When Hurricane Helene tore through western North Carolina last year, it left residents struggling to recover. Now, many fear another storm is coming—this time from Washington.
Donald Trump’s newly passed “Big Beautiful Bill” includes over $1 trillion in federal Medicaid cuts, and rural America is bracing for impact. Healthcare leaders and advocates warn that the consequences will be devastating—especially for regions that only recently benefited from Medicaid expansion.
“It’s going to have to hit them first,” said Laurie Stradley, CEO of Impact Health, a Medicaid-funded nonprofit in Asheville, North Carolina. “People don’t realize what’s coming.”
A Lifeline Under Threat
Medicaid is the largest public health insurance program in the U.S., covering more than 71 million low-income Americans, including half of all births and 60% of nursing home residents. The program was expanded under the Affordable Care Act to cover people earning up to 138% of the federal poverty level.
But the cuts in Trump’s sweeping tax-and-spending bill threaten to roll back that progress. The Congressional Budget Office estimates the legislation will cause nearly 17 million Americans to lose health coverage by 2034—12 million from Medicaid alone.
“This is the biggest rollback of healthcare in U.S. history,” said Joan Akler of Georgetown University’s Center for Children and Families. “It’s all to fund tax breaks for corporations and the wealthy.”
A Devastating Impact in North Carolina
North Carolina could be among the hardest hit. Its Medicaid expansion only took effect in December 2023—and already covers more than 650,000 people. Under the bill, the state stands to lose $32 billion in federal funding over the next decade.
What’s worse, North Carolina has a “trigger law” that automatically terminates expansion if the state has to fund any portion of it without federal backing.
“If that happens, all those people lose coverage overnight,” warned Kody Kinsley, the state’s former health secretary and a key architect of its Medicaid rollout.
A Program That Saves Lives—and Money
Programs like the one run by Impact Health show how Medicaid does more than just provide medical coverage—it helps prevent costly health emergencies.
Stradley recalled one case: a child with asthma visiting the ER multiple times a week. With Medicaid dollars, Impact Health removed moldy carpets, replaced them with laminate flooring, and provided a HEPA vacuum. Cost: $5,000. Result: the child’s ER visits dropped dramatically, saving $4,500 per month.
“This is a hand up, not a handout,” Stradley said. “And it benefits everyone. These families work multiple jobs with no benefits. Without Medicaid, they’re left with nothing.”
Rural Hospitals on the Brink
The effects of Medicaid cuts extend beyond individuals. Rural hospitals—already operating on razor-thin margins—are at risk of collapse.
The Sheps Center at UNC-Chapel Hill found that 338 rural hospitals across the U.S. face possible closure. In Kentucky alone, 35 are at risk. One in three Kentuckians relies on Medicaid.
In Arizona, hospitals could lose over $6 billion in funding over the next seven years, according to the Arizona Hospital and Healthcare Association. More than half of the state’s hospitals would operate in the red. Services like obstetrics and behavioral health could be slashed—or shut down entirely.
“Hospitals will either restrict care or close,” said spokesperson Holly Ward.
Privately Insured Also at Risk
Cuts to Medicaid could drive up costs even for those with private insurance. As hospitals lose public funding, they often charge commercial insurers more to compensate—pushing premiums higher for employers and employees alike.
Adding to the confusion is how Medicaid is branded. In many states, private companies manage Medicaid plans under different names. That means some rural residents may not even realize they’re on Medicaid—until it’s gone.
The Human Cost
Amanda Moynihan, a single mother of three in Kuna, Idaho, says Medicaid expansion gave her family a path out of poverty. It covered medical needs that allowed her to return to school, earn an associate degree, and begin working toward a bachelor’s in social work.
Without Medicaid, she says, “I’d be working minimum wage, barely making rent.”
Idaho voters approved Medicaid expansion by ballot in 2018, but it too has a trigger law. Even if it isn’t activated, the state could face the same funding losses that threaten Arizona.
A Warning Ignored?
Back in North Carolina, Stradley fears many residents won’t realize what they’ve lost until it’s too late. “We’re talking about programs that keep kids out of emergency rooms, that help people work, that support local economies,” she said. “And they’re about to disappear.”
The cuts are being sold as fiscal responsibility. But for millions of Americans, especially in rural and red states, they may feel more like a betrayal.
“The reality is, cutting Medicaid will cost lives,” said nurse Molly Zenkler. “We’re already seeing people suffer. This will only make it worse.”
