Washington politicians seeking to cut health insurance costs could put NC's Medicaid expansion in danger. (Photo: JoeRaedle/Getty Images)

Health insurance coverage on which millions of Americans rely — Medicaid and plans purchased through the Affordable Care Act — were scarcely mentioned during the presidential campaign but may face extensive changes in President-elect Donald Trump’s second term.

At a campaign stop in Pennsylvania last month, House Speaker Mike Johnson promised “massive” changes to health care in a second Trump administration.

Changes could affect people who rely on Medicaid to pay their healthcare costs, those who buy subsidized health insurance under Obamacare, or those who are enrolled in expanded Medicaid.

North Carolina has had Medicaid expansion for less than a year. As of Nov. 3, more than 569,000 people have enrolled, according to the state Department of Health and Human Services.

More than 1 million people in North Carolina selected a health insurance plan through the ACA marketplace this year, according to KFF.

More than 3 million North Carolinians are enrolled in Medicaid.

The ACA and Medicaid are connected, because under the ACA states are allowed to raise the income limit for Medicaid enrollment, as North Carolina did last year, allowing more people to obtain health insurance.

Trump spent much of his first term weakening and trying to repeal Obamacare. A big move in 2017 to kill it, when Trump was president and Republicans held the House and Senate, failed.

Trump said during the September debate with Vice President Kamala Harris he would not try to repeal Obamacare unless he came up with something better.

“I have concepts of a plan,” Trump said during the debate. “I’m not president right now. But if we come up with something I would only change it if we come up with something better and less expensive. And there are concepts and options we have to do that. And you’ll be hearing about it in the not-too-distant future.”

Trump didn’t spell out those options during the campaign, leaving a giant question mark looming over the future of millions of Americans’ healthcare.

“Nobody really knows, probably including President Trump,” said Don Taylor, professor of public policy and director of the Social Sciences Research Institute at Duke University.

Repealing the Affordable Care Act and replacing it with something new would be “a heavy lift,” he said.

Republicans will show up in Washington with a head of steam. They have secured the White House and the Senate majority and are closing in on a House majority.

Larry Levitt, executive vice president for health policy at KFF, was certain Republican dominance in Washington would lead to cuts.

“If Republicans sweep this election, I think the ACA along with Medicaid will have big targets on their back,” he said on the podcast Tradeoffs a few days before Trump won the White House and Republicans took the Senate.

Trump promised to protect Medicare and Social Security.

But his campaign was “deafeningly silent about Medicaid,” said Edwin Park, a research professor at the Center for Children and Families at Georgetown University.

Park found similarities between the Heritage Foundation’s Project 2025, prepared as a playbook for Trump’s second term, and two House Republican proposals for Medicaid.

The overlap signals “radically restructuring Medicaid” will likely be a high priority in a Trump second term with Republican majorities in the House and Senate, Park wrote.

How congressional Republicans and Trump could cripple NC Medicaid expansion

Those changes could reach North Carolina’s hard-won Medicaid expansion.

The federal government pays 90% of the costs of people who are insured through Medicaid expansion. Project 2025 and the two House GOP plans propose to reduce that percentage.

If that happens, it would kill expanded Medicaid in North Carolina.

Included in the state law enabling expansion is a clause that triggers the end of coverage if the federal government stops paying 90% of the cost.

Abby Emanuelson led Care4Carolina, a coalition of businesses, health organizations and faith communities that pushed for Medicaid expansion. With its mission completed, the organization disbanded earlier this year.

If Congress considers reducing the federal 90% cost share, advocates should be ready to press upon elected officials in Washington how great an impact expansion has had on North Carolinians’ health, she said.

In Trump’s first term, his administration allowed states to require some Medicaid recipients to work in order to keep their insurance. Some of the work requirements were challenged in court. The Biden administration rescinded other approvals.

Medicaid work requirements could come back in a second Trump term and this time include North Carolina.

A section of North Carolina’s Medicaid expansion law requires North Carolina health officials to pursue federal approval for work requirements.

Health care advocates consider work requirements a tool for kicking people off Medicaid.

Medicaid work requirements were in effect in Arkansas for less than a year before a court order ended them in 2019. Researchers found that some people didn’t know about the requirement, others were confused about the rules or were unable to report their work because they did not have internet access. People lost insurance coverage and reported that they had problems paying off medical debt and delayed seeking care more often than people who kept their coverage.

The prospect of total Republican control in Washington has health policy experts considering how to fend off deep cuts.

Support for Medicaid has grown since the first Trump administration, Park said. “I think that there is a hope that if there is another push to make really damaging Medicaid cuts, just like in 2017 there will be a large and loud set of stakeholders and beneficiaries who will oppose those kinds of proposals,” he said.

Republican control in Washington could mean trouble for expanded Medicaid in North Carolina

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