By Jaymie Baxley and Jennifer Fernandez
On a Thursday morning in March, Tyrome Powell was holding court over a small group of men at the Tiny House HOPE Center in Greensboro as he talked about basketball.
In the background, news anchors discussed the war in Iran on TV. Across the room, barbers busily cut hair and trimmed winter beards. Volunteers at the center, which serves about 30 homeless people like Powell on weekdays, answered questions, handed out water and delivered mail.
That morning, more than a dozen people stopped by the desk in a corner where Marie Lee and Brittany Scott set up once a month. They work for the Guilford County Department of Social Services to help people apply for federal food aid and Medicaid.
The duo will likely face a lot of difficult conversations about Medicaid next year, when work requirements passed last year by Congress kick in. Those new hurdles are expected to affect about 732,000 North Carolina residents who got health care through Medicaid expansion, which the state’s General Assembly passed in 2023 after a decade-long fight. “Traditional” Medicaid recipients — people with disabilities, low-income older adults and children — will not be subject to the new requirements.
Today: North Carolina prepares for new work requirements that will affect the about 732,000 beneficiaries who received coverage through Medicaid expansion.
Thursday: County DSS workers in different regions of North Carolina anticipate challenges unique to their communities in tracking new work requirements.
Monday: Guilford County’s Orange Card program helps people access care when they don’t qualify for Medicaid or other health insurance.
County social service workers expect to be on the receiving end of people’s confusion and frustration over fulfilling — and documenting — that work effort.
In Guilford County, about 46,000 adults ages 19 to 64 enrolled in Medicaid through expansion, according to the latest state data.
Under H.R. 1, the sweeping federal bill signed last summer by President Donald Trump, Medicaid expansion participants must prove they are working, volunteering or attending school for at least 80 hours a month to maintain their benefits. The new reporting starts Jan. 1, 2027. The law is projected to reduce Medicaid spending by nearly $900 billion over a decade, in part by tightening eligibility rules and increasing oversight of enrollment. It also requires states to conduct eligibility redeterminations every six months. Until now, most states have conducted them annually.
Powell, 60, said he hadn’t heard anything about the new Medicaid work requirements until speaking with a NC Health News reporter. While he hasn’t applied for Medicaid yet — he said he’s never been sick and doesn’t need health insurance — he doesn’t like the changes.
A lot of these programs have extra requirements that are hard to meet, he said.
“You see deaths of people because they don’t have health insurance,” he said. “There are too many requirements to meet already.”
So far, most people seeking help with Medicaid aren’t asking about the upcoming changes, said Sherri “Shea” Malpass, program manager with Guilford County Department of Social Services.
“That’s not real for them right now,” she said.
But it’s all too real for county DSS offices and their employees, who will bear the brunt of the work. North Carolina is one of 10 states where Medicaid eligibility determinations are handled at the county level.
‘A very hard conversation’
North Carolina’s local DSS offices are scrambling to prepare, even though many are not fully staffed. About 10 percent of county social services positions dedicated to Medicaid are vacant, according to the North Carolina Department of Health and Human Services.
Adding to the scramble: They still don’t have a roadmap.
The federal Centers for Medicare and Medicaid Services is expected to release guidance by June. Then, states will be in a mad rush to create policies and procedures, update technology and train frontline workers by January 2027 to work with beneficiaries who are due for recertification at the end of March.
Like the counties, NC DHHS is waiting on final guidance.
“Hopefully, we won’t have to do a lot of rework when the final guidance comes out,” said Melanie Bush, deputy secretary for NC Medicaid.
Getting final guidance in June, with a launch of January 2027, “isn’t anywhere near enough time,” said Matt Salo, CEO of Salo Health Strategies and a former executive director of the National Association of Medicaid Directors.
“States are in a very, very difficult position,” he said.
A new report indicates that 4.9 million to 10.1 million people across the country could lose Medicaid coverage as a result of the new law. In North Carolina, as many as 345,600 people could fall off the Medicaid rolls, according to a March 25 analysis by the Robert Wood Johnson Foundation and the policy think tank Urban Institute.
Bush said the department’s initial estimates for North Carolina showed about 255,000 people could lose coverage due to the changes. She expects that number will increase now that state legislators have indicated they want beneficiaries to meet work requirements for three consecutive months in every six-month recertification period.
Those disenrollments would likely include some people who are meeting the work requirement but face challenges documenting their work activity, the researchers wrote.
How many people lose coverage will depend in large part on choices North Carolina makes in how it implements the new rules. The RWJF/Urban Institute analysis modeled three scenarios — high, medium and low mitigation — reflecting how aggressively states use tools like automatic data-matching and broad exemption definitions to keep people enrolled.
Even in a best-case scenario, work requirements will cause millions to lose Medicaid. But if states do not implement the law carefully, the foundation said, that number could double.
A trickle of information
Salo said CMS has been dribbling out communications, hints and signals for months to give states an idea of where the guidance is headed. States also can look to Georgia, which rolled out a work requirement in 2023, to see what did and didn’t work, he said.
One of the key architects of the federal rollout — Grant Thomas, a senior adviser at CMS — was among the people in charge of Georgia’s troubled work requirement program, Salo said.
North Carolina has reason for cautious optimism. When the state undertook the massive post-pandemic “unwinding” of Medicaid — verifying eligibility for more than 2.5 million participants for the first time since COVID-19 began — it leaned heavily on automation to ease the burden on caseworkers and enrollees. The state implemented an “ex parte” process that used data from wage databases run by the Social Security Administration, the IRS and other agencies to confirm eligibility and automatically renew coverage. Ninety-nine percent of renewals were completed this way — the largest share of any state.
The state drew on similar strengths when it launched Medicaid expansion in late 2023; it automatically enrolled 268,000 people based on existing data on the day expansion went live.
“If you were a state like North Carolina, that really leaned in and said, ‘We’ve got to do it differently,’ that’s exactly the lesson, the message that all these states need to embrace and incorporate to make these work requirements work,” Salo said.
Whether those strengths can be brought to bear on the demands ahead is uncertain. Automating renewals meant checking existing data against known eligibility criteria. Verifying work requirements is different, as it means tracking hours logged at seasonal jobs, informal gigs and volunteer sites, month after month, for hundreds of thousands of people. That’s a problem no state has solved at scale.
North Carolina is making use of that automation and expanding those efforts, Bush said.
“Our goal is to be … as simplified as possible for our beneficiaries, to make this process as easy as possible for them, while also guaranteeing that they are actually eligible,” she said.
DHHS is planning robust messaging, drawing on lessons learned during the expansion and unwinding periods, to reach beneficiaries, Bush said. It’s also retraining Medicaid ambassadors — trusted community members who helped connect with people during expansion — to share information on work requirements.
“There are people that are going to think that it applies to them, [but] it does not,” Bush said. “It’s going to be confusing for the entire Medicaid population.”
Complicating the message: Not everyone understands they are on Medicaid expansion. They just see their health card showing they have Medicaid, Bush said.
And as more people lose coverage, it will fall to overworked caseworkers to share the bad news.
“Nobody wants to tell somebody you’re no longer eligible,” Guilford County’s Malpass said. “That’s a very hard conversation.”
Tomorrow: County DSS workers in different regions of North Carolina anticipate challenges unique to their communities in tracking new work requirements.
About this series
NC Health News reporters, with support from Public Health Watch, reached out to about a dozen counties across the state to discuss the impact of the new Medicaid work requirements. We conducted multiple interviews and spent several hours with county social workers to find out how they are preparing for the changes.
This story is part of “Uninsured in America,” a project led by Public Health Watch, a nonprofit newsroom based in Texas. The project focuses on life in America’s health-coverage gaps and the impact of potential Medicaid and related cuts.
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