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The Republican tax and spending law will cut Medicaid by almost a trillion dollars in the coming years. And states are already planning how to run leaner Medicaid operations. Lawmakers in about a dozen states may actually have another problem. They passed laws preventing them from using state dollars for their Medicaid expansion program. That includes North Carolina. As Nick de la Canal from member station WFAE reports, these states don't have a lot of options if they want to keep health insurance for their citizens.
NICK DE LA CANAL, BYLINE: It's the end of the workday at a community health clinic in Henderson, North Carolina.
LAURA UCIK: Bye. Have a good night.
DE LA CANAL: Staff file out as a receptionist locks up.
(SOUNDBITE OF LOCK CLANKING)
DE LA CANAL: Dr. Laura Ucik hangs around an exam room reviewing her patient notes.
UCIK: Tons of diabetes today, some acute stuff.
DE LA CANAL: She also saw migrant workers and a patient with substance use disorder - all typical cases for this town of 15,000 just south of the Virginia border. Ever since North Carolina expanded Medicaid two years ago, she says more of her patients can finally afford care.
UCIK: They get Medicaid and we're like, let's go, you know? They're the best visits.
DE LA CANAL: She says people with substance use disorder can now get shots that curb cravings. Patients with diabetes can afford insulin and glucose monitors. Across North Carolina, nearly 680,000 people now have health insurance that's at risk under the Republican tax and spending law. That's because North Carolina is 1 of 12 states with some kind of trigger clause. It means if the state pays anything to insure these people from the general state budget, the entire program will end. It's why North Carolina Republican Senator Thom Tillis voted against the bill in June and said President Trump pledged not to touch Medicaid.
(SOUNDBITE OF ARCHIVED RECORDING)
THOM TILLIS: What do I tell 663,000 people in two years or three years when President Trump breaks his promise by pushing them off of Medicaid?
DE LA CANAL: Right now, the federal government pays 90% of the insurance cost. The rest of the money in North Carolina comes from a special tax on hospitals and medical providers. But the federal Medicaid changes require that states cut that special tax on hospitals by nearly half. That means North Carolina needs to fill that gap if it wants to make sure low-income residents have insurance. Lawmakers could just change the trigger law and use state dollars.
JAY LUDLAM: I don't know that we're looking to eliminate the trigger law, so that's not the path that I think we're headed down.
DE LA CANAL: That's Jay Ludlam, deputy secretary of North Carolina Medicaid. He says there's also the new work requirements to get Medicaid in the tax and spending law. States have to set up an administrative apparatus to run that by January 1, 2027. He says it's not clear how North Carolina can pay for it without state dollars.
LUDLAM: But it really needs to move in earnest over the next couple of months in order to meet incredibly aggressive deadlines and timelines.
DE LA CANAL: For now, North Carolina medical providers say they don't know what to expect.
TIM EVANS: We're very much in a wait and see. You know, what is going to actually happen? No idea.
DE LA CANAL: Tim Evans is CEO of Mountain Community Health Partnership in Mitchell and Yancey counties, areas hard hit by Hurricane Helene. He says the possibility of fewer patients having health insurance in a couple of years is like another storm on the horizon.
EVANS: We didn't know that the storm would be coming from Washington as much as from Helene.
DE LA CANAL: But at least this is one storm states can see coming, and they can buy themselves some time. The tax and spending law does allow them to ask for extensions in implementing the work requirements.
For NPR News, I'm Nick de la Canal in Charlotte, North Carolina. Transcript provided by NPR, Copyright NPR.
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