The Cost of Going Without: Georgia’s Coverage Gap Is a Mental Health Issue

Awareness Is Not the Barrier

Every May, Mental Health Awareness Month invites us to talk openly about mental health. But for hundreds of thousands of Georgians without health insurance, awareness is not the barrier. Access is.

In my clinical work, I have cared for patients who waited months, years, and sometimes decades before seeking help, not because they did not recognize their symptoms, but because they knew how much care would cost. One patient comes to mind: a hard-working young man managing persistent depression while juggling multiple jobs in an effort to make ends meet. Without insurance, therapy felt out of reach, and medication was inconsistent at best. Life had become unmanageable after a difficult breakup.

By the time he arrived in care, he was in crisis.

This is a pattern clinicians across Georgia know well. When people finally enter the system, their conditions are often more severe, more complex, and more difficult to treat.

This is not a personal failing. It is the predictable outcome of policy choices that have left Georgia with one of the highest uninsured rates in the nation and one of the weakest mental health access rankings in the country.

A Crisis by the Numbers

Georgia’s mental health system is under strain, and the burden is not evenly shared.

The state ranks 46th in the nation for access to mental health care, according to Mental Health America’s 2025 assessment. That ranking is felt most sharply by Georgians who need care but cannot afford to seek it: nearly 35 percent of adults experiencing mental distress in Georgia could not see a doctor because of cost, one of the highest rates in the country.

A share of that affordability crisis traces back to who is, and is not, eligible for coverage. An estimated 240,000 Georgians fall into what is known as the coverage gap, earning too little to qualify for marketplace subsidies and ineligible for Medicaid under the state’s current rules. The gap exists because Medicaid expansion, originally a requirement of the Affordable Care Act, was made optional for states by a 2012 Supreme Court ruling. Forty states have since elected to expand Medicaid. Georgia has not.

The state’s alternative to expansion, the Pathways to Coverage program, has fallen far short of closing the gap. Pathways offers limited Medicaid coverage to a narrow group of adults, but enrollees must document 80 hours of work, school, or other qualifying activities every month to keep their coverage. Despite costing taxpayers more per enrollee than traditional Medicaid expansion, Pathways has enrolled only a small fraction of the 180,000 to 200,000 uninsured Georgians who could benefit from coverage, even after nearly three years in operation.

Even if a patient like the one I described qualifies for coverage through Pathways, they are very likely to have difficulties completing the steep paperwork requirements while managing their mental health condition.

The mental health implications of this gap are direct. For many uninsured Georgians in the coverage gap, access to mental health and substance use treatment remains out of reach. The coverage decisions of Georgia’s leaders are determining who can access mental health care at all. Federal cuts to health coverage and the expiration of enhanced marketplace subsidies are expected to increase Georgia’s uninsured population in the coming years. State leaders have the option to make the right decision and make it easier for Georgians to find the mental health care they need.

Who Bears the Weight

The consequences of the coverage gap are not evenly distributed. They follow longstanding patterns of inequality.

In my research and clinical experience, these disparities are not incidental. Specific features of the health care system determine who receives care, when they receive it, and what outcomes they experience. Health disparities persist even among insured populations, but without coverage, those gaps widen.

Lack of insurance is an obvious, and fixable, barrier to care.

What Medicaid Expansion Would Change

Other states have made a different policy choice, and the results are clear.

The federal government covers 90 percent of the cost of Medicaid expansion. In the 40 states that have welcomed Medicaid expansion, the average uninsured rate is 7.6 percent. In states that have not, it is almost double at 14.1 percent. Medicaid expansion is a more cost-effective way to insure Georgians than Pathways, and the outcomes at stake are undeniable:

These outcomes are not theoretical. When people have access to coverage, communities also benefit from greater workforce stability and stronger rural health systems. Other states have experienced measurable improvements in access, treatment, and lives saved. Georgia has the same opportunity. The evidence is strong, the funding is available, and the need is clear.

The question is whether our lawmakers will act.

A Choice Within Reach

I often think about the patients I have treated in psychiatric emergency rooms who arrive in crisis. Many could have come sooner and avoided suffering if care had been accessible from the start.

The launch of 988, the national Suicide and Crisis Lifeline, ensures that anyone in crisis can call or text 988 to reach trained counselors at any time. But crisis support alone is not enough. 988 can de-escalate a moment and guide someone toward help. It cannot replace ongoing care such as therapy, medication, and follow-up treatment, which remain out of reach for many uninsured Georgians. Without coverage, many Georgians cycle repeatedly through emergency rooms and crisis systems instead of receiving consistent preventive care.

For 988 to fulfill its promise, it must connect people not into a dead end, but into a continuum of accessible, effective care. Closing Georgia’s coverage gap is one of the most important steps we can take to move from a system that reacts to crises to one that prevents them.

Georgia already has the evidence, the resources, and the federal support to act. What remains uncertain is whether our state leaders will find the political courage to do so.

Every day we delay, more Georgians fall deeper into crisis while preventable suffering continues.

Mental Health Awareness Month reminds us every May that “mental health is health.” It is time our state leaders treated it that way.