States of Innovation: April 2025

As Congress continues to discuss potential federal cuts to the Medicaid program, states continue to highlight the value of Medicaid and analyze the financial and enrollment impacts of cuts. Connecticut, Illinois, Oklahoma, Utah, Washington and Wisconsin published estimates of potential impacts to their programs, while stakeholders in Michigan and Minnesota discussed the critical role of the program and Colorado’s Governor sent a letter to the state’s federal delegation. State-Based Marketplaces are also calling attention to extending Marketplace affordability, with New Jersey highlighting the importance of enhanced premium tax credits. In reaction to federal policy, Massachusetts submitted public comments on the proposed Marketplace Integrity and Affordability rule, and governors in five states sent a joint letter to the Center for Consumer Information and Insurance Oversight (CCIIO) expressing concerns about the proposed rule.

April also saw states pass legislation on affordability and efforts to address cost: Arkansas banned pharmacy benefit managers from engaging in anti-competitive practices, while New Mexico is reducing enrollee costs for the state employee health plan. Efforts to address medical debt included New Jersey, which announced it has forgiven a total of $1.1 billion for over 776,000 residents, and Washington prohibiting collection agencies and healthcare providers from reporting medical debt to credit agencies.

Other state action included Michigan, Pennsylvania and Virginia addressing maternal and infant health, while states also acted in support of reproductive and women’s health: Arkansas held an event at the state capitol offering health screenings and other services to promote national women’s health month, and Colorado passed legislation to strengthen access and privacy for healthcare providers who offer abortion services. 

April also saw significant state activity on mental and behavioral health with California making naloxone available to all residents for $24 and Kansas removing barriers for law enforcement to provide naloxone. Montana launched a grant program to expand community-based forensic stabilization services in local detention centers and North Carolina began offering additional services for defendants with mental illness whom the court has determined incapable of proceeding to trial. Michigan’s task force on preventing gun violence released its first report of recommendations designed to address gun violence and reduce firearm-related deaths and injuries.

Both Arizona and Arkansas submitted waiver requests to the Centers for Medicare & Medicaid Services (CMS) to implement Medicaid work requirements, while Oregon submitted a request to extend and expand its substance-use disorder 1115 waiver. California was approved by CMS to participate in the Cell and Gene Therapy Access Model and North Carolina’s state plan amendment was approved to update the state’s estate value thresholds every five years based on the consumer price index.

Affordability and Efforts to Address Cost

Arkansas is addressing the high cost of prescription drugs by regulating pharmacy benefit managers. Governor Sarah Huckabee Sanders signed legislation banning pharmacy benefit managers from engaging in anti-competitive practices by simultaneously owning pharmacies. 

New Mexico is making the state employee health plan more affordable for enrollees. Governor Michelle Lujan Grisham signed Senate Bill (SB) 376 into law, lowering state employee healthcare costs. Under SB 376, the state’s contribution to employee health insurance premiums will increase, significantly lowering costs for workers. The law also eliminates the state health benefits program’s budget shortfall and is expected to save millions of dollars in general funds in state fiscal year 2026.

Community Engagement

Iowa is engaging the community on aging and disability services. The Iowa Department of Health and Human Services launched a series of virtual monthly Aging and Disability Town Halls as an opportunity for interested individuals—including community members, caregivers, and professionals—to stay informed, share insights, and hear directly from leaders and advocates in aging and disability services. 

Expanding Access to Care

Michigan is investing in communities to improve health disparities. The Michigan Department of Health and Human Services has awarded more than $8 million to 20 organizations to build Healthy Community Zones in Chippewa and Saginaw counties and the City of Detroit to reduce racial disparities in chronic disease. Funded organizations proposed locally tailored strategies to make physical activity, nutrition and social cohesion more easily accessible for community members.

New Jersey proposed a regulatory change to promote healthcare integration. The New Jersey Department of Health announced proposed rules creating a single, integrated license for outpatient healthcare facilities. This reform will cut red tape and enable providers to deliver integrated primary care, mental health, and substance-use disorder treatment services.

Extending Marketplace Affordability

New Jersey highlighted the importance of the federal enhanced premium tax credit to state lawmakers. Department of Banking and Insurance Commissioner Justin Zimmerman testified in front of state lawmakers that the state stands to lose $500 million in federal subsidies if Congress does not extend the enhanced premium tax credits. Commissioner Zimmerman also described potential challenges the state would face as a result of proposed federal cuts to Medicaid and the recently proposed rule impacting health insurance Marketplaces.

Highlighting the Value of Medicaid

Colorado’s Governor and Lieutenant Governor are urging the state’s federal delegation to protect Medicaid funding. Governor Polis and Lt. Governor Primavera are urging Colorado’s federal delegation to protect critical funding for Medicaid. A letter sent to the delegation describes how cuts could take health coverage away from hundreds of thousands of Coloradans and would push thousands of uninsured Coloradans into medical bankruptcy, increase uncompensated care to providers, close rural hospitals, and drive up premiums and costs for all Americans.

Connecticut conducted an analysis of the financial impact of various federal Medicaid proposals. A recent session of the Council on Medical Assistance Program Oversight included presentations highlighting Medicaid Federal Financial Modeling, which analyzes the Connecticut-specific financial impact of various federal Medicaid proposals, and Financial Trends in the Connecticut Medicaid Program.

Illinois held a presentation on the importance of Medicaid and the estimated impact of federal changes. The Illinois Department of Healthcare and Family Services held a presentation about the impact of Medicaid in the state and an analysis of what Illinois stands to lose if Congress implements cuts. The analysis looks at the estimated financial and enrollment impact of work requirements, per capita caps on federal spending, and a reduction in the federal match rate for the expansion population.

Michigan community leaders are discussing the impact of potential federal changes to Medicaid. Michigan Department of Health and Human Services Director Elizabeth Hertel met with state officials and hospital leaders to discuss the negative impacts of potential cuts to Medicaid funding on patient care and the financial health of rural hospitals and their local communities. The state officials and healthcare leaders urged Congress to oppose these cuts, saying potential cuts would impact the healthcare coverage of 2.6 million people statewide, and losing access to healthcare in rural areas weakens the local economy.

Minnesota continues to host roundtables on the changes to Medicaid being debated in Congress. Governor Tim Walz and U.S. Representative Kelly Morrison joined state officials, doctors, and advocates to discuss the impact of proposed federal cuts to vital healthcare programs. This was the sixth in a series of statewide roundtables held to discuss the potential federal cuts to Medicaid. John Connolly, Medicaid director, and Libby Caulum, Chief Executive Officer of MNSure, the state’s official health insurance Marketplace, joined doctors, patients and advocates for the seventh session in the series of statewide roundtables educating Minnesotans on the impact of proposed federal cuts to vital healthcare programs. 

North Carolina announced that Medicaid expansion reached 650,000 enrollees in fewer than 18 months after launching. Governor Josh Stein announced that 650,000 newly eligible North Carolinians have gained access to affordable healthcare through Medicaid expansion. The state’s Medicaid Expansion Dashboard provides detailed information about the impact on all 100 counties.

Oklahoma published estimates of proposed federal changes to Medicaid. The Oklahoma Health Care Authority has modeled the impact of proposals put forth by Congressional leadership on the Medicaid program. The efforts assessed include impacts on the reductions in federal matching funds, restrictions on existing healthcare funding streams, and changes in Medicaid eligibility rules.

Utah published an analysis of the reforms to Medicaid being considered by Congress. The Department of Health and Human Services published estimates of the impact on Utah of potential federal changes to Medicaid.

Washington analyzed the impact of various policies under consideration by Congress. The Washington Health Care Authority held a presentation about the impact on the state of federal proposals to change Medicaid. The policies under consideration include work requirements, reducing the federal match rate for services and administration, reducing the use of state directed payments and provider taxes, and implementing a per capita cap of federal Medicaid funding.

Wisconsin published a report of the impact of Medicaid cuts on people and providers in the state. The Wisconsin Department of Health Services published an analytic report modeling the impact of congressional budget cuts on Wisconsin Medicaid. The policies examined include work requirements, per capita caps on federal spending, and a reduction to the administrative and technology federal match.

SHVS published a toolkit, developed by Manatt Health, providing national and state-by-state data on the potential impact of key cuts under consideration in Congress. The toolkit is designed to help state officials prepare or review their own estimates and to offer estimates to states not undertaking their own analyses. SHVS hosted a webinar to discuss the toolkit and the cuts to Medicaid under consideration by Congress as part of the budget reconciliation process.

SHVS is also tracking the states that are publicly reporting their estimates of proposed cuts to Medicaid. The expert perspective highlights state agencies that have estimated and quantified the potential impacts of various proposals on enrollment and spending. SHVS will continue to regularly monitor published estimates from states and update the expert perspective, as well as our expert perspective tracking national analyses with 50-state estimates.

For those looking to learn more about how the cuts being discussed in Congress would impact children, the latest episode of Heather Howard’s podcast the Princeton Pulse explores how proposed cuts would impact the health, development and future prosperity of the more than 37 million children who rely on Medicaid and CHIP.

Marketplace Enrollment

Colorado published an annual report on enrollment. Connect for Health Colorado, the state’s official health insurance Marketplace, released its annual open enrollment report, which includes new data and information about enrollment for plan year 2025, financial assistance, growth in enrollment in rural areas, assistance available to consumers, and interactive maps.

Oregon published an annual report on  enrollment. The Oregon Health Insurance Marketplace released its annual report detailing key trends in enrollment and financial assistance. The report shows that 80% of enrollees applied for and received financial assistance, obtaining an average of $531 per month in premium tax credits to lower the cost of coverage and more than 11% of Marketplace enrollees have a monthly premium of less than $10 after applying premium tax credits.

Vermont announced record enrollment during the open enrollment period for 2025. The Department of Vermont Health Access released new figures on Marketplace open enrollment for 2025 which showed over 32,000 Vermonters, or an 11% increase, representing historically high enrollment for Vermont Health Connect, the state’s official health insurance Marketplace. The Department highlighted that 95% of enrollees this year were eligible for a higher level of coverage at a lower premium due to the enhanced federal subsidies. If those subsidies do not continue, Vermonters may face significantly higher premiums in 2026.

Marketplace Innovations

Connecticut is leveraging tax season to connect individuals to health coverage. Access Health CT, the state’s official health insurance Marketplace, and the Connecticut Department of Revenue Services announced that residents can now check a box on their state income tax return to get information about health coverage options. In 2023, the state passed legislation which provided authority for this partnership.

Maternal and Infant Health

Michigan declared a week in April to be Black Maternal Health Week. Governor Gretchen Whitmer issued a proclamation declaring April 11 through 17 as Black Maternal Health Week in the state, reaffirming the state’s commitment to addressing racial disparities in maternal health.

Pennsylvania held a summit which discussed the state’s efforts to improve maternal care and access. Department of Human Services Secretary Dr. Val Arkoosh and Department of Drug and Alcohol Programs Secretary Dr. Latika Davis-Jones joined the first statewide PA Black Maternal Health Summit as part of Black Maternal Health Week. During the event, the secretaries hosted a listening session that will inform development of the Shapiro Administration’s Maternal Health Strategic Plan, which aims to improve healthcare access, reduce maternal mortality, and address inequities in healthcare.

Virginia Medicaid is highlighting its community doula program. Virginia Medicaid is promoting the Community Doula Program for enrollees who are pregnant or have given birth in the last six months. A doula is a person who is certified to help and support pregnant and postpartum individuals through childbirth education, lactation support, referrals for health and social services, and support during labor and delivery. For more information on the landscape of Medicaid reimbursement trends for midwifery and doula coverage, see the SHVS issue brief which recommends strategies to enhance access to a diversity of maternal care providers through equitable reimbursement.

Virginia published new data dashboards on maternal and child health. Governor Glenn Youngkin announced the launch of an upgraded Maternal and Child Health Dashboard and two new dashboards to monitor and provide data on maternal mortality and pregnancy-associated deaths. The data are designed to be used as a resource to establish best practices to assist mothers during pregnancy, birth, and postpartum.

Medical Debt

New Jersey has forgiven over $1.1 billion in medical debt. Governor Phil Murphy announced that approximately 629,000 additional New Jersey residents will see a combined $927 million in medical debt retired through the state’s partnership with Undue Medical Debt, bringing total debt forgiven to over $1.1 billion for 776,000 New Jerseyans since August 2024. 

Washington passed legislation that will prohibit collection agencies from reporting medical debt to credit agencies. Governor Bob Ferguson signed legislation that prohibits collection agencies and healthcare providers and facilities from reporting medical debt to consumer credit reporting agencies.

For more information on state efforts to prohibit medical debt reporting and eliminate existing debt, see the SHVS expert perspective Mapping State Efforts to Address Medical Debt and a Health Affairs Forefront article which examines the burgeoning trend of state efforts to cancel medical debt for just pennies on the dollar. SHVS also published a state spotlight profiling North Carolina’s Comprehensive Medical Debt Relief and Reform Incentive Program.

Mental and Behavioral Health

California has made naloxone available to all Californians for $24. Governor Gavin Newsom announced that individual twin-packs of CalRx®-branded over-the-counter naloxone HCL nasal spray are now available to all Californians at $24 per carton–almost half the standard market price. Previously offered only to government entities and businesses in packs of 24, this new direct-to-consumer program expands individual access to this life-saving overdose reversal medication.

Kansas is removing barriers to connect individuals with naloxone. Governor Laura Kelly signed legislation which removes administrative barriers for law enforcement agencies to provide lifesaving care to Kansans during an opioid overdose. Previously, law enforcement officers faced barriers to obtain naloxone due to a statutory requirement mandating agencies to have a medical director or licensed pharmacist.

Montana launched a $6.5 million grant program to expand community-based forensic stabilization services. Department of Public Health and Human Services Director Charlie Brereton announced the agency is accepting proposals for a $6.5 million one-time grant program aimed at building sustainable capacity for community-based forensic stabilization services throughout Montana’s local detention centers. Potential allowable uses of the grants include contracted forensic mental health services to support stabilization, medication management and costs, training and professional development, and more. 

New York invested in suicide prevention efforts aimed to help veterans and uniformed personnel. Governor Kathy Hochul announced the award of 18 grants to expand resiliency and suicide prevention efforts among military veterans and uniformed personnel, including law enforcement, firefighters, emergency medical service personnel, correction officers and emergency dispatchers.

North Carolina is offering additional services for defendants with mental illness whom the court has determined Incapable to Proceed (ITP) to trial. The North Carolina Department of Health and Human Services and the Wake County Sheriff’s Office are partnering to offer additional services for defendants with mental illness whom the court has determined Incapable to Proceed (ITP) to trial. People who are deemed ITP require services to restore their ability to understand and continue trial proceedings. The program, known as NC RISE, will allow ITP criminal defendants who are not eligible to access community-based services to receive treatment within the detention center.

North Dakota is strengthening its statewide family support network with parent and caregiver peer support training. North Dakota Health and Human Services hosted Parent and Caregiver Peer Support Training, equipping participants with the skills to provide peer support to parents and caregivers of children with behavioral health needs. This initiative, supported by North Dakota’s System of Care grant, aims to strengthen resources for families navigating behavioral health challenges. 

Preventing Gun Violence

Michigan’s task force on gun violence prevention published recommendations to address gun violence, reduce firearm-related deaths and injuries. The Michigan Gun Violence Prevention Task Force released its first report featuring recommendations designed to address gun violence and reduce firearm-related deaths and injuries. Task force recommendations address firearms-related suicide, community violence, school safety, intimate partner violence and implementation of existing legislation. 

For more information on gun violence prevention, check out this episode of the Princeton Pulse, which discusses a public health approach focused on firearm safety and injury prevention.

Reproductive and Women’s Health

Arkansas held an event at the state capitol to recognize national women’s health month. The Arkansas Department of Human Services announced the second annual Month of May (MOM) event to kick off National Women’s Health Month with a free block party highlighting health and wellness activities. The MOM event included health screenings, women’s self-care services, informative displays from nutrition and fitness partners, and more.

Colorado passed legislation to strengthen access to reproductive care and privacy. Governor Jared Polis signed legislation that provides additional protections for healthcare providers and implements changes to state law to align with the amendment to the state’s Constitution repealing the prohibition on state funds being used to cover abortion. Under the new protections, providers can now choose to use the practice name rather than the provider name on prescriptions and claims. Additionally, providers that are threatened with an out-of-state lawsuit for providing protected services have a private right of action in Colorado. 

States React to Federal Policy

The governors in Colorado, Illinois, Maryland, New Mexico and Oregon sent an open letter to the Center for Consumer Information and Insurance Oversight (CCIIO) expressing concerns about the proposed Marketplace Integrity and Affordability rule. Governors from five states sent a letter to Peter Nelson, Director of CCIIO, urging the withdrawal of the Marketplace Integrity and Affordability Proposed rule, saying the rule will cause disruption to the administration of health insurance Marketplaces and make healthcare coverage less accessible. As a reminder, SHVS hosted a webinar and published an expert perspective which review the provisions of the proposed rule. 

Massachusetts submitted public comments on the proposed Marketplace Integrity and Affordability rule. The Massachusetts Health Connector, the state’s official health insurance Marketplace, submitted a comment letter to CMS on its proposed Marketplace rule. The comment letter addresses key provisions of the rule that would drive up premiums, hinder enrollment, and create additional administrative burdens and cost to the Health Connector and enrollees.

Waiver and State Plan Amendments, Requests and Approvals

Arizona requested to implement work requirements. Arizona requested to amend its Arizona Health Care Cost Containment System (AHCCCS) demonstration to allow the state to implement Medicaid work requirements. The state also requested to institute a lifetime limit of five years of Medicaid benefits for these adults, and imposing cost-sharing requirements to deter both the nonemergency use of emergency departments and the use of ambulance services for nonemergency transportation. State law requires that the agency submit the proposal (known as AHCCCS Works) to CMS each year. On April 10, AHCCCS received confirmation that CMS had completed a preliminary review of the AHCCCS Works amendment and the federal comment period is open on the proposed demonstration until May 9, 2025. 

Arkansas requested to implement work requirements. Arkansas submitted a request to amend the ARHOME section 1115 Medicaid demonstration. The request seeks approval of the “Pathway to Prosperity” program to establish work and community engagement requirements for the Medicaid expansion population. 

California was approved to participate in the Cell and Gene Therapy Access Model. The California Department of Health Care Services received CMS approval to participate in the Cell and Gene Therapy Access Model beginning on July 1, 2025. This multi-year initiative will expand Medi-Cal members’ access to lifesaving gene therapies for sickle cell disease, a severe genetic blood disorder that disproportionately affects people of African descent.

North Carolina was approved to update its estate value threshold every five years. North Carolina received CMS approval of its state plan amendment to change the Estate Value Thresholds every five years based on the Consumer Price Index. As a reminder, SHVS published a toolkit intended to assist state officials in evaluating their current estate recovery policies and understanding where they may have flexibility to make the policies less burdensome for affected low-income families.

Oregon is seeking to extend and expand its substance-use disorder 1115 waiver. Oregon submitted a request to extend its Substance Use Disorder (SUD) Medicaid section 1115(a) demonstration. Under the demonstration extension, the state intends to continue the SUD program and seeks new authority to provide contingency management incentives as a medical intervention to any eligible individuals. Contingency management is designed to motivate individuals in recovery by offering incentives for meeting treatment goals.