There was a lot of talk about abortion during the presidential campaign, but other health care issues took a back seat. So what will the election mean for health care in North Carolina? WFAE’s Dana Miller Ervin has been digging into that. She discusses this with WFAE's Marshall Terry.
Marshall Terry: Repealing and replacing Obamacare — the Affordable Care Act — was a top priority for President Trump during his first term in office. Is that still a priority for him?
Dana Miller Ervin: Trump said contradictory things about that during the campaign. At one point he wrote on Truth Social that he was looking at alternatives to the Affordable Care Act, but he later backtracked. The ACA is pretty popular, more than 21 million Americans have Obamacare coverage. So I spoke with people who study health policy, and they don’t expect another attempt at repeal.
What they do worry about is spending cuts in health care programs, including some in the ACA. Trump has a lot of expensive spending priorities, such as extending his 2017 tax cuts. That alone will cost at least $400 billion a year according to the Congressional Budget Office. So he either has to make up some of that by cutting elsewhere, or add to the debt.
Terry: If a repeal of Obamacare seems unlikely, where else could there be cuts?
Miller Ervin: One easy cut health policy experts point to, is simply to let the Biden-era enhanced premium subsidies for Obamacare policies expire. Those help people earning up to 400% of the poverty level to pay for coverage. (Now, 400% of the poverty level, that’s about $60,000 for an individual).
Congress doesn’t have to do anything, just let the subsidies lapse. That would save $335 billion over ten years, according to the Congressional Budget Office. So that’s a lot of money, but it’s small change compared to the cost of the tax cuts.
Terry: How many people in North Carolina would lose their insurance if those subsidies went away?
Miller Ervin: Nearly 1 million people in the state get a subsidy. That’s according to KFF, a left-leaning health policy think tank. But we don’t know how many of those would give up their coverage if they lost the subsidies.
Terry: Has Trump brought up other health care programs he wants to cut?
Miller Ervin: Trump has said he won’t touch Social Security or Medicare, the health insurance program for the elderly. But Trump did try to cut Medicaid during his first term in office. Medicaid is the joint federal and state health care program for the poor, elderly, blind or disabled. Three million North Carolinians have some form of Medicaid. I spoke with University of North Carolina health policy expert Jonathan Oberlander about that.
Jonathan Oberlander: I think there’s a very good chance that Medicaid is going to be targeted again for savings and I think there will be a budgetary battle over Medicaid. It won’t be easy though. There’s a lot of opposition to cutting Medicaid. Medicaid has over 80 million Americans enrolled in it.
Terry: How could the Trump administration try to cut Medicaid?
Miller Ervin: There are a bunch of things the administration can do, especially since Republicans will control both the Senate and the House. They could cap federal payments to the states. That would force states to pay more — if they can — or cut benefits. Trump wanted to cap Medicaid benefits in his first term.
Health policy experts also anticipate there could be a move to cut federal payments for the Medicaid expansion program. That provides coverage to almost 600,000 able-bodied people in North Carolina who earn too little to qualify for ACA coverage.
Right now the federal government pays 90% of the cost of the Medicaid expansion program. But if Congress reduces that, North Carolina law says the entire program would be ended.
Terry: The whole program would end automatically?
Miller Ervin: Yes. Republican state Sen. Jim Burgin worked hard to get the state to expand Medicaid — and it finally did so last year. He’s optimistic any cuts — if they do happen — would be gradual.
Jim Burgin: I think you're going to see they're going to say are starting in 2025, we're going to reduce the government's portion of your share 1% a year or 2% a year and start moving it down
Miller Ervin: But the North Carolina legislature would still have to amend the law and agree to pay more for expansion to keep the program going.
Terry: Trump talked about imposing work requirements for Medicaid recipients in his first term. Is that a possibility this time around?
Miller Ervin: Yes, many health policy experts think the Trump administration will allow states to impose work requirements. That would force recipients to work or get training in order to keep their coverage. North Carolina’s Medicaid expansion law says the state must adopt a work requirement program if the administration in Washington allows it.
Terry: What would the impact of work requirements be in North Carolina?
Miller Ervin: That would probably depend on how North Carolina structures its program. Arkansas was the only state to adopt work requirements during the first Trump administration. One study found the program didn’t increase employment, but a lot of people lost coverage, possibly because they didn't know about the reporting requirements
The health policy think tank, KFF, says 55% of Medicaid recipients in North Carolina are already working, but many are at low-wage jobs that don’t provide health insurance.
