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The June 2026 Intersection
State Action, Midterm Stakes, and Health Care Affordability
Note From Natalie Davis, CEO, United States of Care
Dear Friends,
It’s hard to believe we’re already halfway through 2026. Legislative sessions are wrapping up, midterm elections are around the corner, and states are grappling with their role as the leaders of health care reform while Congress remains gridlocked.
This year, the cost of health care has emerged as one of people’s top issues of concern, and health care affordability dominates both policy and kitchen table conversations. This comes as no surprise to us at United States of Care. Even before “affordability” was making headlines, we heard from people over and over again that skyrocketing costs are their biggest worry. Since our founding, we’ve been elevating these concerns to policymakers on both sides of the aisle and passing common sense solutions to address them. In 2026 alone, we are supporting policy-advocacy work in over 18 states (including advancing 9 pieces of legislation) with a big focus on promoting competition and lowering the price of care for people.
Right now the stage is set for innovative health care policy change in the states. H.R. 1’s passage has forced states to step up on top of an already busy midterm election year. We’ve responded by ramping up our state advocacy portfolio, championing people-centered policies that tackle the underlying costs of care, and serving as a connector of those on the ground in states creating meaningful change. We are extremely proud to have launched our “Red State Affordability Cohort” (more on that below), adding to our already robust state affordability footprint. We are also pleased to be the first grantee of the Commonwealth Fund’s State Health Innovation for Transformation (SHIFT) Initiative, a partnership to conduct public opinion listening tours and engage with community members, health care leaders, policymakers, and others in six states.
In this Intersection, you’ll see that we’re focusing our attention where it matters most right now: making health care more affordable for people. The urgency of this moment demands nothing less.
Thank you for being part of this work.
As always, your thoughts and feedback are greatly appreciated.
How United States of Care (USofCare) Works
Our strategy for change is unique. Here’s how:
United States of Care is a listening-first, nonpartisan advocacy organization bringing people’s experiences to the policy decisions that shape our health care system. And now, we’re leveling up our strategy and working to influence the entire health policy conversation. This is our model:
- First, and Always, Listen: We listen to people—hearing in their own words how they experience the health care system in their daily lives, what they need from the system, and where it is failing them.
- Advocate for Change: We translate what people tell us into practical policy solutions and secure state and federal wins.
- Influence Health Care Agendas: We leverage our nonpartisan relationships and influence candidates and policymakers to pass people-centered solutions.
The Health Care Affordability Crisis Everyone Is (Still) Talking About
Health care affordability is at a crisis point. And with nearly one-third of people regularly making tradeoffs just to pay for care, like cutting back on utilities or skipping meals, this will have a major influence on people’s priorities at the ballot box in November.
Insights
- We, the People, Want Action – As costs continue to rise, people want lawmakers to act. Our listening work with our sister organization, USofCare Action, found that 76% of people say that a candidate’s position on health care costs will influence their midterm vote. And nearly 70% of people believe Congress should ensure access to affordable health care, even if that means regulating health care companies.
- H.R. 1 Medicaid Work Requirements Regulation – More Paperwork, More Problems – As the January 1, 2027 deadline for states to implement a number of policies that will reshape Medicaid eligibility and enrollment rapidly approaches, states are scrambling to comply while navigating compressed timelines and endless variables. On June 1, the Centers for Medicare & Medicaid Services (CMS) issued the highly anticipated Interim Final Rule outlining implementation policies for Medicaid work requirements. Until now, states are far along in building new IT systems and processes based on limited information and informal guidance on how federal regulators were going to approach key implementation decisions, including defining terms like “medical frailty” for the purposes of exempting people from the new work requirements. Ultimately, CMS issued a more restrictive policy that is inconsistent with the informal guidance states had been given to date. Additionally, it narrows the conditions eligible for the “medical frailty” exemption from work requirements, and erects a new administrative hurdle requiring people to prove their condition impairs them from working.
- Costs Rise, Congress Takes Note – On Capitol Hill, skyrocketing costs are getting some attention. At a hearing in late April, the House Ways & Means Committee put hospital CEOs in the hot seat to answer for rising hospital prices and discuss cost cutting policies like site neutral payments and facility fee limitations. This hearing followed earlier House hearings that scrutinized insurance CEOs and pharmacy benefit manager (PBM) industry spokespeople, signaling momentum for future legislative action to tackle the affordability crisis.
United States of Care’s Role
- Legislators’ Trusted Partners: We’re advisors to congressional offices on how people experience (un)affordable health care. Hint: It’s more than just the literal cost. While industry giants are flooding congressional offices with priority asks, USofCare provides a critical counterweight on behalf of the people. We help staffers draft materials and equip them with our unique, people-centered insights and policy recommendations as they head into health care affordability hearings.
- Amplifying Insights: We’ve engaged more than 10 state and policy leaders as they assess how they will comply with the new law set out in H.R. 1. In addition to partnering with those on the ground closest to the work, USofCare is bringing important themes and key learnings to CMS, national partners, and leaders. We’re educating reporters across the country with key facts so they can report on what is at stake for their communities.
- Sunshining Hospital Prices: USofCare has long advocated for transparency in hospital prices, especially as it relates to facility fees (fees charged to patients for outpatient services at a hospital-owned facility). Thanks to our advocacy, and the push from multiple stakeholders, Congress passed legislation earlier this year to require additional transparency in hospital billing—unlocking new insights into how hospitals price and bill for services, and laying the groundwork for policies that meaningfully tackle the confusion and cost burden people face in future reforms.
The State(s) of Play: Fifty Labs of Health Care Reform
States have emerged as the laboratories for true health care reform, and are finding creative solutions to make health care more affordable and accessible for people.
Insights
- Rising to the Challenge: States have a wide range of challenges they’re working through, including balancing budgets, implementing H.R. 1 policies on tight deadlines, and deciding which crucial policies to prioritize. Against this backdrop, many have still found ways to improve people’s health care. We’ll be highlighting the key trends and themes out of state 2026 legislative sessions in an upcoming report and webinar, so stay tuned!
- States Tackling the Hidden Costs of Care: State policymakers are addressing the underlying causes of expensive care: hospital pricing and consolidation. We saw Washington pass legislation to give the state more oversight of mergers and acquisitions, and California and Massachusetts recently amended their laws to capture similar private equity-driven transactions. These are important first steps in bringing health care costs down.
- Rural Health Gets a Boost: States have now received the first round of the highly anticipated Rural Health Transformation Program funding and are putting it towards various people-centered initiatives like bolstering the rural health care workforce and investing in digital health. We’re watching to see how they leverage this funding and implement new payment models, such as patient-first (value-based) care.
United States of Care’s Role
We’ve been partnering with state advocates and policymakers to help advance a number of meaningful reforms that align with our state policy priorities.
- Powering State Action to Cut Costs: In 2026, we’re supporting policy-advocacy work in nearly 20 states (advancing 9 pieces of legislation) with a sharp focus on lowering the cost of care for people and increasing competition. One success: in Washington, we worked with advocates and policymakers to provide communications support and testimony to help pass HB 2548, which expands the state’s oversight of health system mergers and acquisitions. The extra oversight and transparency will protect people from harmful corporate mergers that often increase costs and reduce access to services.
- We’re Going on Tour: Through the Commonwealth Fund’s State Health Innovation for Transformation (SHIFT) Initiative, USofCare will embark on in-depth research and public opinion listening tours in six states. This partnership will deploy our unique listening approach and draw on both organizations’ extensive policy expertise to identify health care challenges and opportunities, and develop targeted solutions.
- We Want Mental Health Care, NOW. USofCare is helping expand access to behavioral health care by making it part of the same state reforms that improve affordability and coverage. Last year in Washington, we supported a new law (SB 5083) to cap hospital prices and reinvest savings into primary care and behavioral health for 788,000 public workers. And in Colorado, we helped lead a coalition to pass the Colorado Option, making health care accessible and more affordable for almost 140,000 Coloradans (including free mental and behavioral health visits!).
- [USofCare was instrumental in the passage of the Colorado Option in 2021. Now, years after the program launched, enrollees are paying less for coverage and care, including 15% less on out-of-pocket costs.]
Rallying the Red States
While every state in the country is feeling the strain of high health care costs, states with conservative political environments are under the heaviest pressure. And our recent work in red states has taught us a lot about the unique conditions their leaders are operating under, like tight fiscal constraints and a strong preference for market-based and locally controlled solutions that prioritize efficiency and limit government expansion.
Insights
- The Right Time for Reform. Red states that have historically been less active on health reform are now more open to targeted affordability strategies, especially those that stress fiscal responsibility and consumer impact. Rising health care costs are outpacing wages and state budgets, and the need for policy progress is critical. We’re leveraging this new opportunity to take action where we’re needed most, like advancing policies that address high hospital costs.
- State Voices, In Whom We Trust. We’ve partnered with local advocacy organizations with deep relationships and credibility like the Utah Health Policy Project and Opportunity Arizona. With trust in the health care system declining, people want to feel respected and listened to by leaders who truly understand where they come from. This is especially important in red states, where policy debates are often heavily shaped by personal relationships.
- Midterms on the Horizon. We’re monitoring how upcoming elections may shift political dynamics in red states, including how changes in leadership or legislative priorities could accelerate, delay, or reshape the path for hospital pricing and broader affordability reforms.
United States of Care’s Role
- The Red State Playbook: We launched our “Red State Affordability Cohort” this spring, which is an exciting expansion of our state portfolio. We’re partnering with six leading health care advocacy organizations in states with conservative leadership: Arizona, Georgia, Kentucky, Ohio, Utah, and West Virginia. Together we will focus on people-centered affordability solutions supported across party lines, like price transparency and anti-consolidation.
- Connecting Changemakers. We’re serving as the connectors and conveners of our Red State Cohort partners to build collective power. At a time when federal action is uncertain, and all eyes are on the states to lower the cost of health care, we’re helping partners learn from one another, align strategies, and make lasting change in their communities.
- Bigger Footprint, Bigger Impact. USofCare has grown our state footprint because that’s where the momentum (and the biggest opportunity for impact) is right now. We’re now supporting policy and advocacy efforts in over 18 states, while paying special attention to red states because they’re facing some of the toughest health care challenges in the country.
ICYMI
(I.E., all the other things we wanted to share, but didn’t have enough space)
New Washingtonian Award
DC’s Finest: Our CEO and Co-Founder Natalie Davis was honored as one of Washingtonian’s “Most Influential People Shaping Healthcare Policy.”
Aspen Institute Congressional Program
Coaching Congress: At an off-the-record retreat hosted by the Aspen Congressional Program and the Commonwealth Fund, our CEO and Co-Founder Natalie Davis addressed a bipartisan audience of members of Congress on how to lower health care costs for people. This opportunity reflects our status as an honest, trusted broker in advancing nonpartisan policy solutions.
State Policy Trend Webinar
Eyes on the States: Want to know what’s going on in the state policy world? We’ll be going over the top trends in the states at our webinar next month. We hope you can join!
Want the full experience?
The interactive version of The June 2026 Intersection is also available.