Congress has passed a budget resolution that targets up to $880 billion or more in federal spending cuts from Medicaid over ten years. While specific proposals are not yet known, policies under discussion could limit financing and coverage for the Affordable Care Act (ACA) expansion group. Recent KFF polling shows there is little support for cuts to federal Medicaid spending overall, and a majority of adults (59%) oppose eliminating the enhanced federal match rate for adults covered under Medicaid expansion specifically.

The ACA expanded Medicaid coverage to nearly all adults with incomes up to 138% of the Federal Poverty Level ($21,597 for an individual in 2025) and provided states with an enhanced federal matching rate (FMAP) of 90% for their expansion populations over time, which is greater than the matching rate for Medicaid generally. While federal funding finances 90% of spending on the expansion population, states are responsible for the remaining 10% of costs for enrollees eligible under Medicaid expansion. As a result of a Supreme Court ruling in 2012, the expansion is effectively optional for states, and as of April 2025, all but 10 states have adopted the expansion. While expansion has led to higher government spending on Medicaid, a large body of literature shows that it is linked to reduced rates of uninsurance, increased health care affordability, improvements in access and health and outcomes, and economic benefits for states and providers. KFF polling shows that of people living in non-expansion states, two-thirds (66%) said their state should expand Medicaid to cover more low-income uninsured people.

This issue brief examines Medicaid expansion enrollment and Medicaid spending in expansion and non-expansion states and describes the characteristics of adults covered by the Medicaid expansion.

1. Medicaid expansion is widely adopted by both red and blue states.

Over the past 11 years, Medicaid expansion has been broadly adopted. The 41 states including the District of Columbia that have adopted Medicaid expansion are split nearly evenly between states that voted for Trump (21 states) and those that voted for Harris (20 states) in the 2024 Presidential election (Figure 1). Over half (27) of states adopted Medicaid expansion in 2014, while 14 states have implemented expansion since 2014, with South Dakota and North Carolina adopting most recently in 2023. Most states adopted expansion through legislation; however, in seven states, the expansion was adopted via a ballot measure. As of June 2024, over 20 million people were enrolled through Medicaid expansion, representing nearly a quarter of total Medicaid enrollment across all states and 31% of total enrollment in expansion states.

Medicaid expansion is linked to gains in coverage, access, increased health care affordability, and economic benefits for states and providers. Although establishing direct causality between health insurance and health outcomes is complex, evidence generally shows Medicaid expansion is associated with improved health outcomes, including increased early-stage cancer diagnosis, improved disease management, and lower mortality rates for many chronic conditions.

2. Medicaid median income eligibility for children, pregnancy, and parents, and Medicaid spending per enrollee are higher in expansion states compared to non-expansion states.

Overall, per enrollee spending for the expansion group was higher than for other adults and children but well below per enrollee spending for enrollees over age 65 and people with disabilities. While some critics of Medicaid expansion have argued that expansion diverts resources away from other groups of Medicaid enrollees, including people with disabilities and children, data show that expansion states spend more per enrollee overall and on each eligibility group than non-expansion states. Per enrollee spending for people with disabilities in expansion states is nearly 2.5 times the spending in non-expansion states ($25,170 per enrollee vs. $10,494) (Figure 2). The difference in per-enrollee spending for expansion and non-expansion states holds true for more detailed eligibility pathways for people based on age or disability. Expansion states also spent nearly $2,000 more per child enrollee than non-expansion states ($6,001 vs $4,295). The differences in per enrollee spending may reflect state policy choices about benefits and eligibility, in addition to payment rates, regional variation in health care costs, and state demographics.

In addition to difference in spending, expansion states have higher median income-based eligibility limits compared to non-expansion states for children (266% FPL in expansion states compared to 234% in non-expansion states), pregnant individuals (213% FPL compared to 203% FPL), and parents (138% FPL compared to 33% FPL). There is substantial variation in adoption of optional eligibility and other policies for seniors and people with disabilities, with state expansion status not a strong predictor of these policy choices.

3. Nearly four in ten women of reproductive age and over six in ten 50-64 year olds enrolled in Medicaid are covered through Medicaid expansion.

Medicaid expansion provides coverage across age groups for those 19 to 64 (Figure 3). Many expansion adults are working; however, they work for employers and in industries that are less likely to offer health insurance, leaving them without affordable health coverage options. As discussed below, older enrollees are more likely to have chronic conditions and may face more barriers to work.

Medicaid expansion also provides an important eligibility pathway for women of reproductive age, covering 38% of women ages 19-49 enrolled in Medicaid. For those who become pregnant, Medicaid coverage prior to pregnancy can promote pre-pregnancy health care, which can lead to healthier pregnancies and help reduce the risk of complications. Previous KFF analyses show that in expansion states, pregnant individuals are more than twice as likely to be enrolled in Medicaid prior to pregnancy (59%) than in non-expansion states (26%) (the difference in income eligibility levels for pregnant adults vs. other adults is large in non-expansion states, explaining the difference in pre-pregnancy enrollment rates). Medicaid expansion can provide stable coverage to pregnant individuals after the postpartum coverage period ends. Medicaid expansion coverage of parents also increases enrollment of their children: evidence shows that if children are eligible for Medicaid or CHIP coverage but unenrolled, when their parents gain coverage through Medicaid expansion it has a spillover, or “welcome mat” effect, increasing the number of children who enroll in health coverage. Medicaid expansion also covers adults as they age – more than six in ten Medicaid enrollees ages 50-64 are covered through expansion – and before they become eligible for Medicare.

4. One third of Medicaid expansion enrollees have a chronic physical health condition and a quarter have a chronic behavioral health condition.

Nearly half (44%) of expansion adults have at least one chronic condition, including 33% that have a chronic physical condition and 24% that have a behavioral health condition. Of Medicaid enrollees with at least one chronic condition, 53% are enrolled through Medicaid expansion (data not shown). Similar to all adults on Medicaid, the share of expansion adults with at least one chronic physical condition increases with age (Figure 4). Nearly six in ten (57%) expansion adults ages 50-64 have at least one physical health condition compared to just 16% of expansion adults ages 19-26. While the share of expansion adults with physical health conditions increases with age, the share with behavioral health conditions remains relatively stable, ranging from 19% to 26% across age groups.

Research finds that expansion is associated with improved access to care and outcomes related to behavioral health conditions. For other chronic conditions, expansion has positive impacts on access to care and may improve certain health outcomes. Medicaid coverage helps expansion enrollees manage chronic conditions and supports workforce participation. Medicaid expansion also provides coverage to individuals who have chronic conditions or disabilities that may limit their ability to work. Although some people with disabilities qualify for Medicaid because they receive Supplemental Security Income, most are eligible for Medicaid through other pathways, including the expansion group. While many adults who need long-term care may qualify for coverage through other Medicaid pathways, Medicaid expansion covers some individuals with costly health needs who may otherwise be unable to afford care; two percent (2%) of expansion enrollees, or 395,000 individuals, use long-term care services (LTC) which support activities of daily living such as eating, bathing, or dressing (data not shown). Medicaid expansion is also the primary pathway for Medicaid coverage for people with HIV.

5. Policy changes targeting Medicaid expansion would reduce government spending but also could put coverage for 20 million enrollees at risk.

There are several options under consideration in Congress to reduce federal Medicaid spending that could have implications for enrollees in the expansion group, including work requirements and changes in financing for the expansion. Congress may debate federal legislation requiring states to impose work requirements as a condition of Medicaid coverage. Most adult Medicaid enrollees are already working without a work requirement; estimates of national work requirements show $109 billion in federal savings over 10 years, and an increase in the number of uninsured, but no increase in employment. Beyond legislative changes, a number of states are pursuing waivers to condition Medicaid expansion coverage on meeting work requirements since work requirement waivers were encouraged and approved during the first Trump administration.

Congress may also consider proposals that would alter the financing for the Medicaid expansion. Any approach to reduce federal Medicaid spending for the expansion would shift costs to states, forcing governors to make tough choices about whether to drop the ACA Medicaid expansion, provide alternative coverage options or make up the loss of federal funding by cutting other state programs or raising taxes. Twelve states have “trigger” laws in place that would automatically end expansion or require other changes if the share of federal funding drops below 90%, and two additional states, Ohio and South Dakota, are considering similar action. But all states, including those without trigger laws in place, would examine their ability to maintain the ACA Medicaid expansion if Medicaid expansion financing was altered. An analysis of the impact on Medicaid enrollment if all states eliminated the expansion shows the decline in enrollment would vary across states, ranging from 19% in Massachusetts, Minnesota, North Carolina, and South Dakota to 49% in Oregon (Figure 5).

If states eliminate the Medicaid expansion, individuals with incomes 100-138% FPL would be eligible for subsidies in the Marketplace, but could face barriers transitioning to Marketplace coverage and could face higher out of pocket costs, especially if the enhanced subsidies expire at the end of 2025. However, current Medicaid expansion enrollees with incomes below 100% FPL are not eligible for subsidies in the Marketplace and could fall into the “coverage gap” and become uninsured if they are unable to qualify for Medicaid under a different eligibility pathway, for example based on a disability. Currently, 1.4 million adults are in the coverage gap in the ten non-expansion states; however, that number would likely increase significantly under proposed policy changes targeting the Medicaid expansion. Eliminating the Medicaid expansion could have additional spillover effects, including children whose eligibility status is unchanged but become uninsured after their parents lose Medicaid coverage. People without insurance have more difficulty accessing care and are more likely to have medical debt, with almost one in four uninsured adults in 2023 not receiving needed medical treatment due to cost. Uninsured individuals are also less likely than those with insurance to receive preventive care and treatment for major health conditions and chronic diseases.

Methods Medicaid Claims Data: This analysis uses the 2021 T-MSIS Research Identifiable Demographic-Eligibility and Claims Files (T-MSIS data) to identify Medicaid expansion enrollees, spending, and chronic conditions in Figures 2-4. State Inclusion Criteria: Expansion states: Though Idaho and Virginia expanded Medicaid prior to 2021, adult expansion enrollees primarily show up in the traditional adult eligibility group. Therefore, those expansion states are excluded from Figures 2-4. West Virginia is excluded from Figure 2 (but included in Figures 3-4) of this analysis due to unusable spending data, according to quality assessments from the DQ Atlas.

Non-expansion states: Mississippi was also excluded from Figure 2-3 this analysis due to data quality concerns flagged by the DQ Atlas. Enrollee Inclusion Criteria: Enrollees were included if they were ages 19-64, had full Medicaid coverage for at least one month, and were not dually enrolled in Medicare. Dually enrolled individuals were excluded from these calculations since they may not have had sufficient claims in T-MSIS to identify chronic conditions. Calculating Spending (Figure 2): This figure reflects spending from all states except Idaho, Virginia, West Virginia, and Mississippi. Average annual per capita spending calculations include fee-for-service spending and payments to managed care plans. Spending was calculated by summing the total spending of all claims per enrollee in the T-MSIS claims files. Estimates here do not include prescription drug rebates and most supplemental payments to providers. Defining Chronic Conditions (Figure 4): This figure reflects chronic conditions from all expansion enrollees in expansion states that expanded prior to 2021 except for Idaho and Virginia. This analysis used the CCW algorithm for identifying chronic conditions (updated in 2020). This analysis also included in its definition of chronic conditions substance use disorder, mental health, obesity, HIV, hepatitis C, and intellectual and developmental disabilities. In total, 35 chronic conditions were included and were further grouped into 3 broad categories: behavioral health, physical health, and cognitive impairment conditions. Specific conditions within these groupings include: Behavioral health conditions : Any mental health condition and any substance use disorder. See KFF’s brief, “5 Key Facts About Medicaid Coverage for Adults with Mental Illness,” KFF brief “SUD Treatment in Medicaid: Variation by Service Type, Demographics, States and Spending,” and the Urban Institute, Behavioral Health Services Algorithm for additional details ( Victoria Lynch, Lisa Clemans-Cope, Doug Wissoker, and Paul Johnson. Behavioral Health Services Algorithm. Version 4. Washington, DC: Urban Institute, 2024).

: Any mental health condition and any substance use disorder. See KFF’s brief, “5 Key Facts About Medicaid Coverage for Adults with Mental Illness,” KFF brief “SUD Treatment in Medicaid: Variation by Service Type, Demographics, States and Spending,” and the Urban Institute, Behavioral Health Services Algorithm for additional details Victoria Lynch, Lisa Clemans-Cope, Doug Wissoker, and Paul Johnson. Behavioral Health Services Algorithm. Version 4. Washington, DC: Urban Institute, 2024). Physical health conditions : Hypertension, transient ischemic attack, acute myocardial infarction, hyperlipidemia, ischemic heart disease, atrial fibrillation, heart failure, obesity, chronic obstructive pulmonary disease, pneumonia, asthma, diabetes, arthritis, hip fracture, osteoporosis, cataracts, glaucoma, chronic kidney disease, colorectal cancer, endometrial cancer, urologic cancer, prostate cancer, lung cancer, breast cancer, hepatitis, HIV, anemia, hypothyroidism

: Hypertension, transient ischemic attack, acute myocardial infarction, hyperlipidemia, ischemic heart disease, atrial fibrillation, heart failure, obesity, chronic obstructive pulmonary disease, pneumonia, asthma, diabetes, arthritis, hip fracture, osteoporosis, cataracts, glaucoma, chronic kidney disease, colorectal cancer, endometrial cancer, urologic cancer, prostate cancer, lung cancer, breast cancer, hepatitis, HIV, anemia, hypothyroidism Cognitive impairment conditions: Alzheimer’s, intellectual and developmental delay, Parkinson’s, and dementia

Appendix

The Republican-led Congress is considering plans to cut Medicaid to help pay for tax cuts, with the House budget resolution targeting $880 billion or more in potential reductions to federal Medicaid spending. Medicaid is the primary program providing comprehensive health and long-term care to one in five people living in the U.S and accounts for nearly $1 out of every $5 spent on health care. Reductions in Medicaid could have implications for enrollees as well as plans, providers, and state budgets. While there are several policy options under consideration in Congress to achieve savings, it is not clear how much support there is from Republicans (including President Trump) about these specific policies. The discussions in Congress come at a time when support for the Medicaid program continues to be strong. According to KFF polling, Medicaid is viewed favorably by a large majority (77%) of the public and an even larger share of those on the program (84%). As Congress considers reducing Medicaid spending, nearly half (46%) of all people and nearly two-thirds (62%) of Medicaid enrollees believe the federal government is currently not spending enough on the program.

To better understand the experiences of Medicaid enrollees and their perceptions of potential changes to the program, KFF conducted five virtual focus groups in January, including three groups with participants who had voted for President Trump in the 2024 election and two groups with participants who had voted for Vice President Harris. Focus group participants were asked about their experiences with their Medicaid coverage, views on government’s role in health care, and perceptions of the recent election. Participants were also asked for their reaction to current proposals to reduce federal spending on Medicaid and impose work requirements. Despite differences in who they voted for in November 2024, participants had consistently favorable experiences with Medicaid and concerns with potential cuts to the program. Key findings from our groups include the following:

Many Trump and Harris voters said that their top voting issue in the 2024 election was the economy, though some Trump voters cited immigration, and some Harris voters cited women’s rights as their top issues, and most participants said they did not recall hearing about changes to health care programs (including Medicaid) during the campaign. Most participants said the government has a role to play in making health care more affordable and accessible, but some Trump voters argued the private sector does a better job of controlling costs. When asked about fraud in the Medicaid program, many participants said they thought fraud exists, but views differed on whether it is a major issue and what was the primary cause. Several Trump voters believed the problem was due to people enrolled who were not eligible; however, other participants, including both Trump and Harris voters countered that state verification procedures prevent individuals from defrauding the program on a large scale and that providers and insurance companies were more likely the main source of program fraud.

At the time of the focus groups, most participants had not heard about proposals to reduce federal spending on Medicaid, and while most did not know why the reductions were proposed, some Trump voters suggested they were part of the crackdown on illegal immigration and aimed at removing undocumented immigrants from the program (undocumented immigrants are not eligible for federally-funded Medicaid). Participants opposed cutting Medicaid funding to pay for tax cuts that they did not believe would benefit them. Both Trump and Harris voters expressed fears that these changes would jeopardize the program, take away access to health care, result in worse health outcomes, and increase out-of-pocket costs. A few Trump voters did not believe Trump would follow through on the cuts to Medicaid because they believed he understood their financial struggles.

Both Trump and Harris voters valued their Medicaid coverage and the access to health care services, mental health services, and medications for themselves and their children it provides. Participants also valued Medicaid because it helps to protect them from financial disaster, alleviates stress, improves health outcomes and often supports their ability to work. Participants said losing Medicaid would “be devastating” and lead to serious consequences for their physical and mental health and exacerbate pre-existing financial challenges.

If work requirements were introduced to Medicaid, participants who were working generally felt confident in their ability to meet the requirements; however, they worried about the burden of monthly reporting requirements when those were described to them. Many participants across parties noted that access to treatment for chronic conditions, including prescription medications and mental health treatment, were key in helping to support their ability to work. More Trump voters supported a work requirement but some who were not working were convinced they would qualify for an exemption. Other participants, including both Trump and Harris voters, who were not currently working felt they would face challenges in meeting the requirements. Those who were not working said they wanted to work (and many had been previously working for many years) but were generally unable to because of disability or because they were caring for young children or a sick parent.

Both Trump and Harris voters wanted policymakers to focus on improving Medicaid instead of cutting it. For example, some participants said they would like to see enhanced dental benefits, increased doctor availability, and fewer prior authorization requests. Focus group participants wanted policymakers to consider the implications of federal cuts to Medicaid for people, their health, financial stability, and ability to be productive members of society.

General Situation

Most focus group participants were experiencing financial challenges and were managing an array of physical and/or mental health conditions. Medicaid eligibility requirements mean those on the program, by definition, have low incomes. Most participants described struggling with high food prices and noted the past few years have been financially difficult. Some focus group participants reported difficulties with the current job market or described injuries or disabilities that made it difficult to find employment. Focus group participants were managing an array of health conditions including high blood pressure, diabetes, physical disabilities, chronic pain, asthma, and anxiety and depression. Some were managing more complex and potentially disabling conditions, such as cystic fibrosis and hidradenitis suppurativa (HS). Along with managing their own conditions, some participants were also caring for parents or other family members in nursing care.

“Times are tough right now. You know, everything’s overpriced and no one’s working and can’t afford anything and my health is terrible, so it’s kind of tough times.” 50-year-old, White female

(Trump voter, Nevada)

Experiences with Medicaid

Participants valued their Medicaid coverage and the access to health care services, mental health services, and medications for themselves and their children it provides. Along with regular physical exams for themselves and their children, focus group participants reported using Medicaid to see specialists, access mental health and substance use disorder treatment, receive necessary surgeries, and get prescription medications. Some participants with health conditions requiring frequent visits with specialists or multiple daily medications said they could not imagine day-to-day life without Medicaid.

“Doctor’s visits, I take 30 pills a day, so it covers all that, which is nice. I see the ENT like every other week.” 35-year-old, White female

(Trump voter, North Carolina) “I’m really grateful for it. When I first got on it, it covered for 90 days for me to go to a rehab and then it has covered my prescriptions with no questions asked.” 33-year-old, White female

(Trump voter, Arizona)

Participants described Medicaid coverage as affordable, noting that it protects them from financial disaster and alleviates stress. Participants expressed gratitude that they could access necessary medications with little to no cost sharing, and in general were appreciative that they had no premiums and low out-of-pocket costs. Participants said that having Medicaid reduces stress related to unexpected medical costs. Prior to enrolling in Medicaid, many participants had been uninsured and had gone long periods of time without seeing a doctor. These participants were grateful that they were now able to access regular care. Those who had previously looked into or been enrolled in private insurance described Medicaid as a more affordable source of coverage.

“I never took insurance from where I was employed at because it was always so expensive. By the time they would take out the money, there wasn’t much of a check. So I was basically gonna be paying for insurance, which I know a lot of people have to do. Went a while without anything so Medicaid’s been really great as far as helping me out with doctor appointments, used to help me out with dental. I used it a little bit for mental therapy when I lost my daughter unexpectedly. So it’s been good.” 61-year-old, White female

(Trump voter, Kentucky)

While participants said Medicaid was generally working well for them, some would like to see improvements, including enhanced dental benefits, increased doctor availability, and fewer prior authorization requests. Participants noted that it can be difficult to find doctors accepting Medicaid and frustrating to navigate prior authorizations for needed care. Other complaints included high turnover rates among providers at clinics that accept Medicaid and certain prescriptions not being covered by the program. Many focus group participants also wished that their state either covered dental benefits or had more generous dental benefits.

“There’s not like every doctor available, thankfully the doc I had before, I still am on the same doctor ’cause he is under my Medicaid, which is good. But there’s not coverage everywhere and certain things, so that’s kind of, you know, slight disadvantage there.” 59-year-old, White male

(Harris voter, Pennsylvania)

Views on Government’s Role in Health Care

Participants felt that being able to easily access affordable health care services is essential to ensuring they can work and lead productive lives. Across voting parties, most participants felt that everyone deserved access to affordable health coverage, with many saying that people should not have to pay for what they described as “life or death” care. Some participants noted that being able to access health care services helps them to work, be more productive, and contribute to society. However, a few Trump voters talked about the need for people to take responsibility for their health suggesting that they did not believe health care was a right for everyone.

“Healthcare is a right because you want the American people to work. So in order for the American people to work, they need to be healthy to work.” 52-year-old, Black female

(Trump voter, Pennsylvania) “If we’re healthier, it makes our country healthier and we produce. If you got a bunch of sick people that have no insurance, all you’re gonna do is cause debt, death, and god knows what else.” 56-year-old, White male

(Harris voter, Ohio)

Most participants said the government has a role to play in making health care more affordable and accessible; however, some Trump voters opposed government playing too large a role in running the health care system. Both Trump and Harris voters said the government has a role in making coverage more affordable, but some Trump voters noted that they felt private businesses may be more effective at keeping health care costs affordable than the federal government. More Harris voters (and some Trump voters) felt that the government should play a role in helping everyone access health care and in making the system work better. Both Trump and Harris voters compared the U.S. to other countries with nationalized health care systems, though takeaways from these comparisons differed. Some Trump voters referenced long wait times for care in other countries as evidence for why they did not think the U.S. should move to a socialized medicine model. Others (including both Trump and Harris voters) noted that the government should offer free care for all citizens, similar to other countries.

“It should be available for everybody. And it should be affordable. Because not everybody can afford the same thing… it’s usually the private sector does a better job with lowering costs and making things affordable and having options for people, not the government. I pay enough already in taxes that I don’t need to control anymore what I have to pay taxes for.” 45-year-old, Black male

(Trump voter, Kentucky) “It shouldn’t be an issue in a country this rich that people are going without it. I mean, it shouldn’t even be a question. It should be cut and dry. And we look at other countries, you know, it’s something they already have that the citizens have. And for a country that’s rich as America, it shouldn’t be your money or your life. You shouldn’t have to choose between medicine or buying food, or medicine and paying your life bill. It’s a right of an American citizen.” 61-year-old, Black female

(Harris voter, Kentucky)

Election Experiences

Many Trump and Harris voters said that their top voting issue in the 2024 election was the economy. Most Trump and Harris voters cast their ballot based on economic concerns and which candidate they thought would address their pocketbook issues, including housing costs and grocery prices. Some Trump voters noted that their standard of living was better under the first Trump administration while some Harris voters were worried that Trump would cut benefits. Immigration was a top voting issue for some Trump voters, especially for those living in border states. A few Harris voters cited women’s issues and preserving democracy as the motivations for their votes.

“When Trump was in office from ‘16 to ‘20, you know, my standard of living was better than it is now.” 43-year-old, White male

(Trump voter, Pennsylvania) “Someone who’s not about to cut food stamps, cut housing, cut WIC, cut many stuff that we everyday people need.” 45-year-old, Black female

(Harris voter, Ohio)

Most participants said they did not recall hearing either candidate mention changes to health care programs (including Medicaid) during the campaign. Because other issues, including immigration and the economy, dominated the campaign, most participants were unaware of either candidate’s health care priorities and any policy changes they planned to make. Some Harris voters recalled Harris discussing women’s health care and abortion access, and a couple of participants said they heard that Trump would either try to get rid of Obamacare (the Affordable Care Act) or would fix it. However, for the most part, health care issues were not a dominant factor in the election for these voters.

“I didn’t hear a peep about healthcare. Nope. It’s immigration for me.” 56-year-old, White male

(Trump voter, Arizona) “I think Kamala talked about healthcare like for women’s rights a lot. I feel like that was kind of one of her main points… I had never really heard Donald Trump talk about it. I heard about it in like Project 2025.” 25-year-old Black female

(Harris voter, Pennsylvania)

Proposals to Reduce Federal Medicaid Spending

At the time of the focus groups, most participants had not heard about proposals to reduce federal spending on Medicaid, but Trump and Harris voters had different opinions on why the cuts were being proposed. No Trump voters and only a very few Harris voters said they were aware of proposals in Congress to reduce federal spending on Medicaid, and many were surprised to hear of the proposed cuts. Although most participants were not sure why the spending reductions had been proposed, some Trump voters theorized that it was part of the administration’s crackdown on illegal immigration and an effort to remove undocumented immigrants from the program (undocumented immigrants are not eligible for federally-funded Medicaid). A few Trump voters did not think Trump would follow through on the cuts because they believed he understood their financial struggles. Some Harris voters felt the proposals reflected a pattern by Republican lawmakers to reduce benefits for poor Americans.

“I’m a border state, so we’ve had so many illegals coming through and the previous administration they got all free social services. So I imagine that’s part of the thing that we were giving Medicaid to people who have been here hours and stuff. And so it’s one way to prevent or to get some cost cutting.” 59-year-old, Hispanic female

(Trump voter, Arizona) “Their goal is to make sure that we don’t have anything. So why they’re taking everything outta everything because the rich wanna get richer.” 58-year-old, Black female

(Harris voter, Ohio) “I think Trump knows that people are struggling right now, and I don’t think he’s gonna do, at least not right now, cut anything Medicaid because he just knows people’s financial problems right now.” 45-year-old, Hispanic male

(Trump voter, Arizona)

When asked specifically about fraud and abuse in Medicaid, some participants across both groups believed there is fraud and abuse in the Medicaid program, but opinions were mixed on whether the source of the fraud is people enrolled who should not be or providers and insurance companies taking advantage of the system. The Trump administration has tied current actions to reduce federal spending to eradicating fraud, waste, and abuse within government programs. Many focus group participants agreed there was fraud in the Medicaid program; however, some described fraud as a major problem in the program and others reasoned there is fraud in Medicaid because there is fraud everywhere. When identifying the source of fraud in Medicaid, several Trump voters believed fraud was primarily due to people enrolled who were not eligible. Other participants, including both Trump and Harris voters countered that it would be too difficult for individuals to defraud the program on a large scale, describing how their states verify their income and other information at application and renewal. Some participants believed that providers and insurance companies overcharging the program or billing for services they did not provide were to blame rather than individuals. These participants offered examples of providers in their states who were convicted of fraud.

“Fraud is probably pretty prevalent, just like it was in everything else… People can abuse anything, so. If they have access to that, I’m sure there’s been some fraud over the years with Medicaid.” 56-year-old, White male

(Trump voter, Arizona) “I think it’s organizations more than people. I think it’s kind of hard to defraud with Medicaid. I mean, what are you doing going and asking for prescriptions and then selling them on the side? I mean, I don’t know how you would or having a high paying job and pretending you don’t work. I mean everything is available now on the internet. Everything’s tied in. Like me, our local Medicaid in Arizona was able to access my paychecks even before I saw what I was going to get one time they had it already on their screen.” 59-year-old, Hispanic female

(Trump voter, Arizona) “Most of the fraud that I’ve heard about comes from the actual provider billing for things they didn’t do.” 45-year-old, Black female

(Harris voter, North Carolina)

Both Trump and Harris voters opposed cuts to the program fearing that Medicaid spending reductions would jeopardize the program and take away access to health care for poor people. Likely because of their reliance on the Medicaid program, participants opposed reducing spending on Medicaid, and many used strong language to describe the dire consequences of making major cuts to the program. Some participants predicted people would lose coverage if cuts were made to the program, and one participant suggested the economy would suffer because many of the people currently on the program would no longer be able to get the care they need. Others anticipated that states would cut benefits, particularly for prescription medications and mental health care, and that providers would stop participating in the program.

“We shouldn’t have to suffer because of somebody wanting to propose cuts to it, you know, because we, we didn’t do anything. So, you know, let it, it can come from somewhere else. I just, I would oppose it.” 60-year-old, Black male

(Trump voter, Missouri) “People would be unable to take care of themselves and be healthy and get mental health issues taken care of, to get vision and dental; people would suffer. They wouldn’t be able to work. And the economy would suffer.” 55-year-old, White female

(Trump voter, Oklahoma) “I would oppose [cutting Medicaid] just because there’s a lot of people who need it, who would be affected by it negatively.” 29-year-old, White male

(Trump voter, Pennsylvania)

Participants opposed cutting Medicaid funding to pay for tax cuts that they did not believe would benefit them. Participants explained that because they had low incomes and were already in a low tax bracket, they did not expect their taxes would change much under any tax cut proposal. Both Trump and Harris voters said they would prefer Medicaid coverage to continue unchanged, arguing that the negative consequences of any changes to Medicaid would outweigh any small benefits they would experience from tax cuts. They said other government spending should be targeted to finance tax cuts.

“I don’t make much money to get my taxes affected by that. It would hurt my Medicaid, my medical more.” 50-year-old, White female

(Trump voter, Nevada) “They need to start taxing the right people properly first and then we can discuss that matter. Because we’re the only ones that are paying the taxes… They could put more into the programs if they tax the proper people properly.” 56-year-old, White male

(Harris voter, Ohio)

Participants expected significant changes to the Medicaid program if federal funding were reduced and they worried they would lose coverage or face higher costs. Possible Medicaid spending cuts felt very personal to participants who expected they would be negatively affected by the proposed changes. Participants expressed anxiety over how reduced federal spending may affect out-of-pocket expenses, doctor availability, and covered benefits. Some described life and death consequences of not being able to access mental health care and prescription medications to manage their chronic conditions. Others focused on the financial implications of losing coverage and the impact that would have on their ability to work as well as on out-of-pocket costs for needed care. For participants with family members in nursing homes, the challenge of caring for them at home seemed daunting.

“I would be very worried. It would [mean] not being able to get my antidepressants [and] see a psychiatrist. Yeah, it would, it might crush me.” 45-year-old, Hispanic male

(Trump voter, Arizona) “States are gonna have to start dropping people off the rolls. People like us who are probably single and childless.” 45-year-old, Hispanic male

(Harris voter, Arizona) “It’s gonna be higher out of pocket costs for sure. You know, and that’s something I can’t afford. It’s not just me, it’s me and five other people, you know. So I can’t afford that for me, nonetheless them.” 45-year-old, Black female

(Harris voter, Ohio)

Work Requirements

While some participants were working full-time, many who were working part-time or not working said they wanted to work or work more hours but were unable to because of disability or because they were caring for young children or a sick parent. Participants were working a variety of jobs, including home health aide, dental assistant, tax preparer and gig and contract work, but they needed Medicaid because they were not offered insurance through their work. Several said they were working part-time or not working because of illness or disability or because they were caring for young children or aging parents. Others said that they wanted to be working but have been unable to find employment. For those who were not working for a reason other than disability or illness, several said that to be able to work, they would need supports like affordable childcare, transportation, internet access, or better opportunities in their communities.

“I do self work with Instacart because …I get to pick and choose the days I’m able to work and dealing with my dad, getting in that nursing home and also dealing with my mom now because she’s getting into that phase where she’s needing more doctor appointments.” 52-year-old, Black male

(Trump voter, Missouri) “I can’t work right now because of my back. And I mean, I believe that my back got as bad as it did because I couldn’t go to the doctor when I didn’t have insurance.” 41-year-old, White female

(Trump voter, North Carolina) “Ever since I haven’t been working, I haven’t been able to find a job that’s legal or decent enough for working from home…They all want somebody in the office to stand up or sit down for long periods of time. I can’t even walk to my vehicle without being in pain. Or get into a vehicle and drive that vehicle because of the stress all behind that.” 51-year-old, Black female

(Harris voter, Oklahoma)

Participants who were working said having Medicaid meant they could get the care they needed, especially medications, and provided financial peace of mind that enabled them to work. With high rates of chronic disease among focus group participants, the ability to manage their conditions was described as critical to their ability to work. This was especially true for participants who said their work sometimes exacerbated their health conditions, such as asthma or chronic pain. Keeping Medicaid was important to participants who were working, and several participants noted the challenge of managing work hours to maintain eligibility. One participant described how she lost coverage for one month because she worked too many hours. The income volatility that many workers on Medicaid experience can put them at risk of losing coverage and access to needed prescriptions and health care for a month or longer.

“I can say that even doing the part-time work, if I did not have Medicaid or wasn’t able to do pain management, I wouldn’t even be able to do those, those small amount of hours.” 45-year-old, Black female

(Harris voter, North Carolina) “It would be really hard for me to work a full-time, 9-5 job with all my doctor’s appointments as well as I’m immunocompromised. It’s definitely positive that I can do something I like, something I wanna do and not work as much and still be able to get insurance.” 35-year-old, White female

(Trump voter, North Carolina) “I found out with Medicaid that there’s a cap on how much I can earn. I wasn’t aware of that. And so actually in the fall I was kicked off for about a month because I apparently had earned too much.” 59-year-old, Hispanic female

(Trump voter, Arizona)

Some participants who were not currently working expressed concerns about imposing work requirements in Medicaid, saying they would face challenges meeting the requirements, while others who supported the policy were convinced they would qualify for an exemption. While most participants had not heard about proposals to introduce work requirements for Medicaid, many Trump and Harris voters who were not working said they did not think they would be able to meet the requirements because of chronic pain or other disabilities. Although not currently working, several of these participants described the high demands of jobs they previously held, noting they had to leave those positions because of injuries or other health conditions. More Trump voters than Harris voters supported a work requirement policy, but several Trump voters who were not working and supported the idea of work requirements strongly believed they would qualify for an exemption because they have a disability or caregiving responsibilities. However, most participants with a disability were not receiving disability income and, therefore, may not meet disability exemptions, which in past proposals have been based on receiving Supplemental Security Income (SSI).

“I can’t because I have chronic pain and I just can’t. I worked until I couldn’t work no more.” 57-year-old, White female

(Trump voter, Missouri) “There’s nothing out here from miles and miles. I live in between two towns and it’s still nothing, you know, so people don’t always have the resources or availability to do what they ask.” 39-year-old, Black female

(Harris voter, North Carolina) “I mean, if you’re able bodied then, then you should still be working and trying and proving to them that you’re able to, ’cause like I said earlier, I want to work, but because of daycare costs, financially I can’t.” 34-year-old, White female

(Trump voter, Kentucky) “I already know I am exempt because I’ve seen this proposal and I already know I was exempt from it. But no, I wouldn’t be able to meet it if I wasn’t exempt.” 57-year-old, White male

(Harris voter, Pennsylvania)

Participants who were working generally felt confident in their ability to meet the requirements; however, some worried about the burden of monthly reporting requirements. Given the number of hours they were working, most participants who were working felt that they would be able to meet any new requirements. But on the issue of reporting on work status monthly, participant opinions diverged. Some said that they were already submitting this information regularly to programs such as SNAP, so they were not worried about this requirement also being required in Medicaid. Others, however, expressed concern about having to report to the state each month, noting that they are human and prone to forget and that reporting requirements can be onerous. They also worried about the consequences of losing coverage for a month if they forget to report their work information in a month. As an alternative to submitting additional paperwork, some suggested an automated system, similar to how income is verified at renewal, would be more efficient.

“Required? Oh yeah. Easy. Oh yeah, absolutely. Mind you, I can’t do certain jobs. I can’t drive, if you will, but yeah, I can, I could do it. I can make it work.” 45-year-old, Hispanic male

(Harris voter, Arizona) “It’s gonna be devastating and upsetting to, you know, if you lose your health insurance if I forget as we tend to, we are only humans, sometimes we forget things. So if I don’t do this [report work hours], it affects the rest of my household and I don’t like that.” 45-year-old, Black female

(Harris voter, Ohio) “I would be very worried about them making mistakes. There’s been many times I’ve sent in paperwork and they didn’t get it and coverage was stopped. You know, a lot of room for clerical error and things like that.” 50-year-old, White female

(Trump voter, Nevada)

Consequences of Losing Medicaid Coverage

Both Trump and Harris voters said that losing Medicaid coverage would be “devastating” and would lead to serious consequences for their physical and mental health. Participants emphasized that the health care services and prescriptions they and their children receive through Medicaid helps them “survive.” Across groups, participants said that losing their Medicaid coverage would create financial challenges and expressed anxiety at the thought of being unable to afford prescriptions, doctor visits, or higher premiums on top of pre-existing financial challenges if there were major changes to Medicaid. Although focus group participants were not aware of the nuances of congressional proposals, all participants were residing in Medicaid expansion states and those who were eligible due to Medicaid expansion could be especially vulnerable to proposed changes in the program.

“I think obviously, not having access to healthcare, or having to have the financial ability to pay for your medical needs, your basic medical needs, is something that we shouldn’t have to worry about because we worry about how we’re going to eat. We worry about how we’re gonna pay our bills… Not having Medicaid would be, not distressful, it would be detrimental because I need to see a primary care doctor, I need to see my specialist.” 58-year-old, Black female

(Harris voter, Ohio) “For me it would, it would probably lead to death, and that’s kinda harshly speaking, but it’s the way that it would be. I’ve relied upon Medicaid for myself in order to survive. For my son, it would be survivable, but it would be difficult. He has real bad allergies, he wouldn’t be able to hear.” 55-year-old, White female

(Trump voter, Oklahoma)

When asked to respond to proposals to reduce federal Medicaid spending, participants appealed to policymakers to consider how these changes would negatively impact people. Participants felt that reducing federal funding for Medicaid would have serious consequences and hurt many people on the program. Some participants pointed out that many people enrolled in Medicaid could not afford any other alternatives and would have no way to access care if they were to lose coverage. The message of several Trump voters to policymakers was to focus on improving Medicaid instead of cutting it. Across groups, participants asked policymakers to remember the human impact of potential changes to the program.

By Grace Vitaglione and Rose Hoban

The North Carolina Senate’s proposed budget for the next two fiscal years is packed with policy around new health care initiatives, including repealing North Carolina’s hospital capacity regulation laws, trimming vacant state job openings and increasing rates for child care subsidies.

The spending plan — just over 1,000 pages — calls for allocating about $32.6 billion in the coming fiscal year and $33.3 billion in the next. Part of that spending will go to replenishing the state’s “rainy day” reserve fund, and $700 million is earmarked to Hurricane Helene recovery.

The Senate’s plan would also reduce the income tax rate for North Carolinians from 4.25 percent to 3.49 percent in 2027. In the past, the General Assembly mandated that income taxes could only be reduced further if the state met certain revenue levels, but Senate leader Phil Berger said the budget bill would eliminate some of the restrictions that would have prohibited income tax reductions.

Members of the Republican majority in the Senate say that the spending plan saves taxpayer money while still meeting the needs of North Carolinians. The chamber’s Democrats say the budget falls short on rural health care access while increasing tax cuts that they say disproportionately help the wealthy. They also say that the budget underfunds Medicaid and fails to account for state employees’ increased cost of living.

This spending plan is only the first step in the biennial budgeting process. The plan now moves to the state House of Representatives, which is slated to present its plan in coming weeks. Then both chambers will hash out their different visions for state spending in a conference committee. The budget is due by June 30, the end of the fiscal year, but lawmakers often miss that target.

“State budgets are multibillion-dollar puzzles that we have to put together carefully,” Senate Leader Phil Berger (R-Eden) told reporters in an April 14 news conference about the budget.

Sen. Michael Garrett (D-Greensboro) told reporters after his chamber’s vote on Wednesday that the budget process lacks transparency — the plan was put together without any committee hearings where the public could provide input. He said even some members of the Republican caucus didn’t know what was in the spending plan.

“If you genuinely want to see bipartisanship in the budgeting process, that needs to be transparent, open and done in regular order, and that’s just not the way this leadership operates,” he said.

Under the senate’s plan, state employees would receive a 1.25 percent raise in the coming fiscal year, as well as a $3,000 bonus spread over the two years of the state biennium. State-funded registered nurses, licensed practical nurses and certain health care technicians would receive an additional 2 percent raise.

The spending plan also cuts hundreds of state jobs, including more than 425 positions in the Department of Health and Human Services. The majority of those DHHS job cuts — 290 — would come from the behavioral health budget. Most of those 290 positions would be hard-to-fill jobs at the state’s hospitals and health care facilities that largely serve people with mental health and developmental disabilities where the positions have been vacant for more than a year.

Medicaid funding gets tweaked

Medicaid, the state- and federally funded program that provides health care services for more than 3 million North Carolinians, has costs that fluctuate each year based on the number of beneficiaries and the costs for their care. The state health department creates an annual forecast on how costs might change and then asks the legislature for funding adjustments based on those predictions — known as the “rebase.”

The budget presented last month by Gov. Josh Stein funded that rebase to the tune of $700 million, which is what forecasters at the Department of Health and Human Services say is needed in the coming year.

DHHS also asked for an additional $87 million to support the Healthy Opportunities Program, a pilot project providing services to people in three rural areas of the state. Since its launch in 2022, the program has provided assistance to nearly 30,000 people across three regions of the state.

Only parts of North Carolina are participating in the Healthy Opportunities Program pilot program and each region has a different network leader. Access East in the northeast, Community Care of the Lower Cape Fear in the southeastern region and Impact Health in the west. Credit: NCDHHS

Beneficiaries are eligible for deliveries of food, rides to doctor’s appointments and other services designed to combat social, economic and geographic issues that contribute to poor health outcomes and increased cost.

An independent evaluation shows that by providing qualifying enrollees support for housing, food, safety and non-health care-related transportation (such as to the grocery store), the pilots have driven down the cost of health care by as much as $1,020 per pilot participant per year — largely by preventing beneficiaries from getting sicker or from using more expensive kinds of care.

“In Western North Carolina, this translates to $11.9 million in annual savings through participants’ improved health and reduced hospital and emergency room use,” wrote Laurie Stradley, who leads Impact Health, the organization that oversees implementation of the program in western North Carolina.

The evaluation also predicted that savings will grow over time as participants’ health outcomes improve.

In contrast, the proposed Senate budget provides $500 million for the Medicaid rebase this year and does not explicitly designate extra funding for continuation of Healthy Opportunities (often referred to as HOP).

“The governor’s request was above and beyond the HOP expansion that is in the base budget. He asked for additional funds,” argued budget crafter Sen. Ralph Hise (R-Spruce Pine). “There is a disagreement between central staff at the General Assembly and the governor’s office as to what is rebase and what’s included.”

“This lack of funding for the existing HOP regions puts at risk the positive health and economic outcomes that North Carolina communities, including counties in western North Carolina impacted by Hurricane Helene, have seen through the pilot program,” said a statement from a DHHS spokesperson.

The spokesperson also said HOP partners have been instrumental in helping people in communities affected by Hurricane Helene recover.

State staffing cuts

To realize some savings, Senate budget writers cut state positions that have been vacant for at least 12 months.

Most of those positions at HHS would likely be cut from the three state psychiatric hospitals, Central Regional Hospital, Cherry Hospital and Broughton Hospital, according to DHHS.

Those facilities have struggled to recruit health care staff, but managers of those facilities have tended to use money from the unpaid salaries to hire contract workers, who are often more expensive than state employees, to fill the gaps.

Permanently cutting the staff numbers will reduce the number of patients the facilities can safely serve, the departmental spokesperson argued.

“There are kids that are in EDs,” said Senate minority leader Sydney Batch (D-Raleigh). “We have places that we need to put people in crisis. Mental health crises are increasing, suicidality is increasing, and yet we are doing absolutely nothing. And what you do is say, instead of the crisis where the spigot is wide open, we’re going to actually prevent individuals from getting help, and by eliminating positions that we absolutely need.

“Pay people and they’ll work.”

Berger said he’s not surprised by agency pushback against cuts. He said departments were using lapsed salary money for other things that may not receive adequate oversight.

“We need to pull that money back and make decisions as to whether or not that money might be needed somewhere else,” he said.

Sen. Jim Burgin (R-Angier) said he’s in talks with other hospitals about ways to help open beds in those facilities and get patients in there, rather than having people showing up to emergency rooms.

Boost to child care services

The Senate budget plan also allocates an additional $80 million — $45 million recurring from federal block grants and $35 million recurring from the state’s General Fund — to increase child care subsidy rates. Child care subsidies help eligible low-income families pay for child care so parents can go to work.

This money would increase the subsidy rates to what’s recommended in the 2023 Market Rate Study. NC DHHS conducts these studies — as mandated by the state legislature — to figure out the cost of providing child care.

Charles Hodges, director of the NC Licensed Child Care Association, said the increase is a “step in the right direction.

“The better we can align reimbursements with the true cost of care, that improves the providers’ ability to hire and retain staff, which ultimately will improve access to care for working families,” he said.

One downside is that the adjustment is only to the 2023 rate — costs have increased since then, he said.

Parents receiving the subsidy are currently required to pay 10 percent of their income for child care. This bill would decrease that cost sharing to only 7 percent, which Hodges said the association supports and parents would welcome.

The budget plan could also open up some changes to NC Pre-K, which provides money for preschool programs for eligible 4-year-old children. The bill directs the state health department to report on the number of unused NC Pre-K slots after the 2022-23 program year, as well as think of options for changes that would allow unused slots — which currently are allocated by geography — to be reallocated elsewhere.

Hodges said that would hopefully lead to better utilization of the NC Pre-K program. It’s unfortunate to hear of unused slots in some counties when there is a waitlist for children to get into the program in other parts of the state, he said.

The budget plan is intended to better support the child care industry in tandem with regulatory changes in Senate Bill 528, said Sen. Amy Galey (R-Burlington). Senate Bill 528 — which Galey has sponsored — loosens some regulations around staffing and capacity for child care providers.

Aging faces significant trim

To the surprise of advocates, the senate’s spending plan would cut all state funding for the Senior Health Insurance Information Program, as well as eliminate 11 positions from the state-level agency. The program provides free, unbiased Medicare counseling for older adults in the state and is heavily used by seniors during the annual Medicare enrollment period.

“This would have a devastating impact on SHIIP and its ability to assist the state’s 2.2 million Medicare beneficiaries,” said Jason Tyson, communications director at the NC Department of Insurance.

SHIIP counselors help save Medicare beneficiaries money by directing them to Medicare plans that will work best for them. In 2024, SHIIP counselors counseled more than 69,000 Medicare beneficiaries, and staff answered 24,000 calls and processed 1,063 complaints, according to Tyson.

Tyson said cutting SHIIP funds “would not save a dime,” of the state’s general fund; the Department of Insurance reimburses the state with funds from the Insurance Regulatory Fund.

“Not funding this program may eliminate the best and most reliable free and local resource that Medicare beneficiaries have in North Carolina,” he said.

The Senate’s spending plan keeps dollars for other aging services flat, even as the state’s aging population is swelling. The population of people ages 65 and older in North Carolina is projected to grow from 1.9 million in 2022 to more than 2.8 million by 2042, according to data from the N.C. Office of State Budget and Management.

Mary Bethel, chair of the board of directors of the NC Coalition on Aging, said that increase in the older adult population means there are increased demands for supports and services, but the state investment has not kept up.

She pointed to a lack of state dollars appropriated for adult protective services. County departments of social services that provide adult protective services must rely on federal funding and county resources to protect seniors from abuse.

Bethel said older adults are concerned about having enough funding for these services, especially with increasing reports of abuse, neglect and exploitation of older adults.

LME-MCOs cuts to single stream funding

The spending plan cuts single stream funding for the state-authorized regional mental health services management organizations, known as LME-MCOs.

Those LME-MCOs use state funds, known as single stream funds, for services to provide help for uninsured and underinsured people with mental health, substance use and intellectual and developmental disabilities, as well as people with traumatic brain injury, according to DHHS. The funds also support mental health crisis services for people without a way to pay.

Budget writers claim those cuts to single stream funding would be offset with money received by the state from the national settlement against drugmakers for their alleged role in facilitating the nation’s opioid overdose crisis.

However, a DHHS spokesperson said those aren’t equal replacements. She pointed out that, by the terms of the settlement signed by North Carolina, those settlement dollars must be used for specific projects, whereas single stream funds are supposed to be flexible for LME-MCOs to use as needed.

“Reducing flexible state appropriated funding and back-filling them with funds that have significant restrictions undermines the purpose of these dollars and limits other programs, which have no other funding mechanism,” the spokesperson said.

Other health care policy items of significance

The budget contains the language of a bill that would repeal the state’s certificate of need laws, which regulate how much spending and building hospitals can undertake in a given geographic area. Some lawmakers have long complained that the certificate of need laws constrain competition. Hospitals, on the other hand, say the restrictions on health care spending help keep costs down by eliminating duplication of expensive services and machinery.

The plan directs an additional $638.5 million to the partnership between the UNC and Duke health systems to build a freestanding children’s hospital. The hospital would also be exempted from certificate of need reviews. “The children’s hospital is, I believe, a project that is beneficial for health outcomes for children,” Senate leader Berger said. “I think the children’s hospital also is an economic development project that will spin off additional economic development opportunities, whether it’s just the infrastructure that gets built around the hospital, but there’s also the research possibilities.”

The plan allocates $2.7 million in the first fiscal year and $6.9 million in the second for the Partnership and Technology Hub, or PATH NC. This software is designed to assess and track children monitored by the state’s child welfare system.

The plan directs NC DHHS to move ahead with seeking a work requirement for Medicaid recipients if the federal government gives the OK.

Clarification, April 21, 2025 14:40: In our description of the Healthy Opportunities Program, we mentioned that the pilot program pays for transportation. We have clarified that sentence to reflect that the transportation services paid for by HOP are non-health care-related. NC Medicaid does currently pay for health care-related transportation, such as trips to and from the doctor’s office.

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By Michelle Crouch

The Charlotte Ledger

The total compensation of Atrium Health’s top executives soared by an average of 41 percent last year, according to newly released data from the hospital system, but information about the salary of Eugene Woods, CEO of Atrium parent Advocate Health, was not included in the release.

The executive compensation report from the Charlotte-Mecklenburg Hospital Authority, which does business as Atrium Health, shows double-digit raises across much of Atrium’s senior leadership, with several executives seeing their compensation jump by more than 50 percent.

The four highest paid executives were:

Ken Haynes, president of Advocate Health’s southeast region, received $5.07 million in 2024, up 56.6 percent from $3.24 million in 2023.

Scott Rissmiller, executive vice president and chief physician executive, had compensation of $4.03 million, up 54.3 percent.

Brett Denton, the system’s top legal officer, saw a 68.5 percent pay increase to $3.87 million.

Carol Lovin, chief integration officer and chief of staff, earned $3.6 million, up 57.4 percent.

Each executive’s total compensation includes their base salary, bonuses, plan-based incentives and other forms of compensation.

In 2024, Atrium Health reported $12.6 billion in net operating revenue and $1.31 billion in net income, which some would call profit. Those figures — a new record for the state’s largest hospital system — do not include revenue from Atrium Wake Forest Baptist Health or hospitals in Illinois and Wisconsin that joined with Atrium in 2022 to create Advocate Health.

So far in 2025, Atrium has continued to exceed its budget expectations, with net operating revenue of $3.32 billion for the first three months, according to a report presented at a May 13 hospital authority board meeting.

Public hospitals are required by North Carolina law to disclose the total compensation of their CEOs and highest-paid officers.

Why wasn’t the salary of Advocate Health CEO Eugene Woods reported?

Woods’ pay was disclosed in Atrium’s 2023 report, when he brought home $17.36 million — up 24 percent from 2022 and more than triple the $5.4 million he earned in his first full year as CEO in 2017.

In response to an inquiry from The Ledger/NC Health News, Atrium said Woods’ 2024 compensation will be reported on Advocate Health’s annual Form 990 filing. That document, required by the IRS for nonprofits, typically isn’t filed until later — meaning Woods’ compensation likely won’t be public until this November.

After Atrium combined with Midwest-based Advocate Aurora Health in December 2022, Woods served as co-CEO of the combined system with Jim Skogsbergh. But Skogsbergh stepped down in May 2024, leaving Woods as the system’s sole leader.

The Advocate Health umbrella also encompasses Winston Salem-based Wake Forest Baptist, which combined with Atrium in 2020, creating a new entity known as Atrium Health Inc.

Both “combinations,” as Atrium describes them, have allowed the system to grow in ways it otherwise could not, because as a hospital authority the system is limited by state law in how far it can expand geographically. But the combinations and partnership agreements have also resulted in a more complex leadership structure and blurred each entity’s legal and financial responsibilities, said Ge Bai, an accounting and health policy professor at the Johns Hopkins Bloomberg School of Public Health.

Many senior leaders now hold dual titles, serving simultaneously as executives at Atrium Health and at Advocate Health.

“These convoluted organizational structures make it very difficult for the public to understand who’s accountable for the actions of these organizations,” Bai said.

Atrium’s combinations with other systems to form new corporate entities have allowed Atrium to expand far beyond Charlotte while retaining many of the tax advantages and legal protections of a local governmental entity.

Critics question high salaries, raises

Critics say Atrium’s executive compensation and annual raises are excessive for a tax-exempt nonprofit, thus diverting resources that could otherwise be invested in patient care and health care for underserved communities.

Barak Richman, a professor at George Washington University Law School who studies health care policy, said the public ultimately shoulders the cost of high executive pay through higher health care costs and insurance premiums.

“Everyone in North Carolina who purchases health insurance is contributing to these salaries,” he said. “The higher they are, the more each insured person pays.”

A 40 percent raise “sure sounds high to me, and I think it would sound high to anyone,” he added.

He said he believes raises should be tied to measurable improvements in public health, not to a hospital’s profitability.

“It’d be nice if compensation for a nonprofit health system that enjoys multiple subsidies and legal protections from the state of North Carolina were based on concrete metrics of how the health system improved the health and welfare of the state’s residents,” he said.

Under IRS rules, charitable hospitals must operate in the public interest and demonstrate a measurable community benefit in exchange for not paying taxes, but the IRS does not go into detail about what that means.

Atrium was also eligible to receive boosted reimbursement from the state’s Medicaid program under HASP, the Healthcare Access and Stabilization Program. Under HASP, the state’s hospitals receive more from Medicaid in exchange for paying higher taxes to the state as a way to cover North Carolina’s share of the cost for expanding Medicaid to some 650,000 mostly low-income workers.

Atrium and the state’s other hospitals signed an agreement last year in which they agreed to forgive medical debt for low-income patients and make changes to their financial assistance policies in return for higher HASP payments.

Atrium: Competitive pay necessary to attract talent

In a statement, Atrium Health said competitive pay is essential in an increasingly complex healthcare landscape.

“To attract and retain the best talent to fulfill our purpose, we offer a competitive compensation package determined by our governing board and consistent with governance best practices, which is guided by independent expert advice and national data from similar sized organizations,” the statement said.

Atrium reported $2.97 billion in community benefits for calendar year 2023, including free and discounted care, Medicare and Medicaid shortfalls, medical research costs and community initiatives. (The hospital has not announced its 2024 community benefit number.)

Atrium also has one of the most generous charity care policies in the state, offering free care to patients whose households earn up to three times the federal poverty level ($46,950 for an individual or $96,450 for a family of four).

Atrium Health raised its minimum wage for its North and South Carolina employees to $18.50 per hour this year — meaning Woods’ 2023 compensation was about 451 times that of the system’s lowest paid workers.

Other nonprofit hospital systems in North Carolina haven’t released their 2024 executive pay. In 2023, Novant Health CEO Carl Armato earned $5.8 million and Duke Health CEO Craig Albanese earned $1.4 million.

HCA Healthcare, which operates Mission Health in western North Carolina, awarded its CEO Sam Hazen total compensation of $21.3 million in 2023. The Nashville-based company is the country’s largest health care system and operates as a for-profit entity.

ATRIUM HEALTH 2024 EXECUTIVE COMPENSATION

Name Title 2024 compensation Percent increase Ken Haynes President, Advocate Health southeast region $5,073,340 56.6% Scott Rissmiller Executive VP and chief physician officer $4,029,199 54.3% Brett Denton Executive VP and chief legal officer $3,867,971 68.5% Carol Lovin Executive VP, chief of staff and chief integration officer $3,608,427 57.4% Rasu Shrestha Executive VP, chief innovation and commercial officer $3,287,435 48.3% Bradley Clark Executive VP and chief financial officer $2,831,292 N/A J. Michael Parkerson Senior VP and chief marketing officer $2,449,362 N/A Delvecchio Finley President, Atrium Health Georgia market $2,400,749 11.1% Kinnell Coltman Executive VP, chief community & social impact officer $2,333,488 N/A Andy Crowder Senior VP and chief information and analytics officer $2,298,750 33.1% Roy L. Hawkins Senior VP, president – north area, greater Charlotte market $1,385,414 N/A Rashard Johnson Senior VP and market president – South $1,361,734 23.9% Vicki Block Senior VP and market president – Central $1,280,031 18.9% Brian L. Freeman Senior VP and president – west area, greater Charlotte market $644,058 N/A

This article is part of a partnership between The Charlotte Ledger and North Carolina Health News to produce original health care reporting.

You can support this effort with a tax-free donation.

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Medicaid is the primary program providing comprehensive coverage of health and long-term care to 83 million low-income people in the United States. Medicaid accounts for one-fifth of health care spending, more than half of spending for long-term care, and a large share of state budgets. Medicaid is jointly financed by states and the federal government but administered by states within broad federal rules. Because states have a degree of flexibility to determine what populations and services to cover, how to deliver care, and how much to reimburse providers, there is significant variation across states in program spending and the share of state residents covered by the program.

At the start of 2025, many issues are at play that will affect Medicaid coverage, financing, and access to care. While Medicaid was not discussed much on the campaign trail, Congress may consider big changes as part of tax and spending debates and the Trump administration may make changes to Medicaid through executive actions. Amid the potential changes, this brief highlights ten key things to know about Medicaid.

1. Nationally, one in five people have Medicaid, but this varies across the states.

The percentage of people who report having Medicaid is 21% nationally, but ranges from 11% in Utah to 34% in New Mexico (Figure 1). The percentage tends to be higher in the 41 states that expanded Medicaid under the Affordable Care Act (ACA), which includes 21 states that voted for Trump and 20 that voted for Harris. Rates of Medicaid coverage are also higher in states with lower average incomes and lower rates of health insurance offered through employers.

2. Medicaid is a key source of coverage for certain populations.

While Medicaid covers 1 in 5 people living in the United States, Medicaid is a key source of coverage for certain populations. In 2023, Medicaid covered nearly 4 in 10 children, over 8 in 10 children in poverty, 1 in 6 adults, and almost half of adults in poverty. Relative to White children and adults, Medicaid covers a higher share of Black, Hispanic, and American Indian or Alaska Native (AIAN) children and adults. Medicaid covers more than 1 in 4 adults ages 19-64 with disabilities, who are defined as having one or more difficulty related to hearing, vision, cognition, ambulation, self-care, or independent living (Figure 2).

Medicaid provides coverage for several special populations. For example, Medicaid covers 41% of all births in the United States, nearly half of children with special health care needs, 5 in 8 nursing home residents, 29% of non-elderly adults with any mental illness, and 40% of non-elderly adults with HIV. Medicaid pays Medicare premiums and often provides wraparound coverage for services not covered by Medicare (like most long-term care) for nearly 1 in 5 Medicare beneficiaries (13 million). Medicaid is a key source of coverage for individuals experiencing homelessness and those transitioning out of carceral settings, particularly in states that have adopted the Medicaid expansion.

3. Medicaid is jointly financed by the federal government and states.

States are guaranteed federal matching dollars without a cap for qualified services provided to eligible enrollees. The match rate for most Medicaid enrollees is determined by a formula in the law that provides a match of at least 50% and provides a higher federal match rate for states with lower per capita income (Figure 2). States may receive a higher match rate for certain services and populations. The ACA expansion group is financed with a 90% federal match rate, so states pay 10%; however, the American Rescue Plan Act included an additional temporary fiscal incentive to states that newly adopt the Medicaid expansion. In FY 2023, Medicaid spending totaled $880 billion of which 69% was federal spending. Total Medicaid spending typically accelerates during economic downturns because people may lose income and enroll in the program. To help states manage increased costs, the federal government has temporarily increased the federal share of Medicaid. Most recently, states received an increase in the match rate between 2020 and 2024 to help manage increased enrollment and costs due to the pandemic related continuous enrollment provision.

4. Medicaid accounts for one fifth of all health care spending, and over half of spending on long-term care.

Medicaid provides a major source of funding for the U.S. health care system, covering 19% of all health care spending and 19% of hospital spending (Figure 4). In addition to covering the services required by federal Medicaid law, all states elect to cover optional benefits including prescription drugs and home care. Home care, also known as home- and community-based services or HCBS, is long-term care provided in non-institutional settings including homes, day care centers, and assisted living facilities. Other long-term care is provided in institutions such as nursing facilities. Medicaid is the primary payer for long-term care in the United States, covering 61% of total spending. Beyond long-term care, Medicaid provides other benefits not usually covered by health insurance including non-emergency medical transportation, which helps enrollees get to appointments, and comprehensive benefits for children, known as Early Periodic Screening Diagnosis and Treatment (EPSDT) services.

5. People who qualify for Medicaid based on age or disability account for more than half of spending.

Overall, seniors and individuals with disabilities account for 23% of enrollment but 51% of spending whereas children account for 34% of enrollment, but 14% of spending (Figure 5). The disproportionate spending on certain eligibility groups stems from variation in spending per enrollee across the eligibility groups. Spending per enrollee was highest for enrollees ages 65 and older ($18,923) and eligible because of disability ($18,437). Seniors and people with disabilities often have higher health care costs than other enrollees due to more complex health care needs, higher rates of chronic conditions and being more likely to utilize long-term care. There is significant state variation in the percentage of Medicaid spending that pays for enrollees eligible because of a disability or being age 65 and older: In some states (Alaska, Nevada, Montana, Illinois, and Indiana), only a third of spending went to those populations, and in five states (Alabama, Florida, Kansas, Mississippi, and North Dakota), care for people eligible because of disabilities or being over age 64 accounted for at least two-thirds of spending.

6. Flexibility to administer Medicaid results in variation in per enrollee costs across states.

Across the states, spending per full-benefit enrollee ranged from a low of $3,713 in Alabama to $10,229 in the District of Columbia in 2020 (Figure 6). Variation in spending across the states reflects considerable flexibility for states to design and administer their own programs – including what benefits are covered and how much providers are paid — and variation in the health and population characteristics of state residents as well as overall health care costs. Although all states are required to provide some Medicaid benefits, many others are optional, including prescription drugs (covered by all states), vision services, dental care and most home care. In recent years, states have expanded coverage of behavioral health services and benefits to help enrollees address social determinants of health (SDOH) like nutrition or housing.

7. Three-quarters of all Medicaid enrollees receive care through comprehensive, risk-based MCOs.

Overall, 75% of all Medicaid enrollees receive care through comprehensive, risk-based managed care organizations (MCOs) (Figure 7). Payments to MCOs accounted for more than half (52%) of Medicaid spending in FY 2023. As of July 2024, 42 states (including DC) contract with comprehensive MCOs. Medicaid MCOs provide comprehensive acute care (i.e., most physician and hospital services) and in some cases long-term care to Medicaid enrollees and are paid a set per member per month payment for these services. Medicaid MCOs represent a mix of private for-profit, private non-profit, and government plans. Five for-profit parent firms (Centene, Elevance (formerly Anthem), UnitedHealth Group, Molina, and CVS) account for 50% of all Medicaid MCO enrollment. States have increased their reliance on MCOs with the aim of improving access to certain services, enhancing care coordination and management, and making future costs more predictable. While the shift to MCOs has increased budget predictability for states, the evidence about the impact of managed care on access to care, costs, and outcomes is both limited and mixed.

8. Medicaid coverage facilitates access to care, improves health outcomes, and provides financial protection from medical debt.

A large body of research shows that Medicaid beneficiaries have substantially better access to care than people who are uninsured (who are also primarily low-income) and are less likely to postpone or go without needed care due to cost, as federal rules generally limit out of pocket Medicaid costs. Key measures of access to care among Medicaid enrollees are generally comparable to rates for people with private insurance (Figure 8). Gaps in access to certain providers (e.g., psychiatrists and dentists) is an ongoing challenge in Medicaid that may reflect system-wide problems, but may be exacerbated by provider shortages in low-income communities, Medicaid’s lower physician payment rates, and lower Medicaid physician participation compared with private insurance.

Longstanding research shows that Medicaid eligibility during childhood is associated with positive effects on health (including reduced avoidable hospitalizations and mortality) and impacts beyond health, such as improved long-run educational attainment. Early and updated research findings show that state Medicaid expansions to low-income adults are associated with increased access to care, increased economic security, improved self-reported health status, and other outcomes including increased early-stage cancer diagnosis rates, lower mortality rates for certain conditions (e.g., cancer, cardiovascular disease, liver disease), decreased maternal mortality, improved treatment management for conditions (e.g., diabetes, HIV), and improved outcomes related to substance use disorders. Research conducted by NBER (National Bureau of Economic Research) suggests that the ACA Medicaid expansion had impacts beyond health care use, including on consumer financial outcomes – reducing unpaid bills and medical debt sent to collections.

9. Section 1115 demonstration waivers reflect changing priorities across presidential administrations.

Section 1115 demonstration waivers offer states an avenue to test new approaches in Medicaid that differ from what is required by federal statute, if [in the HHS Secretary’s view] the approach is likely to “promote the objectives of the Medicaid program.” Waivers generally reflect priorities identified by states as well as changing priorities from one presidential administration to another (Figure 9). Waivers have been used to expand coverage or benefits, change policies for existing Medicaid populations (e.g., testing premiums or other eligibility requirements), modify delivery systems, restructure financing or authorize new payments (e.g., supplemental payments or incentive-based payments), as well as make other program changes. Waivers vary in size and scope. States can obtain “comprehensive” Section 1115 waivers that make broad program changes or narrow waivers focused on a specific population. Nearly all states have at least one active Section 1115 waiver and some states have multiple 1115 waivers.

10. The majority of the public holds favorable views of Medicaid.

In the most recent KFF tracking poll, more than three-fourths (77%) of Americans held favorable views of Medicaid, including six in ten Republicans (63%), and at least eight in ten independents (81%) and Democrats (87%) (Figure 10). Medicaid is also viewed favorably by a majority of voters who say they voted for President Trump in the 2024 election (62%). Nearly half of the public (46%) say the federal government doesn’t spend enough on the Medicaid program, with another third (33%) saying it spends “about the right amount,” and around one in five (19%) saying it spends “too much.” With possible changes to government health programs, seven in ten (72%) say they are worried about the level of benefits that will be available to people covered by Medicaid in the future