Georgia is at a crossroads. As we invest in Georgia Access, our new state-based health insurance marketplace, we are also facing a threat that could undermine the very foundation of that investment. Unless Congress acts, enhanced premium tax credits, federal financial assistance that helps eligible individuals and families afford health insurance purchased through the Affordable Care Act (ACA) Marketplace, and which makes health insurance affordable for over 1.4 million Georgians, will expire at the end of 2025.
This would be more than a personal loss for families. It would be a fiscal and economic blow to the state, jeopardizing Georgia Access, increasing our uninsured rate, and driving up our costs across the board — for local governments, small businesses, and ultimately, the taxpayer.
But here’s what we must not overlook: these tax credits are not giveaways. These credits are investments in individual productivity and economic self-sufficiency. They empower hardworking Georgians to participate in the free market and take personal responsibility for their health care. They reduce long-term dependency on emergency care and Medicaid. And, crucially for those of us who value federalism, they support Georgia’s ability to run its own marketplace our way, not DC’s.
Let’s start with the immediate impact. A 60-year-old couple in northeast Georgia earning $82,000 a year currently pays about $581 a month for a silver-level plan. Without the enhanced premium tax credits, their premium jumps to over $2,000 a month — an increase of more than $18,000 a year. That kind of cost is simply unsustainable, especially for those living on fixed or moderate incomes. And it doesn’t just affect retirees — it hits farmers, many veterans, self-employed workers, and small business owners who are buying insurance on the open market.
Combined with the recently-passed reconciliation funding bill, which includes historic cuts to the Medicaid program, the expiration of the enhanced tax credits would mean that 10 million people could become uninsured, putting hundreds of thousands of Georgians at risk of losing their coverage. That means higher rates of uncompensated care, more pressure on rural hospitals, and cost shifts that drive up private premiums. These are not abstract numbers — they’re real budgetary impacts that Georgia counties will be forced to confront.
When people can’t afford insurance, they delay care. They end up in emergency rooms where care is most expensive. Hospitals eat those costs and shift them to those who can pay — raising insurance premiums for employers and employees alike. Local government agencies and boards, who insure law enforcement, frontline workers, and other state employees see their healthcare costs rise. And when rural hospitals teeter on the edge (already a crisis in Georgia), property tax increases often follow to keep them afloat.
These ripple effects threaten the success of Georgia Access, which depends on strong enrollment and market stability. If premiums soar and people drop out, the state may be forced to backfill lost funding or scale back its marketplace infrastructure, putting new pressure on the already-stretched budget. That means state taxpayer dollars doing work that federal subsidies were doing more efficiently.
That’s not a fiscally conservative outcome. It’s unnecessary government expansion caused by preventable federal inaction.
There’s a better way. By continuing enhanced premium tax credits, Congress keeps federal investment flowing into Georgia, over $660 million a year, without expanding the footprint of government. These credits go directly to hardworking Georgians who use them to purchase private insurance in a competitive marketplace. It’s a model that fosters self-reliance, rewards work, and keeps people off taxpayer-funded safety nets like emergency Medicaid or indigent care funds.
It also enhances state autonomy. Unlike federally run marketplaces, Georgia Access allows our state to shape its own enrollment system, tailor outreach strategies, and set priorities that reflect our values. But Georgia Access only works if people can afford to participate. Letting these subsidies expire would force Georgia either to abandon the model or fund it at far greater cost to the state.
As a lifelong Republican, former Habersham County Commissioner, and small business owner, I know that real conservatism isn’t about saying no to everything; it’s about saying yes to smart, efficient investments that help prevent bigger government down the road. Enhanced premium tax credits do just that. They support healthy markets, healthier people, and a healthier budget outlook for Georgia.
This isn’t about ideology. It’s about practicality. If Congress fails to extend these credits, Georgia will be left paying more for less — more uninsured, more hospital strain, and more financial pressure at every level of government. But if Congress acts, we can preserve a system that’s working for individuals, employers, and our state.
Georgia has taken a bold step by creating its own marketplace. Now we need Washington to keep its end of the bargain, not by expanding programs, but by maintaining tools that are empowering people and states alike.
This is what federalism should look like: Washington sets the structure, individuals take responsibility, and states lead the way. Let’s make sure Georgia has the resources and the freedom to do just that. I urge you to tell your Congressional representatives to renew the enhanced premium tax credits that help lift up our great state.
Natalie Crawford, a Republican, is a former two-term Habersham County Commissioner and founder and executive director of Georgia First and chair of the BRIDGE Georgia healthcare coalition.
