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Tennessee and Connecticut Are Transforming Procurement and Grant Management Systems States Transform Procurement and Grant Management System Melissa Touma Learn how Tennessee and Connecticut are transforming their procurement and grant management systems with new tools, smarter workflows, and transparency. Behind every public health initiative — whether it’s expanding rural care, funding local clinics, or responding to emergencies — there’s a complex system working to move contracts, track spending, and ensure accountability. For many health departments across the country, CDC’s Public Health Infrastructure Grant (PHIG) is a critical resource to modernize these foundational systems that power public health. In Tennessee and Connecticut, this investment is already paying off. With new tools, smarter workflows, and a focus on transparency, both states are transforming how they manage procurement and grants. As a result, they’re delivering faster, more reliable services to the communities that need them most. Tennessee Department of Health In Tennessee, innovation took root through a homegrown solution: the Contract Tracking and Reporting Application (CTRAC). The Tennessee Department of Health’s (TDH’s) Operations Analysis Office and Procurement Management Office built CTRAC using Caspio, a low-code platform that allowed the team to design a fully customized application without extensive programming. What began as a manual, email-based process using internal contract processing worksheets is now a fully automated, digital workflow. CTRAC streamlines how TDH initiates, reviews, and tracks contracts, making procurement more efficient and transparent. The system automates the collection of all required documentation for procurement processing, enforces validation rules to ensure data quality, and provides comprehensive reporting capabilities that meet CDC’s PHIG performance measures. It has also been expanded to support Federal Funding Accountability and Transparency Act reporting and invoice management, making it a central hub for multiple financial and administrative functions. Additionally, CTRAC integrates critical control mechanisms that strengthen financial compliance and oversight: Budget review and monitoring tools ensure that funding sources are correctly cited and aligned with contract terms. Fiscal review processes, which are embedded into the workflow, reduce the risk of errors and improve compliance with federal and state regulations. Automated data capture reduces human error and ensures timely, consistent entries. Monthly audits and validation checks maintain data integrity and support continuous improvement. PHIG funding offset TDH’s initial Caspio costs, covering the expenses that supported procurement timeliness improvements. It also enabled the development of internal dashboards that track processing times at key stages. These visual tools improved communication with stakeholders across the department and supported efficient, data-driven decision-making. In parallel, TDH enhanced several Caspio user interfaces to streamline navigation and improve the overall user experience for staff. In addition, PHIG funding supported the expansion of CTRAC to manage post-award grant functions for 22 grantees as part of the Rural Healthcare Resiliency Program project, including tools for electronic reimbursement submissions, real-time budget tracking, and status updates. Connecticut Department of Public Health For the Connecticut Department of Public Health (CTDPH), PHIG funding has been vital to advancing a more transparent, efficient, and data-informed grants and procurement ecosystem. At the core of this transformative effort is a new, agency-wide grants management system, developed using Microsoft Dynamics 365 and Power BI. PHIG’s support enabled CTDPH to hire a dedicated data engineer to design and implement the system’s foundational database, an essential technical capability that underpins the success and sustainability of the initiative. This integrated platform streamlines workflows and enhances accountability and tracking across the grant and procurement lifecycle. By centralizing data and automating reporting, CTDPH can now: Track procurement and contract status in real time, reducing delays and improving responsiveness. Ensure compliance with federal and state requirements through built-in validation and audit trails. Generate dynamic dashboards that provide leadership with actionable insights into spending, timelines, and bottlenecks. Standardize documentation and approvals, reducing variability and increasing transparency across departments. To further strengthen and sustain these improvements, CTDPH is establishing a centralized procurement support team that guides program staff through the often-complex procurement process — ensuring consistency, reducing redundancy, and ultimately improving the speed and quality of contract execution. For health program staff in the agency, this system transformation means less time navigating administrative hurdles and delays, and more time focusing on public health outcomes. Another key focus area for CTDPH is procurement timeliness, an important component of achieving public health goals. CTDPH reported a median procurement cycle time of 137 days in PHIG Reporting Period 4 and set a target to reduce this to 80 days. This commitment aligns with PHIG’s broader goal of improving foundational capabilities and reflects CTDPH’s proactive approach to building a more agile and accountable public health infrastructure. Conclusion Both Tennessee and Connecticut exemplify how PHIG funding can catalyze meaningful change in procurement and grants management. Whether through custom-built platforms like CTRAC or enterprise-grade systems like Dynamics 365 and Power BI, these states are laying the groundwork for more efficient, transparent, and accountable public health operations. As PHIG continues to support foundational improvements, Tennessee and Connecticut’s successes offer a roadmap for other states seeking to modernize their systems and accelerate public health impact. Next, learn about best practices and strategies for procurement PHIG peers are implementing. article yes

State Policy Advances in Extreme Weather Preparedness Margaret Nilz Learn about recent policies that aim to improve extreme weather preparedness, boost community resilience, and ultimately protect public health. Extreme weather events are increasing in both frequency and severity — challenging public health systems, straining infrastructure, and risking lives. As states face rising temperatures, more intense wildfires, historic flooding, and stronger hurricanes, state legislatures are adopting forward-looking policies to improve preparedness. These policies aim to boost community resilience, protect public health, and modernize emergency responses across the country. They reflect a move toward proactive planning and investment, grounded in innovation and cross-sector collaboration. Strengthening Critical Infrastructure A growing area of legislative focus is pre-disaster planning and infrastructure resilience, with jurisdictions considering policies that proactively strengthen critical systems (e.g., infrastructure, energy, and communications). For example, in Maine, LD 1 creates the Office of Resilience, tasked with coordinating and implementing state policies to improve resistance to extreme weather events. It also increases homeowners’ access to home resiliency grants, establishes a revolving loan fund for county, municipal, and tribal hazard mitigation infrastructure projects, and invests in floodplain mapping improvements. Texas SB 75 establishes a Grid Security Commission, directs an evaluation of hazards to the state’s electric grid, and makes recommendations that ensure municipalities have energy, power, and fuel supplies in the event of a catastrophic power outage. Jurisdictions are also considering legislation that would: Amend procedures for cities and counties to finance post-disaster infrastructure repair and long-term climate adaptation projects (California SB 782). Require biennial emergency preparedness exercises as well as conduct disaster preparedness training in vulnerable areas (California AB 1200). Create a real-time, interoperable emergency communication platform to improve coordination across agencies during disasters (Texas HB 147). Addressing Wildfire Risk and Air Quality Jurisdictions are also paying close attention to growing wildfire threats and subsequent poor air quality. They’re moving beyond emergency response, ensuring systems/personnel are in place before a crisis unfolds and advancing wildfire mitigation strategies. Systems and Personnel Hawaii recently enacted HB 1064, establishing an Office of the State Fire Marshal. The office is tasked with increasing the state’s readiness for wildfires, including exploring opportunities to reduce wildfire risk and developing a statewide map that displays wildfire hazard zones. California is considering AB 1003, which would require the Department of Public Health to complete a plan that includes recommendations for counties during a significant air quality event by June 30, 2026. California is considering AB 1003, which would require the Department of Public Health to complete a plan that includes recommendations for counties during a significant air quality event by June 30, 2026. It would also require these plans to incorporate county-specific outreach, stakeholder communication, and implementation. These measures build critical infrastructure for training, staffing, and coordinated response. Mitigation Strategies California (SB 326) introduced policies that accelerate the implementation of ember-resistant zones, enhance risk modeling, and support local governments through grant funding for fire reduction efforts. New legislation (CA SB 629) also updates the state’s fire hazard severity maps and sets new criteria for safety zones, including annual defensible space inspections to help residents manage fuel loads around their homes. In Colorado, recently enacted laws support increased use of prescribed burns to improve forest health (SB 7) and empower local fire protection jurisdictions to mandate vegetation removal from private properties (HB 1009). Oregon enacted SB 85, which requires the State Fire Marshal to develop recommendations for community-based wildfire mitigation and submit them to the legislature by February 2, 2026. Two bills being considered in California would: Require the creation of a framework for wildfire mitigation and a wildfire risk forecast (SB 326). Update the state’s fire hazard severity maps and set new criteria for safety zones, including annual defensible space inspections to help residents manage fuel loads around their homes (SB 629). Together, these policies signal a shift from reactive firefighting to community-level risk reduction and long-term adaptation. Improving Flooding and Hurricane Preparedness Flooding, hurricanes, and coastal erosion remain central concerns for many states, particularly those already experiencing repeat disaster declarations. As flooding and coastal threats intensify, states are taking multi-pronged approaches to preparedness — investing in early warning systems, expanding access to mitigation funding, and examining the readiness of critical facilities. These policies can assist states in both major non-hurricane flood events and hurricane preparedness and response. Several states are working to improve community-level preparedness and emergency alert systems. Vermont recently enacted H 397, which expands the Governor’s authority in the anticipation of a flood event, increases municipal access to weather alert systems, and expands access to disaster recovery grants. Texas recently introduced HB 108, which requires the Division of Emergency Management to develop a flood preparedness guide for local organizations that includes structured guidance around training, communication, and post-disaster recovery. Alongside these efforts, states are strengthening long-term mitigation strategies through grant and buyout programs. Massachusetts (H 980) and New Jersey (A 5226) are considering legislation that would establish funding programs for municipalities to address flooding (i.e., through risk assessments and mitigation measures). In Virginia, recently enacted HB 2077 expands eligibility for the Virginia Community Flood Preparedness Fund to include federally and state-recognized tribes. Employing Innovation and Research Innovation continues to shape the next frontier of preparedness policy as jurisdictions pilot emerging technologies, promote cross-sector collaboration, and rethink how they can adapt infrastructure for a changing climate. In California, legislators are considering three bills that merge cutting-edge science with emergency responses: AB 270 directs the Department of Forestry and Fire Protection to assess whether autonomous firefighting helicopters could be transitioned to operational use in the state. SB 599 proposes improvements to atmospheric river forecasting, a key strategy in flood management. SB 223 would establish a centralized wildfire smoke and health data platform within the Department of Public Health to better inform public health decisions during smoke events. Additionally, jurisdictions are addressing the resilience of the built environment, balancing traditional engineering with nature-based approaches. Mississippi enacted HB 959, extending a program focused on wind hazard mitigation and grants to retrofit homes to July 2028. Additionally, Puerto Rico introduced PS 579 (en español), which establishes the use of natural mitigation structures (e.g., sand deposits and coral planting) as the first alternative to protect infrastructure affected by coastal erosion, flooding, or other events. In Conclusion The scale of today’s public health challenges requires long-term planning, robust infrastructure, and coordination across different sectors and levels of government. Investments in real-time data systems, interoperable communication, and resilient financing tools will be essential. This Preparedness Month, the increasing momentum behind jurisdiction-level policy action shows a clear understanding: Preparedness is public health. And by focusing on resilience, jurisdictions are not only preparing for the next emergency — they are actively creating a healthier, safer, and more climate-resilient future. ASTHO will continue to monitor and provide updates on extreme weather preparedness legislation. article yes

Find funding criteria/distribution details for the Rural Health Transformation Grant, and explore collaboration and tactical considerations for your application.

Learn how state legislation is expanding access to drug checking equipment and screening in this Health Policy Update.

Discover resources that can help your health agency unlock the power of internal policymaking in data modernization efforts.

States Continue to Address PFAS in U.S. Food and Water Supply States Continue Addressing PFAS in Food and Water Supplies Heather Tomlinson, Beth Giambrone Read how federal and state actions aim to tighten regulations to reduce PFAS exposure in the U.S. food and water supply. Use of per- and polyfluoroalkyl substances (PFAS), manufactured chemicals that resist water and heat, has steadily increased since they were first developed in the 1940s. PFAS are present in a wide variety of consumer products. PFAS do not degrade easily and can result in increasing concentrations of contamination in water and soil. PFAS exposure has been linked to a variety of health impacts, causing state and federal governments to enact legislation and create policies that reduce their presence in consumer products. States are also working on ways to address and communicate about PFAS contamination and elimination. PFAS in Food and Food Packaging FDA has been evaluating potential dietary exposure by testing foods most commonly eaten by the U.S. public for PFAS through the Total Diet Study (TDS). The initial findings indicate that the vast majority do not — 97% of the 810 fresh and processed foods samples, to be precise. Nevertheless, some specific food subtypes have shown a higher prevalence, with over half of TDS seafood samples detecting at least one type of PFAS. As part of their technical assistance to states, FDA can test foods produced in areas with known environmental contamination to evaluate potential contamination of human and animal food. One recent example came from two dairy farms in New Mexico with known PFAS groundwater contamination; this sampling resulted in milk samples from one farm showing PFAS levels at a potential health concern threshold and lead to them being discarded prior to entering the food supply. Consumers can also be exposed to PFAS through food packaging. As of February 2024, FDA announced that grease-proofing materials containing PFAS are no longer sold for food packaging in the United States, eliminating the primary source of dietary exposure from food contact surfaces. At least 17 states have introduced legislation in their 2025 sessions to prohibit selling food packaging that contains PFAS, with bills in seven states seeing significant movement. In April 2025, New Mexico enacted HB 212, which prohibits selling food packaging and other products containing PFAS starting January 1, 2027. Bills in California SB 682, Illinois SB 1531, and New York S 187 that would prohibit manufacturing, distributing, and/or selling products containing PFAS (including food packaging) advanced in the first chamber. Regulating Drinking Water In April 2024, EPA used their authority under the Safe Drinking Water Act to establish Maximum Contaminant Levels (MCLs) for PFAS found in drinking water. This National Drinking Water Regulation (NPDWR) established individual MCLs for PFOA,PFOS, PFNA, PFHxS, and GenX and a Hazard Index MCL for mixtures of two or more PFAS (specifically PFHxS, PFNA, GenX Chemicals, and PFBS). Under the rule, public water systems must complete initial monitoring for PFAS by 2027 and continuously monitor thereafter. In addition, they must inform the public about PFAS levels in their drinking water and, beginning in 2029, any public water system that exceeds one or more of the MCLs must reduce the PFAS levels and notify the public of the violation. A recent announcement from EPA stated that while they intend to retain the current MCLs for PFOA and PFOS at four parts per trillion (ppt), they will “rescind the regulations and reconsider the regulatory determinations for PFHxS, PFNA, HFPO-DA (commonly known as GenX), and the Hazard Index mixture of these three plus PFBS.” The agency will also propose to give drinking water systems until 2031 to come into compliance with the PFAS rule. A proposed rule is planned for a fall release, with finalization in the spring of 2026. Finally, EPA plans to establish a framework for exemptions and provide assistance to drinking water systems through the PFAS OUTReach Initiative. EPA delegates responsibility for enforcing regulations for public water systems to states that meet certain requirements. Under the current federal rule, states have two years to establish regulations that are at least as stringent as current EPA standards. At least 20 states currently have regulatory standards for at least one PFAS in drinking water, and so far in the 2025 sessions, at least six states introduced legislation to establish new or updated MCLs: Indiana (HB 1366), North Carolina (SB 384), and West Virginia (HB 3475) introduced bills directing their health departments to establish MCLs for certain PFAS contaminants. North Carolina’s bill also requires the Commission on Public Health to consider adopting MCLs for PFAS contaminants not listed in their legislation if at least two other states have set MCLs or issued guidance. The New York state Senate recently passed S 3207, which would tighten MCLs for PFOS and PFOA from 10 ppt to 4 ppt, and establish MCLs of 10 ppt for PFNA, PFHxS, and HFPO-DA. The measure is currently in the Assembly for consideration. Pennsylvania HB 578 would establish MCLs for PFAS at 10 ppt, and would allow MCLs established by the Environmental Quality Board or executive order of the governor to supersede current MCLs. Vermont H 286 would establish MCLs for PFOS, PFOA, PFHxS, PFNA, perfluoroheptanoic acid (PFHPA), and perfluorodecanoic acid (PFDA) at zero ppt, and MCLs for any other testable PFAS at 20 ppt. Two states also introduced legislation modifying requirements for monitoring or reporting PFAS. Maine recently enacted LD 1326, which codifies the requirements to monitor and report PFAS compounds in accordance with EPA’s final rule and requires public notification of the type and level of PFAS in drinking water if they exceed the federal standard. Delaware SB 72 would require the Department of Health and Social Services to create a website where residents can access information related to the level(s) of PFAS in public drinking water systems, and require water utility companies to provide notice of excess PFAS levels to residents who receive water from that system. The measure passed the Senate in May and is currently in the House for consideration. PFAS is a cross-cutting issue, impacting health departments, agricultural agencies, environmental agencies, and the public. State and territorial health agencies can collaborate with community groups to create a broad coalition that can work together across their respective areas to address PFAS contamination. Many states have created internal cross-agency workgroups to evaluate and address PFAS exposures. ASTHO will continue to provide updates on PFAS elimination and MCL implementation. article yes

Learn how collaborating directly with people with disabilities improves disability data collection in this blog.

Immunization Information Systems: One Foundational Data Source, Endless Health Insights Immunization Information Systems - Endless Health Insights Kim Martin, Mary Beth Kurilo Learn how public health agencies can better share critical data across jurisdictions in this blog post. A Bold Vision Back in 2014, a state health official from the Midwest recognized a problem: immunization information systems (IIS) were jurisdictionally based — mostly at the state level — resulting in data gaps when people moved or received care across state lines. In talking with his ASTHO colleagues, he shared a bold vision: what if ASTHO led a coordinated effort to unite key stakeholders and make widespread, seamless interjurisdictional immunization data exchange a reality? Momentum built quickly, and by the end of the year, ASTHO had convened a broad coalition of stakeholders and meaningful progress followed: A draft memorandum of understanding (MOU) to enable data exchange across jurisdictions. A community of practice that fostered peer-to-peer learning and problem-solving. Stronger support for the development and implementation of the Immunization (IZ) Gateway, a federally sponsored technology solution and infrastructure that facilitates immunization data exchange. As these efforts advanced, organizations like the American Immunization Registry Association (AIRA), a national nonprofit dedicated to supporting and strengthening IIS, played a growing role in supporting IIS interstate data exchange while continuing to advance data standards, improve data quality, and promote IIS modernization across the country. Results: Connections Continue to Expand Today, 57 IIS jurisdictions have signed interjurisdictional exchange MOUs, and 44 jurisdictions are participating in IIS-to-IIS data exchange through the IZ Gateway. Those 44 jurisdictions have connections with their peer IISs for a total of 361 live connections that create pathways for data to securely flow across state lines. Have we completely solved the interjurisdictional data challenge? Not entirely, but we are well on our way to a collaborative solution that addresses a significant proportion of the data gap. As this state health official pointed out, broad collaboration is not only essential to this work — it’s a defining strength of ASTHO, AIRA, and the wider immunization community. Unprecedented Times We often hear that we are operating in unpredictable and evolving times. During recent discussions, immunization program staff highlighted potential risks to immunization infrastructure, particularly IIS, due to cuts in federal funding. With funding winding down, jurisdictions are anticipating impacts such as staffing reductions, the loss of contracted support, and the slowing or halting of ongoing data modernization work. These systems are important not just for supporting routine immunization efforts, but also for readiness in future outbreak or emergency responses. As the funding landscape continues to evolve, it's important to highlight the central role IIS play in providing timely, high-quality data to a wide range of stakeholders, including: State, tribal, local, and territorial health departments, which use IIS data to monitor coverage rates, manage vaccine ordering and inventory, and support reminder/recall efforts. Health care providers, who access IIS through bidirectional connections with Electronic Health Records or pharmacy systems to deliver informed care at the point of service. Long-term care and skilled nursing facilities, which serve vulnerable populations and depend on complete immunization histories for residents. Educational institutions — including colleges, secondary schools, and childcare centers — that verify student immunization status during enrollment. Health payers, who enhance claims data with IIS records to improve Healthcare Effectiveness Data and Information Set reporting and member outreach. Federal partners, who use IIS data to support nationwide surveillance and response efforts. Individuals and families who are increasingly empowered to access their own immunization records for health care, school, travel, and personal use. Immunization data is undeniably a vital resource that supports and strengthens both public and private health systems, helping keep communities healthy and ensuring we are better prepared for the next outbreak or pandemic. Where Do We Go Next? Broad interjurisdictional exchange of immunization data started with a vision from a single state health official. What can we tackle together next? Advocate for sustained IIS funding through public/private partnerships — We need to consider new funding models for IIS. With so many partners valuing and benefiting from IIS data, we have a rich resource to protect and support together. We could look to key partners (CMS and private payers, large health systems, EHR vendors, pharmacies) to support the systems and programs that ensure the secure exchange of immunization data. Support ubiquitous consumer access — All individuals can benefit from convenient and efficient access to their own and their family members’ immunization records to manage their health, inform their health care decisions, or supply documentation for work, travel, or school/childcare requirements. Today, only about half of the United States has direct consumer access to their immunization record in the IIS. Encourage broad IIS participation — We can all actively promote policies or incentives that encourage authorized health care providers and partners to exchange data with their IIS. However, not everything needs to be a formal law or policy. Sometimes, simply fostering a culture of routine reporting to or querying the IIS as the standard of care can make a meaningful difference. It’s also important to ensure onboarding processes are efficient and that providers and partners receive the necessary technical support. Ensure legal and policy support for your IIS — Advocate for laws and regulations that support provider reporting, data sharing, and patient access while safeguarding privacy. Address barriers such as consent requirements that may add burden to providers and limit comprehensive data collection. Together, we can ensure that IIS are robust, reliable, and an integral part of immunization programs and the broader public health infrastructure. By strengthening these systems, we help ensure individuals receive high-quality, personalized care — wherever they are. article yes

Learn how ASTHO's Foundations in Case Investigation/Contact Tracing training helps deepen understanding of outbreak response strategies.

Injuries from falls pose a serious risk to older adults — learn how states are using policy to promote better care for older adults in this Health Policy Update.

Administration and business processes are critical to a strong public health system — learn more in this blog post.

States Stay Prepared by Supporting the Public Health Workforce Margaret Nilz, Christina Severin Learn how states use policy to support emergency preparedness and bolster the public health workforce. Public health — particularly public health preparedness — continues to experience workforce shortages, driven by longstanding systemic challenges such as chronic underfunding, high turnover, limited recruitment, and an aging workforce. While some jurisdictions report increased capacity to hire and train public health staff in recent years, they often rely on short-term or temporary funding streams, which limit long-term sustainability. State, local, tribal, and territorial health agencies have varying capacities to respond to public health emergencies, particularly in rural and underserved communities. Because a limited workforce can inhibit emergency preparedness efforts, jurisdictions recognize the importance of cultivating a resilient public health preparedness workforce to respond to future emergencies. In recent years, jurisdictions have pursued several policy interventions to bolster the public health preparedness workforce such as legislation supporting front-line clinical staff and first responders, and rulemaking and other executive powers to provide structural and financial support to critical personnel. Legislative Efforts Legislative efforts to increase benefits and support for health care and public health workers can help address the root causes of workforce challenges and lay the groundwork for sustainable, long-term investment in public health preparedness. Laws that establish standards and expectations for the preparedness workforce, including expansions of benefits or additional training, support workforce growth and retention. Since 2024, several jurisdictions expanded mental health benefits and related support for first responders and other preparedness personnel. Both Alaska (SB 103) and California (AB 2859) enacted legislation that allows peer support programs for emergency service personnel. In Alaska, the bill creates programs for entities such as law enforcement agencies, firefighters, and emergency dispatchers, while California’s bill creates programs to serve a variety of health care providers involved in emergency medical care, including physicians, nurses, paramedics, and emergency medical technicians (EMTs). Utah enacted HB 378, which requires the Department of Public Safety to annually distribute information about its critical incident stress management program to first responder agencies. The bill also requires first responder agencies to annually notify employees about the availability of mental health resources, including periodic screenings for employees and continued support for retired or separated first responders and their spouses. On a broader scale, Hawaii SB 3279 recently established a well-being project tasked with mental health trainings and support for several community organizations, including first responders, hospitals, and medical staff. In Washington, HB 2311 directs the state’s Criminal Justice Training Commission to develop resources for first responder wellness, including a peer support network for active and retired first responders and their families. States have also enacted legislation expanding traditional employment-related benefits, including Colorado (HB 24-1219), which expanded certain health benefits for firefighters to include part-time and volunteer firefighters, and Idaho HB 55, which allows retired public employees to volunteer with public employers without it being considered reemployment. In addition, Georgia HB 451 requires state and local entities to provide disability benefits for first responders who experience occupational or volunteer-related post-traumatic stress disorder. Finally, several jurisdictions enacted legislation to support education and training for their public health and health care workforce. For example, Kentucky HB 484 established an emergency medical service education grant program that provides tuition support for students pursuing paramedic certification, wage reimbursement to ambulance providers whose employees pursue certification, and funding for institutions planning to offer EMT, advanced EMT, and paramedic programs. Oklahoma HB 1696 expands eligibility for the Oklahoma Medical Loan Repayment program to include certified nurse practitioners. Two new laws in Puerto Rico require police officers with the Puerto Rico Police Bureau to be certified in first aid or immediate rescue (PC 0859) and adds seminars on sign language, suicide prevention, and conflict mediation to the Bureau’s continuing education training (PC 0543). Other Policy Levers: Beyond the Legislature Jurisdictions can also use non-legislative policy tools to enhance workforce capacity in public health preparedness. This includes rulemaking, where executive agencies use existing legal authority to adopt or amend regulations. Regulations have the force of law and can help support the public health workforce by establishing licensure standards, training requirements, and operational protocols. Wisconsin, following the enactment of AB 576 in 2024, is developing rules to establish a program for peer support and critical stress management teams in the state. And Utah recently adopted rules for its first responder mental health services grant, which helps these professionals pursue a degree or certification as a mental health provider. Government agencies can also leverage grants and contracts to fund and otherwise direct workforce development initiatives, support training programs, and expand capacity in targeted areas. Jurisdictions can strategically direct funds to address skill gaps and assist local, state, tribal, and territorial agencies build a more resilient workforce. One example of this is in Michigan, where in 2024 the state health agency issued a request for grant proposals to award up to $9 million in EMS workforce grants, building on similar awards to address EMS shortages in 2023. Executive orders are another policy option for jurisdictions to consider as they explore different pathways to workforce sustainability. Executive orders are issued by a jurisdiction’s chief executive (often the governor) and direct certain policy actions or activities. Generally, the power to issue an executive order comes from existing law or a jurisdiction’s constitution and, in most cases, does not require legislative approval or review. Several states have leveraged executive orders to advance the public health workforce and support preparedness activities more specifically. For example, Vermont and New Jersey have recently used executive orders to create or extend advisory councils on issues pertinent to public health preparedness. In 2024, Virginia’s governor issued an executive order formalizing the Office of First Responder Wellness, which provides training, counseling, and other resources to first responders in Virginia. In 2023, the governor of Maryland issued an executive order establishing a State of Preparedness directive if there is a risk of public emergency, and the actions state agencies must undertake to promote improved coordination and hazard planning. Key Takeaways Addressing public health emergency preparedness workforce challenges demands strategic, long-term policy solutions, but several implementation options are available. Health agencies can pursue a variety of policy interventions to support and prepare their public health workforce for future emergencies. ASTHO will continue to monitor this important issue and provide updates as appropriate. article yes

Shaping Vaccine Cost and Coverage for Medicaid-Eligible Individuals Shaping Vaccine Cost, Coverage for Medicaid-Eligible Individuals Madison Hluchan Learn how state health agencies can use their authority to address vaccine cost and coverage for Medicaid-eligible individuals. Medicaid covers 1 in 5 people in the United States, including 8 in 10 children living in poverty, making it an essential tool for ensuring vaccine access for adults and children alike. Following the Inflation Reduction Act of 2022, the Centers for Medicare and Medicaid Services (CMS) now requires Medicaid and Children’s Health Insurance Program (CHIP) to cover approved vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) and their administration, without cost sharing. Additionally, all Medicaid-eligible children under the age of 21 have coverage of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, which provides comprehensive and preventive services including all ACIP-recommended vaccines. Through the Vaccine for Children (VFC) Program, state Medicaid programs pay the vaccine administration fee for children enrolled in Medicaid. Despite these measures to ensure access to recommended vaccinations among Medicaid members, vaccine uptake is less than those covered by private insurance for nearly all vaccines. For children under 19 enrolled in Medicaid and CHIP, research indicates that vaccination rates declined for all vaccines except for influenza from March 2020 through August 2021. Further, a 2024 MMWR report highlights that among children born between 2011–2020, coverage of one or more doses of MMR, rotavirus vaccine, and the combined seven-vaccine series was lower among VFC-eligible children than among non–VFC-eligible children. And while vaccination rates have been decreasing, the prevalence of vaccine preventable diseases (VPDs)- such as the recent widespread Measles outbreak and spending on VPDs have been increasing. State health agencies can consider their influence and authority as a mechanism to address these concerns. Barriers to Vaccine Administration Among Medicaid Providers and Members Various barriers exist that exacerbate the discrepancy in vaccination coverage among Medicaid members. On an individual level, vaccine hesitancy remains a concern — with higher prevalence of hesitancy among Americans making less than $50,000 — while providers face financial and administrative barriers to providing recommended vaccines to both children and adults. Low Reimbursement Rates for Vaccination Purchase and Administration Fees State Medicaid reimbursement rates to administer vaccines have historically been lower than those under Medicare or private insurance. Providers face numerous costs associated with providing vaccinations (e.g., storage, supplies, and administrative costs). For the VFC program and Medicaid members, providers are given the vaccine for free; however, the additional costs are often significantly higher than the reimbursement they receive (sometimes as low as $5) as the fees for vaccine administration are limited by federal regulation, and have not been updated since 2012. For this reason, providers may maintain only a limited supply or not offer vaccines at all. This limits Medicaid member access and reduces the uptake of recommended vaccinations. For adults, barriers are often greater. The average estimated cost to providers to administer adult vaccines is between $15 and $23, while the median Medicaid payment to providers for a single adult vaccination was $13.62. Further, eight state Medicaid programs do not provide a separate payment for vaccine administration for adults. Provider Reimbursement Restrictions Although some Medicaid programs allow for payments to pharmacies and other provider types beyond the medical home to administer vaccines, not all do. Research from 2017-2022 shows that 15 states restricted Medicaid coverage for vaccines administered by pharmacists, while a recent CDC survey found that only 31 state Medicaid programs reimburse pharmacists to administer vaccines, 29 reimburse nurse practitioners, and four reimburse midwives. Improving reimbursement of multidisciplinary provider types, including pharmacists, could help to improve vaccine uptake among those populations that are less likely to have a medical home and seek regular care from a physician, including those in rural areas. Limited Vaccination Data Reporting While not unique to Medicaid members, inadequate vaccination reporting remains a challenge. Originally developed for childhood vaccination, immunization information systems (IIS) have inconsistent reporting of vaccination records, especially in adults, with some state laws preventing reports to IIS for adults or having opt-in policies that limit engagement. Limited vaccination data hinders the ability to properly identify unvaccinated individuals and provide the recommended care. Approaches to Reducing Barriers with Medicaid Authorities To address barriers related to vaccine administration among Medicaid-eligible individuals, state health agencies can consider a menu of options that may ease administrative burden, improve quality requirements, and enhance cross-sector initiatives and service delivery. Reduce Provider Burden to Incentivize Access and Reduce Hesitancy Reducing administrative and financial burden to providers can increase patient and provider interactions, the avenues by which vaccines are available, and trust among patient populations. Reimburse Vaccine Counseling: States may choose to cover stand-alone vaccine counseling for both adults and children in Medicaid when a provider discusses a vaccine with a patient but does not administer one. States have long had the flexibility to cover stand-alone counseling for adults federally matched at the regularly applicable FMAP via state option. For Medicaid members under the age of 21 eligible for EPSDT, CMS requires states to provide coverage of stand-alone vaccine counseling for all vaccines covered under EPSDT. State options also allow for stand-alone vaccine counseling provided via telehealth. Stand-alone vaccine counseling by trusted providers may reduce vaccine hesitancy for some patients, as it provides additional opportunity to discuss individual barriers to vaccination. Increase Administration Reimbursement Rates: SHAs may consider partnering with Medicaid to develop a State Plan Amendment (SPA) to increase vaccine administration reimbursement as an effort to reduce provider financial barriers. States including Indiana, Michigan, and New Jersey, have leveraged the SPA authority to increase vaccine reimbursement: Indiana submitted an SPA to increase reimbursement of the administration of VFC vaccines from $8 to $15 in 2019. Michigan increased reimbursement rates to $23.03 for beneficiaries 18 years and younger in 2024. New Jersey added in adult vaccine administration reimbursement between $6.36-$12.12 dependent on the vaccine the provider administered and whether they provided counseling, in 2024. State Universal Vaccine Purchasing Program: Another opportunity to consider is the adoption of a state vaccine universal purchasing program, such as those currently in place in 14 jurisdictions, which enable state health agencies to bulk purchase some or all ACIP-recommended vaccines and distribute them free of charge to providers. Public funds, including VFC or Section 317 funds, and private health plans or insurers finance these programs. For example, Vermont began their Vermont Vaccine Purchase Program in 2011. As authorized by law (8 V.S.A §1130), the Immunization Funding Advisory Committee provides the Health Commissioner an annual assessment and per-member, per-month cost for vaccines based on the total number of people covered by health insurers, which is collected from all health insurers in quarterly payments. Vermont Medicaid’s State Plan reimbursement methodology for the adult vaccine purchasing program is a per-member, per-month rate. The rate is set annually in April and effective July 1. The rate is calculated using a reconciliation of prior year program revenue and expenses, and estimated vaccine cost and utilization, program operating and administrative costs, and assessable covered lives for the state fiscal year starting July 1. Vaccines for Adults Program: While the VFC Program is operated at the federal level, no such program currently exists for adults. Instead, some states have developed programs to fill the gaps, often using Section 317 Federal Funding. These programs, such as the New York State Vaccines for Adults Program, provide vaccines at no cost to eligible individuals, including uninsured adults, underinsured adults (i.e., health insurance does not cover the cost of the vaccine to be administered), and students of any age that are enrolled in or entering a post-secondary institution in New York State. While Medicaid members are generally ineligible, given the frequency of “Medicaid churn,” these programs provide a safety net for populations that are often Medicaid-eligible to ensure continuity of care. Consider Opportunity to Influence Managed Care Quality Incentives States operating their Medicaid program under Managed Care may consider addressing provider vaccine administration through Managed Care quality incentives. As part of the requirements for states that contract with Medicaid Managed Care Organizations (MCOs), states must develop a state quality strategy to serve as a blueprint for states and contracted health plans to assess the quality of member service provision and develop targets for quality improvement and network adequacy. While children’s immunization status is a mandatory quality measure for Medicaid and CHIP, the 2025 Core Set of Adult Health Care Quality Measures for Medicaid includes Adult Immunization Status (NCQA 26) as voluntary. To ensure consideration of appropriate vaccination status for adult Medicaid members,

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An Ounce of Prevention (and Public Health Fund) Is Worth a Pound of Cure Catherine Murphy The Prevention and Public Health Fund (PPHF) is critical to state public health work. Historically it has faced cuts even though prevention has proven return on investment. Read the latest information the future of PPHF in this week's Health Policy Update. Among federal funding for public health programs, one line is particularly unique. The Prevention and Public Health Fund (PPHF) is the nation’s first mandatory fund for prevention and public health programs. Before enacting PPHF, there was no fund that guaranteed investment in prevention programs that was not contingent on the annual appropriations process. PPHF was part of the 2010 Patient Protection and Affordable Care Act and it helps provide funding for crucial programs. During the past 15 years, PPHF has been utilized across agencies including CDC, CMS, HRSA, and SAMHSA. In fact, about 95% of PPHF funding goes to CDC. In FY24, the fund contributed 13% of CDC’s overall budget. From FY25 through FY30, PPHF is projected to provide $9.8 billion in funding to achieve these goals. Where the Money Goes As the adage goes, “an ounce of prevention is worth a pound of cure.” Through dollars distributed by CDC — more than 70% of CDC’s budget supports the work of state and local health organizations — PPHF funds numerous critical nationwide efforts including immunization, epidemiology and laboratory capacity, tobacco use, heart attack and stroke, childhood lead poisoning, and the Preventive Health and Health Services Block Grant. Many of these programs receive a majority, if not all, of their funding from PPHF, and the demonstrated return-on-investment is significant. For example, California’s tobacco control program saved $155 in health care cost savings for every $1 invested. CDC has found that removing lead hazards from children's environment can, “generate approximately $84 billion in long-term benefits per birth cohort. Sustained Commitment for the Decade Ahead Unfortunately, PPHF has historically been subject to cuts via budget agreements, including the Bipartisan Budget Act (2018), and to calls to repeal and replace the Affordable Care Act. Since its enactment, PPHF has been amended five times, ultimately resulting in a reduction in appropriations for the fund. Recently, President Trump’s “Skinny” Budget Proposal outlined cuts to a number of PPHF-funded programs, indicating that the overall funding could be at risk. Eliminating PPHF would open a significant funding gap for preventive health programs across the nation. These programs have proven records of promoting health and preventing infectious and chronic disease. Loss of funding would likely result in greater disease burden and health care costs. Investing in prevention isn’t just smart policy, it’s smart economics. The PPHF is designed to build a strong public health foundation, brick by brick, community by community. Over the years, ASTHO has worked in coalition with public health organizations to share the importance of PPHF and to advocate for sustained investment to the fund. ASTHO will continue to monitor discourse and share the importance of this funding in interactions with lawmakers. Table - Blog - An Ounce of PPHF Is Worth a Pound of Cure article yes

Understanding Digital Accessibility Before the ADA Title II Deadline Emily Lapayowker, Adrianna Evans With the ADA Title II deadline looming, learn how to prioritize and improve digital accessibility on your agency’s website. Digital accessibility ensures the digital world is usable for everyone. And while it is an increasingly prominent topic in public health, there is still much to learn. This resource can help public health agencies understand digital accessibility basics and promote accessible communications for the disability community, which is typically underserved in public messaging. Government Laws and Requirements ADA The Americans with Disabilities Act is a federal civil rights law that prohibits discrimination against and requires equitable access for people with disabilities. ADA’s connection to digital accessibility may not be immediately apparent, but digital accessibility is covered under the large umbrella of equal access to public areas that ADA guarantees. In fact, Title II of ADA enforces digital accessibility compliance by requiring state and local government websites and digital tools be accessible to people with disabilities — the Department of Justice has announced a compliance deadline of April 24, 2026, for jurisdictions of 50,000+ people and April 26, 2027, for smaller entities. Sections 504 and 508 Section 504 of the 1973 (Vocational) Rehabilitation Act requires any entity that gets federal funding to provide equal access to electronic information technologies for people with disabilities. Section 508 requires the federal government to meet those same standards. These sections were initially written in 1998 and then updated in 2018 to include requirements for mobile technology. WCAG Is the Industry Standard The Web Content Accessibility Guidelines, or WCAG, is published by the World Wide Web Consortium (W3C), an international organization that establishes open web standards. WCAG is currently in its second version. When evaluating compliance, there are three different WCAG conformance levels: A (lowest), AA (middle), and AAA (greatest). Interestingly, W3C recommends that all web-based information aim to hit AA because it is not possible for some types of content to reach AAA compliance. WCAG 3.0 is currently in development and expected to be a major paradigm shift. POUR Principles WCAG standards are principle-based, which means that rather than requiring all web browsers to meet a specific technical standard, WCAG requires that digital content adheres to the POUR principles. All four principles focus on the user’s experience: Perceivable: All information must be presented in a way that ensures users can perceive it using at least one of their senses. Operable: A website is considered operable if all users can effectively navigate it, even those who employ assistive technology, such as screen readers. Understandable: This is a two-pronged principle — users must be able to understand how to use a site and understand its content. Robust: Content must be robust enough that multiple technologies, including assistive devices like screen readers, can interpret it. These laws and guidelines are minimally prescriptive to promote longevity. Remaining principle-based rather than tech-based means these standards will not become obsolete as technology advances. Where and How to Make the Biggest Impact Health agencies can make small changes to digital content in a few key places that will make a world of difference for users with visual, hearing, physical, and cognitive disabilities. Some examples include emails, PDFs, website and social media content, and staff resources. Link Smart and Sparingly Screen reader technology allows low-vision users to navigate webpages and other digital content in a variety of ways. One is by jumping from link to link without referencing the content around that link. So, make your linked text descriptive enough to stand on its own. Also, avoid typing out URLs whenever you can — screen readers will read aloud the URL as phonetically as possible, which is not a great user experience. Additionally, when a screen reader reaches a link in the content, the software will announce it. Use links sparingly to avoid major disruption to the reading experience, as over-linking can make it hard to keep track of the content. Use the Built-In Text Styles Document hierarchy is another essential part of accessibility remediation. The built-in font styles, such as headers and lists, are for more than just aesthetic — screen readers use these styles to navigate Word documents, PDFs, and webpages. Use headers in order (i.e., never skip a heading level), and deploy ordered and unordered lists thoughtfully. For example, if you list specific steps in a process, use an ordered list. If you list symptoms of a viral infection, an unordered list is a better fit. Use Color and Contrast Correctly Do not rely on color alone to convey important information, because users with low vision or colorblindness may have trouble differentiating between different colors or shades. Best practice is to use additional visual markers to signal the presence of important information and ensure there is at least a 3:1 contrast ratio for graphics. Follow Alt Text Best Practices Screen readers read alternative text (or alt text) to allow users with visual or specific cognitive disabilities to understand the content and purpose of an image, table, or informational graphic. Some alt text best practices: Be succinct. The ideal length is between a few words and a couple of short sentences (use the average length of a post on X as a guide, about 250 characters). The goal is to be brief but still convey the image’s vital information. Avoid phrases like “image of” because screen readers will identify all images as such, which makes this redundant. The context around the image is just as crucial as the alt text. If there is already a detailed description of a virion’s shape in the document's body, repeating all that information in the alt text is unnecessary. Not all images convey information. In those cases, it’s important to use null alt text, which will let assistive technology know that the image is decorative. To do this, either add “decorative” in the alt text field, or mark it as decorative in the platform, if that option is available. When creating complex images such as charts or graphs, communicate what the graph is telling users rather than just what it looks like. Learn More There is a whole world to learn about within digital accessibility, but there are resources and experts to help. You can connect with internal experts on your IT team or external disability and accessibility organizations for support. You can also learn more about digital accessibility at the following resources: Introduction to the Americans with Disabilities Act by U.S. Department of Justice. Civil Rights Division Section 508 (Federal Electronic and Information Technology) by U.S. Access Board What Is Plain Language? by Plain Language Action and Information Network Constructing a POUR Website by WebAIM WCAG 101: Understanding the Web Content Accessibility Guidelines by Level Access Glossary of Disability-Related Terms by University of Washington Accessibility Online by Great Lakes ADA Center Related Content-Blog - DELPH Magazine 4 article yes