Two years ago, North Carolina expanded Medicaid. Since then, 670,000 people have signed on to the health insurance program.
But now, after Congress passed the megabill that President Donald Trump will almost certainly sign in to law, those people, and maybe even more, could see their health insurance coverage declined.
This threatens more than inconvenience: Studies have shown that disruptions to insurance coverage can have serious health consequences.
The health impacts of losing Medicaid
Ciara Zachary, assistant professor in the Department of Health Policy and Management at UNC Gillings School of Global Public Health, says that people in the expansion population — those who gained access in 2023, and who earn between 100% to 138% of the federal poverty line — will be the first affected. That includes adults without children. About 34.5% of that population are ages 19-29. Another quarter fall in the next age bracket, ages 30-39.
Medicaid was designed to assist the most vulnerable among us, including pregnant people, children, those with low income, and those with disabilities, says Zachary.
Without it, people will suffer health consequences; some might even lose their lives. Estimates vary, but all are dire: losing Medicaid and ACA coverage might result in anywhere from 650 to 20,000 preventable deaths per year, depending on who or how you count, according to public health professionals at City University of New York, Hunter College, Cambridge Health Alliance, and University of Pennsylvania.
Otherwise, losing access to Medicaid can impact health in other ways.
- Limited access to care for people with chronic or care-intensive conditions
Cancer, heart disease, and diabetes are examples of chronic conditions that require intensive management.
"Medicaid expansion has been shown to really help folks with substance use and behavioral health or mental health conditions," said Zachary.
Without insurance, patients might not be able to access their medications, leading to behaviors like prescription rationing, like skipping doses or splitting pills. This behavior is harmful, too. One study found that people with cardiovascular disease who rationed their medication due to cost had higher rates of heart attacks and strokes.
- Discontinuous care
If you manage to regain insurance once you lose it, that is not the end of the story. Half of one study's respondents who had a gap in coverage said that losing insurance for any amount of time caused their health to worsen. The same amount of people said that the quality of their care also got worse after changing providers. Some 17% reported needing to change medications.
- Delaying Care
"We know that when people lose relationships with their provider, that can also cause them to delay care," said UNC’s Zachary. That might look like not getting checked out when you’re sick and allowing a condition to worsen.
Delaying care might ultimately backfire, too. If a condition worsens, it might mean needing to take time off work down the line. Or, the disease might progress to a point that the required treatment is much more expensive.
- Foregoing preventive care
Vaccination and screening rates will suffer without regular primary care visits. This is especially consequential for young children, for whom regular checkups are key to growing up healthy.
Preventative care is important at all ages. "Having accessible, reliable care means you're getting your screenings for various cancers or other health issues," said Zachary. "Even just getting education on healthy behaviors and reducing risk that could impact your health in the future."
- Stress and peace of mind
The burden of a medical bill is heavy when you’re uninsured or underinsured, and stress is a health concern on its own. "We all know that everything is getting more expensive, housing is getting more expensive, food is more expensive. So people just have all these stressors of 'Am I going to make it financially?'" said Zachary.
Hear it from a North Carolinian
Darcy Guill has lived in Pitt County, south of Greenville, for 17 years. Before that, she was an elementary school teacher in California and Colorado. She lives with her mom, Milly, who was also a teacher, and many pets around the house.
Darcy says that growing up under her mom’s health insurance, which she bought through her employer, she worried for naught. After all, she never had anything worse than allergies. And, when she started teaching, too, her insurance was "fairly good."
Once, after a vacation, Guill noticed some tingling numbness in her feet. It persisted, and she thought she should go check it out. She had health coverage, so she didn't think twice.
A few weeks later, she got her diagnosis: Multiple sclerosis, an autoimmune disease that impacts the nervous system. There were nine lesions in her brain.
There was a silver lining. "My neurologist says he never diagnosed anybody that early on," she said. Right away, she got on medication. She stayed in education even when she moved to Colorado.
In 2009, she came to North Carolina. She began pursuing a certificate to teach exceptional children in the general curriculum – it was her way to stay involved with education despite her symptoms. While taking classes, she was a part-time substitute teacher.
However, without full-time work, Guill was left without employer-sponsored insurance, and couldn't afford to pay for any out of pocket. She could no longer pay to see a neurologist. She began rationing her stockpile of medications until they ultimately ran out. By 2014, Guill felt too ill to work. Without a job, she could no longer afford health insurance.
For a decade, Guill was completely uninsured. In that time, she sought medical care at a free clinic, sponsored by a local church. Through vocational rehab, she was able to start on a pharmaceutical program that provided her with free medications.
In 2021, the churn began. "Churning" is a term that public health experts use to describe transitions between insurance, including losing and gaining insurance altogether. Guill gained access to Blue Cross, but then couldn't afford the premium. She switched to Friday Health Plans, where the copay was only $11, until they went bankrupt.
The churn continued.
In February 2022, Guill was involved in a severe car accident, and was admitted to the trauma ward for a month. Combined with her unmanaged MS, recovery was grueling. In 2023, she also had an emergency hernia surgery, incurring a $5,000 hospital bill. It turns out she would never need to pay it in totality. In North Carolina, Medicaid expansion was underway.
"It didn't quite dawn on me at the time, but I was going to be one of the people that benefited. I was going to have insurance again," she said.
By December 1, on the first day of the expansion, Guill had her Medicaid card. It marked the end of 13 years of churn. Finally, with healthcare coverage, Guill was able to see a neurologist and consider different medication options. At the beginning of this year, she took an MRI to assess whether a certain treatment plan was appropriate.
"I had 30 lesions on my brain," Guill said. The doctors knew that they had to change course on her treatment. "We have to do something far more aggressive."
"Had I been consistently on medication, yeah, I would have gotten a few more (lesions), but it wouldn't have tripled," reflected Guill. "And the truth is, I thought I was eventually going to be able to go back to work part time. I don't know if I'm going to be able to."
Today, looking forward into the future of health care policy, Guill is angry. "I resent the fact that I might be uninsured again or underinsured again," she said.
Speaking about policy makers, Guill says "they have this preconceived notion about who's on Medicaid, and they're wrong. It's people like me, and I know so many people whose stories are not all that different from mine."
