Earlier this month, outgoing North Carolina Gov. Roy Cooper celebrated the state’s first anniversary of Medicaid expansion. As of Dec. 3, 25,457 Cumberland County residents now have health insurance thanks to the state’s expansion of the health insurance program.
However, national and North Carolinian health policy experts and activists worry those residents could lose coverage if the incoming federal legislature cuts its share of Medicaid funding.
“It’s going to affect all of us in many ways,” Carrol Olinger, Fayetteville field director for advocacy organization Action NC, told CityView.
NC Medicaid expansion 101
Medicaid is a health insurance program for people with low incomes, with program eligibility varying by state. Before Medicaid expansion, North Carolina parents and caretakers were eligible if they made 37% or less of the federal poverty level. All other adult residents were eligible if they made 0% or less of the federal poverty level.
The 2010 Affordable Care Act expanded Medicaid eligibility to any adult with an income below 138% of the federal poverty level — or $15,060 for a household of one in 2024. States can expand their Medicaid eligibility under the ACA or keep their original requirements.
North Carolina chose the former. In March 2023, Cooper signed NC Medicaid expansion into law. Effective Dec. 1, 2023, North Carolina residents aged 19 to 64, who are U.S. citizens or have valid immigration status and whose household meet income restrictions qualify for NC Medicaid.
Cumberland County residents account for about 4.3% of all North Carolinians enrolled in the expansion. Brenda Jackson, director of Cumberland County’s Department of Social Services, said Medicaid expansion helped fill a health care gap. Before the expansion, she said, many residents went without care because they didn’t qualify for original Medicaid and earned too little to be eligible for the Affordable Care Act, also known as Obamacare.
“There are many stories of customers who have benefited greatly from Medicaid expansion,” Jackson said.
Many of those customers are among the county’s unhoused population, Jackson said. She also recalled a mother with many chronic conditions and mental health needs who was covered under original Medicaid rules as a caretaker. Under those rules, the mother would have lost coverage when her child turned 18 since she would no longer qualify for caretaker coverage. But Medicaid expansion made any adult below a certain income eligible for benefits, thereby preventing a gap in her coverage, Jackson said.
Advocates like Olinger and Abby Emanuelson, former executive director of the now-shuttered Medicaid expansion advocacy group Care4Carolina, both spotlighted similar stories from other residents across North Carolina as they pushed to get the state to expand Medicaid. Emanuelson, now an advocacy communications consultant, spent time telling legislators about the financial benefits of expansion.
Medicaid expansion funding created 57 positions within the Cumberland County Social Services Department, which administers NC Medicaid.
“We believe Medicaid expansion has resulted in economic benefits within the county by supporting growth in our healthcare systems, the creation of jobs within the healthcare sector and by removing the burden of high medical costs on qualifying families,” Jackson said.
How Trump’s plans could impact Cumberland County
NC Medicaid expansion came with one stipulation: the federal government must fund at least 90% of the costs of the newly eligible North Carolinians. If the federal funding falls below 90%, North Carolina will stop covering the expanded population “as expeditiously as possible.”
Medicaid is jointly funded by the federal government and a given state’s government. The program is the fourth largest chunk of national spending after Social Security, Medicare and defense.
Reducing government spending is a main platform of President-elect Donald Trump’s new Department of Government Efficiency. While not an official government agency, DOGE leaders Elon Musk and Vivek Ramaswamy proposed a $2 trillion cut to federal spending.
DOGE’s goal comes as Trump promised not to touch Medicare and Social Security spending during a sit-down interview with NBC’s “Meet the Press” host Kristen Welker. The goal also follows a report from the Congressional Budget Office that estimates the Department of Defense’s planned budget will increase by 10% between 2024 and 2038.
“That means almost half of federal spending would be protected from cuts, leaving Medicaid, which is the next largest source of federal spending, and the ACA as prime targets for spending cuts,” Larry Levitt, executive vice president for health policy for health information organization KFF, wrote in an op-ed for JAMA Health Forum. “The math is inescapable.”
Project 2025, a federal policy agenda created for the Trump Administration by a conservative think tank called The Heritage Foundation, also targets the ACA and its expansion of Medicaid eligibility for funding cuts. Meanwhile, a report from the Centers on Budget and Policy Priorities highlights Republican Party budget proposals that suggest lowering the 90% Medicaid expansion federal payment rate. Those proposals include the Republican Study Committee Budget and the House Budget Resolution for fiscal year 2025.
“Taking this much money away from states would make it likely that many states would drop the entire Medicaid expansion, which would result in millions of people losing coverage,” wrote Allison Orris and Gideon Lukens, report authors and fellows for the Centers on Budget and Policy Priorities, a nonpartisan research and policy center.
Medicaid often makes up the largest portion of state budgets. In North Carolina’s fiscal year 2023, before the state’s Medicaid expansion, the state government alone spent $4.61 billion, or 7.8% of the state’s total expenditures that year, on NC Medicaid.
Losing Medicaid expansion would leave over 25,000 Cumberland County residents without health insurance.
“A loss of this magnitude would result in worsening health outcomes for our citizens and could financially devastate individuals and families with medical debt,” Jackson said. “It could result in a strain on our emergency departments, The CARE Clinic and other nonprofits providing services to the uninsured.”
Olinger said free and low-cost resources like The CARE Clinic, a Fayetteville nonprofit clinic providing care to low-income and uninsured adults, and the Cumberland County Health Department’s clinic are overbooked even with Medicaid expansion.
For now, Medicaid expansion is still here
In a November discussion hosted by the Association of Health Care Journalists, Levitt emphasized that none of the predicted cuts are guaranteed to happen.
“There’s a lot of tea-leaf reading in trying to anticipate what might happen,” he said.
While Emanuelson acknowledges concern about possible federal cuts to Medicaid, she believes there’s time for her and other activists to push federal officials to maintain Medicaid funding coming from the national government.
“I don’t think this is going to be immediate,” Emanuelson said. “But I definitely think it’s a piece of education that we need to start advocating for and explaining the benefits of expansion.”
Olinger is focusing on state officials and getting them to keep Medicaid expansion even if the federal government decides to lower its funding percentage.
“It looks like North Carolina needs to find money for us,” Olinger said. “I believe that it’s there.”
Residents can learn more about NC Medicaid, Medicaid expansion and how to apply for the programs on the North Carolina Department of Health and Human Services’ website. They can also visit Reception 21 on the 2nd Floor of the Cumberland County Department of Social Services building on Ramsey Street.
CityView Reporter Morgan Casey is a corps member with Report for America, a national service program that places journalists into local newsrooms. Morgan’s reporting focuses on health care issues in and around Cumberland County and can be supported through the CityView News Fund.