Gizmo Warehouseby Joe Eichenbaum | 17A

Medicaid work requirements · North Carolina

Medicaid work requirements in North Carolina: who is subject and who loses coverage (2027)

Data snapshot 2026-06-03 · part of These 5 Million People Are About to Lose Their Medicaid — But They Don't Have To

North Carolina expanded Medicaid, so the federal work requirement that takes effect January 1, 2027 applies to its expansion adults. About 625,855 of them (9.8% of an expansion pool of 669,048) will have to prove 80 hours a month of work, school, or service, or an exemption, to keep coverage.

This model's bottom-up estimate is that 246,441 people in North Carolina lose coverage by 2034: 227,665 of them still eligible but lost to paperwork and reporting failures, and 18,776 not meeting the requirement. Nationally the same model gives 5,461,400, against CBO's 5,200,000.

Whether those eligible people keep coverage depends on the state's ability to renew them automatically (ex parte) from data it already holds. North Carolina scores 81 of 100 on this model's ex parte capability index, a low band; its eligibility system is NCFAST.

Key figures

Model v2-2026-06-03. "Strict" counts adults whose ACS record shows them subject with no observable exemption; "permissive" allows the broader exemption reading.
MeasureNorth Carolina
Expansion stateYes
Subject to the requirement via waiverNo
Expansion pool (adults 19 to 64)669,048
Adults subject, strict definition625,855
Adults subject, permissive definition613,338
Share of expansion pool subject9.8%
Projected coverage loss by 2034246,441
Hardship exception statusAdopting
Early implementerNo
Ex parte capability score (0 to 100)81 (low)

Who is subject in North Carolina

Of the 625,855 subject adults, 35% already work 80 or more hours a month and 59% are not working. 41% have a child under 14 at home. Among those not working, 53% report a disability and 17% are caregivers.

ACS PUMS 5-year 2020 to 2024, subject adults only.
CharacteristicShare of subject adults
Age 19-2417%
Age 25-3422%
Age 35-4420%
Age 45-5417%
Age 55-6424%
Not working59%
1 to 19 hours a month1%
20 to 79 hours a month5%
80 or more hours a month (meets the bar)35%
Not working: Disabled53%
Not working: Caregiver17%
Not working: Postpartum0%
Not working: Student3%
Not working: Other26%

Why eligible people lose coverage

Of the 246,441 projected to lose coverage in North Carolina, 227,665 meet the requirement or qualify for an exemption but fail to document it. 89,299 of those are working people who cannot prove their hours through data the state can see, and 138,367 qualify for an exemption the state does not detect automatically.

Bottom-up model v8.0-2026-05-30; documentation-failure buckets compound over the 14 six-month renewal cycles through 2034.
GroupProjected to lose coverage
Variable shifts / on-call work25,340
Self-employed (other)17,775
Multiple part-time jobs (aggregation failure)17,430
Full-time students not auto-verified8,617
Volunteering / job training6,925
Cash-paid construction & trades5,908
Seasonal: agriculture, hospitality, food service4,980
Gig / courier (DoorDash, Uber, Lyft, Instacart)2,324
Medically frail without auto-match42,196
Parent caregivers of children ≤13 without auto-match32,713
Caregivers of a disabled adult27,082
American Indian / Alaska Native (tribal exemption)15,019
Kinship caregivers (non-parent) of children ≤1311,311
SUD treatment not flagged in claims data4,253
Other categorical exemptions (foster, AYA cancer, SNAP/TANF)3,232
Recent incarceration (data-match gap)1,976
Pregnancy / postpartum data lag585

Can the state renew people automatically?

The ex parte capability index blends the state's observed automatic-renewal rate (99% in CMS eligibility-processing data), the wage, disability, and other data sources it can query, and its history of churn. North Carolina's composite score is 81 (low band). A low score means more eligible people will be dropped for paperwork unless the state changes its process before January 1, 2027.

ComponentScore
Composite81
Observed ex parte99
Core capability64
Data sources69
Historical churn50

How subjects overlap across exemption categories

Each subject adult sits in exactly one cell. Categories: Working ≥ qualifying hours / income; Parent caregiver of child ≤13; Medically frail; Full-time student.
CombinationAdultsShare
None of the four216,34834.6%
Medically frail105,76216.9%
Working ≥ qualifying hours / income + Parent caregiver of child ≤1395,16015.2%
Working ≥ qualifying hours / income92,68514.8%
Parent caregiver of child ≤1347,2937.6%
Full-time student21,1223.4%
Working ≥ qualifying hours / income + Full-time student14,4802.3%
Working ≥ qualifying hours / income + Parent caregiver of child ≤13 + Full-time student8,9551.4%

Counties in North Carolina

Subject adults concentrate: Wake County (64,206), Mecklenburg County (60,354), and Guilford County (32,294) account for 25% of the state's subject population.

All 100 counties in North Carolina with subject adults, sorted by count. County figures are model allocations of the state estimate by ACS tract characteristics.
CountyAdults subjectSubject rateProjected lossPoverty rateWorking-age population
Wake County64,2068.7%25,2828.0%739,897
Mecklenburg County60,3548.2%23,76511.0%738,324
Guilford County32,2949.8%12,71615.0%328,486
Forsyth County22,85010.0%8,99815.0%229,356
Durham County17,7788.4%7,00112.0%212,328
Cumberland County16,1107.9%6,34418.0%204,486
Buncombe County16,1049.8%6,34111.0%164,062
Union County15,05210.1%5,9277.0%148,768
New Hanover County14,63110.1%5,76113.0%144,599
Gaston County13,1299.3%5,17012.0%140,823
Johnston County13,0979.3%5,15711.0%140,996
Cabarrus County12,9829.2%5,1128.0%141,788
Iredell County11,77610.0%4,6379.0%117,656
Pitt County11,41510.4%4,49520.0%109,282
Brunswick County11,33414.4%4,4639.0%78,586
Alamance County10,67110.2%4,20214.0%104,239
Davidson County10,65110.6%4,19414.0%100,765
Orange County10,36911.2%4,08312.0%92,333
Catawba County10,11410.6%3,98213.0%95,636
Rowan County8,95710.1%3,52716.0%88,322
Randolph County8,84410.4%3,48215.0%85,298
Onslow County8,6926.7%3,42313.0%130,666
Henderson County7,64311.9%3,00911.0%63,940
Harnett County7,3058.8%2,87614.0%82,968
Wayne County6,86110.0%2,70218.0%68,876
Robeson County6,76010.2%2,66227.0%66,002
Moore County6,28611.2%2,4759.0%55,942
Cleveland County6,23210.7%2,45418.0%58,104
Craven County5,93210.2%2,33614.0%58,192
Lincoln County5,81210.6%2,2889.0%54,637
Nash County5,79810.5%2,28315.0%55,352
Rockingham County5,79710.9%2,28319.0%52,991
Burke County5,44710.5%2,14517.0%51,738
Caldwell County5,15311.1%2,02913.0%46,525
Chatham County5,12011.7%2,01610.0%43,658
Watauga County4,94313.9%1,94725.0%35,683
Wilson County4,78110.6%1,88320.0%44,970
Carteret County4,69912.3%1,85010.0%38,186
Surry County4,41810.8%1,74018.0%40,902
Franklin County4,3439.8%1,71010.0%44,254
Wilkes County4,15311.2%1,63517.0%37,040
Haywood County4,01611.5%1,58112.0%34,967
Rutherford County3,98610.8%1,57018.0%36,764
Lee County3,96910.4%1,56316.0%38,221
Stanly County3,89610.4%1,53414.0%37,530
Pender County3,86510.1%1,52212.0%38,136
Sampson County3,54710.6%1,39722.0%33,393
Granville County3,4859.4%1,37214.0%37,002
Jackson County3,32412.6%1,30919.0%26,344
Lenoir County3,18210.5%1,25322.0%30,178
Duplin County3,07011.3%1,20919.0%27,162
Columbus County2,97710.3%1,17221.0%28,894
Beaufort County2,97312.3%1,17117.0%24,173
Edgecombe County2,92010.9%1,15022.0%26,824
Davie County2,91011.8%1,14612.0%24,730
Halifax County2,87110.8%1,13024.0%26,584
Stokes County2,86911.1%1,13012.0%25,934
McDowell County2,69310.3%1,06015.0%26,282
Hoke County2,6428.1%1,04017.0%32,497
Macon County2,58013.0%1,01615.0%19,916
Dare County2,55812.1%1,0076.0%21,200
Vance County2,50510.6%98619.0%23,576
Person County2,47811.1%97617.0%22,398
Richmond County2,45110.1%96523.0%24,350
Transylvania County2,39213.6%94213.0%17,600
Yadkin County2,39211.1%94214.0%21,604
Pasquotank County2,2869.6%90012.0%23,719
Alexander County2,23010.5%87812.0%21,227
Cherokee County2,14114.0%84317.0%15,352
Bladen County1,86711.5%73524.0%16,174
Scotland County1,8599.7%73226.0%19,116
Currituck County1,84610.2%7278.0%18,110
Ashe County1,78412.0%70214.0%14,814
Montgomery County1,59710.9%62916.0%14,666
Madison County1,53012.1%60213.0%12,656
Caswell County1,41010.9%55515.0%12,927
Polk County1,34813.2%53111.0%10,231
Martin County1,32811.5%52321.0%11,508
Hertford County1,26311.4%49720.0%11,097
Anson County1,2529.4%49319.0%13,285
Warren County1,23812.3%48721.0%10,096
Yancey County1,22011.9%48015.0%10,240
Greene County1,1879.3%46723.0%12,774
Northampton County1,12712.8%44419.0%8,792
Avery County1,09510.3%43111.0%10,588
Bertie County1,05210.7%41421.0%9,854
Mitchell County99312.0%39113.0%8,290
Perquimans County93913.8%37013.0%6,802
Clay County88715.4%34913.0%5,776
Swain County85310.5%33620.0%8,128
Washington County82114.7%32322.0%5,570
Pamlico County82012.3%32314.0%6,678
Chowan County80610.8%31721.0%7,452
Alleghany County80213.8%31620.0%5,829
Gates County69011.8%27214.0%5,862
Camden County66310.3%2616.0%6,436
Jones County58011.0%22818.0%5,276
Graham County48411.0%19111.0%4,409
Hyde County2147.5%8430.0%2,859
Tyrrell County20411.3%8016.0%1,799

State brief and methodology

Estimates, not counts. The model rakes to CBO's national subject total and allocates by ACS microdata; state agencies hold the administrative data that would replace these figures.

Sources

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