“Flooding the Zone:” Health Care Edition
In The Know with Indivisible CLT
By Galen Smith
Several health care issues pose significant challenges for the U.S. in general and North Carolina in particular. These challenges relate to Affordable Care Act premium increases, potential tariffs on pharmaceuticals and vaccination distrust. Some refer to the chaotic onslaught of challenges created by the Trump Administration as “flooding the zone.” * It is important to bear in mind that these issues rarely stand alone in a vacuum but are related to other policy decisions. For example, changes in vaccine policies implemented since January 20th are often related to the turbulence and resulting “brain drain” that occurs when government agency experts are randomly dismissed without legitimate cause. And it’s difficult to discuss tax credits impacting the health insurance premiums for individuals enrolled via the Affordable Care Act (ACA) without considering the role that Medicaid expansion may have played in determining ACA enrollment and eligibility in the first place.
Background: Beginning January 1, 2026, Affordable Care Act (ACA) marketplace subscribers will face substantial increases in out-of-pocket health care expenditures. The increases result from the following: (1) increases in the cost of health insurance premiums and/or, (2) expiration of enhanced premium tax credits that were originally established by the American Rescue Plan during the COVID pandemic. These tax credits were renewed in 2022 by the Biden Administration’s Inflation Reduction Act. The debate over whether to extend the ACA premium tax credits into the future was central to the recent federal government shutdown.
Who is affected: Approximately 24 million Americans enrolled in the ACA federal and state marketplaces.
Possible consequences: The expiration of enhanced premium tax credits is estimated to more than double what subsidized enrollees currently pay annually for premiums. Projections indicate that 7.3 million Americans currently enrolled in the ACA marketplaces would choose to not enroll in 2026 if the enhanced premium tax credits expire. Of that number, 4.8 million could become uninsured.
N.C. impact: Nearly 157,000 North Carolinians would lose their health insurance coverage altogether and an additional 888,000 North Carolinians would see their monthly premiums double. As loss of income forces health providers and other businesses to reduce their workforces, failure to extend the enhanced premium tax credits is projected to cost 6,900 North Carolina health care related jobs. Additionally, an increase of $3.2 billion in uncompensated care to health providers (hospitals, physicians, prescriptions, and others) is forecast to occur between 2025-2034 due to a combination of expired premium tax credits and enactment of the One Big Beautiful Bill.
Update: Although the government shutdown has been resolved, the fate of extending the enhanced premium tax credits to ACA subscribers is still in doubt. Congress is slated to address this issue once again in mid-December as part of the shutdown resolution agreement. The situation remains fluid and warrants frequent monitoring by interested parties.
Pharmaceutical tariffs
Background: The Trump administration originally proposed 100% tariffs on imported brand name drugs to begin on October 1, 2025. This proposal was placed on hold as several high-profile drug deals have been negotiated with various drug manufacturers on an individual case-by-case basis. However, the possibility of pharmaceutical tariffs continues as part of the Administration’s ever evolving tariff policies. The proposal exempted:
Generic drugs which account for the vast majority of prescriptions issued in the U.S.,
Drugs manufactured by drugmakers that have a U.S.- based pharmaceutical manufacturing plant for which ground had been broken or was currently under construction,
Ten drugs with negotiated prices for 2026 between Medicare and pharmaceutical manufactures authorized by the Biden administration.
The October 1st date for implementing the tariffs coincided with the deadline for committing to Trump’s “Most Favored Nation” executive order requiring companies to sell their drugs to the U.S. at the lowest price that they sell around the world. However, the tariffs were placed on hold when drug manufacturers such as Pfizer and AstraZeneca negotiated their own deals.
Who is affected: The tariffs remain paused, so no one is currently affected. However, all consumers who have been prescribed imported brand name drugs manufactured by companies that do not have a U.S. “presence” (see “Exemptions” above) might be impacted.
Possible US and NC consequences: If these tariffs become a reality, brand name drugs – which are usually more expensive due to the lack of generic competition – are likely to become even more costly. Among the drugs that may be affected are several biopharmaceutical drugs manufactured by small biotech firms located overseas. These smaller firms are more likely to have to pass the costs of tariffs to consumers due to smaller profit margins than larger firms. Ultimately, the burden for determining an individual’s exposure to potential tariffs falls on the patient – based on their insurance plan coverage – and their health care providers.
Trump Vaccine Policy Confusion
Background: Most of the confusion and controversy surrounding current vaccine policy centers on the influenza, MMRV (Measles, Mumps, Rubella, and Varicella), COVID-19, and Hepatitis B vaccines. Consider the following events occurring in 2025:
March: FDA’s Vaccines and Related Biological Products Advisory Committee (VRBPAC) canceled its meeting to publicly discuss the strains of influenza to include in the 2025-2026 formulation. Instead, the FDA advanced their recommendations without the “sunshine” of public transparency.
September: Changes to the MMRV and COVID-19 vaccination regimens were approved by the Advisory Committee on Immunization Practices (ACIP) – most of whom are vaccine skeptics and embrace scientific misinformation – and forwarded to the CDC for adoption. Changes to the current evidence-based guidelines of administering Hepatitis B vaccine to newborns could occur at ACIP’s December 4th meeting.
September – October: West Coast Health Alliance (WCHA) and the Governors Public Health Alliance were created over concerns of federal guidance shifts and to counter what they describe as the politicization and misinformation from the federal government.
Who is affected: These factors all serve to create confusion for everyone, especially parents, educators, and health practitioners.
Possible consequences: Confusion among the various stakeholders increases fear and loss of trust in what was once reliable. This will result in distrust of vaccinations and lead to reduced usage, leaving people – especially children – more vulnerable to preventable diseases. Conflicting guidance from the federal government and the state health alliances may lead to both state-to-state variability in vaccine supply and insurance coverage gaps.
N.C. impact: The chaos created by these shifting policies has resulted in limiting access to the COVID-19 vaccine. North Carolina pharmacies – restricted by law to adhering to ACIP guidelines – can now only provide the vaccine to:
Adults 65 years of age or older,
Individuals older than 6 months who have a qualifying pre-existing condition, or
Individuals with a prescription.
Lost trust in vaccines may result in increasing cases in North Carolina of measles and whooping cough. At present, only one case of measles has been reported in North Carolina in 2025; this is only the second case since 2018. However, there have been 46 cases of measles reported in South Carolina since July 9th. The vast majority of these cases were centered around Spartanburg County, which borders North Carolina – and increases the possibility of a regional outbreak within North Carolina. Finally, vaccine confusion that suppresses vaccine usage may be especially relevant to whooping cough vaccinations in the face of a surging number of whooping cough cases in North Carolina.
ACA References:
Congressional Stalemate Creates Chaos for Obamacare Shoppers
Experts Weigh in on Fight Over Obamacare Premium Tax Credit Extension
Expiring ACA Premium Tax Credits Could Lead to Nearly 340,000 Jobs Lost Across the U.S. inn 2026
Impacts Of Changing Federal Policy on Insurance Rates and Access to Primary Care
Handful of Senate Democrats Join GOP to Break Funding Stalemate, First Step Toward Ending Shutdown
Tariff References:
Trump’s Prescription for Confusion: How A Push for Tariffs Complicated His Pharma Talks
The 100% Pharma Tariffs is on Hold. What Could This Mean for Your Drug Costs?
Vaccine References:
Health Experts Sound Alarm as FDA Cancels Key Vaccine Meeting
After Canceling Meeting of Independent Advisers, FDA Issues 2025-26 Flu Vaccine Recommendations.
Experts Dissect What Confusing New Vax Rules Mean for Kids, Parents and Schools
Federal Vaccine Guidance Changes Cause Confusion, Frustration
Whooping Cough Surges in North Carolina; Fading Vaccine Immunity Likely Plays a Role
Vaccine Advisory Panel Set to Revisit Hepatitis, Other Childhood Shots Next Month
* For challenges related to Medicare and Medicaid created by the One Big Beautiful Bill, refer to our September 2025 In the Know article: One Bad Brutal Boondoggle: The One Big Beautiful Bill & NC Part 1 Affordable Care Act Enhanced Premium Tax Cuts.
Please check out all our past “In the Know” articles, included in our Indivisible CLT newsletters!
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