The U.S. health care system is massive. It's a $5 trillion behemoth, nearly 20% of the U.S. economy or more than $15,000 per person per year. The cost of health care for consumers, including the cost of health insurance continues to increase. 

On this episode, we sat down with two people who pay close attention to the health care market and to how state legislatures are responding to rising costs. Our first guest is Katie Martin is CEO, and president of the Health Care Cost Institute, a nonprofit research group that collects and analyzes data on health care costs in the U.S. Also joining the discussion is Sarah Jaromin, who tracks health care issues for NCSL. 

Martin noted that her organization taps into data from employers who provide insurance to about half the people in the U.S. as well as data from Medicare and Medicaid. She pointed out that as of 2023, health care costs had increased more than 50% since 2014, and the trend does not show any signs of slowing. 

Jaromin sketched out the legislative landscape and explained how legislatures have tried to slow the growing cost of health care. She noted that NCSL has collected data showing that last year, 48 states, along with Puerto Rico, the Virgin Islands and Washington ,D.C., enacted nearly 500 bills related to health care costs and delivery. 

Resources

In one fashion or another, all state legislatures exercise oversight of state agencies and programs. They do this in a variety of ways using standing committees, rules review, auditing offices, sunset provisions, and more. 

On this episode of the podcast, we dive into the topic of oversight with three guests who all have different vantage points to observe the process. They include Kade Minchey, auditor general with the Utah Office of the Legislative Auditor General; Holly Trice, registrar of regulations in Virginia and on the staff of the Virginia Joint Commission on Administrative Rules; and Will Clark, who works with NCSL's Center for Legislative Strengthening. 

Will Clark started our discussion with an explanation of some of the basics of oversight, the approaches used, and the tools available to legislators.

Kade Minchey explained how his office in Utah uses performance audits to help agencies improve and how the legislative committee responsible for audits uses the information. 

Holly Trice talked about the rules review process in Virginia, how the legislature and executive branch work together, and how they afford all legislators and the public a chance to weigh in. 

Resources

• The Best Practice Handbook: Root Cause Analysis and Driving Results, Utah Office of the Legislative Auditor General
• The Best Practice Handbook: A Practical Guide to Excellence for Utah Government, Utah Office of the Legislative Auditor General
• A Performance Audit of Utah State Correctional Facility: An Examination of Staffing, Culture, Safety, and Security, Utah Office of the Legislative Auditor General
• A Performance Audit of Utah’s Behavioral Health System: A Case for Governance, Strategic Planning, and Accountability, Utah Office of the Legislative Auditor General
• A Performance Audit of Utah’s Election System and Controls, Utah Office of the Legislative Auditor General
• A Performance Audit of Utah’s Water Management: Ensuring Data Integrity, Program Best Practices, and Comprehensive Water Planning, Utah Office of the Legislative Auditor General
• Separation of Powers: An Overview, NCSL
• Separation of Powers: Legislative Oversight, NCSL
• Virginia Register of Regulations
• Virginia Regulatory Town Hall

SUMMARY

Medicaid is the joint state -federal program created in 1965 that provides free or low -cost health care to about 70 million Americans, including low-income elderly people and those living with disabilities. The changes in the 2025 legislation, also known as the One Big Beautiful Bill or H.R. 1, affect eligibility standards for the program and changes in the way states can finance their portion of Medicaid costs.

On this episode, we’re joined by two policy experts on Medicaid. Kathryn Costanza is a fellow at NCSL who closely follows Medicaid policy and Neda Jasemi is a senior policy analyst at the National Association of Medicaid Directors. They both sat down to talk about the significant changes in Medicaid that were included in the 2025 Budget Reconciliation Act. 

Jasemi discussed the challenges state legislatures will face as they craft budgets for Medicaid in their states while facing significant uncertainty about both revenue and how many people will be signed up in their state. Costanza explained the ins and outs of provider taxes and how that will affect state revenue intended for Medicaid costs. She also talked about what we know about the new rules and how they will affect the number of people who will qualify for coverage. 

Resources

• How Medicaid Provider Taxes Work: An Explainer, National Association of Medicaid Directors
• Medicaid’s Next Chapter, National Association of Medicaid Directors
• Medicaid Road Ahead: Policy Options and Budget Impacts | Webinar Series, NCSL
• The Medicaid Puzzle: Piecing Together Policies for a Balanced Budget, NCSL 
• Medicaid Road Ahead: Policy Options and Budget Impacts, NCSL 
• Medicaid Toolkit, NCSL
• National Association of Medicaid Directors
• OBBBA Medicaid Policy Timeline, National Association of Medicaid Directors
• Why did they do it that way? Medicaid Financing, National Association of Medicaid Directors
• Medicaid Financing 101, NCSL

There are more than 5,000 data centers in the U.S. and thousands more on the drawing board. The centers are big consumers of energy to power the racks of servers and big consumers of water to cool those systems. Data centers consume more than 4% of electricity in the U.S. with some studies estimating they may consume as much as 12% by 2030.

On this episode, we discuss data centers and their effect on the energy system with Dan Diorio, vice president for state policy at the Data Center Coalition, a trade group for the data center industry, and Alex McWard, who tracks energy issues, including data centers, for NCSL. 

State lawmakers have long been aware of data centers and some of their impacts, but the focus on data centers has increased considerably in the last couple of years, McWard says. He also discussed changing attitudes toward data centers and concerns about energy consumption and how it could affect rates paid by consumers.

Diorio explained the industry's perspective, pointing out that our society now runs on digital information, whether it's watching a football game or making a credit card purchase, and data centers are the backbone of that system. He also pointed to studies indicating that the industry is pulling its weight in terms of paying for the additional electrical load it's putting on the nation's utilities. 

Resources

• Data Center Coalition
• Policy Snapshot: Data Center Incentives

As a new year and a new state legislative session gets underway, we sat down with Tim Storey, the CEO of NCSL, to discuss the coming legislative session and where he expects legislators to focus their efforts. 

Storey sees a mixed picture on budgets, with most states sitting on substantial rainy day funds but cautious about the revenue picture in the new year. Issues around Medicaid will loom large because of changes to the program included in H.R. 1, otherwise known as the big, beautiful bill. 

K-12 education, as it always is, will get plenty of attention from legislators who are concerned about a number of issues, including lagging student achievement following the pandemic and the alarming increase in mental health issues among young people. Storey also thinks AI, data centers, housing the workforce as major areas of focus in legislatures. 

And not to be left out is the unprecedented attention to mid-decade redistricting that has taken a lot of attention in a handful of states. 

Resources

• Special Report: Legislative Trends and Priorities for 2026, NCSL

Institutional knowledge among legislative staff is a core element to maintaining continuity in legislatures around the country. But passing on that knowledge has become challenging as baby boomers retire and younger staff take on those roles.

On this episode, our two guests discussed how they used a mentor-mentee relationship to prepare for a job transition. Bernadette “Bernie” McNulty is the retired chief assistant secretary in the California Senate. Heshani Wijemanne is the current chief assistant secretary in the Senate.

McNulty explained that, as a manager, she had a critical responsibility to not only find someone to take on her job but to be sure that person was as ready as possible for the challenges ahead. For her part, Wijemanne said learning and absorbing everything she could from McNulty was irreplaceable in preparing herself. 

Resources

• Legislative Staff, NCSL

On this episode we sat down with Curt Stedron, director of NCSL’s Legislative Training Institute, to discuss a presentation he made at this year’s Legislative Summit in Boston on how game theory can help legislative leaders better understand the notion of leading in an infinite game. 

Stedron draws on the work of game theorist James Carse and author Simon Sinek, who popularized Carse’s theories. Stedron explained that the legislature, like many other areas of life, is really an infinite game, where the purpose is to perpetuate the game rather than win it. 

However, as Stedron explains, most people, including many of those in the legislature, actually approach their work as a finite game and that misconception can hamper their efforts to be effective leaders.

Resources

• Legislative Training Institute, NCSL

Distributed energy resources or DERs, things such as rooftop solar panels on homes and small businesses, home or business batteries and electric vehicles are an important option in managing demand for electricity. When these resources are combined through the use of software, they can create what’s called a virtual power plant.

On this podcast, we talk with two experts in the field: Rebekah de la Mora, a senior policy analyst at the North Carolina Clean Energy Technology Center, and Lakin Garth, senior director of grid strategy at the Smart Electric Power Alliance. 

They discussed state legislation and regulations that affect DERs and the benefits to consumers. Garth also explained how DERs can be aggregated to form virtual power plants that a utility can use to manage peak power demand.

N.B.: The NC Clean Energy Technology Center offers complimentary copies of the 50 State studies to federal and state legislators and staffers, utility commissioners, utility commission staff, state consumer advocate office staff, and state energy office staff. Contact the center to request a copy. 

Resources

• 50 State Reports, NC Clean Energy Technology Center
• Database of State Incentives for Renewables & Efficiency, NC Clean Energy Technology Center
• Distributed Energy Resources 101, NCSL
• NC Clean Energy Technology Center
• Smart Energy Power Alliance

On this episode, we talk with Carly Roszkowski, vice president of financial resilience programming at AARP. She joined the podcast on the sidelines of NCSL's Legislative Summit in Boston in August where she was appearing on a panel called “Unretirement: Rethinking Work in the Age of Longevity.”

She explained how demographic trends mean the lion's share of the workforce growth is among the over-50 crowd, and in a related trend, that more than a fifth of retirees are working full or part-time jobs. Roszkowski also discussed the inherent bias in many automated systems that screen job applicants. The companies she talks with, however, are eager to try to eliminate that bias because they value keeping and attracting older workers. 

Resources 

• Work and Jobs, AARP

Private equity investment in health care facilities has grown substantially in the past decade. There have been hundreds of such acquisitions of health care facilities in the past decade, including physician practices, nursing home facilities, and hospitals involving hundreds of billions of dollars.

At its most basic, private equity investors take over a health care company with the intention of increasing its value and reselling it for a profit. Advantages of such a strategy can be more capital investment and management expertise. Downsides include the use of leveraged buyouts that could saddle the acquired company with high levels of debt. 

On this episode, we’re joined by Dr. Zuri Song, an associate professor of health care policy and medicine at Harvard Medical School, and an expert on the financial incentives, public policies, and private sector investment in the health care system. Dr. Song explained what research has found in studying private equity acquisitions in health care. On average, he said, these investments raise real concerns about both patient outcomes and access to care.

State legislatures are at the forefront of regulation in this area with much of the regulation focusing on increased transparency into these transactions. I talked with two state legislators to get their perspective: Senator Tyler Johnson, a Republican from Indiana who is also a physician, and Senator Cindy Friedman, a Democrat from Massachusetts. They each discussed the legislative action in their states and how they view private equity investment.

Resources

• The Evolving Landscape of State Health Care Transaction Laws, NCSL 
• Health Costs, Coverage and Delivery Database, NCSL