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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 brief examines the ways states can support certification for community health workers.

This ASTHOBrief contains three key recommendations for improving the 2013 CDC/CSTE Cancer Cluster Investigation Guidelines.

ASTHO, in collaboration with CDC, provided full-time disability and preparedness specialists to 17 jurisdictions to better meet the needs of people with disabilities. In this brief, specialists share their thoughts on why people living with disabilities may be hesitant to get the COVID-19 vaccine and some approaches public health officials can take to address vaccine hesitancy in people living with disabilities.

Board-certified forensic pathologists play a critical role in public health by investigating death so as to better serve the living. Despite forensic pathology’s contribution to public health surveillance, prevention, and response, the discipline remains largely under-resourced and over strained. These briefs spotlight the critical role that international medical graduates play in minimizing forensic pathology workforce shortages and spotlights a local effort to address financial disincentives for medical graduates entering the field and highlights federal funding opportunities and resources for state partners looking to minimize forensic pathology workforce shortages.

The opioid epidemic has exacerbated the shortage of board-certified forensic pathologists, presenting a major workforce challenge for public health systems.

Environmental health and public health preparedness staff work closely together to respond to natural disasters and climate change—learn how in this report.

Opportunities for Public Health Agencies to Advance Sustainable Financing of Community Health Worker Programs Advancing Sustainable Financing of Community Health Workers Explore how health officials can play key roles as funders, administrators, and policy designers to advance sustainable financing of community health workers. Many states face upcoming funding gaps for community health worker (CHW) positions, with COVID-19 related grant funding streams expiring. Concurrently, many states are rapidly beginning to cover CHW services under Medicaid. In addition, Medicare launched a new reimbursement opportunity for CHWs in January 2024. These factors create an opportunity for state and territorial health agencies to develop or contribute to equitable reimbursement and robust implementation. This report details how health officials can play key roles as funders, administrators, and policy design champions to ultimately advance sustainable financing of CHW services. Get the Report (PDF) website yes

These states are connecting public health and transportation to improve access to healthcare—learn how in this report.

This report analyzes way that public health officials can mitigate the impact of disasters on pregnant people, neonates, and infants through a variety of policies, including policies related to preparing for, responding to, and recovering from a public health emergency.

States Pursue Policy Options to Support Access to Over-the-Counter Contraception State Policy to Support Over-the-Counter Contraception Access Christina Severin Learn about state policy options that can help to support over-the-counter contraception access including levers within Medicaid programs. Effective contraceptive care improves maternal health outcomes by helping individuals plan if and when they become pregnant. Additionally, some contraceptive methods may reduce the risk of certain cancers and protect against sexually transmitted infections. While the most effective methods generally require a visit to a health care provider, over-the-counter (OTC) options may address certain barriers to accessing contraception (e.g., taking time off work for a medical appointment and lack of health insurance or access to health care providers/settings). The New Age of Nonprescription Oral Contraceptives A significant change in the marketplace of OTC options occurred in 2023 when FDA approved the first daily non-prescription oral contraceptive. This progestin-only pill —known as Opill — is considered both safe and highly effective at preventing pregnancy when taken correctly. Opill reached stores in early 2024 and has a suggested retail price of about $20 per month or $50 for a three-month supply. While OTC oral contraceptives like Opill may improve access among individuals not currently using contraception or those using a less effective method, high out-of-pocket costs can be a barrier. One way to limit out-of-pocket costs is to require private health insurance coverage of contraception without cost-sharing. ACA requires most private health insurance plans to do this, but it does not extend to all health insurances or contraceptives. For OTC contraceptives, the landscape is even more complex: While plans are encouraged to cover OTC emergency contraception at no cost and without a prescription, it is not required. HHS and the Departments of Labor and Treasury issued a proposed rule in 2023 that would have required broader coverage of OTC contraception without a prescription or cost-sharing, but the rule was later withdrawn. Without a federal mandate, states can pursue coverage requirements through the health insurance products they regulate. Jurisdictions can also support OTC contraception access in their Medicaid programs. While Medicaid requires coverage of family planning supplies without cost-sharing, jurisdictions have some flexibility in how they design this benefit, and the scope of coverage depends on jurisdiction and state plan-specific factors. Jurisdictions also have flexibility in determining how they provide prescription drug coverage for contraceptive medications and what OTC products are covered. State Legislative Action Legislation is one way for states to promote access to OTC contraceptives, including hormonal contraceptives, through state-regulated plans and provider scope of practice considerations. Since 2024, several states have enacted laws requiring coverage of OTC hormonal contraception, including Delaware (SB 232), which directs insurance carriers to cover FDA-approved OTC contraception with or without a prescription, and Maine (LD 163), which requires coverage of nonprescription oral hormonal contraception. At least two states have clarified the role of pharmacists in supporting access to OTC contraceptives. Massachusetts (HB 4800) allows pharmacist dispensing of OTC oral contraception per a standing order and provides liability protections, while California (AB 50) allows pharmacists to furnish self-administered OTC hormonal contraception without complying with the state’s protocols for prescription-only oral contraceptives. States have also enacted laws to explore or support broader access to OTC contraception, including at least three bills enacted in Maryland since 2024: HB 367/SB 527 requires community colleges to develop an OTC contraception access plan and allows the health department to serve as a resource, including for consultation on vending machine access. HB 1171/SB 944 allows local health department registered nurses to dispense OTC contraception. SB 674/HB 939 creates a collaborative tasked with studying and making recommendations on OTC contraceptive access, with a final report due to the governor and legislature by Jan. 1, 2027. Other Policy Levers Legislation isn’t the only policy lever available to jurisdictions looking to support OTC contraception access. A number of states have taken executive actions to improve access, including (but not exclusively) through Medicaid. While jurisdictions already have the flexibility to support OTC contraceptive access in their Medicaid programs, Medicaid rules require a prescription even for OTC products, which may present a barrier for some individuals. One potential solution is to use standing orders, which allow individuals direct access to OTC products at a pharmacy, without having to visit a separate provider for a prescription first. To ease access to OTC hormonal contraception specifically, several states have recently utilized standing orders that facilitate Medicaid coverage, including Wisconsin, Massachusetts, and New Mexico. Additionally, in 2024, North Carolina announced that it was removing barriers to OTC oral contraception, and would cover condoms and spermicide as OTC products. Outside of Medicaid, several other states have taken action to support access to OTC hormonal contraception: In 2024, the Governor of Arizona issued an executive order directing the Department of Administration to designate Opill and OTC hormonal contraception as a no-cost essential health benefit for state employees, among other actions to expand coverage and access. Also in 2024, Pennsylvania issued guidance to health insurers encouraging coverage of OTC hormonal contraception and highlighting two insurers intending to comply with the guidance. Finally, Michigan’s health agency, in partnership with the Governor’s office, implemented a Take Control of Your Birth Control campaign. This initiative distributed OTC contraception at hundreds of community sites across the state, with a stated goal of connecting individuals to insurance coverage, including Medicaid. While the campaign recently ended, the state distributed more than 400,000 OTC contraceptive resources (e.g., condoms, emergency contraception, and oral contraceptives) and saw an increased number of Medicaid applications. Jurisdictions can play a significant role in connecting public health and health care industry leadership, providers, and other experts — promoting awareness, increasing utilization, and encouraging connection to existing resources. Related Content - Blog - State Policy to Support OTC Contraception Access article yes

Use this toolkit to incorporate flexible funding strategies into your public health agency's operational and project management procedures.

State and federal actions to expand the doula workforce and improve maternal health.

Tobacco Control Programs Use Business Process Mapping to Strengthen Workforce tobacco control programs, preventable disease, tobacco industry, diverse workforce, grants management, mapping workshops, technological support, united states, tobacco product, young people, comprehensive tobacco control programs, public health, tobacco company, department of health, cigarettes and smokeless tobacco, smokeless tobacco products, health care system, youth and young adults, smoking cessation, reduced smoking, tobacco related disparities, astho, association of state and territorial health officials Amy Ciarlo Since the beginning of the COVID-19 pandemic, public health agencies have experienced significant turnover across leadership and staff throughout various programs, including tobacco control. Between 2021 and 2023, nearly 30% of all state and territorial program managers were experiencing turnover (e.g., in some cases, vacancies lasted months) or were new to this role, having less than two years of experience. This decline in workforce reduces capacity to address tobacco use—the nation’s number one cause of preventable disease, disability, and death. Tobacco control program staff require a level of knowledge that can take time to build, including: Historical context of tobacco industry marketing influence. Policy, systems, and environmental change strategies. Emerging products and changing regulations. The complexity that goes into helping people who use tobacco to quit. Finding qualified applicants that will stay in these roles long term has been challenging across jurisdictions. In response to this need, the Tobacco Control Network, in collaboration with CDC’s Office on Smoking and Health, convened a nine-month learning community with three state tobacco control programs (Alaska, Arizona, and New Jersey) to address hiring and onboarding challenges, which concluded in March 2024. Subject matter experts Health Management Associates (HMA) supported by educating participants on business process improvement (BPI) methods, facilitating business process mapping workshops, and consulting on the development of individual state implementation plans to address key challenges identified during the mapping processes. A similar model with specific OD2A grant recipients focused on procurement, contracting, and helping address spend-down of funding. Business Process Mapping and Implementation Planning Each state participated in a two-day, in-person BPI workshop to outline all steps, from filling a vacancy to completing the onboarding of new hires. This was a lengthy exercise, as agencies often have many elaborate processes in place, due to an organizational requirement, an expectation held by leadership, or a past purpose that is no longer relevant. Understanding why the process happens and visualizing the steps in sequential order helped teams identify “waste” or areas for improvement, including overwork (e.g., too many meetings), waiting (e.g., on an approval, for a training to become available), extra processing (e.g., duplicating efforts), and unused talent (e.g., insufficient training and alignment of skillsets). States then drafted implementation plans to address key issues, outlining steps with detailed timelines and tasks assigned to individuals to increase accountability. Each state team finalized their plans as part of the learning community, with some activities in progress or already completed. However, all three varied in their processes, their approaches to solutions, and the activities outlined in their implementation plans: One state’s BPI workshop focused on grantees at the county-level and streamlining onboarding, as counties lacked consistency in their hiring and onboarding approach. Their implementation plan focuses on a team of state health agency staff and local partners establishing a guidance document that assists new local staff in their first three months. Another state’s BPI workshop centered on addressing challenges in building a diverse workforce, with goals to establish a standardized practice for job postings and reduce re-posting of vacancies. The mapping process allowed collaboration across multiple departments and with health agency leadership. During the final state BPI workshop, the team identified excess meetings as a pain point and are reworking them to reduce redundancy and streamline the onboarding process. The implementation plan also prioritizes making training materials more engaging and better understanding training needs among new program staff. Lessons Learned The state teams gathered to share key takeaways from the learning community, as reported by HMA, informing recommendations for other programs looking to address hiring and onboarding challenges. Successes Participation led to team building and a mutual understanding of the process. Participants trusted one another to share with transparency. The mapping activities remained agnostic by highlighting inefficiencies in the process and not the people. Individuals with new perspectives had the opportunity to comment on system improvements. Teams recognized the numerous demands on team members and grantees, how much duplication existed across processes, and the number of approvals or layers in the hiring procedures. Teams created clearly identified roadmaps to improve hiring and onboarding staff. The learning community brought together partners across the state to address challenges that impacted their work but were not part of their everyday tasks. Challenges Staff representatives from HR or Grants Management were not present during the mapping workshops, causing gaps in information during these sessions. Power dynamics created difficulty for all participants to contribute equally. There was a lack of consideration for equity and challenges from new hire perspectives. More structured technical assistance and check-ins following the development of implementation maps were needed to support follow-through. Some participants had a sense of ownership or attachment to the established process and were protective of maintaining the status quo. Recommendations Ensure all participants understand the vision by providing an example of similar work in advance as reference material. Prior to the mapping activities, conduct a series of key informant interviews to ensure the right people are in the room, gain an understanding and awareness of organizational and interpersonal dynamics that may impact the process, and identify opportunities to establish bidirectional communications between state and local staff. Plan for ongoing technical assistance follow-up to ensure understanding of the initiative and support implementation. Ensure logistics can accommodate the process, such as proper room size and technological support. In Conclusion Given the challenges identified in this pilot learning community, states would likely benefit from change management prior to beginning BPI activities. Having intentional conversations up front can prevent these common challenges, as outlined previously. Overall, all state participants agreed that the learning community was valuable to their work, increased their organization’s knowledge and capacity, strengthened their relationships within their agency, and they intend to continue working on their improvement plans. One state team shared, “A major success from this mapping workshop was understanding the significance of engaging and listening to colleagues from diverse departments. The workshop facilitated a clearer understanding of civil service and HR operations, emphasizing the hurdles faced by hiring managers.” While business process mapping and implementation plan development can be laborious, the results are well worth the effort. website yes

Health Agencies Keeping Cottage Foods Safe Heather Tomlinson Rows of homemade jams at the local farmer’s market and a neighbor’s birthday cake on social media have something in common: they are both cottage (or homestead) food products. Cottage foods are home-based, home-made food products prepared outside of a commercial kitchen and sold to the public. Cottage food producers operate on a small scale, often from a home kitchen, selling goods locally. Although cottage foods provide opportunities to small, locally owned businesses, they also create complexity in selling food products to the public that are not inspected and may not meet basic food safety standards. And while home kitchens are not considered food establishments in the FDA Food Code, states are able to define “food establishments” by amending provisions in their food code adoption process or enacting legislation or regulations. In addition to regulating, state health agencies can play a role in keeping cottage foods safe through education, training, and other mechanisms. Cottage Food Regulation Currently, all 50 states and Washington, D.C. allow the sale of cottage food products directly to consumers. Several foodborne illnesses have been linked to products improperly prepared at home, such as botulism outbreaks in home-canned products and E.coli contamination of jerky. Many foodborne illnesses can be prevented by safely preparing, processing, and storing foods, processes often outlined by health regulations. Health agencies use a variety of tools to regulate cottage food production. Types of Foods: The types of foods permitted can vary across jurisdictions with some allowing only non-time/temperature controlled for safety (TCS) foods (e.g., baked goods, jams, candies), while others allow a wide range of products including TCS foods and items that require specialized processes (e.g., pickled vegetables). Some jurisdictions may use an exhaustive or illustrative list outlining permitted foods, while others limit specific food production processes but allow all other food items. Licensing and Inspection: Cottage food producers must follow a variety of rules in the form of permits, licenses, and registration. Although cottage foods are exempt from many inspection requirements, at least fifteen states require an initial inspection of home kitchens before they can sell items. All states allow the investigation of foodborne illness complaints; some states require annual licensure. Food Safety Training: States can require a food safety course to ensure that all cottage food producers understand the basic food safety requirements. Sales Caps: Gross sales caps limit the scale of operations allowed without full food safety precautions. After a cottage food operation exceeds their gross sales cap, they would be required to register as a food establishment and permitting rules would take effect. Sales Venues: States typically only allow direct-to-consumer sale of cottage foods (e.g., farmers’ markets) but some states permit online sales. Federal food safety regulations, which prohibit cottage foods, apply when food products are sold across state lines. Cottage food sales, whether in-person or online, should remain within the state they were created to avoid violating federal regulations. Labeling: All states have a labeling requirement for cottage foods. These labels can vary but typically include the food producer’s name and address, the product name, an ingredients list, allergens, product weight, date of production, and a disclaimer identifying that the product was prepared in a home kitchen that is not inspected. Recent Cottage Foods Legislation in the States Legislators often face tension in weighing the balance between maintaining food safety regulations and supporting small cottage food businesses by reducing the entry barriers (e.g., leasing commercial kitchen space). In recent years, there has been an increase in legislation expanding cottage food parameters ranging from product and preparation inclusions to modifying the gross sales cap. The Arizona House of Representatives passed and the Senate is currently considering HB 2864, which would expand the state’s cottage food item list to include precut and processed freeze-dried fruits and vegetables. Arizona enacted HB 2042, which expands the definition of cottage foods to include foods that require time and temperature control if they're exempt under federal regulations. The Hawaii legislature passed HB 2144 which is now awaiting action from the Governor, which would expand the definition of cottage foods to include pickled products and non-hazardous products that do not contain dried meat or seafood, permit the sale of products in retail stores, and allow for customer delivery via third party vendors or shipping. Several states have introduced legislation to increase the gross sales cap for those who qualify as a cottage food producer. Mississippi (MS SB 2638) and Washington (WA SB 5107) introduced bills that proposed to increase the annual gross sales cap, but both failed in session. There has also been legislation surrounding cottage food preemption. Massachusetts is considering S 2761, which would establish a cottage food regulatory framework and prohibit local health agencies from being able to establish their own cottage food regulations. Microenterprise Home Kitchens In expanding cottage food production, there has been increased legislation on microenterprise home kitchens. Microenterprises typically allow the production of more types of foods, including fully prepared hot meals, but also require stricter regulations (such as preparing and selling the food on the same day). Minnesota (MN SF 4501) and Hawaii (HI HB 1591) have introduced legislation that would allow microenterprise home kitchens and establish a regulatory framework for licensing and safety standards. Raw Milk Considerations Raw milk is an animal milk that has not gone through pasteurization (process of heating milk to a specific temperature for a set period of time) to kill harmful bacteria. Raw milk can carry dangerous bacteria that can cause food poisoning and has recently been shown to test positive for the recent highly pathogenic avian influenza (HPAI) virus. As of March 2024, 30 states allow the interstate sale of raw milk. This session, West Virginia passed legislation (WV HB 4911) and at least six states, Michigan (MI HB 5603), Hawaii (HI HB 1989), Missouri (MO HB 1711), Massachusetts (MA S 43), Louisiana (LA HB 467), and New Jersey (NJ A 1086), considered legislation that would allow unpasteurized, raw milk to be sold to consumers. How State Health Agencies Can Keep Cottage Foods Safe Health agencies consider cottage food inclusions based on food production risks. For instance, many agencies will allow baked goods but do not permit pickling due to the botulism risk associated with pickling. Health agencies evaluate food science to educate their legislatures on the considerations of cottage foods and where they would recommend public health regulations. Health agencies also ensure cottage food guidance is easily accessible and written in plain language, so producers have the needed information to follow regulations. Relevant information may include the permitted products, how to become a cottage food producer, and food safety considerations when preparing home-made foods. For example, the Illinois Department of Health, in collaboration with a diverse collection of stakeholders, created a robust cottage food guide to help producers and regulators understand state requirements and cottage food safety standards. Author card spacing 4 State policy surrounding cottage foods is constantly evolving. ASTHO will continue monitoring these changes and provide relevant updates. website yes

Wraparound Services for All: How Public Health Departments are Connecting Communities to Critical Support ASTHO, Association of State and Territorial Officials, wraparound services, astho delph, diverse executives, linkage to care, medical care, health care, community well being, public health, health outcomes, evidence based, quality of life, strength based, local community, health promotion, improvement health, infectious diseases, maternal and child health, local health departments, public health services, mental health services, public health practices, public health leaders, public health systems, behavioral health ASTHO Staff How health departments across the country are working to link clients to diverse public health services and supports to address their specific challenges and help them succeed in different aspects of life. As the heartbeat of community well-being, health departments find strength in collaboration. Services provided by health departments cannot stand alone when supporting their residents and communities significantly, as several simultaneous and interrelated factors can influence health. In this blog post, ASTHO’s DELPH scholars from cohort #3, Tosha Bock and Sam To, share how their organizations across the country are striving to implement systems to link clients to a diverse range of public health services and supports to address their specific challenges and help them succeed in different aspects of life. Give an overview of your organization and the ‘linkage to care’ efforts. TOSHA: The Oregon Health Authority (OHA) is a government agency in Oregon. OHA oversees Oregon’s health-related programs, including behavioral health (addictions and mental health), public health, Oregon State Hospital for individuals requiring secure residential psychiatric care, and the state's Medicaid program called the Oregon Health Plan. The nine-member Oregon Health Policy Board oversees its policy work. OHA’s goal is to eliminate health inequities in Oregon by 2030. Addressing health inequities in Oregon is crucial as it ensures everyone has equal access to healthcare resources regardless of socio-economic status or background, promoting a more just and inclusive society while improving public health outcomes. One way OHA does this is by supporting investments in Community Information Exchange (CIE). CIE is a network of collaborative partners using a multidirectional technology platform to connect people in Oregon to services and support. Through CIE technology, users can search a shared resource directory, document consent, and make and hear back on the referral status (closed loop). Communities across Oregon are implementing CIE. SAM: Within the Division of Preparedness at the Arizona Department of Health Services, the Office of Rapid Response Disease Investigation (ORRDI) was established during the COVID-19 pandemic and launched statewide case investigation and contact tracing (CI/CT) to support local health jurisdictions (LHJs) with critical investigative support. Soon after, a referral process to connect residents to community organizations was incorporated into all investigations; this provided the ability to directly link residents with vital resources and assistance programs while they navigated their situation. Give an example of the work and why it's impactful. TOSHA: Below is an example of the importance of CIE expressed by a Community-Based Organization interviewed for the CIE: Community Engagement Findings and Recommendations Report. Community-based organizations, peer-run organizations like ours, we are, you know, feet on the ground organizations, we're grassroots, and I think this tool to be able to reach out because we're always underfunded, we're always understaffed, you know, and this cuts down on hours and hours and hours of time that we would be on the phone, we have to do one referral, we can send it out, we can make notes, we can talk back and forth with other people, we only have one consent form, you know, all these things have made it a lot easier for us to operate, making it to where we can spend more time with our feet on the ground. – Interviewee SAM: Throughout Arizona, especially for the state’s most vulnerable populations, isolating or quarantining was found to be a hardship, with adherence to guidance greatly dependent on each individual’s ability to access medical care, attend work, pay for rent and utilities, and to acquire food or medication; those who struggled became a risk for increasing the spread of COVID-19. Community navigators offered a personalized approach to providing services and programs aimed at helping residents achieve self-sufficiency. During one of the most substantial periods of COVID-19 response (between July 2021 and June 2022), ORRDI connected 17,290 cases and 939 contacts to community navigator organizations and successfully administered 18,229 referrals. The top three requested resources across the state were utility assistance, eviction prevention or rental assistance, and emergency food box delivery. This partnership connected various established services and magnified trust with the ORRDI team and within Arizona communities. What do you wish could be done to enhance your programs? TOSHA: CIE networks are foundational to building a more equitable system in Oregon. Additional funding must be provided to implement systems change and expand these networks to create statewide coordination across organizations, sectors, and systems. These investments should also include technical assistance, training, education, and advancing privacy and data protection. SAM: The ADHS ORRDI programs continue to manage COVID-19 CI/CT for much of the state and leverage this partnership to support the needs of Arizona residents affected by COVID-19. However, they have also taken on several other morbidities of public health significance. The objective of the Office is to maintain current community navigator partnerships by offering supportive services, continually improving outreach efforts to cases and contacts, and encouraging enrollment in referrals. Concluding Thoughts In conclusion, breaking down the silos between public health and health care opens avenues for a more holistic approach to community well-being. By simultaneously addressing various determinants of health, organizations can create a comprehensive and interconnected system that fosters lasting improvements. This collaborative effort enhances the effectiveness of interventions and paves the way for a healthier and more resilient community. In embracing this integrated approach, we move closer to a future where the boundaries between public health and health care are blurred, giving rise to a more cohesive and impactful model for community health and wellness. website yes

Learn how states have increased and/or allocated funding to continue supporting core public health services.

In-depth analysis on state health policy surrounding the public health workforce. This is part of ASTHO's annual legislative prospectus series.

Policy Trends Shaping Behavioral Health in 2026 Policy Trends Shaping Behavioral Health in 2026 Learn about the policy trends shaping behavioral health in 2026, including improving access to naloxone, mobile crisis units, and more. Public health efforts remain focused on reducing mental health-related harms and preventing substance use disorder and overdose. In 2024, an estimated 23.4% of U.S. adults — about 61.5 million people or more than one in five — experienced a mental illness, underscoring the widespread and urgent nature of mental health challenges nationwide. After years of rising fatalities, the United States saw its first notable decline in overdose deaths in 2023, followed by a nearly 24% decrease in 2024, with approximately 87,000 deaths reported over a 12-month period. While this progress is promising, overdose is still a leading cause of death in the United States, underscoring the need for sustained prevention, treatment, and recovery efforts. To continue strengthening behavioral health systems and advancing overdose prevention, state and territorial legislatures are considering measures that promote mobile crisis units, support access to overdose prevention tools and treatment, and address the increased use of unregulated substances. Mobile Crisis Response Over the past decade, federal and state policy has emphasized community-based behavioral health crisis response. Building on early local models, the 2021 American Rescue Plan Act created a new Medicaid option for states to fund mobile crisis intervention services with a time-limited enhanced federal matching rate. States also integrated mobile crisis teams into broader crisis response systems aligned with the 988 Suicide and Crisis Lifeline. As implementation expands, state legislatures are considering measures to strengthen service coordination, sustain funding beyond the enhanced federal match period, and address workforce and capacity needs. During the 2025 legislative session, at least 13 states considered and six enacted measures related to behavioral health mobile crisis services. Rhode Island (HB 6118) will require insurance coverage for mobile response and stabilization services for children and adolescents under 18. In Washington, HB 1813 directs additional planning and coordination among service providers to promote access to crisis stabilization services for Medicaid enrollees. Leg Prospectus-2026 - SBH - SAMHSA CMS Naloxone Availability Naloxone is a life-saving medication that quickly reverses opioid overdoses. Approved for over-the-counter sale by FDA in 2023, its expanded availability has increased opportunities for timely intervention. To support access for people at risk for overdose, many states are advancing policies to make naloxone available in public settings — such as schools, libraries, and community centers — to empower bystanders to respond to and prevent overdose deaths. At least eight states have considered legislation to increase naloxone availability with a focus on youth. Colorado enacted SB 25-164 to advance youth overdose prevention, clarifying access to naloxone in school communal areas, like buses, and giving the state board of health authority to establish what entities can receive naloxone for distribution. Michigan is considering SB 404, which would require schools receiving naloxone from the health department to adopt policies regarding administration and explicitly limit liability of school employees administering naloxone. Montana enacted SB 503, which extends liability protections for those who administer expired opioid antagonists — like naloxone — including in schools. Leg Prospectus-2026 - SBH - MOUD Therapeutic Substances for Mental Health Diagnoses Psilocybin and ibogaine are naturally occurring psychoactive substances being studied for their potential to treat mental health and/or substance use disorders. As interest in their therapeutic applications grows, several states are considering legislation to expand access for clinical research and regulated therapeutic use. In 2025, more than two dozen states considered and seven states passed measures related to psilocybin. Arizona (SB 1555), Colorado (HB 25-1063), and Nebraska (LB 72) enacted laws that would allow psilocybin prescribing pending FDA approval, though this approval has not occurred. Iowa (HF 383) and Virginia (SB 1135) passed similar provisions but both governors vetoed the bills, citing the need to wait for FDA approval and DEA rescheduling before taking state-level action. At least 10 states considered legislation to study ibogaine or fund clinical trials exploring its potential to treat PTSD, depression, opioid use disorder, and related conditions. Washington considered SB 5204, which would support the study of ibogaine-assisted therapy for adults with opioid use disorder. And several states — including Nevada (AB 378), New York (S 4664), and Oregon (HB 3817) — considered legislation focused on supporting research and trials that improve the health of veterans and first responders. Finally, Texas enacted SB 2308 to establish a consortium focused on ibogaine research and trials to support FDA approval of the drug for treatment of various mental health and substance use disorders. Kratom Regulation Public health leaders are examining ways to reduce the potential misuse of unregulated substances, including kratom, a product derived from the leaves of a tropical tree that can act as both a stimulant and sedative, and that carries the risk of addiction and abuse. Kratom is not a scheduled drug under federal law, but the FDA has reiterated that there are no legally marketed drugs containing kratom and that it is not an appropriate dietary supplement or approved food additive. While FDA explores a scheduling action for 7-OH, a concentrated byproduct of kratom, a number of state legislatures are considering measures to regulate kratom products. At least 34 states considered and 11 states passed legislation regarding kratom in 2025, including Louisiana (SB 154) which criminalizes the possession and distribution of kratom. Another six states — Colorado (SB 25-072), Mississippi (HB 1077), Nebraska (LB 230), Rhode Island (SB 792), South Carolina (S 221), and South Dakota (HB 1056) — passed legislation restricting the sale of kratom to people under the age of 21 and establishing product labeling standards. Looking Ahead ASTHO anticipates states and territories to continue considering and adopting laws to prevent substance misuse and overdose and reduce mental health-related harms, including those that: Enhance support and capacity for behavioral health mobile crisis units and improve care coordination and entry across the behavioral health care continuum. Expand coverage for peer support specialists and establish baseline standards for peer support specialists in treatment and social support recovery services. Develop measures to study and decriminalize some psychoactive substances for potential mental health and substance use treatment. Develop innovative policies to link recently incarcerated persons to substance use disorder treatment. Improve access to medications for opioid use disorder by expanding telehealth availability, prohibiting prior authorization requirements, and ensuring comprehensive insurance coverage. Explore state regulatory frameworks for commercially available substances with the potential for misuse, including kratom and hemp-derived cannabinoids like Delta-8. OE22-2203 PHIG article yes

Policy Trends Shaping Public Health Funding and Administration in 2026 Policy Trends Shaping Public Health Funding in 2026 Learn about policy trends shaping public health funding and administration in 2026, including increased funding for behavioral health and other areas. Decades of underinvestment in the nation’s public health system have impacted agencies’ ability to respond to health challenges. The COVID-19 pandemic revealed the fragility of a chronically under-resourced sector tasked with responding to a global emergency. While public health has received influxes of funding through the CARES Act and American Rescue Plan Act over the last five years, both were temporary injections of funding in response to COVID-19. There have been efforts to provide longer term funding for public health improvements through the Public Health Infrastructure Grant and the Prevention and Public Health Fund, but this funding faces an uncertain future: There have been multiple reductions in federal funding to the Prevention and Public Health Fund since its creation in 2010. Moreover, state public health agencies are preparing for the possibility of federal funding being reduced or cancelled. This, coupled with balanced budget requirements, is driving states to explore ways to improve their public health investments while bolstering infrastructure — focusing on health departments’ core services, and ensuring access to quality public health programs at the state and local levels. Increased Funding for Public Health In 2025, 47 states enacted or will enact budget bills. While overall nationwide funding for public health in FY26 was roughly equivalent to FY25, at least half of the state health departments had some form of increased funding (e.g., Medicaid, provider reimbursement rates, and specific public health initiatives and programs). For example: Behavioral Health: Colorado SB 25-206 included a $1.6 million increase in funding to provide behavioral health services in primary care settings. Certification: Illinois SB 2510 includes a $6 million increase to support licensing, inspecting, and certifying health care facilities for compliance with state and federal regulations. Maternal and Child Health: Georgia HB 68 provided a nearly $3 million increase in funding to expand a pilot program that provides home visits in at-risk and underserved communities during pregnancy and early childhood. Rural Health: Arizona’s budget bills include $4 million to expand access to health care through the development of rural medical residency programs. School-Based Health Centers: Delaware HB 225 appropriates funding to develop school-based health centers in elementary schools with more than 90% of students classified as low-income, multilingual learners, or underrepresented minorities. Leg Prospectus-2026 - Funding - Rural Health Improved Public Health Administration Several states passed legislation restructuring their public health systems. Nevada enacted SB 494, dividing the previous Department of Health and Human Services into two separate agencies. The bill gives the new health agency, called the Nevada Health Authority, the authority to oversee health programs (e.g., Medicaid and the Children's Health Insurance Program), manage health care compliance and consumer health services, and develop policy that improves health care access and cost efficiency. Hawaii’s HB 1120 formally gives the Department of Health the authority to prevent, address, and abate any issues that pose a threat to public health and/or environmental health, such as toxic materials, vector-borne diseases, and climate change. More than half of U.S. state health agencies are decentralized or largely decentralized, meaning many public health services are provided by city, county, or regional health departments that are separate from the state health agency. In 2025, at least two states enacted legislation enhancing local health departments’ abilities to provide core public health services: Utah SB 172 requires the Department of Environmental Quality to enter into cooperative agreements with local health departments to prevent and respond to potential health and safety threats from the environment. It also establishes a governance committee of state and local health department personnel to evaluate proposed policy changes affecting local health departments and ensure allocated resources meet the minimum performance standard. Washington HB 1946 modifies the membership requirements for local health boards, allowing federally recognized tribes with reservation or trust lands in the board’s jurisdiction to have members on the board. It also allows urban Indian organizations recognized by the Indian Health Service that provide services within that jurisdiction to have members. Looking Ahead ASTHO anticipates states and territories will continue considering and adopting legislation to provide state funding for public health and improve public health infrastructure, including those that: Create contingency plans or rainy-day funds in the event of reduced federal funding. Establish partnerships with neighboring states to share health data. Promote sharing services and resources within local health departments. Leverage regionalization as a tool to consolidate and share scarce public health resources. Adapt the funding and management of public health grants to ensure efficiency. Improve public health data systems to promote greater efficiency. OE22-2203 PHIG article yes