A year ago, when we published our annual forecast of the top issues likely to come before state legislators in the new year, we wrote that the world was full of “uncertainty and tension” headed into 2024, citing “Wars in Israel and the Ukraine,” an up-and-down economy and, of course, big question marks surrounding the presidency.

Heading into 2025, we still have a war in the Ukraine and persistent economic uncertainty, a tentative ceasefire in Israel and, while we know who will become president in January, there remains a lot of disagreement over what the future will hold for a second Trump administration.

Once again, this upheaval can make it hard to predict what will be the hot topics under capitol domes across the country. But with 2024 as a guide, we can make some informed projections.

HEALTH

Weight-loss drugs

As we reported in late June, the popularity of Ozempic has spurred a renewed interest in off-label prescribing practices. Back then, an analysis of State Net data found at least 13 states had considered bills dealing substantively with off-label use of prescription drugs in the current legislative biennium.

The following month, the National Conference of State Legislatures published an article about weight-loss drugs representing a growing problem for state regulators. Specifically, NCSL looked into consumers turning to compound drugs that mimic the formulas of name-brand weight drugs, which are in short supply because of the demand.

Compound pharmacies, which make custom compound medications for patients, are regulated by the states, but oversight differs from jurisdiction to jurisdiction and NCSL found that regulators struggle to keep up with this niche of the healthcare sector.

However it manifests—in off-label prescribing, shortages or something else—the buzz for weight loss drugs isn’t likely to decrease anytime soon. So it’s a safe bet state legislatures will be looking at the impact of these popular drugs in some fashion in 2025.

Medicaid Work Requirements

During the last Trump administration, 13 states received permission to impose work rules on some Medicaid recipients while another nine states requested permission to enact similar rules but didn’t obtain it before President Trump was out of office.

When Joe Biden took office, he rescinded those approvals. But now that Trump is back in the White House, it’s expected that those states will try again. Stay tuned.

Federal Subsides

During the Biden administration, Congress approved major subsidies to help Americans pay for healthcare through the Affordable Care Act’s marketplaces. But those subsidies are set to expire next year—and the president elect has said vaguely that he has the “concepts” of a plan to replace the ACA.

In early November, the New York Times reported that health policy experts said Trump and the Republican majorities in Congress could transform Obamacare simply by allowing these subsidies to sunset. If they do, it’s likely that at least some state legislatures will explore how to replace these federal monies.

We’ll have to wait to see what Trump and the Republicans do. But if they act—or, well, don’t act—it’s guaranteed that we’ll be covering the states’ responses.

Artificial Intelligence Guardrails

AI has been one of the major issues we’ve covered this year—and it’s not going to slow down in 2025. The technology’s use in healthcare, given that it could lead to discriminatory or even inadvertently deadly practices, has made it a particular topic of interest to legislators.

California’s Legislature, as it often does, has lead the way on this front, passing two bills this year to restrict the use of AI in healthcare. This is almost certainly just the beginning of a wave of healthcare-related AI policymaking.

As much attention as AI has received over the last 12 months, it’s a near certainty we’ll be revisiting it again, particularly as it relates to healthcare, next year.

Pharmacy Benefit Managers

Another topic we wrote about this year is pharmacy benefit managers, or PBMs, which contract with health insurers and employers to manage their prescription drug benefits. They’ve been blamed for the rising cost of drugs—and state legislatures have responded, introducing more than 100 bills dealing with them in 2024. Perhaps most noteworthy among those bills was California’s SB 966, which represented a major PBM policy change. But Gov. Gavin Newsom (D)) vetoed it in a surprise move.

SB 966 had near-unanimous support in the California Legislature, suggesting that Golden State lawmakers could take another stab at this next year.

Discount Drug Program

In recent years drug companies have argued that the federal 340B program requiring them to sell drugs at a discount to hospitals and other facilities that primarily serve low-income patients as well as outside pharmacies contracted by such facilities has evolved beyond what was intended when the program was established over three decades ago. In 2020, seven big drug companies said they would restrict or entirely end 340B sales to contract pharmacies.

In 2024, states like Kansas, Maryland and Minnesota pushed back, enacting laws that require drugmakers participating in Medicaid to sell discounted drugs to contract pharmacies.

With the amount of money involved in pharmaceuticals, and the pressure legislatures feel to do something about spiraling drug costs, this has all the makings of a fight that isn’t going to end anytime soon.

INSURANCE

Environmental, Social and Governance

Back in May 2023, we reported that boardroom initiatives like Environmental, Social and Governance regulations had become a new front in the nation’s red vs blue, Republican vs Democrat, culture wars. This past October, we reported that the conflict over ESG had cooled a bit in 2024. But the divide over corporate initiatives could heat up again next year with Trump’s return to the White House. The president elect appears to relish both business issues and culture wars, making a reinvigoration of this fight a definite possibility in the new year.

Earned Wage Access

Just this month, we wrote about the fight over earned wage access apps, which allow employees to access their paychecks before payday. The fintech companies behind these apps assert that their services represent a whole new class of financial products; consumer groups say they’re just offering payday loans under a different name.

It might be cheating (a little) to place a story from the month of December on this list for hot issues next year, but the drum beat just seems to be getting louder, both from the apps and the consumer groups. Don’t be surprised if you see us write about this conflict again next year.

LABOR

Before we get into any specific topics on this section, let’s just state the obvious: the Trump administration is likely to be far less friendly to labor than Biden’s, which could touch off a new round of pro- and anti-labor bills next year. Labor has enjoyed something of a resurgence in recent years, notching some big wins. But it could be under some duress after the inauguration.

Captive Audience Meetings

One issue we wrote about this year is the fight over so-called captive audience meetings, mandatory workplace meetings employers sometimes hold specifically to persuade their employees to reject unionization.

Such captive audience meetings were allowed under the National Labor Relations Board for decades, but in April 2022 the Board’s general counsel said she would try to get the board to change its stance and declare all anti-union captive audience meetings coercive. This helped touch off a series of bills in Illinois and several other states.

You have to suspect that the NLRB, which barred captive audience meetings in November, is going to become far less labor friendly under Trump, which could result in an abrupt about-face on this issue, leading to a strong reaction from blue-state legislatures.

Other Pro-Labor and Pro-Employer Actions

As we suggested earlier, the labor movement has secured some serious victories in the last year plus, including California’s minimum wage for fast food workers and unemployment benefits for striking workers. But keep in mind that even in blue states, these wins aren’t always assured.

Washington state seemed poised to follow California’s lead and grant unemployment benefits to striking workers, but the proposal failed in the Senate, underscoring the uphill battle labor often faces.

Then you have the solidly red states, like Louisiana, which cut rest breaks for child workers as well as certain unemployment benefits in 2024.

The point is, labor has been at the forefront of many state policymakers’ minds this past year and while that isn’t likely to change next year, the power structure in Washington, D.C. could further ignite interest in this area.

TECHNOLOGY

AI Regulation

It’s not at all a stretch to say that AI and AI regulation was one of the biggest policy matters, if not the biggest, discussed in statehouses across the country this year. That’s definitely going to continue into the new year. You can count on it.

We covered the issue extensively in 2024—reporting on, among other things, the common themes of AI-focused bills, like algorithmic discrimination and automated employment decision making, as well as one of legislators’ favorite ways to address AI problems: disclosure laws.

It should come as no surprise that there’s already reporting suggesting that AI legislation will become even more of a priority in 2025, and that Trump’s presidency could supercharge regulatory efforts at the state level.

One thing to look out for: a bill by Texas state Rep. Giovanni Capriglione (R) that could create a red state standard for regulating AI.

The bottom line? We hope you’ve enjoyed our AI coverage, because there’s sure to be a lot more of it next year. 

AI Biggest Issue of 2024

As of mid-November, state lawmakers across the country had considered 679 measures referring to artificial intelligence, according to LexisNexis State Net’s legislative tracking system. Two hundred sixty-five of the bills, introduced in 36 states, dealt substantively with the technology. Twenty-two of those states enacted such bills.

Social Media

While AI was, undoubtedly, the top tech issue for state legislatures in 2024, social media and its negative impacts on children held strong at the No. 2 spot. In November, we reported on the effort by Facebook and Instagram parent company Meta to shift the burden of policing minors’ access to social media off of social media platforms—where lawmakers have been trying to place it—onto app store providers like Apple and Google. South Dakota is already shaping up to be a battleground on the “age gating” issue next year.

In California, meanwhile, Assemblymember Rebecca Bauer-Kahan (D) has introduced a bill (AB 56) that would require social media sites to routinely display a popup warning that social media can be harmful to the mental health of minors. The measure is sponsored by California Attorney General Rob Bonta (D).

As with AI, buckle up for a lot more coverage of social media issues in 2025.

Cryptocurrencies

Finally, we’ll conclude our review of 2024 and preview of 2025 with another issue we recently covered, cryptocurrencies. Bitcoin just surpassed the magic $100,000 exchange rate with the U.S. dollar, which has helped make digital currencies a hot topic in state legislatures.

The president elect has made all kinds of promises about crypto, including creating a “strategic Bitcoin stockpile,” which has digital currency enthusiasts predicting a full-on embrace of their way of life by the new administration.

There’s already been talk in at least two states of creating Bitcoin reserves in the new year. And Wyoming is looking to create its own U.S. dollar-backed stablecoin in the first quarter of 2025 to give consumers and businesses a faster and easier way to execute transactions.

We said earlier this month that Bitcoin was poised for its biggest moments yet in 2025. You can expect state lawmakers to continue focusing on cryptocurrencies and digital assets in the coming year too.

—By SNCJ Correspondent BRIAN JOSEPH

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