The federal government is considering cuts to the Medicaid program, a joint federal and state initiative, which could have far-reaching consequences.

Proposed changes include per capita caps, reductions in state flexibility, work requirements and cost-sharing benefit reductions.

As of May, Medicaid enrollment for the state of North Carolina across all programs, both traditional and expansion, was 3.1 million individuals, representing roughly 28.1% of the state’s population.

The changes will have uneven consequences as there are significant differences in reliance on federal programs across the state.

At the local level, Medicaid enrollment is as follows: 34,979 people in Brunswick, 48,316 people in New Hanover and 18,397 people in Pender.

There is significant variation in sources of health insurance by area due to factors such as industrial composition, demographics and other economic drivers.

Take Brunswick and New Hanover counties, which are part of the same metropolitan area but have vastly different sources of health coverage.

Data from the Census Bureau’s American Community Survey shows that in Brunswick County, 63.4% of residents have only one type of health insurance coverage, compared to 72.9% in New Hanover County.

Employer-based insurance (ESI) alone is more common in New Hanover, covering 43.3% of residents versus just 31.8% in Brunswick.

Similarly, direct-purchase plans are slightly more prevalent in New Hanover (10.7%) than in Brunswick (8.8%).

Importantly, Brunswick County has a higher reliance on public coverage, especially Medicare. The two counties have roughly similar shares of the population on Medicaid (10.9% in New Hanover and 9.7% in Brunswick) residents are covered by Medicaid alone.

The most significant difference between the two counties is in terms of Medicare coverage. Due to Brunswick County’s older population (median age of 62), 11.8 % of its residents have Medicare-only coverage, compared to 6.7% in New Hanover, where the median age is 40.1.

There are also important differences between the two counties in the number of residents with two or more types of insurance: 30.1% in Brunswick, nearly double New Hanover’s 18.1%, which suggests a higher rate of dual eligibility for programs like Medicare and Medicaid, and retirees who maintain private insurance.

In terms of uninsurance, Brunswick has a higher uninsured rate at 12.6%, compared to 10.1% in New Hanover.

Why does this matter?

The variation in public coverage across the counties indicates that changes in federal policy may have uneven effects, and the ripple effects will look different from one county to the next. Therefore, it will be important to understand how access, affordability and economic activity will be impacted at the local level.

 Mouhcine Guettabi is a regional economist with UNCW’s Swain Center and an associate professor of economics at UNCW’s Cameron School of Business.