The law known as the “Great Beautiful Law” President Trump's administration is a reality in the United States, and it comes with tax reforms that will affect health programs such as Medicaid and the Affordable Care Act (ACA) in North Carolina.
The mega-law, identified as the HR 1, includes more than $1 trillion in cuts to these health programs, which will cause 16 million Americans to lose their health coverage.
Full scope of the law pending determination
It is anticipated that with the changes in North Carolina around 600,000 people could lose their Medicaid health coverage and ACA.
However, the full impact of this mega-law on "tax reconciliation" for North Carolinians remains unclear.
The North Carolina Department of Health and Human Services (NCDHHS) said in a statement that it is reviewing the final legislation to determine its full impact on the state and its residents.
He added that he will provide additional information as more details become available.
Responding to the passage of the final bill on Wednesday, July 3, NCDHHS Secretary Dev Sangvai said, “Today’s passage marks a significant moment with real consequences for North Carolina.”
“While the full impact will become clearer in the coming weeks, we already know it will result in billions of dollars being drained from our state's economy and undermine the health of North Carolinians,” he added.
Related: The “Big Beautiful Bill” pushes for mass deportation: more funding, detention centers, and officers
Who has Medicaid in North Carolina
According to NCDHHS data In North Carolina there are 3,115,565 people enrolled in Medicaid:
575,485 (18%) of those enrolled are children
282,989 (9%) are people with disabilities
162,342 (5%) are elderly people
326,426 (10.5%) are Latino or Hispanic
663,557 people are part of the program Medicaid expansion
62,000 Hispanics have expanded Medicaid
Seniors and people with disabilities make up nearly 23% of NC Medicaid enrollees, but account for nearly two-thirds of the program's spending (64%).
On the other hand, 975,110 people in the state are currently enrolled in an ACA Marketplace health insurance plan.
Related: Medical Resources in North Carolina
What the law means for Medicaid
- Health cuts could impact up to 384,000 people in North Carolina who will lose their Medicaid coverage.
- The state will lose up to $ 29 billion in federal Medicaid spending over a 10-year period.
- Most of the patients in the 119 hospitals North Carolinians rely on Medicaid as a source of health insurance coverage.
For example:
-Almost half (43%) of the patients at Davis Regional Medical Center in Statesville are covered by Medicaid.
-A quarter (25%) Of Atrium Health Anson patients in Wadesboro, they rely on Medicaid coverage.
- HR 1 jeopardizes a key lifeline in rural North Carolina: In Robeson (62%), Vance (59%), Edgecombe (58%), Richmond (55%), Scotland (53%), Swain (50%), and Bladen (50%) counties, half or more of the population is covered by Medicaid.
What the law means for ACA
The proposed cuts to the health insurance market in this law are as extensive as the bills to repeal the ACA, also known as "Obamacare," which failed to pass in 2017.
- These policies will cause 252,836 North Carolinians to lose their insurance coverage.
- The law also does not extend the enhanced tax credit that helps more than 950,000 people afford Marketplace health insurance.
What does it mean:
-A 60-year-old couple with an annual income of $82,000 will see an increase in premiums of $18,870
-A family of four with an annual income of $126,000 will see their premiums increase by $8,742.
-A 45-year-old with an annual income of $62,000 will see their premiums increase by $1,604.
- In addition to raising premiums, the law would also increase the annual cost-sharing maximum by $900 for everyone with a private family plan.
- In North Carolina, every year, 919,453 people will have to reapply to maintain ACA health insurance coverage because the law would create new barriers to enrollment and burdensome documentation requirements.
- These policies would eliminate automatic enrollment, a feature that ensures that individuals maintain their coverage at the start of a new 12-month term.
Related: Medicaid budget without agreement in the General Assembly
What the Required Employment Reports for Medicaid Mean
- An estimated 579 lives would be lost annually in North Carolina due to the Medicaid employment reporting requirement.
- Work requirements alone are projected to cost North Carolina up to:
-8,400 direct jobs in the health sector
-17,800 jobs in total
-$1,700 billion in federal funds
-$2,000 in state GDP
-$132,500 billion in state and local tax revenue
What it means for the state's health care sector and economy
Hospitals across the state will face greater financial risk as they assume more uncompensated care costs due to Medicaid cuts.
- Medicaid cuts will burden North Carolina hospitals with an estimated $1,200 billion in uncompensated care costs.
- Rural hospitals are more likely to provide uncompensated care than urban hospitals. For example:
Five rural hospitals are at risk of closure: UNC Rockingham Hospital in Eden, Person Memorial Hospital in Roxboro, Chatham Hospital in Siler City, Angel Medical Center in Franklin and Blue Ridge Regional Hospital in Spruce Pine.
- Medicaid cuts will make it difficult for nursing homes and Community Health Centers (CHCs) in North Carolina to remain open; seniors and others will struggle to find other care.
-There are approximately 420 nursing homes in North Carolina, where 5 out of 8 nursing home residents are covered by Medicaid.
-In North Carolina, there are 43 community health centers (CHCs) operating 567 service sites across the state. Fifty-three percent of these centers are in rural areas.
Twenty-six percent of CHC patients in the state are covered by Medicaid.
Related: What immigration status can you access Medicaid in North Carolina without being a U.S. citizen?
How the law will affect legal and undocumented immigrants
Limits enrollment for ACA: Beginning January 1, 2026, the new law eliminates the provision that allows lawfully present immigrants who are ineligible for Medicaid due to their status and who earn less than 100% of the Federal Poverty Level (FPL) to enroll in ACA coverage.
This means that certain low-income immigrants would not be eligible for the ACA or Medicaid, denying them any path to affordable health coverage.
The only immigrants who will remain eligible for Advance Premium Tax Credits (APTCs) are legal permanent residents/green card holders, Cuban-Haitian entrants, and COFA migrants. All other immigrants would not be eligible for premium tax credits that make marketplace coverage more affordable.
End of Medicare eligibility for many immigrants: In about 18 months, the new law ends Medicare eligibility for many previously eligible, lawfully present immigrants who could receive Medicare if they had the appropriate work experience.
The only immigrant categories that will be eligible are lawful permanent residents/green card holders, Cuban-Haitian entrants, and COFA migrants.
Medicare benefits will be discontinued no later than 18 months after the legislation is enacted for anyone currently receiving benefits but no longer eligible under these changes.
Emergency Medicaid: The law reduces the federal Medicaid matching rate for “emergency-only” services for immigrants in the Medicaid expansion category.
States that expanded Medicaid under the ACA will receive a lower federal Medicaid matching rate (FMAP) for emergency services provided to low-income adults who are not eligible for full-scope Medicaid due to their immigration status.
Instead of the higher FMAP rate for this expansion group, states will receive the same rate as for traditional Medicaid groups. The measure will be effective as of 1 2026 October.
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After the storm
A year ago, Hurricane Helene struck western North Carolina. The Latino community responded with something stronger than the storm: solidarity.
🎧 In this episode, learn how Latino organizations transformed crisis into resilience.
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