The state that's really sweating the megabill Medicaid cuts

Politico

3 days ago

NOT SO BEAUTIFUL — It isn't every day that a two-term Republican senator like Thom Tillis surrenders his reelection bid with a cri de coeur about poor people losing their government-financed health coverage.
He called President Donald Trump's 'Big Beautiful Bill,' which is now on its way to the president for his signature, a promise-breaker that will 'hurt people who are eligible and qualified for Medicaid,' including in his home state of North Carolina.
His purple state gets outsized attention because its health policies are innovative and, highly unusually these days, bipartisan. Much of what North Carolina has achieved on health, however, is now threatened by the megabill. That includes coverage losses in traditional Medicaid, the state's entire Medicaid expansion, and its ambitious 'Healthy Opportunities' pilot program that links Medicaid and social needs like housing and healthy food. The pilot isn't directly affected by the Washington legislation, but it's part of the endangering fiscal and political background noise.
'It will be a crisis … A devastating loss,' said Democratic Gov. Josh Stein, summing up the overall impact of the legislation on his state during a Zoom press briefing this week.
Tillis also sees the massive Medicaid cuts as a gargantuan political gaffe. Republicans will pay for it at the polls next year, he predicted, much like voters lashed out at Democrats in the bumpy early years of the Obamacare rollout.
Obamacare, aka the Affordable Care Act, eventually got popular. Uninsured people got insured. As Medicaid has grown to include more people and services, it too has gotten more popular across party lines, according to polls from KFF, a health care policy and research organization.
Before entering politics, Tillis became wealthy as a management consultant. But he grew up poor and lived for a time in a trailer park. He hasn't spoken about whether he was ever uninsured and his office didn't respond to an emailed question about that.
Nowadays, families in similar economic straits can get covered, in his state and beyond.
But over the next decade, a staggering 16 million people across the country will become uninsured, through changes in Medicaid and the ACA in this bill, plus related federal regulatory changes, according to a Congressional Budget Office forecast.
In North Carolina, where more than 3.1 million people receive Medicaid, state officials project more than 900,000 will lose coverage. And getting and staying enrolled, even for those who remain eligible, will be more cumbersome, so the total number of people losing health benefits could well climb.
Rural hospitals, already on shaky economic ground, could close — many have across the country in recent years. A fund that the Senate added to bolster them is nowhere near enough, N.C. health officials say. That's a big deal in North Carolina, which the Census Bureau says has the second biggest rural population in the country after Texas.
It's not only Democrats who are concerned about the far-reaching impact.
State Senate President Phil Berger, a Republican who has struck deals with Democrats on Medicaid and health innovation, backs President Trump's legislation and reassuringly said on X, formerly Twitter, that the 'legislature will work through any implementation issues.'
But some Republican legislators — even solid pro-Trump conservatives — who play a key role in health policy openly worry about coverage losses and the effect on hospitals and other health providers.
State Rep. Timothy Reeder, an emergency physician in the rural east of the state and a member of the House Health Committee, spoke to Nightly after the Senate voted on the megabill but while the House was still in flux, so he didn't want to get specific about the legislature's possible next moves. But he backs Medicaid expansion and wants to give Healthy Opportunities at least a few more years to experiment and collect data. If the pilot ends, people won't lose their Medicaid coverage but they will lose services — including in the western part of the state still struggling to recover from Hurricane Helene.
As an emergency room doc, Reeder knows that uninsured patients often put off care until they end up in the E.R. That's not good for patients or providers. 'The economics of rural health are just not sustainable unless there's some public support,' he said.
State Sen. Jim Burgin, chair of the Senate Health Care committee, voiced similar concerns. He's pro-Trump and pro-work requirement, but he would support using state dollars for education and training — even child care — so people can go to school and get job training.
'I tell people I don't like safety nets. I like trampolines,' he told Nightly. 'I want to bounce people back. I don't want to let them fall in a safety net and get stuck there.'
But he was an early GOP supporter of expansion and played a role in ultimately getting it enacted. He has embraced Healthy Opportunities and is looking for a deal to keep it going.
All aspects of Medicaid, which is funded jointly by Washington and the states, are at risk.
The state estimates that about 255,000 people will lose coverage because Medicaid will now have work requirements. Two GOP-led states have tried them in the past and some of the people dropped from Medicaid were actually employed – but the online verification systems were so flawed that they couldn't document it.
Medicaid expansion is on the brink. About a dozen states that expanded Medicaid included some form of 'trigger.' That means if Washington scales back its 90 percent share of the cost, they would kill expansion. Conservatives failed to lower the federal payment in the megabill — but North Carolina's trigger would kick in anyway, because of new restrictions on how the state finances the program, explained Kody Kinsley, who oversaw expansion during his three years as state health secretary until January 2025.
Because the state law says if North Carolina has to pick up any expansion costs at all, expansion unwinds. Unless the legislature comes up with a solution that is not now easily apparent, more than 670,000 people will lose coverage.
North Carolinians may lose health coverage by the hundreds of thousands, but 'they're not going to stop getting sick,' Stein said. 'It's just going to be way more expensive to take care of them.'
Welcome to POLITICO Nightly. Reach out with news, tips and ideas at [e-mail]. Or contact tonight's author on X (formerly known as Twitter) at @JoanneKenen.
What'd I Miss?
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— Hakeem Jeffries breaks the House record for longest floor speech: Democratic Leader Hakeem Jeffries delivered the longest speech in House history today, holding the floor for well over eight hours to delay passage of Republicans' domestic policy megabill. His so-called 'magic minute,' as the unlimited speaking time granted to party leaders is known, breaks a record set by Republican Kevin McCarthy in 2021, which in turn exceeded the mark set by Nancy Pelosi in 2018. All were serving as minority leader at the time. The speech was Democrats' last option to slow down the megabill ahead of a final passage vote.
— Judge blocks 'sweeping' asylum crackdown after Trump declared 'invasion' at southern border: President Donald Trump's effort to crack down on asylum claims by immigrants crossing the southern border vastly exceeded his legal authority and must be halted, a federal judge ruled Wednesday. U.S. District Judge Randolph Moss said Trump's Jan. 20 proclamation declaring an 'invasion' of southern border-crossers cannot be used to justify the 'sweeping' unilateral restrictions he sought to impose, including severe limits to asylum applications and the ability to seek protection from torture. Under Trump's proclamation, people who crossed the southern border between 'ports of entry' are barred from seeking asylum or invoking other legal protections that would allow them to temporarily remain in the U.S. while their claims are processed.
— Supreme Court will decide whether states can ban transgender girls from girls' sports: The Supreme Court will decide whether states can ban transgender girls from girls' sports teams, plunging the high court back into the national debate around the rights of trans people. The court today added a pair of cases to next term's docket about state laws in Idaho and West Virginia that ban people assigned male at birth from competing on school teams for women and girls. About half the states have similar laws, according to court papers. The justices announced they will hear appeals from Idaho and West Virginia against lower-court orders that blocked the bans from taking effect. An appeals court ruled that Idaho's law violates the Constitution's equal protection cause by targeting transgender people, while another appeals court concluded that the West Virginia law violates Title IX, the federal law banning most sex discrimination by schools.
— Supreme Court lets Trump admin deport men detained in shipping container for 6 weeks to South Sudan: The Supreme Court on Thursday cleared the way for the Trump administration to deport eight men to South Sudan who have been detained in a shipping container on a U.S. military base in Djibouti for six weeks after becoming caught up in a legal tug-of-war between the White House and a federal judge in Boston. By an apparent 7-2 vote, the justices lifted an order from U.S. District Judge Brian Murphy that had blocked the men's deportation. Murphy took that step despite a Supreme Court ruling last week that put a hold on an earlier, nationwide injunction he issued requiring the administration to give deportees advance notice of their destination and a 'meaningful' chance to object if they believed they'd be in danger there.
AROUND THE WORLD
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Deputy Foreign Minister Majid Takht-Ravanchi said Iran had 'already responded' to the U.S. attack on its three nuclear enrichment facilities late last month, telling NBC News that the country had no plans for additional retaliation in a signal of a temporary calm between the U.S. and Iran following a 12-day war between Iran and American ally Israel.
UNITED FRONT — The European Union is striving to project unity as it races to negotiate a high-stakes trade deal with Washington, but backstage, national divisions threaten to weaken its negotiating hand. 'Nobody in Europe wants to escalate,' European Council President António Costa said last weekend. 'Nobody wants a conflict.'
That's also a message EU Trade Commissioner Maroš Šefčovič will be keen to convey as he meets with U.S. Trade Representative Jamieson Greer on Thursday for a potentially decisive round of talks.
Away from the diplomatic dance, however, EU countries don't always see eye-to-eye on how best to deal with the White House. And as so often, the diversity of views held by the bloc's 27 national leaders — all catering to domestic interest groups and voters — is making it difficult for Šefčovič to drive a hard bargain.
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RADAR SWEEP
LOST IN TRANSPORTATION — If you ever lost something on a plane, train, or bus, it's probably at a store in Alabama. After a 90-day waiting period, clothes, iPhones, watches, and the like are sold to Unclaimed Baggage, a warehouse in Scottsboro which boasts 7,000 lost items and covers a full city block. Beyond the mundane, lie the valuable and sentimental. Wells Tower finds car keys, wedding dresses and baby's combs on a trip to the store. He writes on the strange feeling of reveling in and buying people's lost items for The Cut.
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Jacqueline Munis contributed to this newsletter.
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