As new federal restrictions on Medicaid eligibility take effect, some immigrants in Western North Carolina are losing health coverage, while others who remain eligible are faced with weighing whether enrolling in public benefits could jeopardize their ability to remain in the United States.
In The Smoky Mountain News coverage area, nine people in Jackson County and 26 people in Haywood County have lost Medicaid coverage due to the new eligibility rules, but fear and confusion surrounding the changes may have the biggest impact.
The changes, which took effect Oct. 1 under HR 1, the federal budget reconciliation law also known as the One Big Beautiful Bill, limit Medicaid eligibility for certain noncitizens, including refugees and asylees who previously qualified for coverage.
The restrictions come as separate changes to federal immigration policy have introduced new uncertainty about whether using public benefits could affect some immigrants’ applications for permanent residency.
The consequences extend beyond those who lose coverage. Legal advocates say confusion surrounding the new rules is prompting some immigrant families to reconsider seeking medical care or enrolling in benefits for which they remain eligible.
“It’s causing a lot of confusion,” said Shoshana Barton, an attorney with Pisgah Legal Services, which provides free legal assistance across Western North Carolina. “It’s causing people that, even if they may remain eligible for certain programs, they’re sort of shying away from it or afraid or confused.”
Not everyone will lose coverage. Children younger than 19 and pregnant women, including women who were pregnant within the past 12 months, remain eligible for Medicaid under the rules, provided they meet other requirements.
But for some adults who entered the country through humanitarian pathways, the changes could mean losing access to health insurance even after the federal government granted them protection from persecution in their home countries.
“These are people that applied for status here, applied for protection, and we granted that protection,” Barton said. “And now they’re taking that away.”
Barton said Pisgah Legal Services began hearing from people in August and September who received notices that their Medicaid coverage would end Oct. 1. Some sought help appealing the decisions, though Barton said many of those terminations were the direct result of the new eligibility restrictions and could not be successfully challenged.
In some cases, attorneys were able to help people enroll in insurance through the Affordable Care Act marketplace for the remainder of the year.
For families already struggling financially, losing insurance can force difficult choices between health care and other necessities.
The consequences could be especially serious for people who need ongoing treatment, prescription medications, or routine monitoring for chronic conditions. Without insurance, some may put off preventive care or skip recommended appointments because of the cost.
Barton worries that patients could forgo screenings intended to catch serious illnesses early, potentially leading to worse health outcomes and more expensive treatment later. People who cannot afford private insurance may have few alternatives.
The changes could also affect healthcare providers, particularly in rural communities where medical options are already limited. If more people become uninsured, providers that serve large numbers of Medicaid patients could face additional financial pressure.
Marianne Rupp Martínez, chief executive officer of Vecinos, a nonprofit that provides free, bilingual healthcare services to low-income, uninsured people in the region, said local officials have not yet seen evidence of a sweeping drop in Medicaid coverage tied to the October changes.
She is more worried about how new HR 1 Medicaid eligibility requirements will impact Vecinos service area.
Come Jan. 1, 2027, over 250,000 North Carolinians are expected to lose Medicaid coverage due to new eligibility work requirements that place an increased administrative burden on Department of Social Services employees and Medicaid recipients to establish coverage going forward.
Martínez said she has spoken with Medicaid directors in some of Vecinos’ service counties, but limited information makes it difficult to predict how the changes will affect local healthcare needs.
“We have no idea,” Martínez said. “We’re going to plan for every scenario.”
Vecinos does not accept patients who have health insurance, meaning many people who lose Medicaid could eventually turn to the organization for care. The nonprofit is preparing for that possibility but has not hired additional staff because it remains unclear how much demand will increase.
The organization is also contending with the indirect effects of changes to other public programs. Martínez said cuts to funding for the state’s Healthy Opportunities Program in 2025 have affected partner organizations that previously helped connect uninsured patients with Medicaid enrollment assistance and other services.
Those partnerships helped people navigate the application process and find coverage that could provide access to specialists and hospital care beyond what a free clinic can offer. When partner organizations lose funding, those services can disappear, too.
“Just because we don’t accept people with insurance, it doesn’t mean that we’re safe from any changes,” Martínez said. “It just affects us in a different way.”
Separate changes to the federal government’s public charge policy , which took effect Sept. 18, are adding to immigrants’ concerns about seeking benefits. A public charge is someone who immigration officals believe will depend of the government for support, according to immigration nonprofit USA Hello. Whether someone is considered a public charge can impact their Green Card application.
Under the revised policy, according to Pisgah Legal Services, immigration officials can consider a broader range of public benefits, including Medicaid, when evaluating certain applications for lawful permanent residency, commonly known as Green Cards.
The policy does not automatically classify someone as a public charge simply because they or a family member receives Medicaid. Rather, it gives officials discretion to consider benefit use when reviewing certain immigration applications, including some family-sponsored and employment-based applications.
The rules do not apply to every immigration pathway. People pursuing certain humanitarian forms of relief, including asylum, are not subject to the [public charge test]. The implications for someone who already has a green card can also differ from those facing an initial application for permanent residency.
That distinction can be difficult for families to navigate, particularly when they must make healthcare decisions before knowing what their future immigration circumstances will be.
Barton described how this affects the community using a hypothetical scenario. Consider a student on a visa who becomes pregnant and qualifies for Medicaid, Barton said. If this student hopes to obtain permanent residency through an employer after graduation, she may worry that using Medicaid to pay for prenatal appointments, medical scans, and childbirth could negatively affect a future green card application.
Barton said attorneys cannot reliably predict how an immigration official might evaluate an individual case under the revised policy. The result is a decision that can pit immediate health needs against uncertainty about a family’s future.
For that reason, Pisgah Legal Services encourages people to seek individualized legal guidance rather than assume that receiving Medicaid will automatically harm an immigration case — or that it carries no potential implications.
Barton said the uncertainty is itself a significant part of the problem. Even people who remain eligible may avoid applying for coverage because they fear that accepting assistance could jeopardize their immigration status.
The fear can affect entire households, including children who remain eligible for coverage under the new Medicaid rules.
Martínez said the broader climate surrounding immigration can discourage people from seeking services even when they have a legal right to them.
“It doesn’t really matter if people are losing health insurance or not,” she said. “What matters is they’re not signing up for it.”
Pisgah Legal Services is offering free, confidential assistance to immigrants trying to understand the Medicaid changes and how public benefits could affect their immigration circumstances. The organization can also help people determine whether they remain eligible for coverage, explore available alternatives and address concerns about benefits that may have been terminated incorrectly.
Barton emphasized that eligibility and immigration consequences depend on individual circumstances, including a person’s immigration status, health, age, and potential pathways to permanent residency.
People who need help can contact Pisgah Legal Services at 828.253.0406 or apply online at pisgahlegal.org.
The organization will also host a free online information session about Medicaid changes and public charge issues from 7-8 p.m. Sunday, Oct. 18. The session is open to the public and available at tinyurl.com/18octubre26 .
For families facing the loss of coverage, the immediate challenge may be finding a way to pay for medical care. For others, the challenge is determining whether they can safely seek help in the first place.
As local healthcare organizations prepare for the possibility of increased demand, advocates say making accurate information accessible will be critical to ensuring that eligible families do not forgo coverage out of fear or confusion.