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Moving from Design to Implementation: Lessons on Expanding Contraception Access in New Jersey Liz Gipson, Jahira Sterling, Lauren Moran, Brittany Lee, Sophia Durant Lessons on expanding contraception access in New Jersey. Public sector health leaders play a critical role in influencing reproductive health policy design and program implementation. As the key authorities on state programs, public sector leaders foster necessary collaboration between community partners and other state agencies. In New Jersey, state officials are implementing two contraception access bills, S 413 and S 275, enacted in 2022 and 2023 respectively. This report details lessons learned from New Jersey’s cross-sector and interagency collaboration, which can guide public sector leaders in other states working to expand access to reproductive health services. Get the Report (PDF) website yes

Policy Options to Improve Data Sharing Between State and Local Health Departments Organizational policies on data sharing between state and local public health agencies. This report explores organizational policies related to data sharing between state and local public health departments. ASTHO, in collaboration with the National Association of County and City Health Officials and the Network for Public Health Law developed this report, which aims to serve as a guide for state and local public health leaders as they consider organizational policy options to improve state and local data-sharing efforts. Get the Report (PDF) website yes

This guide captures the experiences and best practices of state and local public health agencies and their partners who are currently in the Cardiff Model implementation phase.

#MaskUp Campaign ASTHO and the Big Cities Health Coalition produced a public service announcement to encourage people across the country to express their compassion for others and #MaskUp. Please download, share, and encourage others to do their part to protect the community from the pandemic. website no

The Keys to Driving Generational Health, Well-Being, and Justice 30:13 Tune in to this podcast episode to hear a discussion about the vital conditions for health and well-being framework to reach full potential. PH Conversations Series - The Keys to Driving Generational Health, Well-Being, and Justice Somava Saha and Andrew Martin from Well-Being and Equity in the World (WE in the World) discuss the vital conditions for health and well-being framework or what we all need to collectively thrive and reach our full health and wellness potential. Through their conversation, they offer reflections and stories around how public health and community collaborations across the country organize around the vital conditions, prioritizing belonging and building civic muscle, to drive health, well-being, and justice across generations. Show Notes Guests Somava Saha, MD, MS, President and CEO, WE in the World Andrew Martin, MS, MHCDS, Director of Networks and Partnerships, WE in the World Resources Organizing Around Vital Conditions Moves The Social Determinants Agenda Into Wider Action | Health Affairs Thriving Together Springboard Vital Conditions | WIN NETWORK Pathways to Population Health Equity PHC Podcast Transcript - The Keys to Driving Generational Health, Well-Being, and Justice website yes

Partnering with Birthing Hospitals to Protect Babies Against RSV Partnering to Protect Babies Against RSV Susan Kansagra, Michelle Fiscus, Kim Martin Learn how immunization programs partnered with birthing hospitals to expand participation in Vaccines for Children and better protect babies against RSV. In 2023, the Advisory Committee on Immunization Practices (ACIP) recommended the use of monoclonal antibodies (mAbs) to prevent respiratory syncytial virus (RSV) in infants, a major milestone in newborn immunization. Unlike vaccines, which stimulate the body’s immune system to produce its own protection over time, mAbs work right away by giving the body ready-made protection against infection. This is especially important for newborns who do not have the protection of maternal RSV vaccination, which causes them to face a higher risk of severe RSV illness and need protection as early as possible. In response to the 2023 ACIP recommendation, state and territorial immunization programs acted quickly to ensure these new protections reached the babies who needed them most. One of the most effective strategies was partnering with birthing hospitals to expand participation in the Vaccines for Children (VFC) program, a federally funded initiative that provides vaccines to children at no cost to their families who might otherwise be unable to afford them. This program enabled the delivery of RSV mAbs — such as nirsevimab and now clesrovimab — to VFC-eligible newborns without any financial burden on their families. High Stakes, Strong Results The stakes were high, as RSV is the leading cause of infant hospitalizations in the United States. It was previously responsible for an estimated 58,000 to 80,000 hospitalizations and up to 300 deaths in children under age five each year. Data on RSV mAbs showed significant results, reducing RSV-related emergency department visits by 63% and hospitalizations by as much as 80%. Administering RSV mAbs in the first few days after birth, during RSV season, ensures that infants are protected before their first exposure — a critical step in reducing illness and health care burden. Strategies for Success Health departments played a leading role in bringing birthing hospitals into the VFC program. Many hospitals were not previously enrolled, often due to limited awareness, logistical barriers, or concerns about administrative burdens. Immunization programs responded by 1) launching targeted outreach, 2) offering tailored technical assistance, 3) simplifying enrollment processes, and 4) providing guidance on proper storage, eligibility screening, and documentation. The Impact of Stronger Partnerships These efforts have generated measurable results: The number of birthing hospitals enrolled in the VFC program increased from 292 in the 2023 season to 1,012 in 2025, boosting coverage from 10% to 36% of all U.S. birthing hospitals. This clearly demonstrates that these partnerships are effective and make a real difference in protecting infants’ health. State data further highlights this success and shows that collaboration across states, hospitals, and public health partners is crucial for achieving measurable impact: Virginia nearly doubled the number of birthing hospitals enrolled in the VFC program, increasing from six to 11 within one year. The state’s immunization program implemented an innovative Replacement Model to simplify requirements and collaborate closely with hospital teams to overcome barriers. Similarly, California provided resources, developed an enrollment checklist, and communicated the benefits of enrollment to birthing hospitals. Finally, across six states, 33 hospitals, and 400 clinics over two RSV seasons, Intermountain Health coordinated a system-wide approach that developed educational tools, enrolled hospitals in VFC, and addressed supply shortages. It also piloted a Replacement Model where mAb product was purchased by the hospital and doses administered to VFC-eligible babies were replaced with VFC-funded stock. These efforts also strengthened relationships between public health programs and birthing institutions. Trust and communication improved, and hospitals became more engaged in broader immunization goals (e.g., access to other birth-dose vaccines like hepatitis B). This expanded partnership not only protected newborns during RSV season but reinforced the capacity of immunization programs to mobilize quickly, implement new recommendations, and ultimately improve health outcomes. Compared to prior seasons, RSV-associated hospitalization rates were 28%-43% lower in 2024-2025, which was the first season with widespread availability of mAbs and maternal RSV vaccine. Future Opportunities Health departments have used a number of strategies to increase VFC enrollment by hospitals and mAbs coverage as a whole, including: Using birth volume data to prioritize outreach to additional hospitals for enrollment in the VFC program. Ensuring linkage to Immunization Information Systems to determine maternal RSV vaccination status and quickly identify eligible infants. Working with health systems on standing orders and protocols to help providers administer mAbs rapidly to eligible infants. Bringing hospitals and payers together to provide financial models that support universal coverage. While bundled payments for labor and delivery stays have been a barrier for private payer coverage, the high ROI for preventing future RSV-related health care utilization may provide additional opportunities for payers to consider alternative coverage models. Sharing promising practices through a Learning Collaborative webinar series developed by the Association of Immunization Managers, in coordination with CDC. The rapid rollout of RSV mAbs through the VFC program is a model of success. It shows that when public health agencies and health care partners work together, we can deliver lifesaving interventions, even in complex, high-volume settings like birthing hospitals. As new immunization tools emerge in the years ahead, the infrastructure, lessons and relationships built through this effort will continue to support the goal of protecting all children from the very start. article yes

This brief details innovative uses of geographic information systems (GIS) in public health. It showcases original research conducted by ASTHO staff to better understand the value of GIS in mapping national public health emergencies

Support for programs and policies that encourage positive mental health in early childhood and provides support for parents and caregivers to have the best chance to improve mental health across the life course.

The Florida Department of Health created an effective algorithm to automate syphilis laboratory result processing that improves case assignment accuracy and prioritization. This tool outlines key steps and considerations for jurisdictions looking to adopt the algorithm.

ASTHO conducted focus groups to examine overdose-related issues and identify potential engagement opportunities for public health and public safety around overdose prevention. This brief outlines key takeaways and is designed to serve as a guide for public health building and strengthening relationships with public safety.

States Partner Across Sectors to Address Lead Poisoning Kayley Humm, Kerry Wyss, Ali Aslam Learn in this brief how three states are using partnerships to improve lead testing and reduce cases of lead poisoning. ASTHO partnered with the National Center for Healthy Housing (NCHH) to provide technical assistance and capacity-building support for lead poisoning prevention efforts in three state health agencies: Maryland Department of Health, North Dakota Department of Health and Human Services, and Arkansas Department of Health. This brief highlights each agency’s strategies for collaborating across sectors along with accomplishments for strengthening lead poisoning prevention capacity in each jurisdiction. Many of these strategies align with those used in a health in all polices (HiAP) approach to lead poisoning prevention. State Examples Maryland Department of Health Maryland adopted a collaborative approach to prevent lead poisoning. The Maryland Department of Health (MDH) has an established lead poisoning prevention program that partners with the Maryland Department of the Environment. The Department of the Environment oversees the childhood lead registry and case management, while MDH focuses on lead testing regulations and Medicaid services. This partnership has been implemented across the 24 local health departments in the state. Maryland enhanced lead case management by providing staff support and tackling complex cases that require additional assistance. In addition to supporting an increase in lead case management activities and lead awareness, ASTHO funding also helped strengthen collaboration and coordination among local health departments, state agencies, and local health care providers. The MDH Environmental Health Bureau also improved efficiency by moving data from the lead registry to MDH for lead surveillance and case management. They also developed and launched sub-county lead testing data as part of their Environmental Public Health Tracking public portal. These activities align with HiAP strategies of developing and structuring cross-sector relationships, coordinating funding and investments, and synchronizing communications. North Dakota Department of Health and Human Services The North Dakota Department of Health and Human Services (NDHHS) made significant strides in building up the state lead program, which recently transitioned from the department of environmental quality to NDHHS. With support from ASTHO and NCHH, NDHHS developed a lead prevention website with a data dashboard, developed a lead screening questionnaire, and built collaborative partnerships. The activities in North Dakota align with the HiAP strategies of developing and structuring cross-sector relationships, synchronizing communications, and integrating research, evaluation, and data systems. Building collaborative partnerships is a key initiative for the NDHHS lead program. Already developed partnerships include stakeholders such as Health Tracks and WIC. Health Tracks developed a newsletter article for their provider network so physicians can stay up to date and aware of the lead program transition and lead testing changes, and WIC will host informational lunch and learns to raise awareness about lead testing within their network. North Dakota is also prioritizing building partnerships with tribal communities. A tribal communications plan was developed with the goal of establishing an effective communication plan between the state of North Dakota and each tribal government for lead-related events. Anticipated outcomes from the communication plan include testing for blood lead levels, conducting environmental assessments on tribal lands, and seeing if a tribal member or government is interested in hosting a lead screening event. Progress has been made with the Standing Rock Sioux Tribe, Turtle Mountain band of Chippewa, and NDHHS is hopeful to establish intertribal meetings with all four governmental tribal representatives. Arkansas Department of Health The Arkansas Department of Health established its lead program in 2011 to support abatement of lead-based paint in residential and commercial properties. With support from ASTHO and NCHH, Arkansas has been using a data-driven approach to gain a more comprehensive understanding of lead exposure burden in the state. These activities align with the HiAP strategy of incorporating health data into decision-making and integrating research, evaluation, and data systems. The Arkansas Department of Health conducts periodic audits on its data system to support access to timely and accurate data. To improve data quality and frequency of blood lead testing reports, the health department is establishing incentive programs to encourage facilities to report cases of elevated blood lead. In addition to conducting outreach to its partners, the Arkansas Department of Health has been working to improve lead case data access and data quality through data mining efforts, case report matching, and migration to a new lead surveillance system. Arkansas has been working to modernize the current reporting system to facilitate automation and promote overall efficiency of data analysis and case identification. Conclusion The collaborative efforts of Maryland, North Dakota, and Arkansas highlight the importance of multi-sector partnerships and data sharing in addressing lead poisoning prevention and align with many of the strategies used in a HiAP approach. Each state implemented tailored strategies that sought to grow collaboration in its unique context. These initiatives highlight the importance of cross-sector collaboration in public health initiatives and may serve as valuable models for other jurisdictions. article yes

Olmsted County Pilots a Regional Population Health Data Hub to Improve Data Accessibility Gelila Tamrat, Sara Black, Reema Mistry, Christina Severin Olmsted County, Minnesota, pilots a regional population health data hub to improve data accessibility, which supports improved decision-making and interventions. Historically, Olmsted County and other local counties in southeast Minnesota have faced barriers to accessing timely and actionable public health data, including limited data analytics workforce capacity, lack of data-sharing agreements (DSAs), and misaligned data suppression standards. To address these challenges, Olmsted County Public Health Services (OCPHS) piloted a regional population data hub, in partnership with the Minnesota Department of Health (MDH) and 10 local health departments (LHDs). OCPHS procured resources to develop a regional data-sharing platform, expanded their epidemiology team, and pursued DSAs. As a result, they gained access to critical data that supports informed decision-making and tailored interventions at the local level. Tina Jordahl - Brief - Olmsted County MN DMI Hub Developing a Regional Population Health Data Hub With financial support from the Minnesota legislature in 2021, OCPHS collaborated with MDH and its regional counterparts to develop a regional population health data hub for smaller LHDs to access community-level public health data. OCPHS maintains the hub by managing data from the state, regional partners, and 10 LHDs, and creating data dashboards to support southeast Minnesota counties’ population health data needs. This effort involved building and expanding relationships with MDH unit-specific epidemiologists, working closely with public health system consultants at MDH, and raising awareness of the need for sustained data analytics workforce support. Following the initiative’s success, OCPHS plans to engage with state and local leaders to identify funding sources that can sustain the hub beyond the pilot funding cycle. Promoting Data Accessibility through Strategic Partnerships and Agreements MDH’s Center for Public Health Practice supports public health system consultants, who offer technical assistance and consultation services to strengthen public health infrastructure across Minnesota. The consultant for the southeast region of the state was crucial in linking state and local staff to advance the development of the regional population health data hub. They helped triage and expedite requests from OCPHS by identifying the right points of contact for datasets and legal counsel within MDH. The collaboration of MDH, OCPHS, and participating LHDs facilitated the development of DSAs, which allowed for proper data flow and enabled OCPHS to request data from MDH on behalf of participating counties, reducing the need for each county to request data. It also helped OCPHS to become the first county in the state to adopt CDC’s ESSENCE tool to monitor hospital visits for syndromic surveillance across Minnesota and neighboring states, better enabling LHDs to address the needs of communities residing along state borders. Hiring Strategies for the Data Analytics Workforce OCPHS focused on hiring staff to support the regional population health data hub with data expertise, strong communication skills, and a particular interest in population health and social determinants of health. OCPHS created two permanent epidemiologist positions to promote sustainability for that position in the future. To expand their hiring pool, OCPHS relied on Olmsted County’s updated remote work policies following the COVID-19 pandemic when many shifted to remote or hybrid work. They also invited leaders from partner counties to help vet candidates who could support other LHDs’ needs. Meaghan Sherden - Brief - Olmsted County MN DMI Hub Advancing Equity Through Data Accessibility Due to data suppression rules, counties in southeast Minnesota had limited access to county-level data for certain statewide datasets. OCPHS worked with MDH to identify appropriate data suppression standards that supported access to community-level public health data and preserved privacy and security, and collaborated with the county IT department to develop the regional data hub with public-facing and internal dashboards, aligned with the required privacy and security standards. The public-facing dashboards show aggregate data with appropriate suppression standards at county, regional, and state levels. The internal dashboards provide complete data summaries and are protected with appropriate permissions and multi-factor authentication for LHD staff to perform population-level analysis. Providing timely, granular data to participating counties allows LHD staff to develop tailored strategies to address emerging health issues promptly, bridging health equity gaps. OCPHS also integrates standard demographic data on race, sex, gender, and age into its dashboards, enabling regional LHDs to gain deeper insights into their communities and fine-tune equity-centered public health initiatives and interventions. Jenny Passer - Brief - Olmsted County MN DMI Hub Implementation Considerations Foster collaborative relationships across state and local health departments to identify opportunities to share resources when advancing data-sharing efforts. Models in which larger LHDs support key data infrastructure needs on behalf of smaller LHDs may bolster data analytics/epidemiology capacity across multiple LHDs and streamline coordination with key partners at the state health department. Consider how state health department consultant or liaison roles charged with providing technical assistance to state or local partners may help facilitate key connections between state and local health department staff pursuing cross-jurisdictional data-sharing efforts. Invest in data analytics/epidemiology workforce strategies that help address specific needs related to population health and relationship building, along with technical skills. Cross-jurisdictional data-sharing efforts require staff with strong data analytics and communication skills, as they work with multidisciplinary leaders and across jurisdictions to inform community-based interventions. Collaborate proactively with legal and IT departments to identify data governance solutions and technical approaches to adhere to required privacy and security standards. Establishing DSAs is important, as it allows sharing of data within required legal guardrails. Similarly, IT leaders can identify technological solutions that support effective access to data. OT18-1802 website yes

Arizona Department of Health Services Pursues Policies to Advance Data Sharing with Tribal Nations Erik Skinner, Christina Severin, Reema Mistry The Arizona Department of Health Services is pursuing policies to advance data sharing with tribal nations, centered around partnerships, education, and more. With leadership support and funding to modernize its public health infrastructure, the Arizona Department of Health Services (ADHS) is pursuing policies to advance data sharing with tribal nations. This includes investing in partnerships with tribal leaders, educating the public health workforce about tribal governments and tribal health care, and working to improve data identification processes to support effective data sharing between the state and tribal nations. Data sovereignty is an important consideration for ADHS, as there are 22 federally recognized tribal nations in Arizona. ADHS recognizes the inherent right of tribal nations to access their citizens’ public health data and is developing a tribal data sovereignty policy that both acknowledges their unique data needs and aligns with state requirements around tribal engagement. Leadership Support and Effective Tribal Engagement ADHS leadership understands the importance of making strong connections with tribal nations and recognizing each nation’s public health priorities while meeting its statutory requirement to develop tribal consultation policies. To that end, ADHS developed the tribal liaison position to serve as a resource, advocate, and communication link between ADHS and Arizona’s Native American health care community partners, including tribal community leaders, health and epidemiology directors, Indian Health Service (IHS), and Tribal Epidemiology Centers (TECs). Understanding cultural norms is essential to building trust with tribal partners; the tribal liaison role has been vital to ADHS engagement with tribal nations on data sovereignty topics. People and processes are important to establishing data sharing policies, and a well-informed workforce is essential for effective collaboration with sovereign tribal nations. ADHS is working with the Native Nation Institute to provide training on tribal sovereignty and cultural humility for staff. It has also developed a tribal handbook for public health staff on sovereignty, cultural trauma, and the roles of IHS and TECs. Identifying Tribal Affiliation within Datasets and Tribal Public Health Priorities ADHS conducted a data assessment to identify instances in which data sharing was active and ongoing between ADHS and tribal nations, and instances in which it had expired. A notable technical challenge was identifying tribal members within existing datasets, as many public health datasets are incomplete (e.g., do not include tribal affiliation) or rely on IT systems that are unable to aggregate data appropriately—making it difficult to ensure tribal authorities receive relevant, comprehensive public health data for their communities. In addition, because each tribal nation’s public health priority areas and data needs could differ from the data that state health information systems collect, sharing relevant data with tribal nations can be challenging. ADHS is working with each nation to identify tribal public health priority areas, find solutions to identify tribal data within state collected datasets, and share it with the respective nations. Ken Komatsu - Brief - AZ DHS Pursues Policies to Advance Data Sharing with Tribal Nations Honoring Sovereignty in Data Sharing Relationships Data sharing agreements with public health agencies often establish that the state agency controls the disposition and use of the data, and that each party benefits. Acknowledging that tribal partners are entitled to their citizens’ data without conditions differs from how ADHS has historically approached data-sharing relationships with others. ADHS plans to formally establish a non-transactional data sharing policy with tribal public health partners, and establish data sharing agreements that align with this approach going forward. Implementation Considerations Considerations for state health agencies in fostering strong relationships and effective engagement with tribal partners around data-sharing efforts include: Center tribal sovereignty when framing data sharing agreements with tribal nations. Engage tribal liaisons in data-sharing efforts with tribal nations. They maintain close relationships with tribes and can help develop mutual cultural understanding, which is essential to engaging tribal partners. Assess datasets to determine data completeness with regards to tribal affiliation and identify opportunities to improve comprehensive data sharing with tribal authorities. Invest in state health agency staff training on tribal sovereignty and cultural humility, so staff can be well-prepared when engaging in data sharing conversations with tribal partners. Gerilene Haskon - Brief - AZ DHS Pursues Policies to Advance Data Sharing with Tribal Nations OT18-1802 website yes

This infographic highlights 10 high-level strategies to advance work in school behavioral health.

This infographic breaks down the top 10 takeaways from the 2022 Climate and Health Capacity Survey.

ASTHO and NAMD Letter Urging Congress to Fully Fund Medicaid and CHIP in U.S. Territories Dear Chair Wyden, Chair Rodgers, Ranking Member Crapo, and Ranking Member Pallone: Strong, sustainably funded Medicaid and Children's Health Insurance Programs (CHIP) are crucial to addressing health care challenges in the U.S. territories. On behalf of the Association of State and Territorial Health Officials (ASTHO) and the National Association of Medicaid Directors (NAMD), we urge Congress to ensure the fiscal stability of the territories’ Medicaid programs by lifting the annual Section 1108(g) allotment cap for all territories and authorizing a permanent 83% Federal Medical Assistance Percentage (FMAP) for Puerto Rico. Robust Medicaid and CHIP are critical components of strong and resilient territorial health systems. The five U.S. territories—American Samoa, Guam, the Commonwealth of the Northern Mariana Islands (CNMI), Puerto Rico, and the U.S. Virgin Islands (USVI)—vary dramatically in population, health care system capacity, and Medicaid program structure. Despite these differences, they share common challenges, including significantly higher rates of poverty (ranging from 16.8 percent in Guam to 54.6 percent in American Samoa in 2019, compared to 10.5 percent in the United States), higher rates of chronic health conditions, and a lack of health care infrastructure. Medicaid and CHIP programs are crucial to addressing these challenges. Chronic underfunding has impaired territories’ capacity to serve their residents, who are U.S. citizens or U.S. nationals. Historically, the territories have faced two statutory funding challenges: 1) A low, fixed FMAP rate that is not tied to per capita income (as is the case in the states), and 2) Annual funding caps. Prior to FY 2023, Congress supplemented low annual funding amounts with short-term additional investments. The short-term nature of this funding limited territories’ ability to plan, undertake large investments, and efficiently deliver services. In the Consolidated Appropriations Act of 2023, Congress permanently increased the FMAP for American Samoa, Guam, USVI, and CNMI to 83% and authorized a 76% FMAP for Puerto Rico through 2027. NAMD and ASTHO applaud and fully support this structural means of addressing longstanding needs. Congress should continue to build on this foundation by extending the permanent 83% FMAP to Puerto Rico to ensure all U.S. territories have access to sustainable Medicaid and CHIP funding. Over and above this FMAP adjustment, Congress must also address the constraints caused by the allotment cap on the territories’ Medicaid and CHIP funding, established by Section 1108(g) of the Social Security Act. When a territory reaches this cap, they are responsible for funding their Medicaid agency solely with local dollars. Due to challenges generating sufficient local funds, many territories have been forced to cut services after reaching these allotment caps, drastically limiting their ability to offer services and destabilizing local health care providers. For example, CNMI expects to hit its FY 2024 cap by July, leaving the CNMI government with more than two months of unmatched Medicaid costs. Congress should eliminate the annual Section 1108(g) allotment cap to ensure sustained access to high-quality public health and health care services in the U.S. territories. Sustainable, equitable funding will allow territorial programs to make long-term, cost-effective investments that support high-quality and innovative Medicaid programs. The Consolidated Appropriations Act of 2023 directed American Samoa, Guam, CNMI, and USVI to develop four-year strategic plans focused on workforce, program integrity, systems development, and financing. The four territories developed comprehensive plans with ambitious goals, including developing electronic eligibility and enrollment, MMIS, and T-MSIS systems, launching initiatives to expand local provider workforces and territory administrative capacity, and strengthening program integrity processes. These plans are evidence of the momentum and energy that territory leaders bring to their reform agendas. Technical assistance from CMS and other agencies will remain a critical resource for capacity-building efforts in the territories. In addition to lifting the statutory allotment cap and providing Puerto Rico with a permanent 83% FMAP, Congress should also consider providing the territories with targeted, project-specific enhancements to their administrative match rates to facilitate necessary technical assistance and change management. These structural improvements will strengthen the impact of Medicaid dollars allotted to the territories. Thank you for your previous support of the Medicaid programs in the U.S. territories and your ongoing attention to this important issue. If you have any questions or require additional information, please reach out to Jeffrey Ekoma (senior director of government affairs at ASTHO, jekoma@astho.org) and Jack Rollins (director of federal policy at NAMD, Jack.Rollins@MedicaidDirectors.org). Sincerely, Joseph Kanter, MD, MPH Chief Executive Officer, ASTHO Kate McEvoy, Esq. Executive Director, NAMD website yes

Strengthening Public Health Systems: CNMI Food Safety Program Spotlight Strengthening Public Health Systems: CNMI Food Safety Spotlight Anya Groner, Taylor Francis Learn a few essential steps for strengthening public health systems, as exemplified by CNMI and their work to adopt the FDA Food Code. Public health systems are designed to protect and improve population health. These vital systems — from food safety programs to disease surveillance — help to prevent disease, respond to health threats, and ultimately improve well-being. To best benefit communities, public health agencies must remain committed to strengthening these existing systems. The Commonwealth of the Northern Mariana Islands (CNMI), a U.S. territory in the western Pacific with a population of approximately 50,000, models this work in their exceptional efforts to improve their food safety system. Managing the risks of foodborne illness requires clear guidelines, government support, and regulatory authority. Yet, when the Environmental Health Disease Prevention Program (EHDP), part of the Commonwealth Healthcare Corporation in CNMI, conducted a voluntary review of their food regulations, the jurisdiction met only a small percentage of the FDA retail program standards, which define what constitutes a highly effective and responsive program for the regulation of retail food establishments. From there, EHDP launched an ambitious plan for the jurisdiction to adopt the FDA Food Code for the first time. The EHDP Office spent several years analyzing the legal and technical implications of adopting the FDA Food Code and garnering leadership support. In November 2024, it was officially adopted — an extraordinary accomplishment. EHDP will now embark on a five-year implementation process which has a strong focus on training, technical assistance, and partnerships with local stakeholders — with an emphasis on education instead of enforcement. Their journey serves as an example for other jurisdictions working to strengthen their public health systems. Getting Started Building better systems starts with identifying opportunities to strengthen those already in place. When EHDP reviewed their existing local regulations against the 2017 FDA Food Code, they found that theirs fell short of the criteria related to risk factor interventions, good retail practices, and effective compliance and enforcement measures. This led to the realization that they needed to strengthen their food safety program and adopt their first FDA Food Code. Pangelinan 1 - CNMI Food Safety Program Spotlight By moving from their old code to the FDA code, EHDP shifted from a focus on basic sanitation to foodborne illness risk factors. With limited resources and staffing challenges, it was vital that the EHDP team knew where to focus their workload and how to streamline inspections. This change will also help EHDP better protect the public’s health. Measuring Progress As health agencies embark on building better systems, it’s vital to have a specific measure to assess progress against. EHDP spent several years working toward adopting the 2022 FDA Food Code. Their previous regulations were outdated, vague, and inconsistent. Plus, there was a lack of clarity around critical food safety practices, like cooking temperatures, cooling procedures, and sanitization. The retail food program standards gave the team a measure to assess their food safety program compared to other programs nationally and helped them better understand gaps. Getting Buy-In and Mobilizing Stakeholders Two additional essential steps are garnering support and coordinating action. For EHDP, there was a lot of training to get internal support not just within the team but also from leadership. Fortunately, the adoption process to implement new regulations was fairly smooth. Their next focus is building the infrastructure, training the staff, and ensuring that the local operators have access to the necessary equipment, supplies, and sample policies. They are also looking to offer certified Food Protection Manager training to food operators. EHDP plans to focus on small behavioral changes, making sure everyone’s on the same page with employee health so retail food establishments can meet the requirements on employee health and reporting. Every September, EHDP hosts food safety week as part of Food Safety Education Month and brings together food handlers and food operators — some of whom are familiar with the FDA Food Code due to working in the continental United States. The EDPH team always talks to them about potential changes that could come about from this new code and, so far, have received great feedback. Pangelinan 2 - CNMI Food Safety Program Spotlight Collaborating with Partners As with any effective public health initiative, collaborating with partners at all levels is crucial – as agencies can learn from others’ skills and experiences. At both the federal and local levels, EHDP worked closely with their FDA retail specialists who provided technical support and training throughout the process. The team also did a three-year mentorship with Northern Nevada Public Health, which helped them improve their field inspections and strengthen internal policies and procedures. These were the key steps in making progress towards the standards and preparing for adoption. In addition, ASTHO connected EHDP with other health departments who had gone through the food code adoption process, enabling them to hear their firsthand insights and practical guidance. The team is willing to support other Pacific Island jurisdictions, like American Samoa, as they work to adopt the FDA Food Code for the first time, too. Pangelinan 3 - CNMI Food Safety Program Spotlight Celebrating Successes It’s always important to take a step back and acknowledge wins throughout essential public health work. EHDP’s work towards the FDA Food Code strengthened the team's skills and expanded training opportunities, as they shifted from focusing on rules and regulations to risk-based inspection and partnering with food operators — emphasizing education, prevention, and collaboration, to get everyone on board. Their biggest success, however, is of course adopting their first FDA Food Code. Pangelinan 4 - CNMI Food Safety Program Spotlight In Conclusion Through EDPH’s efforts to improve their food safety program, they are reducing foodborne illness, protecting public health, and safeguarding their community. As exemplified in CNMI, improving public health systems takes time and hard work — but with that investment comes key successes that benefit communities for years to come. CDC-HHS - $1,000,000 article yes

Data-Sharing Strategies to Support Access to Care Interventions Anna Bartels, Chikamso Chukwu Learn how primary care offices improve community access to health care in this Health Policy Update. Every state public health agency houses a Primary Care Office (PCO), which monitors the effectiveness of that jurisdiction’s health system. HRSA funds PCOs to identify communities with health professional shortages, and PCOs may also administer workforce programs to place providers in those communities. To identify which communities are experiencing shortages, PCOs collect state-level data on where health care providers work, what services they offer, and how many hours they spend on patient care. PCOs also track data on community needs, such as household income levels and community transportation options, to create a holistic picture of whether health care is truly accessible. PCOs across the country have explored different policy pathways to access reliable, accurate data, including laws that support PCO access to certain data sets, cross-sectoral relationships, and data-sharing agreements. According to ASTHO’s national PCO workforce assessment, over 85% of PCOs are part of a formal data-sharing arrangement, with licensing boards and Medicaid agencies serving as two of the most common data sources. This health policy update describes several types of actions jurisdictions have taken to support PCO data access. New Hampshire Law Allows the PCO to Survey Providers During License Renewals The New Hampshire PCO’s Health Professions Data Center administers a survey tied to health care providers’ medical license renewals that gathers self-reported provider and practice data, such as where providers work, how many hours per week are spent delivering direct patient care, and anticipated changes in capacity over the next five years. New Hampshire law outlines the scope of the survey and authorizes the PCO to collect, store, analyze, and report on health care workforce supply and capacity through surveying during license renewal. Although survey responses are the primary source of data on the health care workforce, data from the state’s all payer claims database housed within the Medicaid division provides supplemental information. Given the type of data involved, legal agreements are required between the PCO, licensing agencies, and relevant parties to maintain privacy for providers. These data are critical for the PCO to evaluate current and future capacity — especially in regions with limited providers — and proactively focus recruitment efforts on those communities. Colorado Braids Data Collection Strategies Across Multiple Sources While the Colorado PCO has relied on a similar law that authorizes collecting licensure data for more than 10 years, its data collection efforts have since expanded. The state now collects and integrates data across 16 different sources, each requiring a different procurement strategy. While some data sources are simple to access because they are public use files (e.g., Medicare provider data), other sources — namely state agencies — require the PCO to submit an application or enter into a memorandum of understanding or contract for access. Pursuing multiple data sources in this way takes significant effort and staff time, necessitating the health department to supplement HRSA’s PCO cooperative agreement funding with other sources, including state appropriations and private funding. A commitment to collaboration and investment and a willingness to build new relationships and processes from scratch support the Colorado PCO’s wide-ranging data collection strategy. Iowa Builds on Existing Relationships to Access Provider Data Iowa’s PCO has a long-standing relationship with the University of Iowa and a joint interest in health care workforce data. Currently, the PCO purchases provider phone survey information from the University of Iowa’s existing program and receives data on a biannual basis. The university’s data collection is part of its own research efforts and not collected on behalf of the PCO, so while the data are broader than what the PCO needs, it is still a valuable source of provider information. Because of this existing arrangement, the PCO could pursue a more expansive agreement (that would likely require additional funding) and expand the scope of the data, such as by adding data collection on provider residence or sliding fee scales. Other PCOs may consider approaching partners that have pieces of the data they need so there is an established relationship in place that may be expanded as new resources become available. PCOs Secure Access to Medicaid Claims Data State Medicaid agencies are another frequent data partner for PCOs, with at least 16 receiving provider data from their state Medicaid agency in various formats. In some states the Medicaid agency shares a point-in-time file with the PCO, who may manually recode the data before submission to HRSA. In other states, the PCO has direct access to the Medicaid claims processing system to independently extract the necessary data points. The nature of the partnership between the PCO and Medicaid agency may vary based on the state’s organizational structure (e.g., whether the PCO and Medicaid agency sit within the same department). However, a PCO seeking access to Medicaid claims data should be prepared to justify the need for the data, articulate how it can support the Medicaid agency, and develop the necessary relationships to support a workable solution for both parties. Conclusion Each PCO and state health agency has its own unique structure, and there is no “right” way to collect health care provider practice or access data. However, exploring how different jurisdictions approach these processes can help PCOs think strategically about new initiatives and relationships. ASTHO will continue tracking PCO success stories and remains available to facilitate connections among health agency staff. 2 UD3OA22890-13-00 article yes

The Key Role of Cross-Sector Partnerships in Navigating Barriers Keon Lewis Community partnerships are critical to public health's mission to promote optimal health for all — learn more. Public health departments’ mission and vision statements often share certain values and goals aimed at improving the public’s well-being. Rather than just reactively responding to immediate health threats as they come, public health departments aim to take a more proactive approach through strategies that prevent the future spread of diseases, injury, or other incidences of harm. These actions support their visions of creating communities where all residents can thrive and achieve their full health potential. Strong community partnerships are critical to public health departments’ ability to fulfill their goals. Recognizing this, the Robert Wood Johnson Foundation introduced the Culture of Health Framework in 2015. As a leading national philanthropic organization focused on dismantling barriers to optimal health for all, the framework’s foundation is built upon the following action areas: Making Health a Shared Value. Creating Health. More Equitable Communities. Strengthening Integration of Health Systems and Services. Fostering Cross-Sector Collaboration. The COVID-19 pandemic and its aftermath underscored the factors that created challenges to health outcomes for underserved communities; it also demonstrated the importance of sustaining strong cross-sector partnerships. Public health’s ability to align its goals with the community it serves is vital to efforts to save lives. This alignment allows public health departments to leverage the diverse resources and lived experiences that community partners bring. Recognizing the unique concomitant relationship that it has with government funding, public health departments are now going to have to pivot their strategies to achieve their missions. As public health departments experience budget and personnel cuts, its ability to promote optimal health for all and mitigate the social determinants of health is now even more reliant upon the strength of collaborative partnerships. The Public Health Paradox Public health has always been a component of our nation’s health care system, which primarily reflects specific health issues that have impacted our communities. Rather than focusing on the foundational issues that exacerbate these long-term gaps in underserved communities, government systems often allocate funding based on specific diseases or chronic health issues impacting community health. Although diseases and chronic health issues are significant public health elements that need to be addressed, there are significant nonmedical factors that play just as vital a role in influencing community health outcomes. Identified by the World Health Organization (WHO) and adopted by CDC as the social determinants of health, these variables — which include elements such as social and community construct, economic stability, and education access — have become the central driving force of public health. “The Public Health Funding Paradox,” an article from Sage Journals, offers a great perspective on how an intriguing paradox has been created due to this relationship between public health and government systems. The article underscores the complexity of governmental funding that helps to advance public health strategies while there still exist harmful policies that create barriers for certain communities. The Flint water crisis in Michigan demonstrated this paradox. Flint citizens experienced lead poisoning and death from Legionnaires’ Disease, underscoring how a community’s ability to thrive can be quickly impacted by economic difficulty and leadership decisions made by the accompanying government. The Power of Partnership Public health has long had to combat a barrage of stigmas and policy hurdles. Even at the height of the COVID-19 pandemic, public health departments were not only in contention against the virus but also against the influence of viral misinformation that questioned their practices, strategies, and purposes. Despite these barriers, the nation witnessed the power of true cross-sector partnerships. Health care and grassroot organizations quickly found common ground to help address the needs of underserved populations. From addressing food insecurity to mental health and transportation barriers, communities successfully pivoted toward hope and found ways to save lives. Nonprofit organizations also created innovative and impactful peer-to-peer funding models that enabled them to fulfill their missions in spite of budget cuts. During this time, community health workers became a vital public health resource. As conduits between departments and local communities, community health workers became a necessary element to re-reestablishing trust in systems and care. Although the work of frontline workers and support staff served a critical role in mitigating the future spread of COVID-19, advocates and allies at the grassroots level also played an invaluable role in promoting health for all. As “The Public Health Funding Paradox” demonstrated, public health departments are only as effective as their accompanying government systems. If the leadership within these respective systems fails to align and empathize with their public health counterparts, then as a community we inevitably repeat a vicious cycle that results in poor health outcomes. Identifying Alternative Routes Cross-sector partnerships serve a vital role in enabling public health systems to better serve their communities. Budget cuts and stricter policies have created barriers for local and statewide agencies, academic institutions, and nonprofit organizations. The ability to develop essential personnel, continue pertinent research, and utilize mitigating practices have been inhibited by these barriers. It has become increasingly evident that, rather than focusing on reactive strategies, public health must go upstream and address the social needs of our communities. With cuts to funding, public health systems have to do more with less, making it more difficult to address diseases and chronic health problems. Working upstream to address root causes of health outcomes is one way to better leverage thinner resources. As our public health systems continue to work diligently to monitor, support, and mitigate community health barriers, there is still more research needed to explore the most effective cross-sector partnership frameworks. Public health’s efforts must remain intentional in developing comprehensive health advisory coalitions, leadership development cohorts, civic and community engagement projects, and paradigm shifts in academic curricula. The leaders and changemakers of tomorrow require growth in their competencies today. Cross-sector partnerships must continue to build their foundations upon systems of trust and transparency. Public and private health systems, the social sector, and other community stakeholders can partner to improve the population’s overall well-being while simultaneously achieving a mutually beneficial “social return on investment.” Public health’s ability to align with the achievement of optimal health for all requires more than just serving on the front line when a crisis occurs — it is critical that these departments must continuing enhancing their collaborative partnerships and community engagement. article yes

Population Health Summit Strengthens Pacific Partnership Anya Groner Read about the inaugural Population Health Summit, which was held in the Commonwealth of the Northern Mariana Islands, and learn how it worked to improve collaboration in the Pacific. For Halina Palacios, chief operations officer of public health for the Commonwealth Healthcare Corporation, it was important to break the mold and host a public health summit in the Pacific instead of the Continental United States. She and her team held the corporation's inaugural Population Health Summit in the Commonwealth of the Northern Mariana Islands (CNMI). With firsthand knowledge of the notable work happening across the Pacific, Palacios hoped to create a venue where public health workers from U.S. territories and freely associated states could share their successes and learn from each other. Improving Pacific Collaboration and Confidence Regional collaboration is not new to the Pacific. During the COVID-19 pandemic, the U.S.-Affiliated Pacific Islands (USAPI) worked together to limit transmission until most of their populations could get vaccinated. Palacios knew that a summit hosted in CNMI would build on this existing regional collaboration. Public health summits are typically held in the continental United States and come with high travel costs, meaning that only one or two representatives from each jurisdiction can attend. As a result, the majority of Pacific public health teams don’t directly benefit from information sharing and networking at such conferences. Holding a summit within the region instead would lower those travel costs and boost attendance. In addition, Palacios felt a local summit would boost confidence in Pacific public health officials: The officials who were able to attend public health conferences in the continental United States sometimes told her they felt imposter syndrome, caused in part by the feeling of being in a tiny minority at a national event and from attending presentations that didn’t necessarily address local realities. Halina Palacios 1 - Population Health Summit Strengthens Pacific Partnership Turning Vision into Reality Putting together a conference is a massive undertaking, but Palacios knew her team could do it. They chose “Navigating Pathways Through the Pacific: Building Healthier and Stronger Island Communities” as the theme of the inaugural summit. Broad and ambitious, it encompassed Palacios’s expansive vision. She wanted the event to encourage public health programs across the Pacific to operate with a population health mindset, addressing not only individual medical concerns but also the social, economic, and environmental factors that influence community health outcomes. Spanning three days, the summit schedule included various plenaries, poster presentations, and panel discussions on behavioral health, public health, and clinical practice — centering topics relevant to the region. The team invited faith group leaders and members of recovery communities to speak alongside specialists from throughout the region. Halina Palacios 2 - Population Health Summit Strengthens Pacific Partnership   Population Health Summit Planning Committee members gather in front of a conference banner.   An Impactful Inaugural Event The inaugural summit occurred this past June in CNMI’s capital city, Saipan, and turnout was high. In addition to strong representation from CNMI, more than 50 people came from off-island to share resources, compare programs, and form new collaborations. Popular topics included data capacity, expanding approaches to behavioral health, technical assistance opportunities, and clinical resources. The impact was immediate. Halina Palacios 3 - Population Health Summit Strengthens Pacific Partnership Two speakers, Oncologist Peter Brett and Dentist Angelina Sabino, with clinics in their respective fields at the Commonwealth Healthcare Corporation, educated attendees on the realities they face treating the community. This session led to post-discussions, opening opportunities to collaborate with other USAPI on addressing oral cancer in the Pacific, which is especially important due to recent reductions in national surveillance, technical assistance, and funding for tobacco prevention programs. Island jurisdictions have high rates of oral cancer as a result of betel nut use with tobacco and high smoking rates — and with patients often seeking treatment in Guam, Hawaii, or elsewhere in Asia, the team knew it was a topic that the summit needed to cover. Another topic of particular interest was research and accountability. A panel discussion, which included Palacios, sought to improve data collection and research across the region. Participants noted the need for a centralized Institutional Review Board in CNMI to review and monitor research on human subjects. Without it, health officials can’t easily standardize research methods and practices. Panelists also expressed a need to set higher expectations for researchers who conduct studies using data from the Pacific Island jurisdictions; many fail to meaningfully share the results of their work with participants or public health teams, often doing little more than emailing a link to an article or a Zoom presentation. Halina Palacios 4 - Population Health Summit Strengthens Pacific Partnership The Population Health Summit purposefully centered on Pacific Island culture — each day, it opened and ended with a prayer. Instead of being part of a tiny minority at a large conference on the mainland, participants saw themselves represented in the daily schedule, with presenters from within their community, speaking on topics that addressed their concerns.   A large group of Population Health Summit attendees convene in a conference room.   Looking Ahead Though only a few months have passed since the summit, new projects and collaborations are underway. Some attendees are contacting presenters to schedule training sessions for staff who couldn’t attend. Others are sharing resources on topics such as men’s behavioral health and accountability. Most encouraging for Palacios are the conversations about the next population health summit: who will host it, when it will be, and what the presentation topics might be. Over the next five years, a new cohort of public health workers will start their careers in CNMI and across the Pacific Island jurisdictions. By then, Palacios predicts that the Population Health Summit will be well established and that standards for the profession will have shifted. Halina Palacios 5 - Population Health Summit Strengthens Pacific Partnership CDC-HHS - $1,000,000 article yes