In a NC county that backed Trump, cuts in health insurance will hit hard | Opinion

If North Carolina has a ground zero for hardships caused by President Donald Trump, it might be in a county that has staunchly supported him, McDowell County.

The county of about 45,000 in the mountains of western North Carolina is still recovering from the devastation of Hurricane Helene a year ago. Its difficulties have been made worse by a low level of federal relief funding and bungling by the Federal Emergency Management Agency under Trump and his Homeland Security Secretary, Kristi Noem.

Now, many county residents are facing sharp increases in their Affordable Care Act (ACA) health insurance policies because enhanced tax credits that lower the cost of premiums will expire at year’s end under Trump’s “big, beautiful bill.” Senate Democrats are demanding that the credits be extended. The impasse has shut down the federal government since Oct. 1.

All this is unlikely to shake most McDowell County residents’ faith in the president. This is a MAGA county, 86% white and overwhelmingly Republican. In 2024, Trump won 74% of the vote there. Even scandal-plagued GOP gubernatorial candidate Mark Robinson defeated Democrat and now-Gov. Josh Stein by 63% to 32%

Also on the horizon loom cuts in Medicaid, a health insurance program that covers 36% of the county’s residents. Those cuts, likely to hit in 2026, are also part of Trump’s “big, beautiful bill.”

Amid all this, Amy Stevens tries to keep McDowell County residents connected to health insurance. She’s a federally certified ACA navigator based in the town of Marion. A program director for the nonprofit McDowell Access to Care and Health, or MATCH, she helps people sign up for the ACA and explains the process for enrolling in Medicare or Medicaid.

Sometimes connecting people to the ACA can produce a surprising reaction.

“Here in the western part of the state, which is a red area, I’ve actually enrolled people in the ACA who are so excited to have coverage,” she said. “But then they say, ‘You didn’t enroll me in that Obamacare, did you? I don’t want any of that.’ I get an opportunity to do some educating.”

Now many in McDowell may get a dose of Trump loss-of-care if the ACA’s enhanced tax credits are not extended. If premiums double or go higher, many in McDowell, where the median income is $55,500, won’t be able to afford the ACA policies.

“Being pushed out of the ACA is going to cause a huge financial burden for them,” Stevens said.

The ACA’s premium tax credits were temporarily increased under former President Joe Biden’s “American Rescue Plan Act” of 2021, but set to expire at the end of 2025. The more generous tax credits and increases in eligibility incomes led to a surge in ACA enrollment. In North Carolina, it grew from 500,000 in 2020 to 927,000 today.

Expanding ACA access made a big difference for some people in McDowell County. “A lot of them were dependent on donated care, or charity care, or they were just going without. These tax credits made it a lot more affordable,” Stevens said.

And the effects were clear.

“I have so many stories of people who got insurance for the first time and were able to get to the doctor and find out they had chronic health issues they knew nothing about,” she said.

Ginger Webb, a community organizer with the McDowell County Community Engagement Project, sees the widespread need for affordable insurance and is dealing with it in her own family of four.

She and her husband, a building inspector, do not get insurance through an employer. By taking full use of the ACA’s enhanced tax credits, they still pay a premium of $880 a month. If that premium doubles, they may have to switch to a low-cost catastrophic plan with very high deductibles.

“I know there are a lot of people in the same situation as us, people working full-time jobs,” she said, “Lots of us may have to go without health insurance because we can’t afford it.”

Webb said public protest might preserve the higher tax credits. “I hope that every time someone opens a renewal notice they email their representatives,” she said. “It’s going to take people pushing back.”

Stevens worries about the potential for a health insurance double setback coming after two steps forward. North Carolina’s Medicaid expansion extended health insurance to more than 600,000 people. The enhanced tax credits helped nearly a half-million more people gain coverage under the ACA.

Now both are in jeopardy because of Trump’s “big, beautiful bill,” and the effects could strip health insurance from millions, including those in a county that helped return Trump to the White House.

Said Stevens said, “It’s a scary time for folks.”

Associate opinion editor Ned Barnett can be reached at 919-404-7583, or [email protected]

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