Health Policy Issues to Watch in 2026
Key Takeaways
- In 2026, state vaccine policy is diverging as some states form alliances or enact legislation to replace federal guidance, while others move to roll back school vaccine mandates and emphasize parental choice.
- States are preparing to implement the rural health transformation program, with $50 billion in funding driving legislative changes around licensure compacts, certificate of need, and scope of practice to improve rural healthcare delivery.
- PBM reform legislation in states is expected to continue in 2026, with bipartisan support for transparency and licensure requirements, though more aggressive measures like delinking and pharmacy ownership bans may face resistance.
- Medicaid work requirements in states and six-month renewal processes will be a major focus for Medicaid agencies in 2026, as states respond to new federal mandates and significant reductions in federal Medicaid funding.
Healthcare Issues to Watch in 2026
State Vaccine Policy Shifts and Federal Guidance Changes
As federal vaccine guidance becomes more variable, we are seeing more states assert authority over vaccine policy. In late 2025, several states formed regional or state-based collaboratives or alliances to coordinate vaccine guidance and procurement, while others enacted legislation to replace federal recommendations with state-based or professional association advisories or to authorize state officials or agencies to issue vaccine guidance. Conversely, some states may align with federal guidance and seek to roll back school vaccine mandates, lift vaccine requirements, and emphasize parental choice through legislative or regulatory action. Early signs of this approach have emerged in Florida, where the Department of Health initiated the development of rulemaking regarding school immunization requirements after the Surgeon General Joseph Ladapo announced his intention to get rid of vaccine mandates.
Rural Health Transformation Program Implementation
At the end of December, the Centers for Medicare & Medicaid Services (CMS) announced funding awards for the Rural Health Transformation Program (RHTP). The $50 billion in funding is split across five years, with 50% of the funding distributed equally among states, and the other 50% is allocated based on individual state metrics, policy actions, and initiatives. States will begin to operationalize their RHTP plans in 2026, with many states engaging in discussions on the distribution of the funds. In addition, state policy was a factor in the application, leading several states to commit to legislative and regulatory changes around certificate of need, licensure compacts, and scope of practice to boost their application. Notably, North Dakota, which does not meet in regular session this year, is planning a special session starting next week to approve the funds and consider legislation related to pharmacist scope of practice, the physician assistant licensure compact, nutrition continuing education for physicians, and the presidential physical fitness test in schools.
Pharmacy Benefit Manager Reform Legislation Continues
States accelerated legal and regulatory action in 2025 to curb perceived pharmacy benefit manager (PBM) practices affecting independent pharmacies, rebate transparency, and linking PBM profit to drug list prices. While approaches differed, 2025 produced several notable enactments. In 2026, states are expected to continue experimenting with reform legislation. There will be bipartisan support for increased transparency and licensure requirements, while some states may be more cautious in pursuing more aggressive measures, such as delinking and pharmacy ownership bans that face sustained litigation and strong industry opposition.
Medicaid Changes Under Federal Revenue Cuts
There was robust activity by states in 2025 on Medicaid reform and policy, but nothing was more influential than the sweeping federal Medicaid changes enacted under the One Big Beautiful Bill Act (OBBBA). Over the next decade, states will be dealing with new federal requirements and the loss of over $1.02 trillion in federal Medicaid revenue. In 2026, the administrative implementation of Medicaid work requirements and six-month renewal processes for the expansion population will dominate much of the work for Medicaid agencies, which may require additional resources from the state. Meanwhile, legislatures may consider cost-saving interventions as they consider near-term and long-term impacts of federal revenue losses. Such interventions could include cuts to provider rates, more restrictive eligibility, and/or reduced benefits coverage. For instance, Colorado has already opted to freeze expected reimbursement rate increases and reinstated certain prior authorization requirements for outpatient behavioral health services as mechanisms to reduce costs.
Track Health Care Policy
The ever-evolving state health policy landscape will continue to influence how health care organizations make business decisions. MultiState’s team pulls from decades of expertise to help you effectively navigate and engage. MultiState’s team understands the issues, knows the key players and organizations, and we harness that expertise to help our clients effectively navigate and engage on their policy priorities. We offer customized strategic solutions to help you develop and execute a proactive multistate agenda focused on your company’s goals. Learn more about our Health Care Policy Practice.