Sustaining the Gains: Protecting Rural Health Care Access in North Carolina

A policy brief on Medicaid expansion and the rural hospital safety net

Prepared by Nehala Chandolu | August 2026

At a Glance

The Problem

Rural North Carolinians face persistent, compounding barriers to health care. More than 60% of the nation's Health Professional Shortage Areas are rural, and when rural hospitals close, these shortages worsen as local physicians and nurses relocate along with inpatient services. Since 2010, 149 rural hospitals have closed nationwide, and North Carolina has not been immune to the trend.

Medicaid expansion measurably narrowed these gaps.

Rural residents represent about 26% of North Carolina's total Medicaid population. More than 233,000 rural North Carolinians gained coverage through expansion. Because rural hospitals depend disproportionately on Medicaid revenue, expansion also improved their finances: nationally, rural hospitals in expansion states run a median operating margin of +1.5%, compared to −1.5% in non-expansion states.

That financial footing is now eroding from two directions at once:

1. Federal Medicaid cuts passed in 2025 are expected to hit rural hospitals hardest because of their reliance on Medicaid reimbursement.
2. Lapsing ACA subsidies at the end of 2025 triggered a 22% drop in North Carolina marketplace enrollment—the steepest decline in the nation.

Analysts expect the state's uninsured rate (9.2% in 2023) to rise for the first time in years as a result.

The Data

The following indicators shape this issue statewide:

Indicator	North Carolina	Source/Year
Statewide uninsured rate	9.2% (≈ 965,200 people)	U.S. Census / America's Health Rankings (2023)
Total NC Medicaid & CHIP	≈ 3.01 million (43% children; 26% rural)	KFF (May 2025)
Expansion enrollment	650,000+ adults	NCDHHS / Gov. Stein (Apr. 2025)
Rural expansion enrollees	233,000+ (>1 in 3 newly eligible)	NCDHHS (Apr. 2025)
Hospitals at risk of closing	9 of 56 (6 at immediate risk)	Center for Healthcare Quality & Payment Reform (Apr. 2026)
Rural hospital margins	+1.5% (expansion) vs. −1.5% (non-exp)	Chartis 2025 State of Rural Health
ACA marketplace changes	975,110 → 761,457 (−22%)	KFF (May 2026)

Local Spotlight: Chatham County

Chatham County illustrates both the promise and the limits of North Carolina's current approach. While the county ranks 10th out of 100 on overall health outcomes, strong averages mask unequal access within the community.

Indicator	Chatham County	Source/Year
Health outcomes rank	10th of 100 NC counties	County Health Rankings (2021)
White–Black life expectancy gap	4.4 years, down from 6.8	Chatham Co. Public Health (2020)
Primary care workforce	Fewer physicians & NPs per capita than NC average	Chatham Co. Public Health (2025)
Care barrier reported	38.4% report ≥1 barrier	Chatham Co. Public Health (2025)
Opioid-related ED visits	Lower and declining faster than NC rate	NC DETECT (2024–2025)

Chatham's experience suggests that statewide coverage gains must be paired with targeted, county-level attention to access and equity.

Recommendations

North Carolina policymakers should treat Medicaid expansion as infrastructure to be defended, not a settled achievement. We recommend pairing that defense with targeted rural supports:

• Protect rural hospitals from the federal Medicaid cuts taking effect under the 2025 reconciliation law—including by pressing the state's congressional delegation to mitigate the reductions.
• Offset the loss of enhanced ACA marketplace subsidies through state-funded bridge subsidies or a reinsurance mechanism, particularly in rural counties where carrier exits have been steepest.
• Grow the primary care workforce in underserved counties by accelerating initiatives such as the UNC System's nursing expansion and loan-repayment programs for rural providers.
• Track and report health outcomes by race and geography, following Chatham County's example, to ensure county-level improvement doesn't obscure persistent disparities.