Five states enacted significant healthcare legislation during spring 2026 sessions. Arizona launched AI-powered Medicaid fraud detection, while Iowa banned insurers from using AI to deny prior authorizations under HF 2635. Missouri's comprehensive HB 2372 awaits gubernatorial approval, expanding Medicaid coverage and hospital transparency requirements. Maryland's Prescription Drug Affordability Board capped Ozempic payments at Medicare rates for state plans. Connecticut's budget bill (SB 1) overhauled Certificate of Need requirements for hospitals.

Nine states have established Prescription Drug Affordability Boards to control drug costs, but implementation has proven complex and lengthy. Virginia's Governor Spanberger vetoed PDAB legislation citing ineffectiveness and high costs. Maryland, Colorado, Washington, and Minnesota have authority to set upper payment limits, though none have taken effect. Colorado finalized its first UPL in October 2025, effective January 2027. New Hampshire repealed its PDAB, while Louisiana passed limited transparency-focused legislation.

Colorado's Prescription Drug Affordability Board became the first state to set an upper payment limit on prescription drugs, establishing a $600 cap per unit for Enbrel effective January 2027. The state reviewed five drugs, finding three unaffordable. Nine states now have PDABs, with four authorized to set payment limits. The action faces ongoing litigation challenging constitutional grounds, with outcomes potentially impacting other states' affordability programs.

Attorneys general are expanding their influence over health policy through opioid settlements, PBM reform, and Medicaid oversight. The Purdue/Sackler settlement yielded $7.4 billion effective May 1. Bipartisan coalitions of 39 and 45 attorneys general advocated for PBM reforms. Republican attorneys general challenged FDA mifepristone regulations, with Louisiana's litigation prompting Fifth Circuit action. Texas and Florida launched Medicaid fraud investigations and task forces.

Tennessee's HB 1959, prohibiting PBM pharmacy ownership, passed the House Insurance Committee 16-3 and advances to Government Operations Committee. House Speaker Cameron Sexton co-sponsored the bill citing anti-competitive concerns. Oklahoma's HB 3538 unanimously passed committee with similar restrictions but includes exceptions for rare and orphan drugs, awaiting full House vote. Similar legislation is pending in seven additional states.

States are advancing healthcare legislation across three key areas as legislative sessions conclude. Multiple states enacted insurance reforms targeting utilization management and prior authorization, with Iowa, Utah, South Dakota, Washington, and New Mexico leading efforts. Indiana, Wyoming, and Utah passed Medicaid eligibility verification measures responding to federal reforms. Several states expanded scope of practice for pharmacists and mid-level providers to qualify for Rural Health Transformation Program funding.

Virginia's Senate passed legislation to establish a Prescription Drug Affordability Board with upper payment limit authority, with similar House legislation pending under new Governor Abigail Spanberger. Four states currently have PDABs with UPL authority. Colorado became the first to set a UPL in October, effective January 2027, using Medicare's maximum fair price as the benchmark, though legal challenges remain ongoing.

Congress passed comprehensive PBM reforms requiring 100% rebate pass-through to ERISA plans, detailed disclosure requirements, and Medicare Part D compensation limits to bona fide service fees. California and Colorado already adopted delinking practices, while New Jersey and Virginia introduced similar legislation. Ten states have introduced rebate pass-through bills, with federal transparency standards potentially becoming state-level requirements.

States enacted significant pharmacy benefit manager reforms in 2025, with Arkansas implementing the nation's first PBM-pharmacy ownership ban despite facing legal challenges. Massachusetts passed comprehensive licensing requirements, while Colorado and California adopted "delinking" laws prohibiting PBM compensation tied to drug prices. Utah mandated rebate pass-through mechanisms. These diverse approaches reflect growing bipartisan momentum toward curbing PBM practices affecting independent pharmacies and drug pricing transparency.

Colorado finalized the nation's first prescription drug upper payment limit, capping Enbrel at $600 per dose effective January 2027. Maryland conducted affordability reviews on four drugs and voted to set UPLs for Jardiance and Farxiga. Oregon reviewed 23 drugs with final recommendations expected March 2026, while Washington and Minnesota prepared for upcoming reviews.

Connecticut Governor Lamont signed comprehensive healthcare reform including mental health parity reporting and step therapy prohibitions. Iowa and Montana submitted federal waivers for Medicaid work requirements, seeking 100 and 80 monthly hours respectively. Oklahoma's Governor Stitt issued an executive order implementing "Make America Healthy Again" initiatives, including SNAP waivers to exclude soft drinks and ending public water fluoridation endorsements. Maine's legislature passed PDAB expansion legislation, but Governor Mills postponed her decision until January 2026.

With rising prescription drug costs a concern for consumers, state legislatures have taken an array of actions to contain costs. In recent years the establishment of Prescription Drug Affordability Boards (PDABs) has emerged as a strategy across the country. Eleven states have established a PDAB or a similar drug cost control entity. PDABs in four states (Colorado, Maryland, Minnesota, and Washington) have the authority to set upper payment limits (UPLs) on prescription drugs they determine to be unaffordable after review.

In 2025, state lawmakers are expected to prioritize healthcare affordability and access, building on key legislative trends from this year. Here are our thoughts on key trends and issues from 2024 and how they might show up in state capitols next year.