What the "One Big Beautiful Bill" Means for Healthcare Access in WNC

Image Credit: White House

In the latest episode of the WNC Health Policy Initiative Podcast, we sit down with Katie Alexander and Ali Houghton from Pisgah Legal Services to discuss a very controversial piece of federal legislation — the so-called “One Big Beautiful Bill Act,” or H.R.1, which passed on July 4, 2025.

Though not technically a healthcare bill, this legislation includes deep cuts to Medicaid, SNAP (food stamps), and clean energy funding, alongside extended Trump-era tax breaks and increased spending on immigration enforcement. It’s a sweeping and polarizing bill — dubbed the “One Big Beautiful Bill” by president Trump, it is increasingly being criticized as the “One Big Broken Bill” or “Big Bad Budget Betrayal” due to its anticipated impact on millions of Americans’ ability to access healthcare.

Why This Matters to WNC

Healthcare is already inaccessible for many in WNC, with the Mountain Area Health & Education Center (MAHEC) reporting that 1 in 6 adults in WNC are without health insurance. Through their WNC Health and Economic Opportunity Program, Pisgah Legal Services is one regional human service organization committed to addressing this issue through their healthcare navigators services. Walking with residents step by step through the enrollment process and well-versed in the often confusing legal implications of policy, Pisgah Legal joins HPI Audio Producer Andrew Rainey to explore what this bill could mean for real people across Western North Carolina, particularly:

• Medicaid recipients, especially in rural areas where access is already fragile

• People who rely on health insurance tax credits through the ACA marketplace

• Documented immigrant communities (e.g., DACA recipients, refugees, people with work permits)

• Residents with disabilities and others who depend on safety-net programs

A Closer Look: What’s in the OBBBA?

While packaged as a “tax and spending reform,” the bill has serious consequences for healthcare access, especially in lower-income and rural communities.

What the Bill Includes:

✅ Extended 2017 Trump tax cuts

❌ $1.2 trillion in cuts to Medicaid and SNAP over 10 years

❌ Loss of health coverage for over 10 million Americans at key milestones over the next decade, including:

• August 2025: DACA recipients lose coverage access on the ACA

• 2026: Americans lose enhanced advance premium tax credits for monthly ACA insurance premiums

• 2027: Refugees and asylees, including children and victims of domestic violence, lose access to ACA coverage 

• 2027: 80 hours-a-month work requirements for Medicaid Recipients

• 2027: Medicaid recertification frequency increases from 1x a year to 2x a year 

❌ Rollbacks of clean energy incentives

✅ Increased funding for border enforcement

💰 An added $3.3 trillion to the federal deficit, per Congressional Budget Office estimates

How North Carolina’s Lawmakers Voted — And Why

U.S. Senate

• Sen. Thom Tillis (R-NC): ❌ Voted NO
  Tillis broke with his party, citing serious harm to Medicaid recipients in North Carolina, especially in rural counties. Days later, he announced he would not seek reelection, drawing speculation about pressure from party leadership.
  

• Sen. Ted Budd (R-NC): ✅ Voted YES
  Budd supported the bill, calling it a win for taxpayers and a step toward economic independence and energy security.
  

U.S. House (NC Delegation)

• All 10 Republican Representatives: ✅ Voted YES
  House Republicans framed their support around tax relief and promises of protections for rural hospitals and vulnerable groups — though critics argue these safeguards are underfunded or inadequate.
  

• All 4 Democratic Representatives: ❌ Voted NO
  House Democrats opposed the bill over its cuts to essential health and social programs and its potential to deepen inequality in the state.
  

Key Takeaways from the Podcast

• The bill’s real-world impact will be felt most by low-income families, immigrants, people with disabilities, and rural residents, with an approximate 650,000 North Carolinians expected to lose their healthcare insurance due to the bill.

• Despite 92% of Medicaid recipients already working, work requirements and increased paperwork are being added to the process, and are predicted to create near impossible circumstances to maintain healthcare for many recipients, a prediction supported by studies of other states who have implemented similar requirements.

• Pisgah Legal Services is preparing to continue supporting residents to understand their rights, appeal insurance denials, and navigate the legal consequences of shrinking safety nets.

• Volunteers and advocates are needed more than ever to help meet rising demand for support and guidance.
  

Get Engaged

Katie and Ali share several ways to support community health and equity:

• Volunteer with Pisgah Legal Services (legal aid, community outreach, language support)

• Share your experience with healthcare by contacting lawmakers or helping educate neighbors about their options

Learn More

Episode 15 of the WNC HPI podcast, featuring interviews with Pisgah Legal staff, is a must-listen for anyone concerned about healthcare access, public policy, and the future of community well-being in Western North Carolina.

And if you’re interested in other podcasts around health in WNC, 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.

Disclaimer

This content was developed by the WNC Health Policy Initiative in consultation with people and organizations with connections to the health of people of Western North Carolina. Individual or organizational opinions, findings, conclusions, or recommendations are those of the relevant 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.