How the Nov. 5 election will shape health policy in the coming legislative session

By Will Atwater, Anne Blythe, Rachel Crumpler, Rose Hoban, Taylor Knopf and Grace Vitaglione 

Even as former President Donald Trump coasted to victory in North Carolina, Democrats maintained control of the governor’s office: Voters cast 160,000 more votes for state Attorney General Josh Stein in his successful gubernatorial campaign than the Republican presidential candidate received. 

This contrast at the top of the ballot played out down the ballot, where early — but unofficial — results show that Democrats eroded Republicans’ veto-proof majority in the General Assembly by one seat in the House of Representatives. 

That could have an impact on how health policy is made in North Carolina during the next two years, since the Democratic governor will have more power to push back against bills he considers flawed or problematic for the state. 

“I think what that’s going to lead to is gridlock,” said Chris Cooper, a political scientist from Western Carolina University. 

So far in this legislative biennium, the General Assembly has passed fewer laws than in previous sessions over the past decade, Cooper noted. But that might be because Republican lawmakers already have achieved many of their political goals.

Republicans had a long to-do list when they achieved legislative majorities in both General Assembly chambers in 2010 — the first time in more than a century. Since then, they have checked off many of their priorities: transforming Medicaid to a system run by private insurance, passing limitations on abortion access, whittling away at hospital certificate of need laws and relaxing regulations. 

Democrats have achieved some health policy wins, too, top among them the expansion of the state’s Medicaid program. 

“With all that said, it is hard to imagine what exactly could be on the list that hasn’t been realized,” Cooper said. 

And with strong likelihood that ballot counting will result in Republican majorities in both chambers of the U.S. Congress, the next two years could be a time of change and instability in health policy at the national level, with downstream effects on states. 

N.C. General Assembly majorities change

Right now, Republicans’ supermajorities in both chambers allow the General Assembly to easily override vetoes made by Gov. Roy Cooper. If Tuesday’s results stand after provisional ballots are counted and the official canvassing takes place later this month, that one extra Democratic vote in the state House means it will be harder for Republican lawmakers to get their way. 

WCU’s Cooper said it’s likely that legislative leadership will call a special session in the coming month to enact policies they might have more difficulty passing next year after Stein gets that one House member to reinforce the strength of his veto stamp.

Rep. Donny Lambeth (R-Winston Salem) confirmed that there’s “a very strong possibility” the next couple of months could be busy ones.

Lambeth said he hopes lawmakers can find common ground on improving access to care, getting rid of siloed care, controlling health care spending in the new year and reducing administrative costs.

“There’s this huge learning curve when folks come into office, or when folks change the scope of their responsibilities, and that won’t be different this time around,” said longtime lobbyist Corye Dunn from Disability Rights North Carolina. 

She said she’s interested to see how a new speaker of the house could affect the relationship between the state House and Senate, and to see what a new speaker’s policy priorities will be. In the past, she said “party affiliation has not brought unanimity.” 

Child care funding

Child care is likely to be a big topic in the next year’s legislative session, Lambeth said. Legislators will likely appropriate money to keep child care centers afloat while working on a longer-term solution to the dropoff in funding created by the end of federal pandemic relief dollars, he said.

“We’ve been looking at ways that we can actually meet some of the child care needs, reduce some of the regulations and increase capacity,” he said.

That could mean modifying the star rating system, an idea that was included in a House budget proposal last session but didn’t make the final cut.

Parents still need a way to see how well centers are doing, Lambeth argued, but the star rating system needs reform.

The election results aren’t likely to change the dynamics around child care advocacy at the legislature because there’s bipartisan interest in the issue, said Michael Cooper, senior director of advocacy at NC Child, an advocacy nonprofit.

“The election is over, but the issues aren’t going away,” he said.

Adequate compensation for teachers and public investment are still needed to address the child care crisis that’s been “years in the making,” said Beth Messersmith, campaign director of the N.C. chapter of MomsRising, a national advocacy group focused on economic security for women, mothers and families.

“The same things that were true yesterday are true today,” she said.

Federal-level funding is also a significant support for child care, Messersmith said, so changes at the federal level could have implications for North Carolinians.

“We can’t talk about state policy in a vacuum,” she said.

One possible federal health policy contained in Project 2025, an initiative led by the Heritage Foundation conservative think tank, proposes eliminating Head Start, a federally funded program that supports development and growth in eligible children from birth to age 5. 

Project 2025’s policies were created as a road map for the next conservative president, according to the website, although Trump’s campaign has worked to distance him from the plan.

Head Start plays “a huge role” for families in the state and is an important part of the child care ecosystem, Messersmith said.

“It would be very short-sighted to eliminate it,” she said.

Aging health policy challenges

Stein has a good track record on supporting older adults from his time in the General Assembly, said Mary Bethel, longtime aging advocate and chair of the Board of Directors for the NC Coalition on Aging. She said she’s optimistic Stein will be receptive to the state Multisector Plan on Aging released in late September.

The aging plan provides a framework for addressing the demographic growth of older adults in North Carolina, she said, with aims to improve home- and community-based services for people who need them, address workforce shortages and help people afford the care they need, among other things.

“If we don’t address these things now — even in the short term it’s going to be challenging — but the long term it’s going to be a huge challenge,” Bethel said.

Aging advocates will need to meet with legislators to make sure they’re aware of the critical needs, she said. 

Rep. Donna White (R-Clayton) is a nurse and aging advocate in the House, and Sen. Jim Burgin (R-Angier) is a strong advocate for health and human services and aging issues in the Senate, Bethel said. Both were reelected by comfortable margins.

Still, the legislature is likely to be leery of committing any funding, said Bill Lamb, aging advocate and member of the executive committee for Friends of Residents in Long Term Care. Support for the direct care workforce may be an opportunity for a bipartisan effort, he said.

“Our health systems, hospitals, nursing homes, home care — all of that’s going to be a crisis if we can’t respond to developing and expanding the workforce,” he said.

Just as with child care, some federal appropriations that come to the state are vital for older adults, such as the Older Americans Act, Bethel said. If the Trump administration scales back federal funding in those areas, there could be major implications for older people.

The administration may also strike down the recent Biden administration’s staffing requirements for nursing homes, Lamb said. 

Oversight of long-term care facilities at both the federal and state level could be “soft,” he said, as the state legislature isn’t likely to expand appropriations to the Division of Health Services Regulation and therefore may decrease the department’s capacity.

Project 2025 also proposed increased privatization of Medicare, such as making the default enrollment option Medicare Advantage plans, or a Medicare-approved plan from a private company. A little over half of North Carolina’s 2.2 million Medicare enrollees are in Medicare Advantage plans.

But Jon Oberlander from UNC’s Gillings School of Global Public Health said any changes made to the popular program would come at great risk to lawmakers. 

Medicaid, health insurance funding at risk?

Even as Oberlander thought that Medicare funding was likely safe, he speculated that funding for Medicaid — which covers low-income children, some of their parents, people with disabilities and low income seniors — could be at risk. 

Oberlander said there’s a strong chance that a Republican Congress will want to extend the tax cuts that went into effect in Trump’s first term, and that would require cuts elsewhere. 

“It’s hard for them to make the budgetary math work without Medicaid cuts,” he said. 

Since North Carolina expanded Medicaid in 2023 to cover low-income adults, the program’s rolls have swelled to more than 3 million beneficiaries in the state. Nationwide, Medicaid now covers some 72 million people. 

And while repealing the Affordable Care Act was not part of the health policy conversation on the campaign trail, Trump and Congress may target the Biden-era insurance premium subsidies that allowed for a record 21.4 million Americans to get covered through the ACA this year. 

“On the one hand, you would think, ‘Yeah, there’s no way they’re going to extend them. Why would they do something to support Obamacare when they haven’t in the past?’ They can strike a blow against the ACA by simply doing nothing,” Oberlander said. “On the other hand, if they let those subsidies expire in an election year, no less, for the midterms, in an instant, they’re going to make health insurance more expensive for millions of people.” 

Including 1,027,930 people in North Carolina who bought insurance through the ACA marketplace last year.

“They’re onto some really politically risky terrain there, if they’re going to go down that road,” he said. 

In sum, Oberlander said, there could be major changes that transform Medicaid, transform the Affordable Care Act and have downstream effects on states.

“And I don’t think that was necessarily clear during the election. I think people are about to discover it,” he said. 

What about abortion access?

North Carolina Republican lawmakers passed a stricter abortion law last year, shrinking abortion access in the state from 20 weeks of pregnancy to 12 weeks. 

Some Republicans on the ballot this year — including Mark Robinson and Dan Bishop, who both lost — had expressed a desire to roll back abortion access further in the state, but more restrictions imposed by the state legislature seem unlikely with Stein, an abortion rights supporter, taking office. 

And with the House supermajority gone, Republicans won’t be able to steamroll policy over a gubernatorial veto — the mechanism used to enact Senate Bill 20’s increased abortion restrictions.

But Trump’s win, and the Project 2025 agenda that outlines many strategies to limit abortion access, could bring more restrictions at the federal level that affect physicians and patients in North Carolina. 

The plan, for example, recommends revoking the abortion pill mifepristone’s U.S. Food and Drug Administration approval, despite multiple studies that have reaffirmed the medication’s safety. Mifepristone was used in about two-thirds of abortions in the state in 2021, and that number has likely climbed in the wake of last year’s ban.

For Jenna Beckham, an OB-GYN and abortion provider in the Triangle, the state-level results give her some ease about continued abortion access in the state, though there’s new uncertainty at the national level. 

In anticipation of election results, Beckham said she saw increased anxiety from her patients and thinks those feelings are only going to continue. She said the looming fear of reduced reproductive health access has led some of her patients to delay or forego pregnancy. Others have sought long-acting contraception or to have their IUD exchanged even if it technically wasn’t expired because they were afraid they wouldn’t get a new one. Some have even sought surgical sterilization.

“We shouldn’t have to be going through this every two to four years of having to think again, ‘Well, what’s going to happen this time, and how drastically might things change?’ Our medical care should not be so fragile or so vulnerable to the whims and moods of whoever’s in power versus who’s not.”

Can environmental health policy move?

Mary Maclean Asbill, director of the Southern Environmental Law Center’s N.C. office expressed cautious optimism about the future of environmental initiatives at the state level due to newly elected Gov. Josh Stein.

“We expect the environmental and health agencies to have great leaders appointed by Governor Stein, so that’s encouraging,” she said. “We still have the recent legislative laws that change the appointment power on all the various boards and commissions. So we still have those roadblocks, but overall, we’re looking forward to working with this governor and a strong [attorney general].”

Legislative environmental champion Rep. Pricey Harrison (D-Greensboro) agreed that there is an opportunity for progress in the General Assembly that wasn’t there before this week’s election.

“Now, one vote isn’t a lot of cushion, and I know that the speaker in the past has called it an effective supermajority,” she said. “But it does give some negotiating room.” 

Emily Donovan, co-founder of Clean Cape Fear, a group looking to hold PFAS polluters accountable, is also mindful of the positive signals that came from the state elections. 

“It’s definitely a better environment than the last couple of years. That’s a positive, and it’s a positive that we have agreeable administrators,” she said.

“I still think this is a bipartisan topic, especially in southeastern North Carolina,” she said, noting the fight over PFAS has lasted almost a decade. “The ones that are going back to Raleigh from our area have failed to get things fully accomplished to the level that we feel our community deserves.”

Oral health

In an interview with NPR’s Steve Inskeep the morning after the election, Robert F. Kennedy Jr., a member of Trump’s transition team and quite possibly a member of the administration, said an early priority for the 47th president would be to recommend a health policy of removing fluoride from drinking water.

Fluoride has long been touted as a prominent 20th century public health achievement — an effective tool in lowering tooth decay in children and adults.

The North Carolina Dental Society, which represents about 4,000 dentists, supports the use of fluoride in community water as “safe and effective.” The society’s website notes that fluoride resulted in a 25 percent to 30 percent reduction in dental decay in communities using it.

Kennedy’s push to ban fluoride from local water supplies has prompted swift pushback from oral health providers and municipal officials.

Terry Mahaffey, an Apex Town Council member, posted this to X: “The Town of Apex will not remove fluoride from our water while I am a Council Member, I don’t give a shit what RFK Jr says.”

Despite the criticism, several North Carolina counties have embraced the idea and already engaged in contentious debate about the benefits and potential side effects of fluoride. The Union County board of commissioners voted in February to ban fluoride in the water supply. Stanly County commissioners also have discussed the proposal. 

It remains to be seen, though, whether they’ll be outliers or trendsetters.

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