Opinion: Congress, not our state legislature, will decide whether NC’s Medicaid expansion is eliminated

North Carolina is proud of its long-sought passage of Medicaid expansion. Since November 2023, it has extended health coverage to 640,297 citizens, including 231,300 in rural areas. 

However, unbeknownst to most North Carolinians, national Republicans’ newly proposed Medicaid spending cuts will automatically eliminate Medicaid expansion in the state,  without any action by our state legislature. The fight to save Medicaid expansion will take place this spring in Washington, not Raleigh.

Medicaid expansion has provided huge benefits to North Carolinians

Medicaid expansion has benefited all North Carolinians, but especially rural residents. Medicaid now covers nearly 1 in 4 North Carolinians (3.1 million people), with 39% of those covered (1.2 million) living in rural areas. 

Beneficiaries not only live longer and healthier lives, but Medicaid expansion bolsters and stabilizes rural and smaller hospital finances, preventing their closures.

Medicaid cuts are a prime congressional target

Congress has a bull’s eye on Medicaid cuts. Congress is seeking large budget cuts in order to offset in part an increase in deficit spending from a proposed extension of the Trump administration’s $4 trillion in prior tax cuts and $1 billion in additional spending for border security and defense.

In late February, the House passed a budget resolution that provides a framework for $1.5 trillion in future cuts. Congress sought to conceal that $880 billion in cuts would come from Medicaid. 

Its resolution directed the House Energy and Commerce Committee, which has jurisdiction over primarily Medicaid and Medicare spending, to find $880 billion in unspecified spending cuts. Since cutting Medicare is considered politically untouchable, that leaves Medicaid as the only feasible target for spending cuts to reach that figure.

Federal budget battles are expected to come to a head in late April or early May, 2025. Congress is anticipated to vote on a budget reconciliation bill that will set future federal spending amounts. Congress is using the budget reconciliation process because it requires only 50 votes in the Senate, avoiding the Senate’s 60-vote filibuster hurdle.

North Carolina’s automatic trigger

If Congress cuts Medicaid this spring, North Carolina’s Medicaid expansion could automatically terminate. North Carolina, and eight other states, have enacted an automatic trigger, which eliminates Medicaid expansion if the federal government reduces its 90% match. 

To reinstate the program, our state legislature then would have to vote to appropriate additional funding to make up the difference. The cost could be up to $15.6 billion over ten years. At a time when the economy looks uncertain and with other proposed state cuts in federal funding, our state legislature seems highly unlikely to reinstate Medicaid expansion.

North Carolina’s senators hold the fate of Medicaid in their hands

Because the Senate Republican majority is very slim, it will take only four Republican senators to block the Medicaid cuts. Several conservative Republican senators already have expressed serious concerns with cutting Medicaid, since millions of working-class Trump voters would lose their health coverage.

Medicaid supporters should focus on pressuring North Carolina Republican Senators Tillis and Budd. Unlikely North Carolina’s Congresspersons, whose districts are gerrymandered to prevent political competition, Senators must run statewide in our very competitive, purple state.

It is no secret that rural North Carolinians voted overwhelmingly for Donald Trump in 2024. Most likely they do not know, and will not like, that they would lose their Medicaid coverage. We need to get busy pressuring our two senators.