How Trump’s ‘Big Beautiful Bill’ Is Shaking Up Health Care in N.C.

This article was produced in collaboration with Main Street Media Cooperative, which offers the services of experienced journalists to help local outlets report about the effect of changes in Washington on their communities. 

The “One Big Beautiful Bill” that Congress passed earlier this year will create significant changes to how many North Carolinians access and pay for their health care, some of which will result in sharply higher premiums next year.

The new law appears likely to affect millions of state residents covered under Medicaid or who buy private insurance through the marketplace created by the 2010 Affordable Care Act (ACA).

Here’s what North Carolinians can expect as the changes take hold.

How Do North Carolinians Pay for Health Care?

Describing health care in the U.S. as a “system” is a misnomer. That’s mostly because there are so many ways people pay for care.

A little less than half of North Carolinians get their health insurance through their employers, who generally pay a portion of the costs. Another 2.2 million, or roughly 20% of the state’s population, are enrolled in Medicare, the federal program covering those over age 65. Medicare is partly funded through payroll taxes and the federal government. 

About 1 million people, or 9% of the state, have private insurance via the state ACA marketplace. Nine commercial insurers offer several tiers of benefits on the marketplace, at different price points. (Aetna, Celtic/Wellcare, and CoreSource are dropping coverage in 2026, citing higher costs.)

Low-income people can qualify for Medicaid, which is funded by both the federal government and the state. In North Carolina, an individual with an annual income of $21,597 or less is eligible, while for a family of four the annual cutoff is $44,367. About 3 million people in North Carolina depend on Medicaid, of which 1.2 million are children. Medicaid recipients also select their coverage from the ACA marketplace.

Why Are Premiums Rising?

Health insurance costs are expected to increase for most people in 2026, largely attributable to people using more medical services and coverage for expensive new technologies and medicines. But those who buy insurance through the ACA exchanges are getting the most intense sticker shock as they enroll for next year.

That’s because the Big Beautiful Bill removed pandemic-era tax subsidies that helped make monthly premiums more affordable. The credits ensured that people who bought ACA plans paid no more than 8.5% of their incomes. North Carolina Gov. Josh Stein estimates the increases could price about 157,000 people here out of coverage.

Blue Cross Blue Shield of North Carolina recently estimated that a couple making $125,000 a year could pay $24,392 a year more in premiums next year; a single adult making $25,000 a year could pay $1,200 more.

Democrats wanted to reinstate the subsidies as part of a deal to end the recent federal shutdown but ultimately voted to reopen the government without resolving the subsidy issue. Lawmakers are still debating whether to reinstate the subsidies.

What About Medicaid?

The Big Beautiful Bill also made some big changes to Medicaid that could affect North Carolinians.

In December 2023, North Carolina became the 40th state to expand Medicaid coverage, allowing people making up to 138% of the federal poverty line to qualify and adding 650,000 more people to the program. 

The ACA enabled that change, as Washington took up 90% of the cost of the expansion enrollments, while the state only covers 10%. (The federal government pays a lower share of the cost for people who would have qualified for Medicaid without the expansion.)

Two in five children in the state are covered by Medicaid, according to the Kaiser Family Foundation. About a quarter of N.C. recipients live in rural areas, and one in six have three or more chronic conditions. In North Carolina, 42% of adults covered by Medicaid work full-time. About 25% work part-time, and 33% are unemployed.

The law Congress passed this year imposes new work requirements on Medicaid recipients. Non-elderly and nondisabled adults who received coverage via the expansion will be required to work, attend school, or volunteer for at least 80 hours a month, with some exceptions. The state Department of Health and Human Services estimated that as many as 255,000 North Carolinians could lose coverage under the new rules, which go into effect in 2027. Health officials predict many people may lose coverage simply because they have difficulty navigating the employment verification process twice a year. Health leaders across the country also are unsure whether departments can keep up with the workload the verifications will require.

The Big Beautiful Bill also caps the hospital taxes that North Carolina uses to fund the expansion. State law says if funding for its portion of Medicaid falls short, the expansion should be “discontinued.” Thousands of people could lose coverage unless either the state or the federal government changes its law.

To offset some of the losses, Congress included a Rural Health Transformation Program that will provide states $50 billion over the next 10 years. Much of that is designed to help rural hospitals, which are expected to be hit hard if many people lose Medicaid coverage.

North Carolina has asked for $200 million a year for five years. The U.S. Department of Health and Human Services will announce on December 31 which states receive funding.

Eighty-five of North Carolina’s 100 counties are designated as eligible for rural health support. The state plans to use those funds for things such as preventive health services for diabetes and hypertension, buttressing mental health and substance abuse care, and helping rural hospitals adopt new payment models that prioritize keeping people healthy. 

So Why Is N.C. Medicaid Making Cuts Now?

Medicaid accounts for about one-third of the state’s annual spending. The state increased Medicaid spending by $500 million earlier this year due to growth in enrollment, higher drug prices, and other factors. That was still $319 million short of what the program needed, according to the N.C. Department of Health and Human Services.

Republicans who control the state House and Senate both proposed closing that gap but disagreed on how to do it and could not reach a resolution. State lawmakers appear to be done passing legislation for the year, even as the state predicts that Medicaid could run out of funds as soon as April without action. 

To conserve funds, the state announced that it would reduce rates it pays to medical providers by 3%, as well as bigger cuts for inpatient and residential services and behavioral therapy. 

Judges have blocked cuts to payments for personal care in adult care homes and for Applied Behavior Analysis therapy for children with autism. 

What Happens If I Lose Coverage?

Some people who lose coverage may be able to take advantage of North Carolina’s network of free and charitable clinics. In 2023, these nonprofit clinics provided medical, mental health, and dental care for more than 80,000 people who didn’t qualify for government or ACA plans but met certain income thresholds, according to the North Carolina Community Health Center Association. 

But none of these clinics offers or pays for any inpatient or emergency room care. 

Medical providers and hospitals often will negotiate payment plans, or even reduced fees, for uninsured patients who request help. Additionally, in 2023, North Carolina created a Medical Debt Relief Program to help families regain financial stability. Last year, participating hospitals eliminated $6.5 billion in outstanding medical bills affecting 2.5 million state residents.

Michael Waldholz is a veteran health care reporter. He previously covered the beat for The Wall Street Journal and Bloomberg News.