Column: Government Shutdown Is all About How We Perceive Health Insurance Coverage

Congressional Republicans have shut down the U.S. government because they are trying to convince Americans that Democrats want to give away health coverage to immigrants who entered our country illegally. Let's clear up this talking point.

There is nothing in Medicaid that permits undocumented immigrants to get financial assistance. There is a 1986 law (EMTALA) that requires Medicaid-participating hospitals (like FirstHealth's Moore Regional Hospital in Pinehurst) to give anyone coming to an emergency room a medical screening examination. If they have an emergency medical condition, the hospital must provide stabilizing treatment, regardless of the patient's insurance status or ability to pay.

When hospitals give emergency "charity care," there is a specified level of reimbursement, called State Directed Payments (SDPs), that comes from Medicaid. Republicans want that payment to hospitals to be reduced for everyone who is too poor to pay the price of emergency medical care. Democrats want to go back to the level it was before the "One Big Beautiful Bill" because the new rates being proposed by Republicans will have a devastating financial impact on many rural hospitals.

The "One Big Beautiful Bill" that became law this summer limits the level of SDPs to a level that is half or even a third of previous rates. North Carolina's expected overall reduction is 45 percent, but this would be disproportionately felt by rural hospitals. The estimated 10-year impact on North Carolina's health providers is in excess of $20 billion.

The American Hospital Association said in a recent statement, the "One Big Beautiful Bill … will result in irreparable harm to our health care system, reducing access to care for all Americans, and severely undermining the ability of hospitals and health systems to care for our most vulnerable patients. It will force hospitals to make service line reductions and staff reductions, resulting in longer waiting times in emergency departments and for other essential services, and could ultimately lead to facility closures, especially in rural and underserved areas."

Let's clear up some common misconceptions:

• Undocumented immigrants are not eligible for Medicaid.

• Despite lower family incomes, legal immigrants under age 65 are less likely to be covered by Medicaid than are U.S. born citizens.

• Emergency Medicaid spending makes up less than 1 percent of total Medicaid expenditures.

• North Carolina expanded Medicaid coverage for lawfully present immigrants (subject to very restrictive conditions) as well as children and pregnant women.

• Immigrants use the health care system less often than people born in the U.S.

The other reason Democrats are insisting that Republicans come around on revising the One Big Beautiful Bill is its negative effect on the cost of health care for everyday Americans. These costs will be impacted by both "hard" increases and "soft" increases.

The average annual premium for those covered by the Affordable Care Act — what some call Obama Care — is expected to double if the 2026 tax credits are left to expire. Average annual premiums will go from $888 to $1,904.

About 45 percent of ACA Marketplace enrollees have incomes between 100-150 percent of poverty, about 28 percent have incomes between 150-250 percent of poverty, and roughly 10 percent have incomes above 400 percent of poverty. On average, a 60-year-old couple making $85,000 would see yearly premium payments rise by over $22,600 in 2026. Some of this is attributable to rising health care costs; insurers were expected to raise premiums about 18 percent with or without the credits.

None of this takes into account the "soft" costs of premium pressure. For one thing, as more people drop off insurance rolls, the corresponding increase in uninsured people will need to seek emergency room care. Emergency department care is the most expensive type of care.

How long should anyone expect hospitals to eat the cost of providing this care to people who have no way to pay for it? The only way to recoup those costs is to raise the price of other services for those that can pay. That's why a Tylenol in the hospital could cost $10 per pill. As provider costs escalate, there has to be a corresponding increase in the cost of premiums for those that remain in order to cover the newly inflated price structures.

Additionally, as the cost of health insurance increases regardless of the ACA increases, the healthiest people (mostly young) will decide they don't need insurance. That changes the risk pool for insurers as only the sickest clients remain covered. When that happens, everyone's premiums go up.

These factors ensure that everyone, whether you are covered by the ACA or not, will share the burden of the One Big Beautiful Bill's effect in raising health care costs for us all.

Let's call this shutdown what it is: an attempt by Republicans to transfer wealth from everyday working people to the very rich elites who determine GOP policies.

Lowell Simon is a retired business owner, former public school teacher and a political activist. He currently chairs a number of nonprofit organizations and is president emeritus of the Sandhills Jewish Congregation. You can read his other writings at substack.com/@simonsez.