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Looking to the future, states are improving access to care, providing subsidies for tuition costs, expanding hours of licensed facilities, increasing access, and meeting the needs of both parents and children.

The 2020 holiday season is coinciding with a nationwide surge of COVID-19 cases. With great concern that holiday travel to see loved ones may exacerbate community spread of the virus, many states are increasing public health measures before the winter holiday season. As of November 16, 2020, 13 states and D.C. had a quarantine requirement for out-of-state travelers. The U.S. territories also have instituted travel restrictions to limit the spread of COVID-19.

Several states and territories, as well as many local governments, are going beyond recommendations and requiring individuals to wear face coverings when they are in public settings and spaces (i.e. grocery stores, retail stores, restaurants, public and private transportation services, parks, etc.). Ongoing research and evidence suggests the relationship between mandatory face coverings and declines in daily COVID-19 growth rates is statistically significant.

State Legislatures Moving to Increase Rural Health Care Access How States Are Incentivizing Health Care Providers to Practice in Rural Areas Lana McKinney Hospital closures and fewer care options in rural areas cause worse health outcomes for Americans in those areas. Read about state policies aimed at bringing providers to back to rural America. People living in rural areas face greater health risks than those living in urban areas. Rural populations not only experience increased poverty and higher rates of chronic disease; they are also older and have less access to both health care providers and health insurance. States are exploring several strategies to improve health care access for rural residents, including recognizing a new hospital type, exploring alternative methods or sources of health services, and offering financial support for health care facilities and the rural health workforce. Access to Care Among many factors contributing rural areas accessing health care, hospital closures are a major one. Almost 200 rural hospitals have closed since 2005. When rural hospitals close, people living in those communities must travel farther for care. Rural areas may also experience shortages of and less access to health care professionals, including specialty care, as compared to urban areas. To reduce the number of hospital closures and provide support for existing hospitals in rural areas, the Consolidated Appropriations Act of 2021 created a new Medicare provider type known as the Rural Emergency Hospital (REH). These facilities offer a more limited scope of services than acute care or critical access hospitals and have their own conditions of participation and Medicare reimbursement structure. There have been 36 REH conversions in 16 states since 2023. Jurisdictions continue to explore legislation to formally recognize REHs under state law, State recognition of REHs is crucial for establishing licensure, defining service scope, and enabling participation in state health care programs like Medicaid, ensuring these facilities can legally operate and provide necessary care. with Florida (SB 644) enacting legislation in 2024, and Hawaii (HB 1179) considering legislation so far in 2025. A number of other jurisdictions have recently received approval to amend their Medicaid State Plans and define the payment methodology for REHs serving Medicaid recipients, including Iowa, Kentucky, Nebraska, Nevada, New Mexico. States are also exploring other policies to financially support rural hospitals during the 2025 legislative session. Alabama (HB 86) is considering a rural hospital investment program that would create tax credits to incentivize donations to those hospitals that could support service delivery. And bills to establish grant programs to support rural hospitals are before the legislatures in both Oklahoma (HB 2754) and Indiana (HB 1274). States are also exploring the role of technology, and community needs and resources, to support rural access to care. In 2024, Colorado enacted at least two bills with a rural population focus, including SB 24-168 to invest in remote patient monitoring to support rural health facilities and requires reimbursement. SB 24-055 creates an agricultural and rural community behavioral health program to understand the relevant issues and improve access to care. So far in 2025, at least two states are exploring ways to better serve people in rural communities. Hawaii (SB 1004) is considering legislation that would establish a pilot program to utilize community health workers in rural areas, while North Dakota (HB 1567) is proposing a legislative management study focused on improving access to oral health care, and would require review of telehealth options for reaching rural areas and workforce incentives for dental providers. Rural Health Care Workforce Jurisdictions are also using financial supports—including scholarships, tax incentives, and loan cancelation programs—to increase the number of health care providers in rural areas. At least three states modified financial support programs for practitioners working in rural and underserved areas in 2024. Mississippi’s S 2729 expanded the scope and responsibilities of its rural physician and dentist scholarship programs and their respective governing commissions. And Georgia (HB 872) amended its cancelable loan program to include dental students. California (SB 909) amended the requirements for its physician corps program, which provides financial assistance to those who practice in underserved areas, removes the limit on the amount of loan repayment available, and reduces the duration of service obligation from three to two years. Jurisdictions have also pursued tax policy changes aimed at supporting rural health care providers, including state tax credits for individual practitioners working in rural areas. In 2024, Georgia (HB 82) amended its rural physician tax credit to include dentists living and working in rural areas. In 2025, at least two states are considering expansion of tax credits for providers serving rural communities. In New Mexico, HB 52 would expand the state’s rural health care practitioner tax credit to include additional provider types, including speech language pathologists and occupational therapists. And Oregon is considering several bills to expand existing rural provider income tax credits, including HB 2549 to add pharmacists and HB 2204 to add podiatrists. Finally, legislatures are continuing to consider other policy initiatives to bolster the rural health care workforce in 2025. Acknowledging a shortage of nurses in rural communities and barriers for rural nursing students, Washington SB 5335 would establish a rural nursing education program in the state health department with a goal of improving nursing care in rural areas of the state. And in Nebraska, LB 119 would formally enact the state’s rural health opportunity program, which provides tuition waivers for students from rural areas pursuing health care careers, into law. ASTHO will continue to monitor this issue and provide any necessary updates. article yes

ASTHO's 2024 Legislative Session Update: Part Two Beth Giambrone, Maggie Davis, Christina Severin ASTHO's Public Health Legislative Update on Tobacco, Mental Health, Environmental Health, Workforce, and Containing Infectious Disease By the end of April, at least 36 states will have concluded their regularly scheduled 2024 sessions, with several states passing laws on important public health issues. Earlier this month, ASTHO provided a brief update on five of the top 10 public health state policy issues to watch during the 2024 state and territorial legislative sessions; this update examines the remaining five. Containing the Spread of Infectious Disease Public health agencies have a responsibility to keep their communities safe and healthy by maintaining foundational public health services including identifying, containing, and preventing the spread of communicable disease. ASTHO supports maintaining and guaranteeing robust public health legal authorities allowing public health leaders to meet their responsibilities for containing the spread of infectious disease. Following the COVID-19 pandemic, state and territorial legislatures considered many bills to change public health agency’s legal authorities to meet their responsibility, a trend that ASTHO anticipated continuing into 2024. So far, at least 28 states have considered, and at least two legislatures passed, bills relating to public health authority to address the spread of infectious disease in 2024. For example, the Hawaii legislature passed SB 3122, expanding public health authority by providing the state health official broad authority to issue standing orders for people 18 years and older to receive evidence-based services recommended by the U.S. Preventative Services Task Force. In March, however, Utah enacted HB 405, which limits local public health official’s authority to issue an isolation or quarantine order to specific conditions unless the local legislative body agrees that a new, drug resistant, or reemerging pathogen likely to cause high mortality or morbidity needs containment. Environmental Health Under the Safe Drinking Water Act, the EPA has the authority to set national standards for public drinking water. These standards establish legally enforceable Maximum Contaminant Levels (MCLs) and non-enforceable Maximum Contaminant Level Goals for public water systems. In April 2024, EPA released a final rule establishing legally enforceable MCLs for six PFAS compounds that occur in drinking water. Public water systems have until 2027 to complete initial monitoring and inform residents of the levels of PFAS in their water, and until 2029 to act if their drinking water levels exceed the MCLs. To date in 2024, at least four states have enacted or are considering legislation that would aid in monitoring and remediating PFAS in drinking water. Virginia recently enacted HB 1085/SB 243, which requires that the Department of Health notify the Department of Environmental Quality (DEQ) of any results from their monitoring of public water systems that show MCL exceedances, at which time requires DEQ to implement a plan to prioritize and conduct assessments of the public water system's raw water source(s). The Rhode Island House of Representatives passed H 7439, which would require the Department of Environmental Management to determine the maximum number of PFAS detectable by standard laboratory methods, and specifies the types of water systems that will be required to monitor untreated drinking water for those PFAS by June 1, 2025. Massachusetts is considering H 853, which would require the Department of Environmental Protection to maintain a list of municipalities where PFAS levels exceed the MCL and provide vouchers to homes in those municipalities to purchase home water filtration equipment. Strengthening the Public Health Workforce With several successes in 2023, ASTHO anticipated legislatures to continue considering legislation to strengthen the public health and health care workforces that represent the communities they serve during the 2024 legislative sessions. One strategy is establishing career pathway programs that provide students training and support to pursue public health careers. At least six states have considered, and three have passed, bills creating or strengthening a career pathway program during the current legislative sessions. At least two states have enacted programs to address health care provider shortages in April. Maine’s legislature passed LD 2268, which would allow internationally trained physicians to receive a limited license to practice medicine and address provider shortages in rural areas of the state. Washington enacted SB 5582, directing community and technical colleges to develop a plan in consultation with local workforce development councils and health care employers to train more nurses over the next four years. In May, Hawaii’s legislature passed HB 1827 appropriating funds to support public high school health care workforce certificate programs to support graduates seeking entry-level positions in the health care industry. Supporting Mental Health Children and adolescents continue to experience mental health issues, with teen girls reporting significant challenges. Schools can play an important role in supporting the mental health of all students through direct services or policies that address prevention, education or coordination. In 2024, a number of jurisdictions considered legislation related to youth mental health, through training requirements for staff and students, and support for treatment flexibility in the school setting. At least six jurisdictions considered bills related to mental health education for students, including specific suicide and violence prevention content. Virigina enacted HB 603, which requires school health instruction to include information about common mental health challenges, helpful coping strategies, the importance of seeking help from a professional or other adult, and available school resources. Several jurisdictions, including Virginia (HB 224), Minnesota (HF 4363) and Missouri (HB 2471), also considered establishing or amending suicide prevention and related mental health training programs for teachers and other school staff. Finally, several jurisdictions considered legislation to explore or otherwise support using telehealth services in schools for mental health services. Minnesota is considering legislation that would create a pilot program to determine whether the availability of telehealth services in schools increases mental health access (SF 4236) as well as a requirement to provide space at secondary schools for students to receive telehealth mental health services (HF 3542). New York is currently considering S 8976, which would authorize telehealth services in schools to be delivered by licensed providers, while Maryland enacted HB 522 in April, which requires school districts to develop guidelines to allow telehealth appointments at schools starting in the 2025-26 school year. Tobacco and Nicotine Products According to the American Lung Association, 22 states do not have comprehensive smoke-free laws that help protect against the dangers of second-hand smoke in a variety of settings (e.g., multi-family homes, public spaces, restaurants), or reduce the number of people who start smoking. At least 16 states have introduced legislation aimed at creating, promoting, or expanding smoke-free environments. Connecticut recently enacted SB 132, which expands their clean indoor air act to prohibit vaping at dog race tracks. The Maryland legislature passed HB 238/SB 244, which would update their Clean Indoor Air Act to prohibit vaping in public indoor areas, indoor places of employment, and mass transportation. In addition, the Alabama Senate recently passed SB 37, which would prohibit vaping in public places. In addition, at least 14 states have introduced legislation to either prohibit or further restrict the sale of flavored tobacco products, including menthol products. For example, bills introduced in Hawaii (HB 2441/SB 3130), Minnesota (HF 2177/SF 2123), and New Jersey (S 1947) would prohibit the sale of flavored tobacco products, including menthol, within their jurisdiction. In addition, a bill in New York (A 699/S4477) would ban the sale of flavored smokeless tobacco products within five hundred feet of a public or private school. ASTHO’s state health policy team continues to monitor these important public health issues and will provide relevant updates. website yes

Continuing ASTHO’s Legislative Prospectus series—which highlights the top 10 public health policy issues for 2022—this post focuses on mental and behavioral health, as well as supporting the public health workforce.

A pressing public health issue before the COVID-19 pandemic hit, the need for public health interventions to reduce tobacco use is heightened with a strong association between tobacco use, in all forms, with severe COVID-19 outcomes. Additionally, tobacco use remains the leading cause of preventable death in the U.S., claiming approximately 480,000 deaths each year. Evidence-based policies to reduce tobacco use like raising the age of sale to 21, increasing tobacco pricing, and prohibiting the sale of flavored tobacco products are common public health strategies enacted through state legislation. As anticipated in ASTHO’s 2021 Legislative Prospectus on E-Cigarettes, states are considering many of these evidenced-based tobacco reduction strategies during the 2021 legislative sessions.