represents independent pharmacies.

Meanwhile, Centene’s Georgia Medicaid plan, the Peach State Health Plan, lost its bid last year to continue its longtime participation in a Georgia Medicaid program in which for Medicaid recipients for a set fee from the government rather than for each medical service provided. The company, which has been part of the contract since the managed-care program began in 2006, over the contract awards, saying that the process was “mismanaged, rife with errors and reckless practices.”

Nationally, pharmacy benefit managers, or PBMs, have come under increased scrutiny over accusations of pocketing discounts on medications or inflating costs in the years since Centene started settling its Medicaid-related allegations. Members of Congress have proposed major policy constraints on PBMs. Centene has since overhauled its PBM operation.

Still, a possible settlement in Georgia could bring in significant money to the state. California had the largest publicly disclosed settlement at $215 million, split with the federal government, but a settlement with Georgia could be in the range of the $88 million that Centene agreed to pay in the Ohio dispute, Reybold said.

The state should aggressively pursue a settlement with Centene, said Roland Behm, co-founder of the , who is a critic of Centene and its Georgia Medicaid plan. Behm said state Attorney General Chris Carr should take “the same tenacious prosecutorial action” against Centene that Carr’s agency takes against individuals involved in fraud against Medicaid, the federal-state program that provides health insurance coverage for those with low incomes or disabilities.

Carr’s office said in 2022 that it stood ready to represent Georgia in settlement negotiations with Centene. Carr, a Republican who has announced he’s running for governor in 2026, received tens of thousands of dollars in campaign contributions from Centene, its subsidiaries, and its executives, as did Kemp, a fellow Republican, Â鶹ŮÓÅ Health News reported in 2022. Contributions to the Kemp and Carr campaigns were part of more than $26.9 million that Centene, its subsidiaries, its top executives, and their spouses donated to state politicians in 33 states, to their political parties, and to nonprofit fundraising groups from 2015 through 2022.

Since 2022, the company and its political action committee have contributed, combined, at least $2 million more to the campaigns of Florida and Georgia candidates of both political parties, along with state party organizations and political committees, according to state campaign finance records.

When asked about a possible settlement, a spokesperson for Carr, Kara Murray, directed a reporter to the Georgia Department of Community Health, which administers Medicaid.

Fiona Roberts, a spokesperson for that agency, then told Â鶹ŮÓÅ Health News that the department “is actively pursuing options to ensure regulatory compliance with the state’s contract.” She declined to comment further.

Florida’s attorney general’s office directed a reporter to the state agency that oversees Medicaid, the Florida Agency for Health Care Administration. But that agency did not respond to multiple phone calls and emails requesting comment.

Rebecca Grapevine of Healthbeat contributed to this article.

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The program, called “Georgia Pathways to Coverage,” is the nation’s only active Medicaid work requirement.

Pathways has cost tens of millions in federal and state dollars on administration and consulting fees while enrolling 5,542 people as of Nov. 1, according to Â鶹ŮÓÅ Health News’ reporting. The congressional letter cited the reporting in its request to the Government Accountability Office.

“Republicans are hell-bent on putting mountains of red tape between Americans and their health care,” Sen. (D-Ore.), head of the Senate Finance Committee, said in a statement about the letter he co-wrote. “Taxpayers deserve to hear from an independent watchdog about the true costs of the Republican health care agenda.”

Georgia Sens. and co-signed the request.

The Democrats’ letter asks the GAO to prepare a summary of the costs to run the program — and detail how much of that has been picked up by the feds, break down the cost of the program per person, and assess how Georgia has used contractors to run the program and how federal officials have overseen it.

The request comes as President-elect Donald Trump, who supported work requirements in his first administration, is set to take office and potentially transform how people qualify for Medicaid, the joint federal-state health insurance program for people who are disabled or have low incomes.

Many GOP-led states have pushed for work requirements in public benefits programs such as Medicaid, arguing that they promote employment. Georgia’s Pathways program requires some Medicaid applicants to prove they are working, volunteering, or studying for 80 hours a month.

The first Trump administration in 13 states. Only Georgia’s program, which started on July 1, 2023, is in effect. A Medicaid work requirement launched in Arkansas was halted by a court order in 2019.

In November, South Dakota voters gave lawmakers a green light to seek a work requirement for some Medicaid enrollees. In 2023, North Carolina lawmakers if the federal government would approve such a waiver. And some GOP-led states have indicated they might also seek work requirements.

Georgia’s program has been a priority of Republican Gov. , and his team defended the program.

“The Senators should be more focused on examining the failures of the federal government to adequately provide the services they’re required to administer than looking for every opportunity to criticize states that are taking innovative approaches,” Garrison Douglas, a Kemp spokesperson, said in an emailed statement.

Enrollment in the program, which as of Dec. 13 was 5,903, has fallen far short of the state’s initial projection of more than 25,000 in the first year.

The program has cost more than $40 million in state and federal funds, largely administrative costs and not medical care for enrollees, Georgia officials have said. Â鶹ŮÓÅ Health News reported in March that Georgia officials estimated the program’s administrative costs could increase to $122 million over four years.

A spokesperson for Georgia’s Medicaid agency, Fiona Roberts, said the costs “increased significantly” because of the program’s delayed launch. While it was approved by the Trump administration, the Biden administration attempted to block it, resulting in a legal fight.

Â鶹ŮÓÅ Health News has also reported that the program has slowed processing times for other Medicaid applications and for public benefits such as cash assistance and food stamps.

Meanwhile, more than a year after Pathways’ launch, Georgia officials said they still had not removed enrollees for failing to prove they are working, volunteering, or studying for 80 hours a month, Â鶹ŮÓÅ Health News has reported.

“State leaders continue to put taxpayer dollars behind their ineffective health care program that has failed by nearly every metric,” Warnock said.

Previous federal research suggests that the high costs per enrollee associated with Georgia’s program could be repeated elsewhere. The Trump administration didn’t properly weigh administrative costs in state applications for work requirements, according to . Pathways is slated to expire on Sept. 30, unless federal officials grant an extension.

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In July, his parents, Haresh and Nina Adhvaryu, received a letter saying their applications would be delayed, he said. In August, the Adhvaryus started calling a Georgia helpline, he said, but couldn’t leave a message. It wasn’t until September, when they visited state offices, that they were informed their applications were incomplete.

The couple were mystified. They had Medicaid coverage when they lived in Virginia, before their recent move to metro Atlanta.

While they waited, Adhvaryu’s parents — ages 71 and 76 — delayed care, fearing they couldn’t afford it. They have Medicare, and, in Georgia, Medicaid pays for its premiums, copayments, and deductibles. The lack of extra coverage strained their fixed incomes.

“It was concerning,” Deegant Adhvaryu said, because his family lost a critical financial “lifeline.”

It took Adhvaryu’s parents until late October — more than 120 days after applying — to finally get their Medicaid cards in the mail. Federal rules require states to process most Medicaid applications within 45 days.

For years, Georgia’s public benefits system has been plagued by problems like the Adhvaryus’ — a glitchy website that’s often down for maintenance, a shortage of staff to process applications, and technology that malfunctions, according to consumer advocacy organizations, former state employees, and researchers.

But a Â鶹ŮÓÅ Health News analysis shows processing times have worsened since July 2023, when Georgia launched the nation’s only active Medicaid work requirement program, “.” The program began three months after the state began redetermining the eligibility of all Medicaid enrollees following a covid-19 pandemic pause.

The percentage of Medicaid applicants waiting more than a month and a half to have their applications processed has nearly tripled in the first year of Pathways, the analysis of state and federal records found. Georgia had the in the country as of June, for income-based applications. Preliminary data from July puts the state as the second-slowest. The percentage of applications for financial and food assistance that take more than 30 days to process has also risen by at least 8 percentage points.

Pathways “is really bogging down” a system that was “already functioning relatively poorly,” said , director of health justice at the Georgia Budget and Policy Institute, a nonprofit research organization that supports full Medicaid expansion.

Georgia’s effort to run Pathways reveals the challenges that loom for states looking to launch Medicaid work requirements under a second Donald Trump presidency. His first administration approved them in more than a dozen states. On Nov. 5, South Dakota voters gave lawmakers the green light to seek a work requirement for its existing Medicaid expansion population.

Conservative lawmakers around the country would like to add work requirements to Medicaid, the state-federal insurance program for people with disabilities or low incomes, said , who leads Georgetown University’s Center for Children and Families. “If Georgia fails, that’s a big black eye for the Republican Party.”

Pathways is one of Republican Gov. Brian Kemp’s signature health policy initiatives and his alternative to fully expanding Medicaid eligibility under the Affordable Care Act. Applicants must document that they’re working, studying, or doing other qualifying activities for 80 hours a month in exchange for health coverage.

Consumer advocacy organizations, former state employees, and researchers say the initiative adds inefficiencies and bureaucracy that slow down other public programs, like the Supplemental Nutrition Assistance Program, or SNAP, and the Temporary Assistance for Needy Families program, or TANF.

As of Nov. 1, just 5,542 residents were participating in the work requirement program. Under a full Medicaid expansion program, nearly health coverage, according to the Robert Wood Johnson Foundation.

Georgia’s work requirement hasn’t been cheap to implement. An found about $13,360 in state and federal spending for each enrollee from January 2021 through June 2024, largely on administrative costs, not health benefits. That doesn’t account for the cost to prepare and submit the application for Pathways to the feds or the fees associated with legal fights over the program.

Officials in Georgia told Â鶹ŮÓÅ Health News that, as of June 30, Pathways had cost $40.6 million in state and federal funds.

Pathways also has increased the workload for state staffers who must manually verify complex eligibility requirements and monitor enrollees’ continued eligibility, according to consumer advocacy organizations, former state employees, and researchers.

The Kemp administration blames the processing slowdown of state benefits, in part, on what’s known as the ,” which began in April 2023 as states had to redetermine the eligibility of all enrollees in the wake of the coronavirus pandemic.

“Georgia Pathways is an innovative, Georgia-specific program that has provided coverage to thousands of Georgians who otherwise would be without care,” said Garrison Douglas, a Kemp spokesperson.

Critics say the Pathways rollout stressed a system that’s had snags for years. In contrast, Chan pointed to North Carolina, which fully expanded Medicaid during the unwinding, covering more people for less than the cost per person of Pathways and without creating additional backlogs for other public benefits programs.

Waiting for benefits approval can have concrete consequences for people’s health and well-being, say doctors, researchers, and patient advocates.

Flavia Rossi, a pediatrician in Tifton, about 180 miles south of Atlanta, said some parents skip their kids’ checkups because they fear expensive out-of-pocket costs while waiting for Medicaid coverage for their children.

In October 2023, Ellenwood, Georgia, residents Gloria and William Felder, who have custody of a granddaughter, were told by the state that her Medicaid coverage had lapsed. William Felder said they reapplied three times but waited 11 months for her coverage to be restored, during which they spent over $1,500 on her care. “We wanted to make sure she had coverage,” he said.

After a health insurance navigator queried the state, Felder said, the state finally informed them in September that she had Medicaid again.

Georgia officials haven’t invested enough in the state agency that processes public benefits applications, said , executive director of Georgians for a Healthy Future, a nonprofit policy advocacy organization. The problem is exacerbated by staffing shortages, high staff turnover, and outdated technology, she said.

In November 2023, the U.S. Department of Agriculture notified state officials that Georgia was “severely out of compliance” with timeliness standards for processing SNAP applications. A recent progress report details the scope of the issues: a system that incorrectly prioritizes applications, not enough staff to handle a backlog of nearly 52,000 new applications, and no system to promptly reassign applications when staff are off.

“These delays create real hardship, forcing families to make choices between paying for medicine, food, or rent while they wait for the support they’re entitled to,” Colbert said.

The state of about 2.7 million residents when the pandemic-era Medicaid continuous coverage requirement ended. Nearly half a million Georgians lost coverage — including nearly 300,000 children, according to an analysis by Alker’s nonprofit.

Instead of investing more to ensure that people who were wrongly removed could reenroll, the state continues to pour money into the Pathways program, Alker said. She cited a recently launched $10.7 million ad campaign aimed at boosting Pathways enrollment with money from federal pandemic recovery funds.

The contract for that work was awarded to the consulting firm Deloitte, which has already received millions from Georgia to build and implement Pathways. It’s also responsible for the state’s Gateway technology system, which people use to access public benefits and Georgia officials have described as having ongoing problems, according to Â鶹ŮÓÅ Health News’ reporting.

Deloitte did not respond to a request for comment for this article. It previously told Â鶹ŮÓÅ Health News that it does not comment on state-specific issues.

In a November letter to Â鶹ŮÓÅ Health News, Deloitte spokesperson Karen Walsh said the firm’s clients — state governments — “understand that large system implementations are challenging due to the complexity of the programs they support, and that all IT systems require ongoing maintenance, periodic enhancements and upgrades to software and hardware, and database management.”

Deegant Adhvaryu had to help keep his parents afloat as they waited months to get approved for Medicaid and SNAP. He bought them groceries and helped cover their rent. Not every applicant is that lucky.

“There are people in the state of Georgia with far less financial resources, far less family connections to be able to help them that need these services,” he said.

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It wasn’t a bake sale, but the sweets bring extra revenue as pharmacist and co-owner Nikki Bryant works to achieve profitability at her business on the town square.

Bryant said she is doing all she can to bolster it against a powerful force that threatens her and other independent pharmacists: the middlemen who manage virtually all prescriptions written in the U.S., called pharmacy benefit managers, or PBMs. Serving as brokers among drugmakers, pharmacies, and health insurers, these health care entities have drawn scrutiny from Congress, the Federal Trade Commission, and state legislatures for their role in the increase in drug prices.

Bryant and other independent pharmacists say PBMs not only create higher costs but also make it harder for patients to access medications. So they were hopeful about state legislation this year that would have increased their reimbursement to match the average prices paid to retail chain pharmacies through the state employee health plan. But Gov. Brian Kemp vetoed the bill.

Kemp that it would cost the state as much as $45 million a year and said “the General Assembly failed to fund this initiative.”

Underlining the Georgia legislative reform effort against pharmacy benefit managers was an analysis by the American Pharmacy Cooperative, which represents independent pharmacies, that reviewed the price differential paid to a north Georgia pharmacy and nearby chain stores.

The analysis early this year showed chains were paid well beyond the family business for many of the same medications: For example, the chains received an average of nearly $54 for the antidepressant bupropion, while Bell’s Family Pharmacy in Tate, Georgia, got $5.54, the analysis said. For a drug used to treat blood pressure, amlodipine, chain pharmacies received an average of $23.55, while Bell’s got $1.51.

Bell’s Family Pharmacy closed earlier this year.

“The differences in Georgia are unbelievable,” Antonio Ciaccia, who runs Ohio-based consulting firm 3 Axis Advisors. “If you’re a pharmacist, you don’t have any control over which drugs you dispense and which you don’t.”

By controlling prices and availability, pharmacy benefit managers cause patients and employers to spend more for medications, according to the Federal Trade Commission and pharmacy groups. On Sept. 20, the FTC sued three of the largest PBMs — CVS Health’s Caremark, Cigna’s Express Scripts, and UnitedHealth Group’s Optum Rx, which together control about 80% of U.S. prescription drug sales. The agency said they created a “perverse drug rebate system” that artificially inflates the price of insulin. Each company denied the allegations.

The lawsuit followed a in July that said the “dominant PBMs can often exercise significant control over which drugs are available, at what price, and which pharmacies patients can use to access their prescribed medications.”

The trade group that represents PBMs, the Pharmaceutical Care Management Association, said the insulin market is working well and blamed drugmakers .

Bryant and other independent pharmacists, though, say they lose money filling certain prescriptions while reimbursements favor chain pharmacies like CVS that have corporate ties to pharmacy benefit managers. And even the chain pharmacies have retrenched, with CVS, Rite Aid, and Walgreens announcing layoffs or store closures in recent months.

“PBMs are like the mafia,” Bryant said. “They pay us what they want to pay us. They are sucking all the money out of health care.”

Pharmacy benefit managers will charge some health insurance plans more for a medication than what they reimburse a pharmacy, keeping the extra money as profit, critics say. This practice is known as “spread pricing.” Large PBMs also take money from drugmakers as a “rebate” to give their drugs preferential treatment on health plans’ lists of medications, independent pharmacies say. And by favoring certain pharmacies with whom they have business ties, experts say, these drug brokers help force independent stores such as Bell’s to close.

The veto by Kemp, a Republican, came despite the GOP-led General Assembly voting overwhelmingly for Senate Bill 198 on the last day of the legislative session.

Kemp spokesperson Garrison Douglas said, “The governor remains entirely and wholeheartedly supportive of Georgia’s independent pharmacists and the need for PBM transparency.”

In his veto message, Kemp voiced support for a study of independent pharmacy drug reimbursements and PBM practices. And he said independent pharmacists are getting an extra $3 dispensing fee this year on state employee prescriptions.

The state Department of Community Health, which oversees the State Health Benefit Plan, told Â鶹ŮÓÅ Health News that CVS Caremark, the PBM handling the state employee business, supplied the cost estimate Kemp used to justify his veto.

Fiona Roberts, a spokesperson for Community Health, said the department didn’t have time to conduct its own analysis.

CVS Caremark said it used historical claims data to calculate the cost impact of the higher reimbursement.

Nationally, criticism of PBM practices intensified over the summer with the Federal Trade Commission report.

The Pharmaceutical Care Management Association pushed back, saying the report “is based on anecdotes and comments from anonymous sources and self-interested parties and supported only by two cherry-picked case studies that are implied to be representative of the entire market.”

Members of both parties in Congress have tackled PBM reform. House members recently introduced another proposal, known as the Pharmacists Fight Back Act, which supporters say would add transparency, limit costs for patients, ensure they get the benefit of drugmaker discounts, and protect their pharmacy choices.

The consolidation that has combined health insurers with PBMs — including their operating their own retail, mail-order, and specialty pharmacies — has created financial behemoths, said U.S. Rep. Buddy Carter, a Georgia Republican and a pharmacist. “I’m interested in busting them up,” he said.

Alexander Oshmyansky, co-founder of Mark Cuban Cost Plus Drug Company, said the PBMs siphon off about a third of the $400 billion a year spent on pharmaceuticals.

“What we could do as a society with $100 billion as opposed to paying some companies to process drug payments,” Oshmyansky said.

PCMA, the trade group, cited funded by the three biggest pharmacy benefit managers that said their operating margins are less than 5%.

And the group says that discussions about congressional reform “reflect a one-sided view informed directly by the pharmaceutical industry’s blame game designed to vilify PBMs to keep prescription drug prices high and increase drug company profits.”

Underpayments by PBMs, however, have accelerated the closures of mom-and-pop pharmacies across the country, said the National Community Pharmacists Association, which represents independent pharmacies.

The U.S. loses almost one such pharmacy a day, said Anne Cassity, a senior vice president of the association. Rural pharmacies, which are hard to reach for patients lacking transportation, are especially vulnerable, she said.

Bryant’s two pharmacies deliver to several counties, including to patients who have a disability or no transportation. The cost to patients: zero.

Most states have passed some version of oversight or restrictions on pharmacy benefit managers.

In Montana, state officials have collected financial reports from pharmacy benefit managers over the past two years after passing a bill to promote transparency in these businesses.

shows that rebates in Montana rarely are directly returned to people buying prescriptions. Instead, they’re pocketed by the PBMs or returned to health plans.

Josh Morris, who owns three independent rural pharmacies in southwestern Montana, said his pharmacies have seen reimbursement rates for medications bought under PBM-managed plans drop.

Morris said his business routinely either breaks even or loses money. “Our plan is that once we reach a certain level of cash, that we will be out,” Morris said. “As in ‘closed.’”

Frank Cote, with Montana’s insurance commissioner’s office, said that the state has tried to make business easier for small pharmacies but that state officials still don’t control how much PBMs pay. Cote said the state will look for ways within existing rules or future legislation to support rural pharmacies.

Following Kemp’s veto in Georgia, the pharmacy pay differential sparked criticism from an unusual place: within the board of the state Department of Community Health, the agency that runs the State Health Benefit Plan.

Mark Shane Mobley, a board member, said at an August meeting that independent pharmacies’ pay in the state employee plan should be on par with a chain’s. The PBM profit “is going to line people’s pockets that are far outside of the state,” said Mobley, president of Avilys Sleep & EEG, a Georgia provider of sleep disorder and electroencephalogram testing. “Our independent pharmacies, they’re hiring people locally. They’re taking care of the local community.”

Community Health Commissioner Russel Carlson said the agency has an ongoing dialogue with CVS Caremark, the PBM handling the state employee plan medications.

“We don’t have our head in the sand. We know there are some frustrations out there that exist in this space,” he said. “But we acknowledge that we do have contractual responsibilities.”

In Cuthbert, Bryant said she can make more profit on cake and coffee than with many medications.

Still, she’s in business while a nearby CVS pharmacy closed recently. “We outcompeted them on service,” Bryant said.

Montana correspondent Katheryn Houghton and senior correspondent Arthur Allen contributed to this report.

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The children, Deas said, often have been exposed to violence on hotel properties, exhibit aggression or anxiety from living in a crowded single room, and face food insecurity because some hotel rooms don’t have kitchens.

“Social trauma is the biggest challenge” when students first arrive, Deas said. “We hear a lot about sleep problems.” To meet students’ needs, Deas developed a schoolwide program featuring counselors, a food pantry, and special protocols for handling those who may fall asleep in class.

“Beyond the teaching, there’s a social part,” he said. “We have to find ways to support the families as well.”

Extended-stay hotels are often a last resort for low-income families trying to find housing. Nationally, more than 100,000 students lived in extended-stay hotels in 2022, according to the Department of Education, though officials say that is likely an undercount. Children living in hotels are considered homeless under federal law, and in some Atlanta-area counties about 40% of homeless students live in this kind of housing, according to local officials.

And with rising rents and evictions, and decreased access to federal public housing, the use of extended-stay hotels as a long-term option is becoming more frequent. Like other forms of homelessness, hotel living can lead to — or exacerbate — physical and mental health problems for children, say advocates for families and researchers who study homelessness.

In the Atlanta area, inspections of extended-stay hotels have revealed ventilation issues, insect infestations, mold, and other health threats. Children living there also can experience or witness crime and gun violence. The increasing use of extended-stay hotels is a warning sign, observers said, a reflection of the lack of sufficient affordable housing policy in the U.S.

And the crisis is having “lifelong consequences,” said Sarah Saadian of the National Low Income Housing Coalition. “The only way that we can really address that shortage is if there are significant federal resources at scale. Build more housing and bridge the gap between rents and wages.”

Often, evictions force families into hotels — and can keep them trapped there. Many landlords refuse to rent to people with evictions in their credit history, even if the tenant isn’t responsible for the displacement, said Joy Monroe, founder and CEO of the Single Parent Alliance & Resource Center, or SPARC, a nonprofit group in metro Atlanta that has helped hundreds of families move from hotels to apartments or rental homes.

Black women and other women of color, often with kids, are evicted at much higher rates and are more likely to find themselves living in extended-stay hotels, advocates say.

Some residents are also families fleeing domestic violence, they say.

Hotels often don’t require security deposits, application fees, or background checks, thus providing immediate relief for families seeking shelter. While there are higher-end options, the average rate for an economy-class extended-stay room was $56.68 a night during the first three months of 2024, according to the Highland Group, a research firm that focuses on the hotel sector — which works out to more than $1,700 a month.

And while the rooms offer respite from other forms of homelessness — like sleeping in a car or in a tent — a hotel “is no place to raise children,” said Michael Bryant, CEO of New Life Community Alliance, which helps families in South Dekalb, a part of metro Atlanta, move from hotels to homes.

Children living in hotels are often behind on vaccinations, and they may end up in the emergency room because of delays in care, said Gary Kirkilas, a pediatrician in Phoenix who helps children, teens, and families who are presently homeless or at risk of homelessness. About 75% of children with unstable housing whom he sees have at least one developmental delay, and others experience significant emotional and behavioral issues.

Tanazia Scott, who has bounced between two extended-stay hotels for several months, said her three children “feel depressed and upset” over hotel life.

An eviction sent Kassandra Norman, 58, and her two daughters into a months-long journey of staying in Atlanta-area hotels. For three months, they slept in a car outside a convenience store. “It’s hard to do homework in a car and in the hotel,” said 19-year-old Kazuri Taylor, Norman’s younger daughter.

Some hotels prohibit kids from playing outside in their parking lots, leading to additional stress, advocates say. That was the reason Yvonne Thomas, 45, and her family were evicted from an extended-stay hotel in DeKalb County, she said: “They put us out for nothing.”

And there are other problems. More than a dozen students at Dunaire Elementary live on an extended-stay property called Haven Hotel. In August, the hotel had “not maintained minimum life safety standards.” Roaches and spiders live in rooms and breezeways, according to state health inspection reports. Residents say they have been charged $1 for a roll of toilet paper.

The hotel’s owner and manager could not be reached for comment after multiple attempts.

“No one is talking about these families,” said Sue Sullivan, a community advocate and a volunteer with the Motel to Home coalition in Atlanta, who brings toys, bookbags, food, and toiletries on her hotel visits.

A February public health inspection at another DeKalb County hotel found several rooms with poor ventilation, insect infestation, and mold, among other potential health threats. In May, two people were fatally shot there.

Children who witness violence can develop anxiety, depression, and other disorders, said Charles Moore, director of the Urban Health Initiative at Emory University School of Medicine. “They can feel emotional aftershocks,” said Moore, who has visited Atlanta-area hotels.

Closing such hotels, however, can hurt families, given the shortage of affordable housing, the absence of national federal renter protections, and a dearth of places to go, said Terri Lewinson, an associate professor at the Dartmouth Institute for Health Policy and Clinical Practice. Extended-stay hotels do “offer a low-barrier option for families who have no other options,” she said.

To alleviate the housing problem, county officials and nonprofit organizations around the country have been creatively filling the gap. In the Seattle area, for example, King County officials purchased hotels and converted them into affordable housing, said Mark Skinner of the Highland Group.

In metro Atlanta, SPARC and the local United Way’s Motel to Home offer funding to help people transition into an apartment.

In DeKalb County, where Dunaire Elementary School is located, more than a third of the 1,300 homeless students live in hotels, according to Commissioner Ted Terry.

“I hope we can rescue the children,” he said. “It’s not a safe environment for them.”

Advocates who seek to help people living in hotels propose the construction of more affordable housing and stronger protections for renters against eviction. The federal government has failed to invest in repairs needed to maintain current public housing units, and 25-year-old legislation effectively prohibits the construction of new public housing.

It’s also “extremely fast, easy, and cheap” to evict tenants in Georgia, said Taylor Shelton, an associate professor of geosciences at Georgia State University, whose research focuses on social inequalities and urban spaces. “The playing field is tilted heavily toward landlords.”

Under such circumstances, the cycle of poverty is difficult to break, said Jamie Rush, a senior staff attorney at the Southern Poverty Law Center. “Most parents would want their kids in a safe, stable home,” Rush said. “You can’t budget your way out of poverty.”

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A fifth patient with similar symptoms later arrived at another local facility, according to a health system spokesperson.

The day after the Sept. 4 school shooting that killed two students and two teachers, some 80 families showed up in a county office to receive counseling from volunteer therapists who converged from across the Atlanta metro area, according to one medical provider. That Sunday, nine people received free treatment at a local church for post-traumatic stress disorder from volunteering Atlanta-area providers. On Monday, the state to help locals find counseling, faith-based support, or other aid. The needs are still great.

“We don’t really … know how we’re doing,” Amanda McKee — whose son, Asa Deslonde, is a senior at Apalachee — said two days after the shooting. “It’s second by second. It’s minute by minute. The last couple days have been unimaginable.”

When shootings of any magnitude occur, they often leave the survivors with invisible injuries that can create life-changing symptoms that sometimes paralyze them.But such problems can take time to emerge. Panic attacks and anxiety can spike across a community after a shooting and can be most intense when people return to the scene, said , chair of the Council on Communications for the .

So health providers worry that in the coming days, months, and years the community will struggle to find help for their mental health needs. Barrow County, along a highway that connects Atlanta to the college town of Athens, is a community where agriculture is steadily giving way to development.

Prior to the shooting, the area had one stand-alone inpatient mental health facility, located in Gainesville, about 30 miles away from where the shooting occurred in Barrow County, that was “constantly overwhelmed,” said Sean Couch, a spokesperson for Northeast Georgia Health System. And, the latest federal data shows, Barrow would need to add at least 13 full-time providers to no longer be considered a mental health workforce shortage area.

“We put a band-aid on a chronic situation and that band-aid isn’t going to last,” said Roland Behm, a co-founder of the Georgia Mental Health Policy Partnership, an advocacy group that represents mental health organizations in the state. “What happens three months from now?”

The scarcity of mental health providers in Barrow County is emblematic of the state as a whole. Georgia ranks nearly last among states in access to mental health care resources, according to , a nonprofit that advocates for increased mental health spending. More than live in mental health care professional shortage areas like Barrow County.

Paying for mental health care to treat such trauma is difficult nationwide. But Georgia is one of the 10 states that have for Medicaid, the nation’s safety net insurance for those with low incomes and also the largest payer for mental health services. The state has an uninsured rate of 13.6%, which is 4.1 percentage points higher than the country as a whole, according to from the U.S Census Bureau.

Even people with private health plans have trouble finding affordable, in-network mental health care because of a lack of providers willing to accept low insurance reimbursement rates, Behm said.

Tamara Conlin, CEO of , said the people who came to the initial counseling sessions that her group helped arrange in a county office showed a lot of sadness and anxiety.

“Some of them are still in shock and trying to wrap their heads around what happened,” she said.

Even before the shooting, students at Apalachee High School reported significant mental health challenges.

Nearly 200 of 1,725 student respondents reported that they had seriously considered attempting suicide one or more times in the prior year, according to . Top motivators included problems with peers, friends, or family. About half of the students from the school who answered said they felt sad, depressed, or withdrawn at least once in the prior 30 days.

County residents complained about having to travel for psychiatric care and said the “shortage of psychologists and counseling services led to untreated high anxiety and depression rates,” during a 2019 about health care access.

The lack of mental health care remained a top concern in the region during a . That year, the opioid overdose death rate in Barrow County was among the highest in Georgia, according to , and the five-year suicide rate was .

The Barrow County School System, which includes Apalachee High School, received a to boost mental health resources in schools from 2023 through 2028.

But immediately following the shooting, mental health providers across the region still had to cobble together free resources for area residents. Three volunteers helped with last Wednesday’s response at Northeast Georgia Medical Center Barrow. Advantage Behavioral Health Systems kept its Barrow clinic open on Sunday and is providing counselors to community events and local schools as they reopen.

William Smith, who heads the Atlanta Center for EMDR, is planning sessions using eye movement desensitization and reprocessing therapy to address PTSD — at least one for first responders and another for residents.

Over the weekend, brought nine golden retrievers as “comfort dogs” to help the grieving. The group’s dogs have been deployed in the wake of other school shootings, including the Uvalde, Texas, massacre.

“We can’t fix what they’re feeling,” said volunteer Paul Soost, as people gathered around a campus flagpole where they delivered flowers and messages. “We can provide comfort.”

Many health care providers expect the community’s needs to spike when students return to Apalachee High School and as the national attention on the shooting recedes.

“That’s when people start experiencing the trauma,” said Conlin, with Advantage Behavioral Health Systems, who compared the current crisis to the surge of patients she saw after the immediate threat of the covid-19 pandemic passed.

Her clinic in Barrow County already had about 750 active clients before the shooting, with about 120 under the age of 18.

McKee said she knows healing will be a long process for her son, Asa. One of his football coaches, , was among the four killed. A key step came the day after the shooting, she said, when the school’s head football coach convened the team to share how much he was hurting.

“The coach validated that they were hurt, and encouraged them to embrace that they were injured,” McKee said. “They’re not the physical injuries that were incurred by the senseless act, but they are injuries nonetheless.”

If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

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Whitehouse, a consultant for a local health care company that wants to build a hospital there with at least 150 beds, said the group could break ground within a year. The idea, he said, is to provide medical services beyond those currently provided by Wellstar Sylvan Grove Medical Center, an aging, nonprofit “critical access” hospital that offers limited services, including emergency care, rehabilitation, wound care, and imaging.

But it took a new law, pushed by the state’s powerful Republican lieutenant governor, Burt Jones, to clear the way for construction. The land is partly owned by his father, Bill Jones, a successful businessman whose interest in developing a hospital in his home county drew attention from state Democrats and the hospital industry.

The situation has been portrayed as “this billionaire entrepreneur, Bill Jones, exploiting the legal system through his son, imposing his will on people and trying to cash in,” Whitehouse said. “Nothing could be further from the truth.”

Woven through the drama in Butts County are arcane but consequential rules that require state approval for hospital construction and expansion. The rules, used nearly nationwide until the 1980s, require potential builders to apply for permission for new projects. State officials evaluate need based on criteria such as population growth and existing hospital capacity.

This year, Georgia lawmakers joined several other states in targeting those “certificate of need,” or CON, regulations for dramatic change. Some states have exempted certain medical providers from the process; others have been more dramatic, including South Carolina, which is .

Attempts to pave the way for a new hospital in Butts County show how debate over certificate of need laws can intensify as legislatures try to reconcile the often conflicting priorities of politicians, the health care industry, and communities.

The laws have been criticized for limiting competition, and some health care analysts, like Matthew Mitchell, a senior research fellow at West Virginia University, feel everyday people may get the short end of the stick.

“This kind of a regulation is often there because powerful businesses want them,” Mitchell said, “not because they protect consumers.”

Bill Jones, a 79-year-old former state legislator, supported a 2022 legislative push to open a new hospital in Butts County. But the effort ran into formidable opposition from Wellstar Health System, which operates Sylvan Grove and 10 other hospitals in Georgia.

“As a nonprofit health system, we are always exploring partnerships that expand our mission of enhancing wellbeing in the communities we serve,” said Matthew O’Connor, a Wellstar spokesperson. “Our analysis indicates that another hospital in this area is not needed at this time.”

This year, Georgia Democrats thought they could leverage Republicans’ interest in loosening the rules to gain support for Medicaid expansion. But Democrats were outnumbered in the legislature, and lawmakers eased several rules without that trade-off.

For example, certain hospital projects in rural counties are now exempt. Jones’ project and his home county look likely to benefit.

Burt Jones, Georgia’s lieutenant governor, who is being investigated for his role as a fake elector for Donald Trump in the 2020 presidential election, maintains his push for changes to the rules isn’t about helping his father.

“It will give people access to health care in a reasonable travel time and convenience for them as well,” Burt Jones said.

Bill Jones has used Butts County as the home base to build his business network, which includes petroleum distribution, retail convenience stores, and fast-food restaurants. In a recent interview, he complained about media coverage of his son’s legislative connection to the hospital project.

He said his interest in opening another local hospital is about community need and, at least in part, stems from his personal experience. His wife gets medical services at Emory Healthcare, more than 40 miles away in Atlanta.

“You’re not going to get the attention you need medically” at the 25-bed Sylvan Grove hospital in Jackson, he said. “Health care ought not to be about politics.”

But the lieutenant governor had to be somewhat aware that legislation he was pushing could be seen as financially benefiting a close family member, said Josh McLaurin, a Democratic state senator whose district runs from Atlanta into its northern suburbs. Fellow members of the Democratic Party were encouraged to support the certificate of need bill, even though the GOP has a majority in the Georgia Legislature, he said.

“If they want Democrats on board on a bill they could probably pass without our votes, that tends to suggest that there’s a concern about the narrative,” McLaurin said.

Hospital industry lobbyists, aware of the Jones-Butts County connection, watched the debate with fear of wholesale repeal of the certificate of need laws, which ultimately didn’t happen.

The final bill doesn’t name Butts County specifically. But it does exempt “a new general acute care hospital in a rural county” from having to obtain a certificate of need. With a population of about 27,000, Butts County meets the definition of “rural” outlined in Georgia law.

Now, the small local company for which Whitehouse works — Interstate Health Systems, which is partly owned by Bill Jones — is moving forward. Land is being cleared for medical office buildings, potentially to lure providers to the area.

Whitehouse said major hospital systems already operating in Georgia are interested in partnering on construction and operation of a new facility.

Members of the Butts County Hospital Authority, which oversees Sylvan Grove, declined to comment. But last year, county commissioners passed encouraging the hospital authority to pursue a new facility.

Byrd Garland, a retired attorney and former hospital authority member, said he’d appreciate any project that gives people local access to health care, “so they don’t have to drive an hour or two hours to get to it.”

Garland said he’s received both good and bad care at Sylvan Grove, and sometimes would rather make the trek to Atlanta to a better-resourced hospital.

“You get that kind of mindset when you’ve grown up out here in this medical desert that we’re in now,” he said.

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In the town of Cuthbert, some 160 miles away, the Southwest Georgia Regional Medical Center also remains shut after closing four years ago, another Southern hospital casualty in a region dotted with them. Even a smaller facility replacing the former Cuthbert hospital “would be tremendous for the county,” said Steve Whatley, chair of the Randolph County Hospital Authority.

The two hospitals — one inner-city, the other rural — faced some of the same financial pressures, including not having enough patients with private insurance.

This year, they also shared the attention of some of Georgia’s most powerful lawmakers. by Gov. Brian Kemp, a Republican, included a provision pushed by U.S. Sen. Jon Ossoff, a Democrat.

The law amends the state’s “certificate of need” system, which allows existing hospitals and other health facilities to block would-be competitors’ plans to expand by arguing there’s insufficient need for their services.

Certificate of need laws exist in , according to the National Conference of State Legislatures. The hospital industry, especially nonprofit facilities, generally support the rules, and have argued they reduce health care costs and preserve access to quality medical services. Under CON requirements, health providers must obtain approval from the state before offering some new services or before building or expanding facilities.

Whether the laws improve care or reduce costs is questionable, researchers have found, and critics say more competition would decrease spending by insurers and consumers. In 2018, the Trump administration issued a report recommending that states their certificate of need requirements, arguing they increase health care costs.

“The evidence is pretty darn overwhelming that CON laws don’t achieve the initially stated goals of increasing access, lowering costs, and improving quality,” said Matthew Mitchell, a senior research fellow at West Virginia University.

Dan Sullivan, a Georgia-based consultant who often helps hospitals and other medical providers in their effort to preserve the laws, said that by limiting the number of providers offering very specialized health services, such as organ transplants, states can better maintain high quality of care.

Certificate of need laws can reduce fraud, Sullivan said. Florida repealed its certificate of need requirements for hospitals and many other health providers following the Trump administration’s recommendation. Fraud accelerated in the state after regulations were phased out, he said.

“At least when you file a CON, there’s at least a minimum of investigation,” Sullivan said.

He argued another benefit of the laws is that they frequently mandate a baseline level of charity care.

Other Southern states recently peeled back their certificate of need laws. Tennessee’s legislature passed a bill this year exempting more medical providers from needing to apply for a certificate. North Carolina rolled back some restrictions in an overhaul that paved the way for Medicaid expansion last year. South Carolina made a significant change to its rules last year.

This year, Republicans in Georgia’s legislature attempted to repeal the state’s certificate of need rules. The effort fell short in the face of fervent hospital opposition.

The narrower legislation that Kemp signed would instead ease the rules for building rural hospitals and exempts a potential new hospital that would partner with Morehouse School of Medicine, one of the country’s few historically Black medical schools.

That could potentially fill much of the gap left by Atlanta Medical Center’s closing.

Hospital industry officials said Morehouse would probably need a well-heeled partner, and Atrium Health, part of Charlotte, North Carolina-based Advocate Health, may be a logical match. The growth-oriented nonprofit health system has partnered with Morehouse Healthcare to run a clinic in East Point, south of Atlanta, and has a growing presence in the state. Both Morehouse and Atrium declined to discuss a potential hospital partnership with Â鶹ŮÓÅ Health News.

The shuttered AMC main campus, meanwhile, is ensnared in a moratorium the city imposed on redeveloping the site — a response to the jolting decision by its owner, Wellstar Health System, to close the hospital.

In 2022, Mayor Andre Dickens temporarily halting any new development on the site. He has criticized the “unusually abrupt closure of one of Atlanta’s most important medical centers.”

Atlanta’s city council extended the ban another 120 days in June.

A new inner-city hospital “would be a heavy lift financially,” said Josh Berlin, CEO of rule of three, an Atlanta-based health care consulting firm. That’s because it would draw largely from the area’s high level of uninsured and Medicaid patients. Georgia is one of 10 states that have not fully expanded Medicaid, and thus has a high rate of uninsured patients.

“You’ve got a community that is struggling to find care in the wake of the Atlanta Medical Center closure,” he said.

Grady Memorial Hospital and other Atlanta facilities have seen a bump in patient volume since the closure of AMC. Grady is regularly deemed “dangerously overcrowded” in .

The need to handle additional patients has sped up expansion plans for Grady, including adding more than 150 beds, said its chief strategy officer, Shannon Sale. “We knew that was going to be needed over time. The Atlanta Medical Center closure sped up that process,” she said.

In southwestern Georgia, plans are more modest.

Community leaders, including Whatley, are awaiting the results of a feasibility study that is expected to propose a downsized “rural emergency hospital,” a new federal designation that directs extra funding to eligible facilities.

The program guarantees hospitals in rural communities extra Medicare payments and an additional payment of about $3.2 million a year if they close costly inpatient services and offer only emergency and outpatient care.

Ossoff won almost $12 million in three different appropriations bills to support a rural emergency hospital in Cuthbert. He said he met with state leaders to secure the provision in the Georgia certificate of need bill that would allow it to reopen. Southwest Georgia Regional Medical Center would also have to get an exemption from federal officials to qualify for a rural emergency hospital because of its closing date.

“This is a very challenging thing to do, and we’ve still got significant hurdles to clear,” Ossoff told Â鶹ŮÓÅ Health News.

Even if it reopens, the Cuthbert facility will face the same pressures that led to its shuttering in the first place — what Ossoff called “failures of state policy.” At the time, Georgia’s decision not to fully expand Medicaid in the wake of the closure.

Brenda Clark, who works in a wellness center across the street from the closed Cuthbert hospital, said some locals are skeptical about the facility reopening.

“It’s much needed. People are hoping and praying we get it back,” she said. But “there are some people who say, ‘We’ll believe it when we see it.’”

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Cox, 40, qualified for an Affordable Care Act marketplace plan with no monthly premium due to her relatively low income. And after she cut her hand severely, the 35 stitches she received in the ER led to an out-of-pocket expense of about $300, she said.

“I can’t imagine what the ER visit would have cost if I was uninsured,” she said.

Cox is among 1.3 million people enrolled in health coverage this year through the ACA marketplace in Georgia, which has seen a 181% increase in enrollment since 2020.

Many people with low incomes have been drawn to plans offering $0 premiums and low out-of-pocket costs, which have become increasingly common because of the enhanced federal subsidies introduced by President Joe Biden.

Southern states have seen the biggest enrollment bump of any region. Ten of the 15 states that more than doubled their marketplace numbers from 2020 to 2024 are in the South, according to a . And the five states with the largest increases in enrollment — Texas, Mississippi, Georgia, Tennessee, and South Carolina, all in the South — have yet to expand Medicaid under the Affordable Care Act, driving many residents to the premium-free health plans.

But with the federal incentives introduced by the Biden administration set to expire at the end of 2025, and the possibility of a second Donald Trump presidency, the South could be on track to see a significant dip in ACA enrollment, policy analysts say.

“Georgia and the Southern states generally have lower per-capita income and higher uninsured rates,” said Gideon Lukens, a senior fellow and the director of research and data analysis for the Center on Budget and Policy Priorities, a nonpartisan, Washington, D.C.-based research organization. If the enhanced subsidies go away, he said, the South, especially states that haven’t expanded Medicaid, will likely feel a bigger effect than other states. “There’s no other safety net” for many people losing coverage in non-expansion states, Lukens said.

When Cox was enrolling in Obamacare last fall, she qualified for premium tax credits that were added to two major congressional legislative packages: the American Rescue Plan Act in 2021, and the Inflation Reduction Act in 2022. Those incentives — which gave rise to many plans with no premiums and low out-of-pocket costs — have helped power this year’s record . The extra subsidies were added to the already existing subsidies for marketplace coverage.

The states that didn’t expand Medicaid and have high uninsured rates “got most of the free plans,” said Cynthia Cox, a Â鶹ŮÓÅ vice president who directs the health policy nonprofit’s program on the ACA. Zero-premium plans existed before the new subsidies, she added, but they generally came with high deductibles that potentially would lead to higher costs for consumers.

A Trump presidency could jeopardize those extra subsidies. Brian Blase, a former Trump administration official who advised him on health care policy, said that eliminating the extra subsidies would bring the marketplace back to the ACA’s original intent.

“It’s not sustainable or wise to have fully taxpayer-subsidized coverage,” said Blase, who is now president of the Paragon Health Institute, a health policy research firm. People would still qualify for discounts, he said, but they wouldn’t be as generous.

Karoline Leavitt, a spokesperson for Trump, did not answer a reporter’s questions on the future of the enhanced subsidies under a new Trump administration. Despite his comments at the end of last year that he is “” to Obamacare, Leavitt said Trump is not campaigning to terminate the Affordable Care Act.

“He is running to make health care actually affordable, in addition to bringing down inflation, cutting taxes, and reducing regulations to put more money back in the pockets of all Americans,” she said.

While views on Obamacare may be divided, the wide support for subsidies crosses political lines, according to a released in May.

About 7 in 10 voters support the extension of enhanced federal financial assistance for people who purchase ACA marketplace coverage, the poll found. That support included 90% of Democrats, 73% of independents, and 57% of Republicans surveyed.

The enhanced assistance also allowed many people with incomes higher than 400% of the poverty level, or $58,320 for an individual in 2023, to get tax credits for coverage for the first time.

Besides the financial incentives, other reasons cited for the explosion in ACA enrollment include the end of continuous Medicaid coverage protections related to the covid public health emergency. About a year ago, states started redetermining eligibility, known as the “unwinding.”

of those who lost Medicaid coverage moved to the ACA marketplace, said Edwin Park, a research professor at the Georgetown University Center for Children and Families.

In Georgia, Republican political leaders haven’t talked much about the effect of the Biden administration’s premium incentives on enrollment increases.

Instead, Georgia Gov. Brian Kemp, among others, has , an online portal that links consumers directly to the ACA marketplace’s website or to an agent or broker. That agent link can create a more personal connection, said Bryce Rawson, a spokesperson for the state’s insurance department, which runs the portal. Employees from the agency and from consulting firms helped market the no-premium plans throughout the state, he said.

Yet Georgia Access didn’t become fully operational until last fall, during open enrollment for the marketplace. Republicans also credit a reinsurance waiver that, according to Rawson, increased the number of health insurers offering marketplace coverage in the state, leading to more competition.

Reinsurance is likely not a major reason for a state’s increased Obamacare enrollment, said Georgetown’s Park. And a found that Georgia’s reinsurance program had the unintended consequences of increasing the minimum cost of subsidized ACA coverage and reducing enrollment among individuals at a certain income level, .

The state’s insurance department said the study “does not accurately reflect the overall benefits the reinsurance program has brought to Georgia consumers.”

When asked whether the governor would support renewal of the enhanced subsidies, Garrison Douglas, Kemp’s spokesperson, said the matter is up to Congress to decide.

Another reason for the soaring ACA enrollment is the 2023 fix to the “family glitch” that had prevented dependents of workers who were offered unaffordable family coverage by employers from getting marketplace subsidies.

States that have run their own marketplaces, though, generally have not seen the same level of enrollment increases. Those 18 states, plus the District of Columbia, have expanded Medicaid. Georgia will join the list of states running their own exchanges this fall, making it the only state to operate one that has not expanded Medicaid.

The federal Centers for Medicare & Medicaid Services credits a national marketing campaign and more federal funding for navigators, the insurance counselors who provide education about marketplace health coverage and free help with enrollment.

That level of financial support for navigators may be in jeopardy if Trump returns to the White House.

The Biden administration injected nearly $100 million in funding for navigators in the enrollment period for coverage this year. The Trump administration, on the other hand, for navigators from 2018 to 2020.

The marketplace is usually “a transitional place” for people coming in and out of coverage, Â鶹ŮÓÅ’s Cox said. “That marketing and outreach is pretty essential to help people literally navigate the process.”

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