Inside the Politics of Health: A Conversation with Dr. Chris Cooper
Image via Dr. Chris Cooper
Health policy doesn’t happen in a vacuum—it’s the product of political negotiation, lobbying, legislation and often a delicate balance of regional interests. On a recent episode of the WNC Health Policy Initiative Podcast, we had the opportunity to sit down with Jackson County’s own Dr. Chris Cooper, Robert Lee Madison Distinguished Professor and Director of the Haire Institute for Public Policy Western Carolina University at Western Carolina University, and author of Anatomy of a Purple State, to take a deeper look at the dynamics shaping health policy in North Carolina today. In this article, we explore the current background and landscape of health policy in North Carolina touched on by Dr. Cooper, as well as review some of the relevant legislation coming up on the NC General Assembly’s consideration in the coming months.
Understanding the Health Policy Landscape of North Carolina
North Carolina Politics in a Nutshell
North Carolina operates amidst tensions between the Republican-led House and Senate, who despite working for the same party often have significant disagreements on issues of funding and policy design. This tension was a factor in the slow adoption of Medicaid Expansion, and is currently contributing to the delayed state budget. The absence of a full budget has resulting a hiring freeze and leaves some health policy funding in a state of limbo. Included in this latter category is the Healthy Opportunities Pilot, which in WNC is overseen by network lead Impact Health, and has been a project of national interest due to the cost savings, improved health outcomes and other regional benefits reflected in its recent evaluation. See WNC HPI podcast episode 10 for a breakdown of the evaluation’s findings.
In our conversation with Dr. Cooper, we discuss several state bills that may be on the budgetary table, and what their benefits for North Carolina would be. For example, H433 would allow new school nurses with certain backgrounds to be paid at a higher rate than previously, a strong strategy for recruitment and retention. H455/S370 is another item of significant interest to those looking to expand access to healthcare. The bill would repeal NC’s long-standing Certificate of Need law, which requires providers to gain approval from the NC Department of Health and Human Services before they can build new facilities. Passage of this bill could allow more specialization in our remaining WNC hospitals and increase the number of facilities in our region.
NC’s Medicaid Expansion…and Possible Contraction
One of the biggest policy issues in the mix in North Carolina is Medicaid Expansion. Two Western North Carolians, Casey Cooper (CEO of Cherokee Hospital) and Sen. Kevin Corbin (R) of District 50, were influential in the state’s movement adoption of Medicaid Expansion. While expansion has led to many positive impacts in WNC, both economically and in terms of health outcomes, the dynamics between the state and federal legislation creates a tension that could put the increase in healthcare coverage gains the state has achieved at risk.
The H.R.1. budget bill, aka the “One Big Beautiful Bill Act” (OBBA), potentially puts some 650,000 North Carolians in the expansion population at risk of losing their healthcare coverage over the next couple of years due to a “trigger” clause in NC’s expansion law. This clause gives the state the option to shut expansion down should the federal funding contribution drop below a specific threshold, which the OBBA would likely do. It also removes non-citizens from eligibility and puts onerous and potentially unmanageable work and re-enrollment requirements on beneficiaries that could result in folks losing coverage despite being fully eligible. An especially concerning provision of HR1 prevents anyone who loses Medicaid coverage due to these burdensome reporting requirements from subsequently accessing subsidized ACA Marketplace plans, making the risk of failing to qualify especially punitive. To regain health care coverage, individuals must reapply for Medicaid and meet the requirements, or reapply for Marketplace coverage during the next open enrollment period. But they will not be able to receive financial assistance, aka premium subsidies, to do so. Considering that many counties in NC have little to no infrastructure, staffing or funding to support this additional reporting, and that the state is having to create these structures almost from scratch, it is virtually guaranteed that thousands will fall through the health care coverage cracks as these systems fail, or simply end up being too complex and glitchy to navigate.
The delay of many these cuts and provisions until after the midterm elections in 2026 is designed to distance the negative impacts from state legislators who supported it (including Sen. Chuck Edwards and several House Representatives from North Carolina).
So far, no clear state policies to preemptively protect those at risk of losing Medicaid and other healthcare coverage due to the OBBBA are on the table. Our recent conversation with Pisgah Legal Services in Episode 15 offers more insight into the impacts those cuts are already having and will have on WNC residents, for those who want to dive deeper.
The Power of Lobbying
Federal powers stand to shape much of North Carolina’s health policy direction in the coming years. But lobbying is another influential factor in the design of our policy landscape. In addition to financial contributions, lobbying is one of the primary means legislators rely on to gain information on issues they’ll be voting on. As a result controlling a large part of the “informational pipeline” feeding into our legislature, lobbying plays an outsized role in directing policy outcomes that impact our region, state, and nation. To learn who is likely to benefit financially from a particular health policy bills, you can visit the NC Secretary of States’ website here and look at the ‘principals’ to see who is sourcing our legislators’ information.
Learn More: Health Policies of Interest in NC’s 2025-2026 Session
Below is a brief summary of some of the bills up for consideration in our state’s current legislative session.
H433 “Registered Nurses in Schools”
Registered nurses with hospital or clinic experience are now eligible for higher pay scales when hired into school nurse positions—a move aimed at improving recruitment and retention. The law also lowers barriers to entry by removing the requirement for a four-year degree in certain cases, making it easier for experienced RNs to enter the school system. To promote consistency, the State Board of Education is tasked with setting uniform rules around qualifications and pay. However, the changes apply only to new hires or contracts, meaning current school nurses won’t automatically see pay increases unless their roles are reclassified or renewed under the new guidelines.
H434 “Lower Healthcare Costs” / “The CARE FIRST Act”
A bill that tightens regulations on insurance companies' review processes, appears to give more power to medical professionals, and may improve transparency and patient protections—especially for people with chronic conditions or needing urgent care. A version passed both the house and the senate and are in a committee to resolve differences.
H455 “Repeal Certificate of Need Laws”
House Bill 455 is the companion legislation to S370, also aiming to eliminate CON laws across the state. Introduced in March 2025, it mirrors the Senate’s efforts to deregulate healthcare facility growth and reduce bureaucratic barriers. The bill passed its first reading and is currently under review in the House Rules Committee. If passed, it would mark a major shift in how healthcare infrastructure is developed in North Carolina.
H672 “Physician Assist. Omnibus/Team‑based/Compact”
If it passes and becomes law, there will be changes in what PAs can do in “team‐based” settings, expanded cross‑state practice via the compact, and more autonomy under defined conditions. As of now, it has not yet passed and is still pending in the House Health committee
H681 “Update Opioid Abatement Treatment Prog. Rules”
This bill may improve opioid treatment by making care more flexible and patient-focused, removing barriers like strict counseling schedules and harsh discharge rules—helping more people stay in treatment. It is under review in the senate.
H682 “Public Safety Through Food Access Act”
If passed, this law would allow people with drug felony convictions to access food assistance and Temporary Assistance for Needy Families benefits earlier and with fewer restrictions—mainly by linking eligibility to doing substance abuse treatment, rather than being automatically banned. However, tt’s not law yet — it’s still under consideration in the North Carolina House.
S370 – “Repeal Certificate of Need Laws” (see H455, above)
Senate Bill 370 seeks to fully repeal North Carolina’s Certificate of Need (CON) laws, which currently require healthcare providers to get state approval before opening or expanding certain facilities or purchasing major medical equipment. Supporters argue it will increase competition and access, especially in rural areas, while critics warn it could lead to oversaturation and undermine existing hospitals. The bill passed the Senate and is now in the House, where it's been referred to the Rules, Calendar, and Operations Committee.
Get Engaged
Want to weigh in on the issues that matter to you? You can connect with your elected leaders to express your views on these or any other proposed legislation at the links below:
✅ Policy Pro-Tip
The best way to make a lasting impression and get your point across is to share your own personal story! Whether it’s a phone call, and email or a letter, these are the stories that matter most to policymakers, and can make a real difference in how they think about the policies they’re called to take action on. Here are three tips to make the biggest impact:
Make it personal: Tell your representatives how these issues are impacting or will impact you, your organization and/or your community. Share real-life stories, examples, and concerns, either from your own experience or the experiences of those you represent. When appropriate, you can also share your ideas and recommendations about best practices, improvements or alternative policies that would do the most good in those situations.
Make it memorable: Original, authentic communications from individuals or groups will be far more meaningful than a 1000 versions of the same “copy-paste” email or petition. The former help put a real face on the policies impacting our legislator’s communities, while the latter can often just get filed as a single point of faceless contact on an issue.
Make it concise: Policymakers are extremely busy and have very limited time and attention to spare for any one person or group, so keep your message short, sweet and to the point. Lead with the impact, and save any background, details, and data for afterward, if time permits. You can always follow up with and/or leave behind a fact sheet, flyer, or other detailed information once you’ve given them a reason to want to look deeper.
Disclaimer
This content was developed by the WNC Health Policy Initiative in consultation with people and organizations with connections to the health of people of Western North Carolina. Individual or organizational opinions, findings, conclusions, or recommendations are those of the relevant author(s)/interviewee(s) and do not necessarily reflect the view of the WNC Health Policy Initiative or its host institutions of the University of North Carolina Asheville (UNCA), Mountain Area Health Education Center (MAHEC) or our funders.
