One Big Beautiful Bill and what's next for North Carolina's 670,000 Medicaid expansion recipients

On Sunday, North Carolina Senator Thom Tillis criticized the Senate GOP for rushing to pass the Trump Administration’s “One Big Beautiful Bill” without fully considering the impact of its Medicaid proposal. Deputy Secretary for NC Medicaid Jay Ludlam says two key provisions of the bill, which already passed the U.S. House, would jeopardize Medicaid expansion in the Tar Heel state, leaving hundreds of thousands of people without health care. Ludlam spoke with WFDD's David Ford.

Interview Highlights

On the current role of Medicaid in North Carolina:

"We have a little over 3.1 million individuals who rely on traditional Medicaid, and that includes 670,000 people on Medicaid expansion. We have a program that has focused on rural communities, looked to support rural hospitals, has looked to expand access, including access to behavioral health services, mental health services. And so, you know, the stakes are really high. And I think that depending on which direction Congress goes, a lot of what, if not most of what we've accomplished over the last eight to 10 years here in North Carolina is at risk.

On the new work requirement verification in the bill:

"There's really two components to the work requirements. The first is that Congress is proposing that people on Medicaid will have to demonstrate that they are eligible for Medicaid twice a year, at least twice a year, and so they are pushing up the number of, we call it redeterminations, or re-verifications. They're going to now double that. ... And so what that means, though, practically for us is here in North Carolina, our county offices do the redeterminations. They're the ones who do the reverifications, and so they're already, currently, some of those counties are behind in the work, and now we're going to double the amount of expectation that we have on them, and we're very worried about their ability to keep up with that pace. So that means that we're going to have to make big investments in the technical systems. We're going to have to hire more people again, train them, and it's going to be very difficult for the state to meet the deadlines that Congress is suggesting that we'll need to do, given the resources that we currently have."

On the bill provision to freeze taxes on health care providers that have been used by states to help pay for Medicaid expansion:

"I think that the provider tax piece is that we're not permitted by local statute to use state dollars to pay for the costs related to expansion, we have used provider taxes to cover any additional incremental costs, and so if they freeze the provider tax and it remains prohibited to use state dollars, we will not be able to, from our perspective, be able to meet the demands of those work requirements. And we worry that we're going to risk losing Medicaid expansion for the 670,000 people currently on it." 

On the prospects for more state funding to fill in the gaps:

"I think that there's going to be real hard decisions that the legislature is going to have to debate around. Where do we put our funding? We've gotten estimates that a system like work requirements, just to bring it up, include, you know, maybe $150 to $225 million, and then we're gonna have to run this every year. And then, if you look at the federal changes that are being proposed right now as well, it's not just in Medicaid, but we're also at risk of losing SNAP [Supplemental Nutrition Assistance Program], you know, our food support program, where we estimate anywhere from $225 million to $700 million cost shift from the federal government to the state will occur. So the General Assembly is going to have some really hard decisions on where they put needed tax dollars, and we'll continue to work with the General Assembly on what that looks like when it finally passes, and we get regulations from CMS, and then the General Assembly is able to weigh in probably this time next year."