The News & Observer by Luciana Perez Uribe Guinassi
It’s looking increasingly likely that Medicaid will face changes — and possible cuts — at the federal level that could jeopardize the program’s expansion to hundreds of thousands more North Carolinians and potentially cost state government billions in lost federal funding.
On Tuesday, House Republicans, after hours of hesitation from some members, passed a budget blueprint that would extend tax breaks and fund President Donald Trump’s priorities through $2 trillion in spending cuts over a decade, the Associated Press reported.
About $880 billion of that would come from cuts over the decade to the areas overseen by the committee responsible for Medicaid and other health programs. No final spending plan has passed yet, though — and details could shift.
All House Democrats opposed the bill, joined by one Republican, Rep. Thomas Massie of Kentucky. Every North Carolina Republican in the delegation voted “yes.”
Rep. Deborah Ross, a Democrat representing the state’s 2nd Congressional District, said in a news release that her Wake County district alone could lose $1.14 billion in funding for Medicaid and the Children’s Health Insurance Program (CHIP), which covers kids in families earning too much for traditional Medicaid.
Charlotte-Mecklenburg Board of Education members are also expressing concerns about the House bill, saying it could endanger Medicaid and free school meals for thousands of Charlotte-Mecklenburg Schools students, The Charlotte Observer reported.
The House bill doesn’t specify how the $880 billion in cuts should be made, but a late-January list from top congressional Republicans floated options, including slashing federal funds for states’ Medicaid expansion programs.
In North Carolina, under a cost-sharing mechanism, the federal government covers 90% of expansion costs versus 65% for the non-expansion population. State law mandates ending expansion if that 90% match drops.
Rep. Donny Lambeth, a key Republican architect of North Carolina’s expansion, told The News & Observer in January that if expansion ended, “there’s no way, under a new scenario, that it would pass again.”
‘Elephant in the room’
Jay Ludlam, deputy secretary for NC Medicaid, addressed state lawmakers Wednesday during a meeting of a joint health committee at the General Assembly, calling potential cuts to Medicaid the “elephant in the room.”
He estimated up to a potential $27 billion federal funding loss for North Carolina should cuts be enacted, with rural communities hit hardest.
According to data presented by Ludlam, in 29 mostly rural counties, 40% or more of their total population is enrolled in Medicaid.
Expansion could also collapse, he warned, stripping coverage from about 630,000 residents — insured just 15 months ago or less — and costing state government more than $6 billion in related federal funds. A 1% cut in the federal match rate for Medicaid translates to $185 million lost, he added.
Medicaid expansion was signed into law in North Carolina in March 2023 following bipartisan work, expanding access to the health care program to all adults with income below 138% of the federal poverty level. In 2025, for an individual that’s about $20,000, and for a family of four it is about $44,000.
Prior to expansion, childless adults in the state were not eligible for Medicaid, while the income limit on eligibility for a parent or caretaker was 41% of the federal poverty level.
Ludlam also said “people will not stop getting sick” and should Medicaid face cuts, predicted rising costs of uncompensated care for health care providers as the newly uninsured flood emergency rooms.
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