Health Care

7 themes that will dominate state legislatures in 2023

Mental health and abortion are just two of the topics set to pop up during legislative sessions across the country.
The California State Capitol Building in Sacramento (Reid Wilson / Pluribus News)

State legislators preparing to kick off legislative sessions in the early weeks of the new year are flush with cash, nervous about a recession and armed with mandates from voters to tackle some of the most controversial topics facing the nation today.

Every state will confront its unique challenges, from a massive drought threatening the seven states along the Colorado River to electrical grid concerns in New England and Texas, from transportation and traffic issues along the I-95 Corridor to housing crises in the Midwest and the West Coast.

But common themes emerged in dozens of interviews conducted in recent months with legislative leaders, important committee chairs and rank-and-file members. Here are the seven issues we expect to dominate the headlines in legislative sessions this year:

Mental Health

America faces a mental health crisis, a long-festering catastrophe accelerated by the pandemic. It has manifested in a growing epidemic of death caused by drugs and alcohol, a steep decline in school outcomes, and a wellspring of loneliness infecting those in their pre-teen years as well as those who have retired.

“Mental health might not be first and foremost on everyone’s mind, but it’s something that could really lead to some bad issues if we don’t address it,” Rhode Island Senate President Dominick Ruggerio (D) said.

States are short on hospitals to handle those with mental health issues. But the problem goes beyond beds — even if states build new hospitals and clinics, most don’t have the workers who can staff facilities that exist today.

“I’ve got one of the state mental hospitals in Wichita Falls. We’re 300 people short right now, employee-wise, and that means we’re 200 beds short,” Texas Sen. Drew Springer (R) said. “We’ve talked about building new hospitals, new beds. I can’t even staff the hospital we have now.”

Abortion Fights

The Supreme Court’s decision last year striking down Roe v. Wade gave the states an opportunity to define how abortion rights are treated within their borders. Red states cracked down on abortion rights, while blue states moved to codify rules guaranteeing access to reproductive procedures and birth control medication.

That divide will deepen this coming year, as states where abortion rights are legal prepare to handle an influx of patients from states where those rights are restricted.

Republican states, even those with some of the most restrictive measures on the books, will move to limit abortion further, efforts that will lead to conflicts with medical providers who are unsure what actions they can legally take when a woman’s life is at stake.

States like South Carolina and Idaho will see measures to bar abortions at earlier phases in pregnancy, or to end exceptions for pregnancies caused by rape or incest.

“You’ll see … a movement by what we call the abolitionists to basically outlaw all abortions, even in the case of life and death of the mother or rape and incest,” Idaho Senate President Pro Tem Chuck Winder (R) said. “We need to clarify, if necessary, for the medical community if we can get to some agreement on what is really a medical treatment and what’s an emergency so that there isn’t any confusion there and we’re protecting the life of the mother.”

Democrats, emboldened by midterm election wins and voters who embraced pro-abortion rights positions in ballot measures even in deeply red states such as Kansas and Kentucky, are moving to adopt new protections. Majorities in Washington and Minnesota are preparing to enshrine abortion rights, something California did before the end of the year.

Those states where abortion rights are already protected are now turning to privacy concerns, especially for those who show up from other states seeking medical care.

“One of the things we’re looking at is making sure that not only do Coloradans have a right to an abortion, but that [those] who are coming from other states for care, that they are protected also,” Colorado Senate President Steve Fenberg (D) said.

Election Reform

For years, election reform issues were the relatively noncontroversial, nonpartisan domains of secretaries of state fine-tuning the voting process. Both conservative and liberal states expanded mail-in voting, automatic voter registration and military access to ballots.

That changed about a decade ago, when a new range of Republican-led states began implementing voter identification requirements and curtailing alternative voting access.

Now, in the wake of four consecutive national elections in which former President Donald Trump and his allies have undermined voter confidence in election results with delusional conspiracy theories, Democrats have become fully engaged — and they see democracy as a winning issue.

States that have historically resisted modern adaptation of absentee voting and early voting — especially Northeastern states like New York, Connecticut and Massachusetts, where in-person participation is a legacy of Colonial times — are beginning to modernize. In Connecticut, voters last year approved early voting, though they left specifics up to lawmakers.

“You’ve got to give people more options,” Connecticut House Speaker Matt Ritter (D) said. “I really believe if you give people the option, it will increase voting.”

Some Republicans, whose voters pressure them to restore trust shaken by the former president, are considering ways to speed the vote-counting process.

Arizona Sen. T.J. Shope (R) said legislators are looking at giving county election administrators the authority and ability to count ballots before the polls close.

“That alone would speed up the process tremendously,” he said. “But it will cost money.”

Preparing for a Downturn

States are historically flush with cash. Rainy day reserve funds have never been larger, and tax collections continue to come in higher than expected in most states.

But the predictions of a looming recession are making legislators skittish — and the painful memories of the darkest days of the Great Recession are never far from the minds of veteran lawmakers.

“We’ve been very fiscally prudent, making sure that we develop reserves in our state, right, to make sure that we prepare for the next downturn, so we don’t have to make the tough cuts that states do when you can’t print money,” California Assemblyman Joaquin Arambula (D) said in an interview. “You have to live within your means.”

Governors and legislators have preached caution, spending surplus dollars on one-time projects or one-time tax rebates rather than committing to long-term spending.

“We know it’s going to rain. It’s not a matter of if, it’s a matter of when,” Massachusetts Senate President Karen Spilka (D) said.

But state legislators are still feeling the pressure to return surpluses to taxpayers.

“We’re trying to be cautious, we’ll always be conservative in our spending. For three years in a row we lowered personal income tax, corporate tax, and we gave I think several billion dollars back in tax relief through rebates,” Idaho’s Winder said. “There will be some pressure to do some of that again with the surplus.”

Infrastructure Spending

The bipartisan infrastructure law signed by President Biden in 2021 has been a remarkable windfall for state legislators, who can suddenly fund both classic infrastructure and forward-looking programs for years to come.

The sad state of the nation’s roads and bridges will get a lift as repair budgets are filled. Electric vehicle infrastructure will get a major lift right as the industry begins to take off. Even basics such as sewer and water systems, long overlooked in favor of more pressing concerns, will get a lift.

“We want to double down on just basic infrastructure,” West Virginia House Speaker Roger Hanshaw (R) said. “We want to deliver potable water and sewer to every address in the state of West Virginia.”

Most states are using infrastructure money to close what legislators see as the widening gap caused by varied access to technology, a crucial ingredient to modern economic success.

“We’re really spending a lot of the money on broadband. We’re making sure that every corner of our state gets access to the internet. Hopefully it’s high-speed internet, and hopefully it’s affordable,” Virginia state Sen. Barbara Favola (D) said. “That’s the big divide of our century. You can’t have families and children and workers not being able to look for jobs or look for educational opportunities. That just can’t happen.”


The era of technology as a panacea has ended, and states are beginning to grapple with disruptor companies and social media giants such as Facebook, TikTok, YouTube and Twitter that have outgrown their curiosity phase.

Those companies, legislators now realize, have a substantial impact on American life, from the mental health of teenagers to the misinformation spread during the coronavirus pandemic and in recent elections. At the same time, those companies are making billions off consumer data — what some have called the oil of the 21st century.

“These are relatively new issues,” Rhode Island Senate Majority Leader Ryan Pearson (D) said.

Several states will take up measures this year aiming to protect consumer privacy from all manner of technology companies. California has already passed a measure governing how social media companies can market to children; similar bills have been filed in New York and Minnesota.

“I see facial recognition and biometric information being issues that we’re going to be tackling this session,” Montana Senate President Jason Ellsworth (R) said in an interview.

Workforce Development

A decade ago, in the wake of the Great Recession, states fought bitter battles to attract new companies to their areas. Now, those same states are fighting over the workers those companies need to survive.

The workforce crisis is one that touches every element of economic life. Teacher vacancy rates are at record highs. Health care facilities cannot attract enough nurses and doctors. Restaurants don’t have enough staff to operate at full capacity. Help wanted signs are everywhere.

And the crisis is only going to get worse.

“We’ve known for 40 years that when Baby Boomers start to retire in droves, there’s no way for the next generation to replace them,” Washington House Speaker Laurie Jinkins (D) said at a recent conference. “We have to be much more creative and innovative than we ever thought of being before.”

To develop the next generation, states will spend record amounts on apprenticeship programs, career technical education and community colleges. Others will cut licensure requirements. In many cases, the companies that once demanded tax credits to locate a facility in a state are now demanding that the state spend money on nearby education facilities.

“When you talk to employers today,” Texas’s Springer said, “they say ‘I don’t need somebody with a four-year degree. I don’t need somebody with an associate’s degree. What I need is somebody with these three unique micro-certifications, and then I’ll pay that person $40 an hour.’”

Austin Jenkins and Sophie Quinton contributed reporting