Amid a sea of economic, political and cultural uncertainty impacting our country resulting from mismanagement and manipulation by the current federal administration, the American healthcare system is on the verge of implosion. As of September 2026, nearly 20 million Americans are covered by the Affordable Care Act’s Medicaid Expansion plan.
Let’s begin our exploration into what challenges the country’s population as a whole — including those in the Carolinas — can expect next month and continuing into 2027.
Beginning Jan. 1, 2027 coverage for many Americans (various sources estimate between seven and 10 million) is set to change significantly. For non-citizens it will change even sooner. As a result of the budget reconciliation law Trump signed last summer, H.R. 1, also known as the “One Big Beautiful Bill Act,” many Americans will potentially lose access to Medicaid Expansion coverage due to stricter eligibility requirements. Already 26 states across the union have sued the Trump administration in an effort to overturn some of the regulation outlining Medicaid work requirements for fear of disqualifying beneficiaries as a result of bureaucratic red tape and the narrowing of medical exemptions.
What to expect
The soonest changes we can expect will take place next month starting October 1. Non-citizens will lose all eligibility for Medicaid, albeit with a few exceptions: lawful permanent residents with green cards; children younger than 19 without permanent immigration status; women who are pregnant or gave birth in the past 12 months without permanent immigration status; Cuban or Haitian immigrants; and residents of the United States who are citizens of the Freely Associated States including Micronesia, the Marshall Islands and Palau.
All of these groups will be exempt from the new federal policy and will retain eligibility for Medicaid coverage. However, any undocumented immigrants, refugees, asylum seekers, survivors of human trafficking or those with Temporary Protected Status will no longer be eligible.
As indicated earlier in this article, broader and more complex changes will begin on Jan. 1, 2027. Across the 40 states that expanded access to Medicaid under the Affordable Care Act, including North Carolina, recipients will now be required to prove on a biannual basis (every six months) that they are working, volunteering or attending school for at least 80 hours a month. These activities may be combined in any way to achieve that 80 hour total, and additionally they may be combined in part with a maximum of 40 hours of job searching.
The new law will also require the beneficiary to retroactively prove their satisfaction of this work requirement, meaning provide proof that they are currently meeting the requirement and that they have been meeting the requirement for the three months leading up to their biannual determination.
If the household of a recipient generates a total monthly income of at least $580 and no more than $1,835, the recipient will continue to receive benefits and will not be required to complete the 80 work hours.
Others exempt from these requirements include: women who are pregnant or gave birth in the past 12 months; former foster care youth; American Indians and Alaskan Natives; a parent, guardian, caretaker relative or family caregiver; veterans rated 100 percent disabled by the VA under 38; “medically frail” individuals; people complying with TANF work requirements; people in a SNAP household subject to SNAP work requirements; individuals in drug or alcohol treatment and rehabilitation; inmates of a public institution; and adults with disabilities.
Across the country anywhere between 4.9 and 10.1 million people are projected to lose access to Medicaid benefits in 2028, according to the Robert Wood Johnson Foundation. In North Carolina that number is estimated at anywhere from 152,000 to 330,000 people. Currently about 735,000 North Carolinians are enrolled in Medicaid through expansion. That’s a potential loss of health care access for 45 percent of that population.
How to prepare
If you or someone you know is at risk of losing health care coverage in the new year, take note of these important steps you can take to prepare for the stricter upcoming requirements and more frequent eligibility determinations.
Before anything else, check to see if you qualify for any of the exemptions listed above. If you do, make sure you have documented proof of that exemption. For example, if you have an illness or otherwise restrictive condition that prohibits you from working, have your physician or specialist write an official email or letter detailing your condition and how it disallows you from the work requirement. As a caregiver for a family member, you may also qualify for an exemption, and there are a few ways you can prove you have caregiver status.
Make sure you have both financial and medical power of attorney (POA), a HIPAA authorization form signed by the care recipient, and a personal care agreement detailing responsibilities, compensation (if any) and hours logged. For more details on how to document your caregiver status, visit archwellhealth.com/blogs/essential-caregiving-documents-checklists-and-organization-tips.
If you do not fall under any of the aforementioned exemptions, make sure you have your work requirement hours documented starting as soon as possible. To qualify for enrollment, you will need to prove that you are currently working 80 hours per month and that you have been for three months prior. That means there is no time to waste in getting all of your enrollment documents, pay stubs and volunteer logs together so that you can continue to receive Medicaid benefits. Finally make sure your contact information is up to date with local DSS offices and check your mail and email regularly to ensure you don’t miss any upcoming deadlines or document requests.
Healthcare in South Carolina
Non-emergent healthcare in South Carolina continues to be more difficult to find for a number of reasons.
All but five of South Carolina’s 46 counties are experiencing a healthcare professional shortage. According to the Cicero Institute, the state ranks 38th when it comes to the availability of primary care physicians.
It is estimated that by 2030, South Carolina will have a shortage of more than 3,000 doctors, with more than 800 of those being primary care providers (PCPs).
The average wait for getting an appointment with a PCP in the state is a little more than a month. To see a specialist takes even longer.
Even if one can find a provider, paying for the care is another matter. Approximately 18 percent of South Carolinians are uninsured, compared to 14 percent nationally.
Out of a population of around 5.5 million, a little over a million are covered by Medicaid, and not the Medicaid Expansion Plan. That’s not an option in the Palmetto State for those of lesser economic means.
In South Carolina, the following qualify for Medicaid in one or more of the state’s Medicaid programs: Aged, Blind or Disabled; Breast and Cervical Cancer; Disabled Children; Family Planning; Former Foster Care; Nursing Facilities; Medically Indigent Assistance; OSS (Community Residential Care); Parent/Caretaker Relatives; Partners for Healthy Children; Pregnant Women and Infants; Specified Low Income Medicare Beneficiaries; and Working Disabled.
Each program has its own guidelines for eligibility, income limits and benefits.
The bottom line is, if you are an adult (19-64) with no dependent children or disability, qualifying for Medicaid is difficult, even if you live at or close to the federal poverty level.
Those who don’t qualify and can’t afford the skyrocketing premiums of marketplace coverage live in what’s called the coverage gap. Many of them work for small employers who do not offer health insurance. About 70 percent of small employers (having no more than 50 employees) in South Carolina do not offer access to coverage.
According to the Household Pulse Survey, gay and lesbian individuals, especially those of color, are more likely than their straight counterparts to live at or near the poverty line. They live in the coverage gap.
As noted by the Center for American Progress back in 2022, “LGBT individuals were more likely than non-LGBT individuals to report that it has been somewhat or very difficult for their household to pay for usual household expenses in the past week.”
Hospitality, retail and administrative/support sectors employ the most low-wage uninsured workers in South Carolina, many of whom are gay or lesbian.
That means little or no money to pay for either health insurance for those who do not qualify for Medicaid or for paying out-of-pocket for direct health care.
A federal law subsidizing premiums on the health insurance exchange, which in South Carolina grew from 200,000 to more than 600,000 enrollees, expired in 2026.
With rising premiums across the board charged by the major health insurance providers and the decision of South Carolina not to expand Medicaid coverage, it is projected by CoverSC.org that more than 180,000 South Carolinians will join the swelling ranks of the uninsured in the coming year.
The Trump impact on transgender healthcare
In the Carolinas, the transgender community faces countless barriers in healthcare. Whether they’re unable to obtain a doctor’s signature for hormone treatment, find insurance or simply pick up their prescription, finding reliable healthcare in the Carolinas is overwhelmingly frustrating.
The Trans Legislation Tracker found around 46 bills (13 in North Carolina and 33 in South Carolina) that were proposed in 2026. About 13 of those bills restrict trans healthcare either by reducing aid or complicating the process altogether.
Most of these attacks on the trans community target minors (ages 18–19 years and under), but many hospitals and family doctors have reduced both minor and adult gender-affirming care because of state retaliation or lack of funding.
Campaign for Southern Equality stated, “In North Carolina — it is legal and possible for transgender adults to access gender-affirming care. However, in 2026 we’re seeing new barriers to care for transgender adults — including some clinics preemptively stopping the provision of gender-affirming hormone therapy for adults, despite no law requiring them to do so.”
As funding for gender-affirming care shrinks, doctors decide if a trans health program is worth their reputation. Both South Carolina and North Carolina have restricted trans patients and their providers’ rights.
In North Carolina, House Bill 606 (NC H606) claimed that, “A medical professional or entity may not seek a contractual waiver of the liability arising in subsection (d) of this section. Any attempted waiver is contrary to the public policy of this State and is null and void.” Any doctor who would take on a trans patient would be fully liable for any procedure. For some hospitals, the proposed bill would be enough to end a trans health program.
As trans-centered programs and doctors leave, the need for trans care grows. Gender-affirming medication like Hormone Replacement Therapy (HRT) can only be obtained with a physician or psychiatrist’s signature. Depending on where a person lives, that signature can be difficult to find. Even with a vetted physician, obtaining medication is a delicate task.
According to a report from The Assembly, Carolinians have experienced pharmacists and medical professionals who refused to serve them. In South Carolina, a bill that protects pharmacists who refuse to hand out gender-affirming medication has been introduced but not yet ratified. Still, how it could legalize discrimination is frightening.
The proposed SC S00054 or Medical Informed Consent bill claims, “[…] the pharmacist [can] object to filling the prescription for religious, moral, or ethical reasons pursuant to the Medical Ethics and Diversity Act…”
A pharmacist’s refusal of service builds on the already constricting guidelines of gender-affirming medication. Once a pharmacy refuses to serve someone, that trans individual must travel to another location or wait for their physician’s approval.
The good news is that many programs, non-profits and organizations continue to provide information and aid to the trans community. Though Medicaid doesn’t cover gender-affirming care, private insurance like Blue Cross Blue Shield covers a majority of costs.
For uninsured Carolinians, programs like Charlotte Trans Health have affordable and confidential services. A trans health database, the website gathers several local services and education on gender-affirming care in the Charlotte area. Individuals seeking care and medical professionals can find information on trans healthcare, reputable psychologists and events that support or advance LGBTQ+ health. Other organizations like UNC at Chapel Hill use funds to help reduce the cost of gender-affirming surgery. And Truth U Clinic provides hormone therapy across South Carolina for uninsured individuals.
Challenges for gay men and HIV-positive individuals
The Trump administration’s changes to Medicaid and the Affordable Care Act are creating new conditions for maintaining health coverage, with potentially significant consequences for people living with HIV and for low-income gay and bisexual men who have historically relied heavily on Medicaid and ACA coverage.
The most consequential Medicaid change comes from the “Big Beautiful Bill” signed by Trump, which requires 80 hours a month of employment, community service, education or certain other qualifying activities to maintain eligibility.
The new requirements matter particularly to people with HIV because Medicaid is the largest single source of health coverage for Americans living with the virus. The website KFF reported that 46 percent of people with HIV had Medicaid coverage in 2023. In states that expanded Medicaid, 60 percent of adults under 65 with HIV received coverage through the ACA expansion pathway.
HIV itself does not automatically exempt someone from the new work requirement. Under rules issued by the Centers for Medicare and Medicaid Services, states must determine whether such a condition qualifies as medical-frailty and significantly limits a person’s ability to meet the community-engagement requirement.
That creates an administrative burden and a mass of red tape for some patients and their doctors. KFF confirms that people with HIV could face coverage interruptions if they cannot document employment, qualifying activities or medical-frailty status. Interruptions can interfere with anti-retroviral treatment and viral suppression.
Another factor: the ACA Marketplace has undergone major change. Enhanced premium tax credits that had lowered premiums for millions of Americans expired at the end of 2025. KFF reports that Marketplace premiums rose for many consumers in 2026, while average deductibles increased by about $1,000.
The changes also matter to gay and bisexual men who are HIV-negative. The ACA requires most health plans to cover HIV pre-exposure prophylaxis, or PrEP, without cost-sharing, including the medication, medical visits and necessary laboratory testing. That protection remains in place for most qualifying plans, but not all.
The impact, however, will not be uniform. Federal HIV treatment guidelines updated Sept. 24, 2026, warn that insurance changes can produce lapses in treatment and viral suppression. The guidelines specifically identify the new Medicaid work requirements and the expiration of enhanced ACA subsidies as coverage changes requiring in-depth attention.
Qnotes journalists contributing to this article include David R. Gillespie, Jaylen Jones, David Aaron Moore and Bailey Sides.
This story is brought to you by Rosedale Health and Wellness and Dudley’s Place.
