Key Takeaways:
- Democrats are poised to take control of the N.C. House for the first time in 15 years.
- Health care affordability, rural access and Medicaid are emerging as legislative priorities.
- A divided General Assembly could shape how far the incoming majority can advance its agenda.
By Ashley Fredde
For the first time in 15 years, Democrats are poised to control the North Carolina House of Representatives — a political shift that should reshape the state’s approach to health policy.
Rep. Robert Reives (D-Sanford), the presumptive new House speaker, spoke about several health care priorities for the incoming majority during a news briefing this past week. He pointed to rising medical costs, dwindling access to rural providers and changes in the federal Medicaid system as issues the incoming majority wants to address.
The shift comes as North Carolina’s health care system faces mounting pressure from new federal requirements that could jeopardize Medicaid coverage for hundreds of thousands people who’ve recently enrolled and from continued gaps in rural health care access.
Even with a sizable majority in the House, how much Democrats can accomplish remains uncertain. Unofficial election results indicate that Democrats will hold 71 seats in the 120-member chamber, compared with 48 Republicans and one unaffiliated lawmaker. Republicans appear poised to retain a narrow majority in the Senate, meaning legislation will require cooperation not only between the two parties, but also the two chambers — which is always a tall order.
Reives, who has been House minority leader for several terms, acknowledged that the Democrats have a limited window to pursue their priorities before lawmakers face voters again in 2028.
“Our reality is, for 15 years, I’ve not agreed with everything that’s happened,” he said. “We’ve got two years to correct what we feel are 15 years of missteps in other areas.”
As the dust of the whirlwind midterm election has settled, Reives outlined several priorities while adding that the caucus has not settled on a legislative agenda. With a number of new members joining the House Democratic majority, he said he intends to listen before determining which proposals to pursue.
“I’ve got 22 brand new members who have 22 ideas, and they’ve all been very clear about making sure I knew those ideas over the last couple of days,” he said.
The House Democratic Caucus is expected to meet next week to organize its leadership ahead of the 2027 legislative session, and current House and Senate members will return for a lame duck session.
Health care affordability and rural access
Reives said health care affordability is at the top of the list for voters and for the incoming majority.
“Health care costs are out of control,” he said, and “health care availability in a state that is 80 percent rural has become increasingly terrible.”
He pointed to the challenges pregnant women in rural communities face, including traveling long distances for maternity care. Some women have to drive up to an hour and half to see an obstetrician or gynecologist — and distance to care for rural obstetric patients has been linked to higher rates of cesarean sections, preterm births and maternal complications.
That kind of distance has been a long-standing problem in North Carolina, where rural hospital closures, workforce shortages and the loss of labor and delivery services have left some communities with fewer options for getting care close to home. For pregnant women, those gaps also mean it’s harder to get specialized care and that there’s greater risk when emergencies arise.
Reives framed access to affordable health care as one of several basic conditions necessary for North Carolinians to achieve financial stability, alongside education, employment and the cost of everyday necessities.
“There is no reason that the richest country in the world, in the richest civilization in the world, at the richest time in history, has most of its people trying to make a decision between buying prescription medicine, and getting health care, and paying off their mortgage,” he said.
While he was careful not to identify specific legislation or a particular approach to medical expenses, he emphasized that the incoming majority should focus on solutions that provide lasting relief over short-term savings.
“I don’t want a temporary reduction in health costs,” Reives said. “I want a consistent and permanent reduction.”
Medicaid and the federal policy landscape
Medicaid could also be a priority for the incoming House majority as North Carolina prepares to implement sweeping changes mandated by the federal program.
Reives criticized the state’s delay in expanding Medicaid, which took effect in December 2023 after more than a decade of legislative debate. Since expansion began, more than 700,000 additional North Carolinians have gained coverage through the program, which provides health insurance to eligible low-income residents, children, pregnant women, older adults and people with disabilities.
In July, lawmakers passed legislation to align with the changes to Medicaid outlined in the federal budget reconciliation law enacted in 2025, commonly known as H.R. 1 or the One Big Beautiful Bill. The law created new Medicaid work and reporting requirements, more frequent eligibility checks for some beneficiaries, and other changes that are expected to reduce federal Medicaid spending over the coming decade — in no small part by people dropping off the program as they fail to fulfill eligibility requirements.
Those provisions place new responsibilities on states and could lead some eligible beneficiaries to lose coverage if they cannot meet or document compliance with the requirements.
The party shift in the North Carolina House could open the door to changes in the state law, which ruled out beneficiaries being able to self-attest their eligibility for exemptions. The outgoing legislature also set a requirement for beneficiaries to prove they met the work or activity requirement for at least three of the six months preceding each redetermination instead of the one month required by H.R. 1.
Reives said that state lawmakers should look for ways to mitigate the effects of the federal changes.
“I think we have an obligation as a state to fight the terrible health policy that you’ve seen at the federal level, and so every gap that we can fill, we should do so,” he said.
When asked about work requirements, Reives stated that debates over eligibility often overlook the circumstances of people who have spent much of their lives working but later need assistance in obtaining health care.
He pointed to his uncle who worked for decades, including 35 years in a brickyard, and who recently had two hip replacement surgeries. His uncle, Reives said, represents a large portion of those who rely on government health coverage.
“As a person who probably spends more time around people who fall into the Medicaid gap — nothing was more offensive to me than to sit in a building full of people who have inherited millions, who have got tons of wealth, who have retired from successful jobs, judging people that needed help with health care,” Reives said. “Because I know those people.”
As federal policy changes reshape the state’s spending obligations for Medicaid and other safety-net programs, lawmakers could face questions about how to sustain existing health initiatives as federal support decreases. As those cuts roll into effect in the coming years, Reives noted that lawmakers will need to be clear with constituents about how policy decisions affect how — or whether — they get care.
“When you don’t talk to people and explain to them what they’re losing, or what is actually the effect of a law, then you get misconceptions,” he said.
That clear communication will also have to reach across the aisle and across the chamber, he added. While the election has changed the balance of power in the House, the Democrats will still need to negotiate with Republicans in the Senate to turn their priorities into law. Reives signaled a willingness to work with the GOP, noting several areas of opportunity for bipartisan legislation.
“For 15 years, Republicans have controlled the General Assembly — and throughout that time we have worked with them when we could, and we push back when appropriate. That’s not going to change,” Reives said. “Compromise is not capitulation. Compromise is the job. That was true then, that is true today, and that will be true in January when the gavel passes.”
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