The Cost of the One Big Beautiful Bill: WNC’s Fight for Healthcare Access - WNC Health Policy Podcast Ep. 15
Image Credit: Titiwoot Weerawong
In this full-length version of the WNC Health Policy Initiative podcast, we sit down with Katie Alexander and Ali Houghton from Pisgah Legal Services to explore the impact of the so-called One Big Beautiful Bill Act on healthcare coverage. We discuss the services provided by Pisgah Legal, and how this sweeping legislation could reshape healthcare access across Western North Carolina, including for:
Medicaid recipients
Residents using tax credits on their marketplace insurance
Documented immigrant communities such as individuals with work permits, DACA, asylees, and refugees, &
Residents with disabilities
Tune in for insights into what this means for healthcare access in WNC and opportunities for guidance and volunteering to engage in the topic.
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About the WNC Health Policy Podcast: In each installment, we speak about different public health strategies for improving health and well-being in Western North Carolina (WNC). The WNC HPl is a collaboration between the NC Center for Health & Wellness at UNCA and MAHEC, with generous support from the Dogwood Health Trust.
Individual opinions, findings, conclusions, or recommendations expressed in this podcast are those of the author(s)/interviewee(s) and do not necessarily reflect the view of the WNC Health Policy Initiative or its host institutions of the University of North Carolina Asheville (UNCA), Mountain Area Health Education Center (MAHEC) or our funders.
Transcript
Katie Alexander: Medicaid expansion supports not just people who are on Medicaid, but also our hospitals, our federally qualified health clinics. Medicaid is a big part of our health care system. And the more that we weaken that, the more that the rest of our health care system is weakened.
Andrew Rainey: You're listening to the Western North Carolina Health Policy Initiative podcast. a collaboration between the North Carolina Center for Health and Wellness at UNCA and MAHEC, with generous support from the Dogwood Health Trust. I'm Andrew Raney. In each installment, we speak about different public health strategies for improving health and well-being in western North Carolina. Individual opinions, findings, conclusions, or recommendations expressed in this podcast are those of our participants and do not necessarily reflect the views of the Western North Carolina Health Policy Initiative or its host institutions of the University of North Carolina Asheville, Mountain Area Health Education Center, or our funders.
Recorded on the flickering internet waves of mountainous Appalachia, in this installment, we'll be hearing about some of the anticipated changes to healthcare insurance access for both Medicaid recipients and folks signed up through the Affordable Care Act on the Healthcare Marketplace.
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Back in December 2023, North Carolina expanded Medicaid. unlocking coverage for over 600,000 residents by allowing more federal funds into the state. It was a breakthrough nearly a decade in the making, giving North Carolinians–especially in rural areas like western North Carolina–a new path for preventative care, mental health support, and chronic disease treatment. Funds supported our struggling clinics in rural hospitals and, while still facing challenges, more North Carolinians were able to get basic treatment and medications.
Less than two years later, we may see a similar number of 600,000 across North Carolina lose access to insurance once again, also pulling the plug on resources to our rural hospitals. On July 4th of 2025, President Trump signed a budget reconciliation package into law, calling it the “One Big Beautiful Bill Act,” although names like the Big Broken Bill or Big Bad Betrayal have begun to stick as folks learn more about it. While framed as a tax and budget overhaul, for health care the bill includes sweeping rollbacks to Medicaid and the ACA Marketplaces, measures that could strip millions nationwide of coverage and bring new red tape and barriers to care.
In North Carolina, the bill passed with near-total support from the state's Republican congressional delegation, with one dissenting voice from Senator Tom Tillis. Tillis explained that his vote against the bill was due to the impact it would have on rural health care, undoing the gains North Carolina had only recently begun to see.
So how will this bill impact health in western North Carolina and the rest of the state? To learn more, we're joined by Pisgah Legal Services to break down some of this bill's impact on our health.
AR: Thanks for joining me, y'all. Can I have you first introduce yourselves and the work of Pisgah Legal Services?
Allie Houghton: My name's Allie Houghton. I work with Pisgah Legal Services. Katie and I are part of the Health and Economic Opportunity Program. So our work as part of Pisgah Legal Services is kind of an advocacy wing where we assist folks with applying for and understanding health insurance, and then part of that work is we also assist folks to prepare their taxes and get tax refunds. So that's the scope of our work.
Katie Alexander: And I'm Katie Alexander. I am the Director for Training and Volunteers for the Health and Economic Opportunity Program at Pisgah Legal Services with Allie. And just a little bit about Pisgah Legal Services: Pisgah Legal is a nonprofit law firm. We do a lot of work across the spectrum of nonprofit law. We work with folks on immigration issues, domestic violence, housing, and like Allie said, our corner of that is more in that advocacy, direct services world where we help people with their health insurance and taxes.
AR: Could you walk us through how y'all connect people to healthcare coverage?
KA: Yeah, so we've been doing this work of helping people gain access to healthcare coverage for well over a decade. We started back when the ACA was first passed and the Marketplace was created. We've been doing it every year since then. And we've got skilled volunteers and staff who are what we call navigators. So, they really sit down with consumers and that can be in person or over the phone or on Zoom, and they talk through what someone might be eligible for, so, whether that's health insurance on the Marketplace or health insurance through Medicaid. We take people through the online application, which can be difficult and complicated, especially if you're not used to doing those types of applications online. We help people figure out what their income looks like, and then we take them through that enrollment process and apply for coverage for them.
When we're looking at the ACA Marketplace, we also take people all the way through by helping them choose a plan that fits best for them. So this year on the Marketplace, there are, I think, 120 plans, depending on what county you're in, that you might be eligible for, and it's really overwhelming to look through that information. A lot of folks are not always sure what a deductible is, what an out-of-pocket maximum is. And so we help people with educating them about health insurance in general, helping them choose a plan that works for them. And every year we have people who come back to us who we’ve been working with for years. We help every year with renewing their Marketplace plan. We also have people every year who this is their first time on the Marketplace. So whether that means they've lost a job or they're newly self-employed, we have some people who have never had health insurance before and we're able to enroll them in either Medicaid or Marketplace plan coverage. So that's kind of the main role of our staff and volunteers is just walking them through that entire process.
AR: Who and what parts of Western North Carolina do you serve?
AH: Our program and Pisgah Legal Services, we work in the 18 westernmost counties of Western North Carolina. And so it's a broad range of counties, folks in the Asheville area, but we work a lot with folks in the more rural counties as well. And so some of the populations that we work really heavily with are low-income folks who are working but have a job that doesn't offer health insurance. We also assist a lot of folks who cannot work because they're sick and are in need of health insurance in order to get back on their feet, be able to work, and make sure that they are well enough to be able to do these essential things. We work a lot with self-employed folks across the region. And then 25% of the folks that we work with are Spanish speaking. So we have a large bilingual staff. We work a lot with the Afghan population refugees in the Asheville area.
And as we mentioned, we're part of this kind of broader Pisgah Legal Services, this nonprofit law firm. So there are many folks that come to Pisgah Legal for maybe a legal issue. We have an immigration team, we have a domestic violence team. So many times we'll work with folks who are coming to Pisgah Legal for something that's going on, and then they'll identify through the legal services that this person may not have health insurance, and it can be this important piece of their overall well-being. A big part of the work that we do is kind of understanding who folks are and what that means in terms of their health care needs and their overall well-being.
AR: What are some of the ways that this federal bill will impact folks' access to healthcare?
KA: Yeah, so I'll start with Medicaid. I'll talk about the ACA Marketplace as well. There are a lot of parts of that bill that are going to be pretty devastating in terms of healthcare coverage to a lot of people across the country. One of the most difficult parts is going to be the inclusion of work requirements for some people who are on Medicaid. Lots of these folks are working. They're just not working enough hours to afford health insurance or to qualify for their company's health insurance plan.
AR: We heard from the North Carolina Medicaid office just earlier this year that of the folks currently enrolled in Medicaid, 92% are already working.
KA: And so these new work requirements, and these will go into effect the last day of 2026, so December 31st, 2026. That's going to require most enrollees in this Medicaid expansion category to work for 80 hours a month in order to keep their coverage. And for so many people, that is just not doable. For people who are sick, for people who are caretakers, people who aren't able to find work–it's not realistic for all these folks to be able to get to that 80 hours a month.
And just kind of thinking about an example in that, if you're thinking about someone who's maybe diagnosed with cancer. They're unable to continue working. They're going through chemotherapy. They need that health insurance. It's not a permanent disability, and so they're likely not able to get onto disability. But if they're not able to access health insurance because they're not working, then they're out of luck. That's a pretty tough situation to be in.
So this is going to be really scary for a lot of people in North Carolina across the country. But in North Carolina, you know, some estimates are that about 250,000 people are expected to lose coverage because of this.
AR: Oh, wow.
KA: That means they lose access to medications, they lose access to their doctor's appointments. If they have an emergency, they risk bankruptcy for having to go to the ER. So I think that's the biggest threat that we're seeing right now to healthcare coverage for North Carolinians.
AR: This is only one of the impacts the bill will have on Medicaid coverage?
KA: There are lots of other parts of the bill that negatively impact Medicaid. One of the things that will change is that people used to have to recertify for Medicaid once a year. That's going to change to every six months starting in 2027. That means that DSS offices are going to be overwhelmed. They're going to be doing twice as much work to be able to recertify people. It's gonna be really difficult for people to keep on top of that paperwork. People aren't gonna be expecting it. A lot of people are gonna miss their recertification period and are gonna be dropped off coverage, even though they're still eligible. So those are kind of the things that we're looking at with Medicaid.
Thinking about Marketplace coverage as well, there were a lot of things that are gonna change in Marketplace coverage. In 2020, the American Rescue Plan increased subsidies so that health insurance was more affordable on the Marketplace. So you get advanced premium tax credits that are based on your income, and that lowers your premium. And that's what makes health insurance affordable, because without that, you're looking at $1,000 a month for health care coverage for a single person. So the advanced premium tax credits make it affordable for folks. In 2020, those subsidies were expanded so that health insurance was made more affordable. And those enhanced subsidies are ending this year, which is going to drastically increase people's premiums.
AR: Premiums being the amount folks pay each month for their insurance. How much higher are we talking about here due to the bill?
KA: So there are different estimates that you can find. Some are saying that for people below 200% of the federal poverty line, their premiums may increase up to five times. And so that's going to make it impossible for some people to be able to keep their health insurance coverage.
AR: So really hundreds of dollars higher per month for folks' insurance, especially for folks who are considered to be living in poverty now.
KA: We're gonna be looking at people who are gonna have to make some really impossible decisions on whether to keep their health insurance or, yanno, be able to feed their family, to be able to get new tires on their car. And so a lot of people at that point will probably drop their health insurance coverage.
AR: So this bill stands to impact millions of Americans, although certain aspects of the bill directly target some more than others. I wonder if you could speak a little bit more about who is especially impacted here.
KA: There's some really devastating impacts for immigrant populations that are going to happen, mostly starting in 2027. So a lot of immigrants who have documentation–they are here legally–currently, some folks are eligible for health insurance coverage on the Marketplace. Starting in 2027, they will no longer be eligible for that. So that includes refugees, asylees, folks who, again, have documentation.
Just thinking about here in Asheville, we've got a pretty large Afghan population, and these are folks who are here as asylees. They helped the U.S. in the war with Afghanistan. They are here with documentation as asylees. We've worked with a lot of folks to help them gain access to healthcare coverage. We've enrolled them in plans on the Marketplace, and they're going to lose that coverage. They will not be eligible for that coverage.
AH: They may be refugees, asylees, victims of domestic violence, children. These folks are currently eligible for health insurance through the Affordable Care Act Marketplace, and none of those groups will be eligible for really any type of coverage starting in 2027.
KA: Even just this month.
AH: It's August, 2025.
KA: DACA recipients are gonna lose access to the Marketplace at the end of this month. So some of those changes are happening even quicker.
Losing health insurance can mean, again, losing access to your medications that you need. It makes it a lot harder for some people, if you lose your health care coverage, to be able to go to work, to be able to care for your family. So this can have a really devastating impact on a lot of folks.
AH: The other group I wanted to mention is these work requirements for Medicaid will disproportionately impact folks with disabilities. And so oftentimes, I think something that we don't realize is that it takes a very long time to apply for disability. And so someone may be eligible, but gets stuck in a loop of applying for disability for…it can take years. And so folks who may not have been approved for their disability, but otherwise qualify, may not be able to work, will not be able to meet that 80-hour month work requirement, and may lose their health insurance under Medicaid.
AR: The NC Budget and Tax Center listed a figure of over 600,000 North Carolinians who are expected to lose coverage due to this bill, including people affected by changes to both Medicaid and the Affordable Care Act.
You had mentioned how the work requirements could drop some 250,000 people across the state currently enrolled under a Medicaid expansion alone. I guess it's hard to make an exact prediction of the total number of folks who will be impacted, but I wonder if you could unpack that a little more.
KA: In the next 10 years, they're expecting across-country 10 million people to lose their ACA coverage because they can't afford it because of these changes in immigration. The 600,000 might also be including folks who are going to lose Medicaid because of the change in the determination timeline. So people who are going to still be eligible, but they're going to miss that re-upping their Medicaid. It's hard to tell what exactly those numbers are going to be, so I think there's a wide range of what it could be.
AR: Before we move on, I wonder if you could just lay out a loose timeline of the big picture changes that we can expect to see - who will lose what and when?
AH: Yeah, so there's a number of timelines set out by the bill. This is something we're paying attention to and learning because it's all new as we help folks navigate applying for health insurance. So there are some protections that are ending at the end of August that will impact specifically low-income folks, August of 2025.
Starting in 2026, there's an additional rollout of changes. A lot of that will mean fewer protections against higher premiums. Folks may have to pay more back at tax time starting this year for the Affordable Care Act.
And then, yes, in 2027, that is when the work requirements for Medicaid really start in earnest. I believe the work requirement starts the last day, December 31st, 2026. and some of these explicit changes of folks who will lose eligibility altogether for health insurance begin in 2027.
AR: How do you see this policy change impacting the services that you all offer to get folks connected to health insurance?
KA: We're trying to prepare as much as possible, even though, you know, some of these things are gonna be wrapped up in lawsuits, we're not sure exactly how it's all gonna shake out, but we're trying to prepare as much as possible.
One of the big things is I think our call volume is gonna drastically increase this year. Folks who enroll themselves in Marketplace plans and don't usually reach out to us for help, I think when they see their premiums increase as much as they will, I think we'll get a lot of calls of people saying, “I must've done something wrong. Can you help me with this?”
Education is another big piece of what we'll be trying to do to just make sure people are aware of what the changes are and how those changes came about. And honestly, in terms of preparing our staff and volunteers for that, I think it's going to be a really emotional, difficult year for helping people. I think people are going to be rightfully upset at the changes to their health insurance. We'll see people lose their coverage. Like I said, people who are going to have to make really impossible decisions about keeping health insurance coverage or, you know, being able to get that needed repair on their car, being able to feed their family, being able to pay rent. And so I think we're going to have a pretty emotionally difficult year with talking people through that. A big part of our job is also just kind of being there as a support for folks, listening to folks. So that's something that we're trying to make sure we're as prepared for as we can be.
AR: Y'all offer a range of services beyond healthcare enrollment support. I'm curious if you see a relationship between that healthcare access and the other issues you address, like housing.
KA: Yeah, I mean, it's such a snowball effect. So, if you have a chronic illness and you can't get health insurance anymore to help you manage that chronic illness, you need that health care coverage in order to keep your job. You need that in order to access food, in order to pay your rent, in order to care for your family.
And so if you lose that health care coverage, it's a snowball effect of what that impacts down the line. And so if you're not able to manage your chronic condition, then all of a sudden, you're not able to show up at work because you're in bed, you're ill, you don't have the medications you need, you lose your job, you can't get on Medicaid because you're not working those 80 hours a month. All of a sudden, you lose your job, you don't have an income anymore, you're not able to get access to food, you're not able to pay your rent. So it really just creates this horrible kind of dominoes effect that impacts people down the line there.
Another thing that was part of the HR1, as well, there was a really big decrease to SNAP funding, which is the food stamps program. And so essentially, they drastically decreased the amount that the federal government was going to contribute to SNAP in the states. And if North Carolina can't cover those federal funds, then the entire SNAP program may be at risk. We may lose the entire SNAP program if we can't cover what the federal government was previously covering. And so that's access to food for families. So if we're looking at people who are losing access to health coverage, access to food, I mean, these are just basic needs, basic rights that people are no longer going to be able to get. You can't get a good full-time job with health insurance coverage if you are struggling to feed your family every night.
So I think that these are all so interconnected. The social determinants of health are so interconnected. As one gets harder to access, so do the others. So yeah, it's scary to think about how this is gonna have such a drastic impact in that way.
AH: I just wanted to add, too, we've seen this a lot since the storm how exhausted folks are from having to navigate these really challenging systems. And so these systems are only getting more challenging. There are so many additional verification documentation requirements with the ACA, as Katie has mentioned with Medicaid, that folks will need to recertify every six months instead of every year.
And so I think there's this level of fatigue and hopelessness that happens as folks are kind of forced to navigate these systems that are very challenging to navigate - intentionally! And so it may mean that folks don't have the capacity to access these systems that are meant to be supportive–like SNAP, like Medicaid–but that the barrier to just getting into the system is so high that folks don't have the bandwidth to be able to do that.
AR: What kinds of policy changes or resources do you think would best support healthcare access as North Carolina braces for this vast loss of healthcare coverage?
KA: Yeah, I think one of the most important things is preserving Medicaid expansion as it is. So making sure that this group of folks who–I mean, it's only been 20 months that they've had access to health insurance coverage–preserving that for people to make sure that they are still able to access their Medicaid. So that means keeping the Medicaid expansion category open, rolling back the work requirements so that people do not have to work those 80 hours a month. And, you know, not having people have to re-up their Medicaid and recertify for their Medicaid every six months. I think those are kind of the biggest things, it’s keeping Medicaid expansion strong, keeping Medicaid strong as a program. Because the program also supports not just people who are on Medicaid, but also our hospitals, our federally qualified health clinics. Medicaid is a big part of our healthcare system, and the more that we weaken that, the more that the rest of our healthcare system is weakened.
So I would say that's really the biggest thing. And then in terms of other health insurance coverage with the ACA and the Marketplace, continuing those enhanced premium tax credits. So re-upping what was done in 2020 in the American Rescue Plan to keep health insurance affordable. Because what we're going to see in this next open enrollment period is a lot of people losing their health care coverage because they can't afford it. So I think that's something on the federal level that would be incredibly helpful for folks. And then on the state level, preserving that Medicaid expansion on the federal level, rolling back those work requirements.
AR: We know that in Western North Carolina, partner collaboration is a big part of how the region has survived isolation, whether from historic lack of funding from governing bodies or just the geographic isolation that we saw as recently as Helene. How does Pisgah Legal think about collaborating across Western North Carolina to mitigate issues like losing healthcare coverage?
AH: Yeah, so a big part of our work is doing outreach to work with partner organizations. So a lot of that is federally qualified health centers, other clinics in the area, workers. We also work with a lot of community organizations. And so I think we are... adapting to these changes, as are our fellow nonprofits and organizations.
So we're really making an effort to expand our list of resources. As Katie had mentioned, many folks, for example, who may have a social security card and a work authorization, a person who's an immigrant or a refugee. will no longer be eligible for health insurance starting in 2027. And so making sure that we know where folks can go to access health insurance if they lose it altogether.
So we're really expanding those lists, connecting with folks, and yeah, it's very quickly evolving. But we see here in our community in Western North Carolina, organizations are facing a lot of barriers, reduced access to funding, and they continue to really show up for the community and make sure that our resources are as connected as possible and as accessible as possible, even when there's an increased amount of confusion and more barriers to entry.
AR: Well, this is a federal bill. Do you see opportunities on the local or regional level to engage the issue?
KA: Yeah, so the Medicaid expansion category itself is threatened because of decreases in funding. And so I think people being able to share their stories of people who got Medicaid through that expansion category and what that's meant for them, I think is really important. Calling local legislators to just sort of talk about how Medicaid has impacted you, I think it's really important and just making sure that our stories are known.
I think it's really easy when you don't think that you know anybody on Medicaid. We all know people who are on Medicaid, but if you think that you're not impacted by that, you think that your loved ones aren't impacted by that, it's easy to kind of other that. And that's just not our reality. We all have. loved ones, neighbors, ourselves who are on Medicaid and need that coverage. And like I said, it impacts so much more than just people who are using that healthcare coverage.
So I think people sharing their stories of what that means for them to have that coverage with local leaders and local legislators is really critical.
AR: Well, to wrap things up, how can listeners learn more about Pisgah Legal and the services you offer?
KA: Yeah, pisgalegal.org is our main website. There are tabs at the top to take you to all the different programs that we work in.
For folks who are interested in getting help and accessing health insurance coverage, you can go to our website or you can call us at 828-210-3404. That's our specific health insurance and tax hotline.
And we're also always looking for volunteers to help do this work of helping people enroll. We're in the process right now of training a new cohort of volunteers to be able to do this. And so we welcome folks who are interested in helping people go through that complex process.
AR: Well, we appreciate you sharing how you anticipate seeing Trump's big bill effect in Western North Carolina and your commitment to working with others in the region to connect folks to basic resources. Thanks for speaking with us on the podcast.
KA: Yeah, thank you so much, Andrew. This is really great to be able to talk this through.
AH: Yeah, thank you so much. Bye.
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AR: You've been listening to the Western North Carolina Health Policy Initiative podcast, a collaboration between North Carolina Center for Health and Wellness at UNCA and MAHEC, with generous support from the Dogwood Health Trust.
To listen again or learn more about public health issues in Western North Carolina, check out the website at wnchealthpolicy.org or listen to more of our shows on Apple Podcasts or Spotify.
If there's a Western North Carolina health issue that you'd like to hear more about, speak about, or comments about anything you've heard on an HPI podcast, feel free to send us an e-mail at info@wnchealthpolicy.org or write a comment on wherever you listen to podcasts.
Music includes the old ballad “Little Margaret,” performed on banjo by Kath and Phil Tyler, found on the Free Music Archive, it is licensed under an attribution non-commercial share-alike 3.0 United States license. Additional music includes the track “Some Nights End” and “Night Watch,” by the Blue dot Sessions. These tracks are found on the Free Music Archive under License Attribution International CCPY 4.0.
If you're interested in other podcasts around health in Western North Carolina, we invite you to check out the work of our friends at MAHEC in the Just Us: Before Birth and Beyond podcast, which focuses on perinatal and community health. Hosts join forces with doulas, midwives, nurses, lactation consultants, physicians, and more from across North Carolina to share best practices, lived experiences, and lessons learned, while always bringing it back to the mountains. For policy nerds, two episodes that speak to health policy include an exploration of paid family leave in Season 4, Episode 7, and the North Carolina Pregnant Workers Fairness Act in Season 3, Episode 6, and with the pleasure of speaking with one of the hosts, Caitlin Moss, in Episode 1 of the HPI Podcast.
As always, you can find more by looking at our website at wnchealthpolicy.org. Thanks for listening.
