Healthy North Carolina 2030 (HNC 2030) identifies key public health indicators for our state. The State Health Improvement Plan has engaged statewide leaders in ongoing efforts to improve the health of North Carolinians through policies, programs, and systems related to these health indicators. Two HNC 2030 indicators that are closely tied to access to health care in our state include primary care access and insurance rates. With ongoing developments in federal funding and policy, the NCIOM will be analyzing what we know about these developments and their potential impact on HNC 2030 indicators.
President Donald Trump signed the One Big Beautiful Bill Act (OBBBA) on July 4, 2025. Among many things, the OBBBA includes changes to how many people will access health insurance through both Medicaid and the Affordable Care Act (ACA) Marketplace. This article highlights what we know about those changes and how they might affect insurance rates and access to primary care in North Carolina.
What is Medicaid?
A state-run program that provides health insurance to people with lower incomes.
Where do funds for Medicaid come from?
Both federal and state governments.
Who can sign up for Medicaid?
In North Carolina, people with incomes at or below 138% of the Federal Poverty Guidelines are eligible. For an individual, that is $21,597 per year, and for a family of four, that is $44,367 per year in 2025.*
How many people are enrolled in Medicaid?
In North Carolina: 3,012,000 children and adults.**
**https://files.kff.org/attachment/fact-sheet-medicaid-state-NC
States will need to implement their own systems by December 2026 to verify that some individuals enrolled in Medicaid are working at least 80 hours a month [1]. The verification will need to take place at enrollment (looking back three months) and will need to be renewed at least every six months, although states can choose to require it more frequently [1]. Individuals who will need to complete this verification are those who are both:
As of July 2025, 669,527 individuals in North Carolina were enrolled in Medicaid under expanded eligibility [3]. There is no publicly reported data on the employment status of the expansion population or how many would be excluded from the work reporting requirement, however an NC Health News article reported that “a spokesperson for the North Carolina Department of Health and Human Services (NCDHHS) said an estimated 92% of the state’s 1.6 million adult enrollees — a figure that includes traditional Medicaid enrollees and the expansion population — ‘are working individuals or are care giving, too disabled to work, or may be in school’” [4].
Trials of work reporting requirements for those enrolled in Medicaid have shown that disenrollments occur related to work status, but also from administrative challenges with the reporting process. Arkansas implemented a work reporting requirement for Medicaid expansion adults aged 30–49om June 2018 to March 2019 [5]. Individuals were required to report their work status monthly and were disenrolled after three months of not reporting work [6]. During the nine months the policy was in place, 18,000 people, or 25% of those subject to the reporting requirement, lost Medicaid coverage [7]. Many enrollees lacked awareness of the reporting requirement, and administrative challenges, like the inability to contact individuals about reporting, were common [8]. Additionally, some who were exempted from the reporting requirement were disenrolled because of errors in data systems [9].
What is the ACA Marketplace?
A health insurance portal for people to purchase individual plans (i.e., not employer-sponsored plans).
Who can purchase plans on the Marketplace?
Most people are able to purchase plans in the Marketplace; however some people qualify for advanced premium tax credits to help pay the cost of the insurance premium.
Who qualifies for advanced premium tax credits (APTCs)?
Citizens and some immigrants currently qualify if their income will be over 100% FPG in the coming year, they do not qualify for affordable employer-sponsored insurance, and they do not qualify for other public coverage (e.g., Medicaid). Different levels of tax credit are provided based on family income.
The OBBBA enacted changes to processes for ACA Marketplace enrollment and advanced premium tax credits (APTCs):
These changes will “effectively eliminate autoenrollment into Marketplace coverage, a practice currently used by 88% of Marketplace enrollees” [10].
In addition, Congressional action is needed to maintain the enhanced APTCs that were implemented in 2021 through the American Rescue Plan Act. These enhanced APTCs were originally set to expire in 2022 and were extended through 2025. The enhanced APTCs gave 15 million people an average of $800 in annual savings in 2023 [11]. Many more people were able to find plans that would cost $10 or less per month with the enhanced APTCs compared to before them—80% of marketplace enrollees in 2023–2024 compared to 36% in 2020 [11].
Because some details of these new policies will vary by state, estimates of the numbers of people impacted are provisional. One calculation based on early estimates from the Congressional Budget Office is that 252,836 North Carolinians may lose coverage through the ACA Marketplace and 270,670 could lose coverage through Medicaid [12, 13].
Lack of insurance has a direct effect on people’s willingness to seek both preventive and necessary health care services. One study found that people who were disenrolled from Medicaid or the ACA Marketplace were more likely than those who had continuous enrollment to experience:
An increase in the number of uninsured patients also negatively affects hospitals, primary care, and safety net health care providers. One report estimates the changes in health care spending and uncompensated care for health care providers in North Carolina. The estimates below are based on the OBBBA policies and an assumption that the enhanced APTC will not be extended.
| Decreased Spending | Increased Uncompensated Care | |
|---|---|---|
| Hospitals | $13.4 billion | $1.1 billion |
| Physicians | $3.3 billion | $0.4 billion |
| Prescriptions | $12.2 billion | $0.6 billion |
| Other | $11.8 billion | $1.1 billion |
| Total | $40.7 billion | $3.2 billion |
While we have some estimates of how these policies will impact insurance rates and access to care for North Carolinians, there are still significant unknowns that are dependent on additional policy discussions and implementation. These include:
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Written by
Brieanne Lyda-McDonald, MSPH
Project Director, NCIOM
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