The Current State of Medicaid in 2025
You can’t go to a food bank for health care.
Health care is a system, not a charitable resource, and when it fails, families in both rural and urban communities feel the consequences immediately.
Rural North Carolinians anchor the state economy.1 Nearly 18% of the state’s jobs are in rural communities, and rural families drive the agricultural and manufacturing power that fuels our growth.1,2 Let’s be clear in what I am saying. Rural North Carolina is at the center of North Carolina’s deepest potential.
That potential is being undermined by the erosion of our care economy. The compounded toll of the coronavirus pandemic and the financial hardships that rural North Carolinians have faced since the Great Recession continues to strain families. Fourteen years later, many communities are still struggling to regain economic traction. Lawmakers have not done enough to help.
Behind every policy debate are real people. Parents skipping medication. Workers delaying doctor visits. Communities holding on as hospitals disappear.3 These are the decisions families make because the system is unstable, not because their need is small. As a state senator representing rural and urban communities, my focus has remained on expanding and protecting access to care.
The lack of hospital care in most rural areas contributes to rising infant mortality in the state, which is higher among Black rural women.4 Rural women are more likely to experience complications during pregnancy than those in urban centers. Telemedicine is a preventative tool, and in North Carolina, more than 80% of rural counties are designated as primary care shortage areas.4 It can identify issues before they become harmful to the parent and child. Medicaid expansion is the bridge that connects families to the perinatal and preventive care they cannot reach. This is especially critical in regions where residents travel long distances for basic services. Expanding broadband access is essential to telemedicine’s promise in rural areas; Senate Bill 551, which I sponsored, helps low-income families afford reliable internet so they can access virtual health care just as dependably as in-person care.
Our care economy suffers from years of delayed action on Medicaid. Farmers and agricultural workers, whose labor sustains our food system, often pay out-of-pocket for insurance while facing rising costs of production. They need access to disease prevention and health promotion. Families need stable pathways to care.
When I was on PBS recently, we discussed how the cost of prescriptions, the accessibility of clinics, and the rules that determine who gets care and who goes without shape the health of North Carolina families. We talked about Medicaid reimbursement cuts, uncertainty over Affordable Care Act protections, and the strain on community clinics preparing for the potential fallout of a government shutdown. Awareness about needs is growing, but rural hospitals are struggling to stay open.3 Health care access cannot depend on charity or luck.
Who Does and Doesn’t Have Access to Care
Medicaid remains the foundation of care for hundreds of thousands of North Carolinians, connecting people in both rural and urban communities with preventive services, chronic disease management, and maternal health support. In the 1st year of expansion, enrollment has risen steadily.5 More than 600,000 North Carolinians have enrolled since implementation began, and communities have begun to feel early signs of stability after years of hospital closures and workforce shortages.5
The stakes are not about partisanship. They are about whether families can reliably access doctors, urgent care, prescriptions, and maternal health services.
If Medicaid expansion is rolled back, you’re going to have more people go into the emergency room.6 Access is not only about coverage. It is about providers, hospitals, and support systems. Your insurance premiums are going to go up. In rural North Carolina, some families drive an hour or more to reach a hospital. In urban centers, emergency departments are strained by demand that should be managed through primary and preventive care. People will show up on their deathbed at the ER because they’ve lost their health care coverage.
We have health care deserts where community health centers are often the only point of care. In North Carolina, more than 20 rural counties have no hospital at all, and many others rely on a single clinic to meet the needs of thousands of residents.3 Cuts to Medicaid reimbursement and federal subsidies directly impact the ability of centers to keep their doors open. These cuts threaten rural clinics already operating on narrow margins. It is hurting patients and it is hurting constituents.
How Medicaid Expansion Has Impacted Coverage and Care
The MOMnibus, modeled after the federal Black Maternal Health Momnibus Act, is a comprehensive legislative package designed to improve maternal health by addressing access, workforce development, bias, and community support. I introduced Senate Bill 571 and supported House Bill 725, our North Carolina MOMnibus, to expand perinatal care access, fund lactation consultant pipelines at HBCUs, support community-based programs, and require implicit-bias training for providers. Earlier efforts, Senate Bill 393, Senate Bill 732, and Senate Bill 463, built pathways toward Medicaid-covered doula services. Across these bills, the goal has been consistent: strengthen Medicaid’s role in improving maternal outcomes, especially in care-poor communities.
Medicaid expansion brought preventive care, behavioral health treatment, and maternal health services to residents who had long been disconnected from the system. Early evidence shows improvements in hospital stability and reductions in uncompensated care.6 In expansion states, hospitals experienced a significant drop in uncompensated care costs, with KFF reporting reductions of more than 50% in the years following implementation, but these gains depend on steady federal and state funding.
Predictions vs. Actual Impacts
We haven’t had Medicaid expansion long enough to see the full benefits of reduced costs from increased enrollment. The foundation is visible. Early enrollment gains, reductions in uncompensated care, and expanded maternal health services show what steady investment can deliver, but the full impact requires time and sustained investment. Cuts to Medicaid or Affordable Care Act protections will push families back into instability. We will return to overcrowded emergency rooms. We will continue to lack the workforce required to meet demand.
Federal proposals to reduce Medicaid funding place rural hospitals, maternal health programs, and local health infrastructure at significant risk. The uncertainty in federal dollars impacts every single department we have. Cuts jeopardize the sustainability of MOMnibus initiatives, doula care pathways, and perinatal support programs that depend on Medicaid reimbursement.
The Economic and Community Impact
Families are not losing care because resources do not exist. They are losing care because rising costs and reduced coverage place essential services out of reach. People will sit at kitchen tables deciding whether to pay for food or insurance. Communities already facing long travel times, limited provider options, and high chronic disease burdens would feel the impact immediately.
Health care access is not a charitable resource. It depends on durable systems that allow people to see a doctor when they need one. Communities cannot replace these systems in order to play the role of government. Durable policy, not charity, delivers access.
Conclusion
Medicaid expansion has delivered stability to families across North Carolina. Its future requires bipartisan commitment and recognition that health care is a system, not a stopgap. Our responsibility is to maintain the structures that allow every person, not just those with means, to receive care when they need it.
Acknowledgements
Thank you to the constituents who share their stories and experiences with me, and the colleagues who are working towards a better health care system for all North Carolinians. The author has no conflicts of interest to declare.