Nearly 17,000 Buncombe residents would lose benefits if North Carolina rolls back its 2023 Medicaid expansion in the wake of the Trump administration’s recent tax and spending bill, according to the county’s initial analysis of the legislation’s impact.   

Even without a rollback, 6,270 Buncombe residents could lose Medicaid, according to the analysis, which was presented by Economic Services Director Phillip Hardin to the Buncombe County Health and Human Services board in its July 25 meeting.

Federal changes to Medicaid mandated in the massive legislation, known as the One Big Beautiful Bill, will also force the state to pay an extra $420 million to fund the full benefits of SNAP or end the program, which as of April provided basic food and nutrition to 29,123 Buncombe residents. According to the county’s analysis, even if the program survives, 1,800 adults could lose their benefits.  

“This is a burden, not only for Buncombe County; it’s a burden for every county in this state,” Hardin said at the meeting. 

There are 62,792 people currently enrolled in Medicaid in Buncombe County, according to July North Carolina Department of Health and Human Services data.

After the BCHHS meeting, Hardin told Asheville Watchdog, an attendee approached him and said, “That was a very depressing presentation.” 

“I don’t disagree,” Hardin told The Watchdog. “I’ve been handed a lot of things over the years, for sure, but this is probably one of the bigger kinds of challenges that we’ve faced.”

Hardin, who has worked in social and human services for 36 years, including more than a decade with Buncombe County, faces an impending one-two punch of cratered services and potential loss of staff, in part because of a reshuffling of federal funds that will take away $3.5 million for about 40 Buncombe government employees who work in food assistance. It’s unclear whether the state will be able to compensate for the loss or if that burden will fall on Buncombe.

“My staff are on pins and needles,” Hardin said. “But at the end of the day, probably the more stress on them is what this does to the residents of the county.”

“There are so many unknowns right now,” Hardin told the county’s health and human services board members. “A lot of it’s based on what maybe the General Assembly does do or doesn’t do.”

‘I have some really grave concerns’

It will be strategically difficult to make staffing decisions without more clarity from state legislators, Hardin said, and the outlook is grim. 

On July 10, the General Assembly received an online briefing that gave the clearest picture yet of exactly what the state may stand to lose after the narrow passage of the bill.

The state will lose $49.9 billion in Medicaid funding over 10 years, with more than 70 percent of the loss coming from cuts to hospital expenditures, according to a briefing document obtained by The Watchdog that was assembled by subject matter experts and top NCDHHS officials.

While county leadership waits for guidance as it begins preparations to budget for 2027 and beyond, the General Assembly is not rushing to make decisions, Sen. Julie Mayfield, D-Buncombe said. 

“There is absolutely something that the legislature could do to assure county DHHS offices and those folks that the benefits that they have now will continue,” Mayfield said. “We could do that by committing the resources that we know we will need to commit.” 

But that commitment is not going to happen, Mayfield said. The cost and disagreements about spending will prevent elected officials agreeing on guidance before counties must start planning for the potential cuts. 

“We don’t even have a budget right for the state of North Carolina, because the House and the Senate cannot agree on the tax cuts,” Mayfield said. “But they are going to have to figure that out in order to address these gaps.”

Sen. Warren Daniel, who represents a portion of Buncombe, did not respond to an email and a phone call to his office.

Much of the impact on local governments comes from the federal bill’s work requirements, which will force able-bodied recipients of Medicaid between ages 19-64 to prove they’ve worked, volunteered or were enrolled in an educational program at least 80 hours a month.

North Carolina doesn’t currently have work requirements. That means much of the work associated with complying with the bill will be building and implementing the infrastructure behind how county offices process work requirement reports.

“There are a lot of variables that go into this,” Hardin said in the July 25 meeting. “Probably our caseloads will decrease, but our administrative burden increases, because there are lots of things that are in the policy that add to the work that our staff already does.”

Critics of the new work requirement measures say it’s likely to jettison people who need it most from Medicaid because of those administrative hurdles.

Though the county projects the bill’s burden on Buncombe will be extreme and will potentially put residents’ welfare in jeopardy, any significant changes to SNAP and Medicaid likely will not go into full effect until Jan. 1, 2027, and states can ask for a two-year delay if they’re making a good-faith effort to comply with the bill’s mandates.

In the meantime, uncertainty abounds among service providers.

“I have some really grave concerns about the healthcare industry as a whole,” Hardin said. “I mean, if you take that kind of money out of the healthcare industry, especially rural health providers who count on some supplements through Medicaid to help them stay in business, you take that kind of stuff away, then I don’t know. I don’t look at it as being favorable in a lot of ways for the people that we serve or my staff.”

Nutrition hub, physicians, care networks calculating impact, too

MANNA FoodBank spokesperson Mary Nesbitt said the cuts would essentially double the existing need in the region. 

The organization, which helps western North Carolina residents access SNAP benefits, provided food for 190,000 people last month alone, Nesbitt said. 

While stressing the organization is nonpartisan, Nesbitt said the cuts will affect mostly vulnerable people. 

“Who are these people? The majority are children, seniors, working families, veterans and people with disabilities and so on,” Nesbitt said. “So, yeah, we are deeply concerned.”  

Local healthcare providers say they’re waiting for guidance and crafting their own response. 

“At this point, we do not yet know the full operational impact of the legislation on our Buncombe County services,” Mountain Area Health Education Center CEO William Hathaway said in a statement to The Watchdog after the bill passed. “However, we are actively reviewing the bill’s provisions and modeling potential scenarios internally. These include impacts on Medicaid reimbursement, patient eligibility, and the broader public health infrastructure that supports access to care.” 

MAHEC is one of the largest providers of health care services in the region, covering 16 western North Carolina counties. Many patients who use its services are on Medicaid, Hathaway said.

Physicians with the center are brainstorming ways to address cuts, but, like Buncombe County, are waiting for more information. 

“Members of MAHEC’s network of clinics and partners across Western North Carolina are working collaboratively to assess the likely consequences of the bill’s provisions,” Hathaway said. “We are coordinating with peer organizations, advocacy groups, and policymakers to better understand regional implications and will continue to share information with stakeholders as it becomes available.”

Karen Wallace-Meigs, executive director of the Western Carolina Medical Society which represents more than 700 physicians and physician assistants in 16 counties, has said her group is preparing to fill gaps where needed.

WCMS runs a healthcare initiative called Project Access, which connects uninsured, low-income residents in Buncombe and Madison counties with free medical care, serving more than 2,500 individuals each year.

“We call upon our neighbors to hold each other up in the spirit of humanity and togetherness. Use your voices,” Wallace-Meigs said in a statement. “We ask our large network of care providers, for whom we are grateful each day, to continue to stand with us and our neighbors.”

Buncombe’s largest health care provider and largest employer, Mission Health, did not respond to questions about local Medicaid cuts. 

Some have downplayed the potential loss of services, including Republican U.S. Rep. Chuck Edwards, who voted for the legislation.

The Watchdog sent Edward’s office the state’s briefing on Medicaid and SNAP cuts — which outlined severe rollbacks and losses to hospitals and community benefit programs — and asked the congressman for his response.

“H.R. 1 reinforces Medicaid to restore its original intent: to serve children, individuals with disabilities, low-income seniors, and other vulnerable populations,” Edwards said in a statement. “This bill addresses waste, fraud, and abuse that has caused costs to balloon out of control by 60 percent over the past five years. This bill does nothing to affect the qualification of anyone receiving Medicaid unless they can work and choose not to, are in the country illegally, or obtained Medicaid through fraudulent means. It does nothing to change anyone’s qualification based on their income or health condition.” 

Edwards said nothing about the additional administrative work that counties must add to comply with the bill’s mandated work requirements. 

Asheville Watchdog welcomes thoughtful reader comments on this story, which has been republished on our Facebook page. Please submit your comments there.

Asheville Watchdog is a nonprofit news team producing stories that matter to Asheville and Buncombe County. Andrew R. Jones is a Watchdog investigative reporter. Email arjones@avlwatchdog.org. The Watchdog’s reporting is made possible by donations from the community. To show your support for this vital public service go to avlwatchdog.org/support-our-publication/.

Related