ASHEBORO, N.C. (ACME NEWS) — When North Carolina expanded Medicaid in December 2023, the state began automatically enrolling many low-income residents who had been buying private insurance through the federal Marketplace into State run Medicaid plans. Now, a new federal policy in H.R. 1, known as the “One Big Beautiful Bill Act,” threatens to strip those individuals of all coverage options if they fail to meet proposed work requirements, creating a potentially devastating coverage gap.
North Carolina did not participate in the initial Medicaid expansion under the Affordable Care Act (ACA) when it launched in 2014. For nearly a decade, the Republican-controlled General Assembly resisted expansion, citing concerns over long-term costs and uncertainty about federal funding. In 2013, the legislature even passed a law blocking any governor from expanding Medicaid without explicit legislative approval.
That changed in 2023 with the passage of House Bill 76, “Access to Healthcare Options.” Introduced on February 8 and championed by bipartisan sponsors, the bill was fast-tracked following a promised $1.75 billion federal “signing bonus” from the American Rescue Plan, and a shift in position by Senate leader Phil Berger. The Senate approved the bill 44-2, and the House followed with an 87-24 vote on March 23.
Governor Roy Cooper signed the bill into law on March 27, calling it “a once-in-a-generation investment” aimed at strengthening rural hospitals, expanding mental health services, and extending coverage to roughly 600,000 low-income adults.
Because implementation was tied to the state budget — delayed until September — the expansion did not begin until December 1, 2023, after federal approval. On launch day, about 300,000 residents were automatically enrolled; by December 2024, nearly 600,000 had been signed up, reaching the two-year goal in half the time.
However, many who were switched from subsidized private plans through the Marketplace to Medicaid now risk losing their coverage altogether under the work requirements proposed in H.R. 1.
Under current federal rules, individuals with incomes between 100% and 138% of the federal poverty level (FPL) who don’t qualify for Medicaid can typically receive subsidies to buy private plans through the ACA Marketplace. This safety net helps prevent what experts call a “coverage gap.”
The new work requirements would mandate that most adults aged 19 to 55 enrolled in Medicaid prove they work, actively seek work, or participate in qualifying activities such as job training or community service for at least 80 hours a month. Exemptions would include pregnant individuals, full-time caregivers, people with documented disabilities, and those deemed “medically frail” by the state.
Individuals who fail to meet the requirements or miss reporting deadlines could be locked out of Medicaid coverage — even if they meet income qualifications. More controversially, the bill would also cut off Marketplace subsidies for these same individuals. That means those who lose Medicaid for not meeting work requirements would not be able to return to subsidized private plans, leaving them with no options for affordable coverage.
This “lock-out” provision applies only in Medicaid expansion states like North Carolina. The North Carolina Department of Health and Human Services estimates the impact will be significant.
“An estimated 255,000 people in North Carolina, including workers, students and caregivers, could lose their Medicaid coverage because of unnecessary work requirements and administrative burden,”
“An estimated 255,000 people in North Carolina, including workers, students and caregivers, could lose their Medicaid coverage because of unnecessary work requirements and administrative burden,” NCDHHS said in a email to Acme News. “This number also includes 213,000 people who only recently got coverage thanks to Medicaid expansion.”
The department also warned of broader consequences for the statewide health care system.
“The provider tax freeze included in the U.S. House bill could limit services and access to care for North Carolinians and erode the health care system by reducing necessary funding to facilities, including rural hospitals and nursing homes,” the statement said. “Rural hospitals may be forced to reduce staffing or quality of care or potentially close without these funds.”
Thousands of North Carolinians who were previously paying for private insurance through the Marketplace were automatically moved to Medicaid—and now, under this federal policy, they risk losing all coverage options entirely, with no safety net left.
We attempted to reach Senator Tillis, Senator Budd, and Congressman Hudson by phone several times at each of their offices this week for comment, but were unable to reach any of the representatives of their staff by phone. As of June 13, 2025, H.R. 1, the “One Big Beautiful Bill Act,” has passed the U.S. House of Representatives but faces significant hurdles in the Senate.
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