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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.

The COVID-19 pandemic has negatively impacted youth mental health, particularly as a result of school closures, social isolation, family economic hardship, fear of family loss or illness, and reduced access to healthcare. However, states have many strategies to choose from to improve youth mental health and reduce suicide.

This toolkit is designed to support public health leaders in leveraging the policy development process to achieve health equity in their jurisdiction.

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.

Policy Trends Shaping Healthy Food and Chronic Disease in 2026 Policy Trends Shaping Healthy Food & Chronic Disease in 2026 Learn about policy trends shaping healthy food and chronic disease in 2026, such as regulating ingredients and modifying SNAP. A growing focus on links between nutrition and public health outcomes is driving legislative efforts across the country, with states actively responding to rising rates and the cost of chronic disease. As state legislatures consider ways to combat chronic diseases, they are also implementing policies aimed at addressing the food environment by introducing and enacting bills that regulate ultra-processed foods (UPFs), adjust SNAP benefits, and improve access to healthy food. Regulating Food Ingredients and Ultra-Processed Foods While efforts to define and regulate UPFs are still in development at the federal level, several states have decided to move forward with legislation targeting the use of specific artificial dyes and chemical preservatives in food products. West Virginia enacted HB 2354, prohibiting the sale or manufacturing of any food containing a list of specified dyes and certain preservatives. Similarly, Vermont is considering H 260, and New York is considering companion bills S 1239/A 1556. These bills aim to ban the manufacture, sale, or distribution of food containing a core group of chemicals (e.g., potassium bromate, propylparaben, and Red 3). Meanwhile, North Carolina introduced HB 440, which would prohibit additional color additives and ban the sale of food products containing nine specific dyes and chemicals. Pennsylvania introduced HB 1134, which focused on warning labels and would require foods with dyes Blue 1, Blue 2, Green 3, Red 40, Yellow 5, or Yellow 6 to include a label that states, “This product contains synthetic colors, which may have an adverse effect on activity and attention in children.” Leg Prospectus-2026 - CD - CA Restricting Ingredients in School Meals While previous years have focused on access to school meals, a growing wave of recent state legislation aims to eliminate UPFs, synthetic dyes, and chemical preservatives from children's diets. Several states have enacted or advanced bans on specific chemical additives in school meals: Utah’s HB 402 and Virginia’s HB 1910 prohibit schools from offering food containing common food dyes (Blue 1, Blue 2, Green 3, Red 3, Red 40, Yellow 5, and Yellow 6) or certain preservatives like potassium bromate and propylparaben. Similarly, Texas enacted SB 314 prohibiting specific additives in free or reduced-price school meals and SB 25, which mandates warning labels and expands state nutrition curriculum. In addition, other jurisdictions have introduced but not passed numerous bills proposing similar restrictions including South Carolina's HB 4339, which would prohibit certain additives in school meals. Modifying SNAP SNAP is the nation's largest federal food assistance program, providing benefits to low-income households. While the program is federally funded and administered by USDA through its Food and Nutrition Service, individual state agencies operate and manage eligibility and distribution. Since SNAP is governed by federal law, states must obtain a USDA waiver to implement changes that deviate from the federal rules. Several states are exploring waivers to limit the use of SNAP funds for purchasing candy and sweetened beverages or soft drinks, with Arkansas (SB 217), Idaho (HB 109), and Texas (SB 379) having passed legislation. Arkansas's new law requires the Department of Human Services to request a waiver to exclude candy and soft drinks, and reapply annually if denied. This dual ban was also the subject of bills introduced in Wyoming (HB 323) and South Carolina (HB 4061). Indiana (HB 1486) considered broader restrictions on “accessory foods,” aiming to prohibit the use of SNAP benefits for items like chips, energy drinks, sweetened beverages, soft drinks, and prepared desserts while New Jersey (A 5697/S 4348) introduced a narrower set of proposed restrictions, focused on soft drinks (including soda and sugary/sweetened beverages). Expanding Detection and Coverage for Chronic Diseases In response to high chronic disease rates — including diabetes, cardiovascular disease, cancer, and respiratory illnesses — states are enacting and proposing legislation focused on treatment coverage, awareness, and prevention. Several states are directly addressing obesity and pre-diabetes by mandating insurance coverage. Colorado (SB 25-048) enacted legislation requiring large group health plans to cover treatment for obesity and pre-diabetes, including medical nutrition therapy and metabolic/bariatric surgery. In Nevada, AB 555 caps patient cost-sharing for a 30-day supply of insulin for people with state-regulated commercial health plans. To aid early detection of diabetes, New Hampshire (SB 102), Louisiana (SB 26), and Florida (SB 958) enacted new laws requiring the creation of informational materials on Type 1 diabetes risk factors, warning signs, and screening available to students and parents. To reduce financial barriers to necessary cancer screenings, several states have enacted bills to mandate insurance coverage and/or lower the cost of diagnostic breast exams and supplemental testing. Virginia (HB 1828), Florida (SB 158), and Oklahoma (HB 1389) have enacted bills to limit or lower the cost of such breast imaging. Meanwhile, Colorado enacted HB 25-296, clarifying that health insurers cover medically necessary diagnostic and supplemental breast imaging that goes beyond routine screening. Looking Ahead ASTHO expects state and territories to continue advancing legislative proposals that focus on the prevention of chronic diseases and access to healthy foods in 2026. Future legislative action may include: Establishing policies to address food insecurity and promote access to nutritional foods by targeting food deserts. Exploring policy and leadership options to discourage the consumption of high-sugar drinks. Developing and adopting standards for healthy food procurement policies for state agencies and public institutions to increase the demand for nutritious products. Continuing to enact insurance coverage mandates for comprehensive chronic disease screenings and treatment. OE22-2203 PHIG article yes

Outcomes and Implications of ACIP’s Vote on the Hepatitis B Vaccine for Newborns Implications of ACIP Vote on Hepatitis B Vaccine for Newborns Susan Kansagra, Andy Baker-White, Kim Martin, Jessica Baggett Learn about the outcomes and implications of the December 2025 ACIP vote on the hepatitis B vaccine for newborns. On Dec. 4 and 5, the Advisory Committee on Immunization Practices (ACIP) held a long-anticipated meeting featuring two major topics of discussion: the hepatitis B birth dose and the pediatric vaccine schedule. The committee voted on two questions related to the pediatric hepatitis B vaccine schedule, both of which passed. To briefly summarize the outcome of the meeting, ACIP shifted from recommending a universal birth dose of the hepatitis B vaccine for all newborns to individualized decision-making for newborns born to HBsAg-negative mothers. There was no change to the recommendation for infants born to HBsAg-positive mothers or whose HBsAg status is unknown. CDC has not yet adopted these changes. In the meantime, many states are taking actions to provide clarity to providers and promote public confidence in the vaccine. How States Are Taking Action In response to (and in some cases before) the new ACIP recommendations, several states issued recommendations, guidelines, standing orders, executive directives, and health alerts for providers to provide clarity. States Recommending or Encouraging the Full Vaccine Series Some states are issuing their own guidance and recommendations for the hepatitis B vaccine series or encouraging providers to adhere to the series as is it was before the new ACIP recommendations: The Northeast Public Health Collaborative released a consensus statement before the ACIP meeting recommending the hepatitis B vaccine birth dose and a schedule that aligns with clinical recommendations. Collaborative members also issued statements reaffirming their adherence to established hepatitis B vaccine recommendations, including Connecticut, Maine, Maryland, Massachusetts, New Jersey, New York, Pennsylvania, and Rhode Island. Maryland also released guidance for parents and caregivers about its childhood immunization recommendations. States in the West Coast Health Alliance issued statements supporting the universal birth dose of the hepatitis B vaccine. These states include California, Hawaii, Oregon, and Washington. Many individual states also issued statements affirming the recommendation for the continued use of the hepatitis B vaccine birth dose, including Arizona, Colorado, Illinois, Michigan, New Mexico, and Vermont. States Issuing Standing Orders and Executive Directives At least two states issued a standing order or executive directive related to the hepatitis B vaccine: The Maryland Department of Health issued a standing order to ensure hepatitis B vaccine access for infants and children in the state. The standing order authorizes qualified health care providers to administer the hepatitis B vaccine and outlines the policies and procedures for administering the vaccine. In New Jersey, the acting health commissioner issued an executive directive recommending the hepatitis B vaccine birth dose and full series. States Issuing Public Health Alerts and Advisories Well before the recent ACIP meeting, the Maine CDC issued a health advisory to providers recommending the hepatitis B vaccine birth dose and full series. Since the ACIP meeting, at least two other states have released provider advisories. Maryland issued a letter to providers laying out the state’s hepatitis B vaccine recommendations, and New Hampshire issued a health alert with a continued recommendation for the full hepatitis B vaccine series and birth dose. In addition, Vermont sent a guidance letter to the providers in the state’s vaccine program. States Reexamine State Statutes and Agency Rules Linking to ACIP Recommendations Over the last several months, many states have proposed and enacted legislation to move away from sole reliance on ACIP recommendations. More recently, Massachusetts adopted H 4761, authorizing the health commissioner — in consultation with a newly established committee on immunization recommendations — to review and issue alternative standards to ACIP recommendations. States are also proposing changes to agency rules related to school and childcare immunization requirements. For example, Colorado’s health department has issued a proposed rule to modify the state’s standards for school and childcare immunization requirements and to align its rules with recent changes to state statute. Additional Considerations for States If CDC adopts the proposed ACIP recommendations, states can consider the following actions. Hepatitis B Screening States should continue to work with health care providers to close gaps in hepatitis B screening and follow-up for infants of HBsAg-positive mothers. Data show the most common cause of perinatal infection occurs when a mother with hepatitis B gives birth and the infant does not receive follow-up postexposure prophylaxis. Insurance Coverage While public and private insurance, including the Vaccines for Children program, are still required to cover the hepatitis B vaccine, such as any birth doses given to infants of HBsAg-negative mothers under shared clinical decision-making, states can consider creating additional coverage requirements. Some states have passed policies on insurance coverage, and other states have proposed legislation related to other vaccine coverage. Implementation of Shared Clinical Decision-Making While health care providers and parents have the flexibility to determine their approach for infants of HBsAg-negative mothers (i.e., continuing to recommend/give a birth dose), ACIP recommendations that rely on shared clinical decision-making have increased provider questions on how to have and document these conversations. States can work with medical associations, provider boards, and health care partners to ensure clinicians understand how to apply shared clinical decision-making recommendations. This includes educating staff in birthing hospitals, community clinics, and pediatric practices on how to counsel parents and document informed discussions. Jurisdictions can also develop or adapt educational materials and decision aids that clearly outline benefits, risks, timing, and follow-up options to support both providers and parents. More information on shared clinical decision-making is available from CDC and Common Health Coalition. States can also encourage providers and birthing institutions to examine workflows, Immunization Information System documentation, and follow-up to ensure scheduling of future doses. Implications for Vaccine Supply States can examine vaccine supply through the Vaccines for Children program to understand how the new recommendations impact supply of single antigen hepatitis B vaccines. If a significant percentage of the population receives vaccines on a different timetable, it could impact supply and timing for other vaccinations, given the reliance on combination vaccines for hepatitis B dose two and three, which can include DTaP, polio, and Hib vaccines. Supplemental Resources Common Health Coalition: Vaccine Resources December 2025 ACIP Meeting: Hepatitis B Updates for Health Leaders (PDF) Vaccine Integrity Project – Hepatitis B by Centers for Infectious Disease Research and Policy Understanding the Benefits of Vaccines: Common Questions by HealthyChildren.org Childhood Vaccinations (PDF) by Your Local Epidemiologist Hep B Birth Dose Media Toolkit by Hepatitis B Foundation Reframing the Conversation About Child and Adolescent Vaccinations by Frameworks Institute CDC: ACIP Shared Clinical Decision-Making Recommendations ACIP Meeting Materials for Public Posting: Hepatitis B Birth Dose Briefing Document (PDF) Hepatitis B Birth Dose Vaccination (PDF) 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

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

State Policies Aim to Eliminate Food Deserts Beth Giambrone Learn how states are working to improve access to healthy foods and eliminate food deserts in this Health Policy Update. The environment where we live, work, and play can shape eating habits and make healthy eating difficult. This is especially true when nutritious foods are costly and unavailable and unhealthy foods are abundant and accessible. More than 47 million people nationwide live in food insecure households, including more than 7 million children. In addition, more than 27 million people live in "food deserts," generally defined as areas where residents do not have a convenient option for affordable, healthy food, like a supermarket or large grocery store. People who live in food deserts may be at higher risk of obesity and chronic disease. Furthermore, children and young adults who live in food insecure households are more likely to have poor academic outcomes. Increasing Access to Healthy Foods In recent years, jurisdictions have taken a multi-layered approach to increasing access to healthy foods. In 2023, the Texas legislature enacted HB 3323, which established a food system security and resiliency planning council, and requires a food system security plan for reasonably-priced food to ensure public health and welfare, economic development, the protection of the state’s agricultural resources, and includes legislative recommendations to facilitate the availability of food in the state. In 2024, Delaware enacted SB 254, establishing the Delaware Grocery Initiative to expand access to healthy foods in the state’s food deserts and areas at risk of becoming food deserts. The bill authorizes the state’s Division of Small Business to award grants and financial assistance to entities that provide or support affordable, accessible, or healthy food, including food banks and pantries, supermarkets, and corner stores. It also directs the Delaware Council on Farm & Food Policy to develop a strategy to address food insecurity in communities throughout the state and issue a report by June 1, 2025. Also in 2024, Colorado enacted HB 24-1416, codifying an incentive program designed to increase access to fresh fruits and vegetables in low-income communities. In 2024, jurisdictions also enacted legislation that makes supplemental nutritional assistance more accessible. California (AB 2786) requires the Department of Food and Agriculture to allow newly created certified mobile farmers’ markets to participate in the Women, Infants, and Children Program (WIC) Farmers’ Market Nutrition Program, if approved by USDA. Connecticut (HB 5003) requires the Department of Agriculture to purchase and make needed equipment available so certain nutrition program participants can make purchases at farmers’ markets. And Pennsylvania (SB 721) established a permanent Women, Infants, and Children State Advisory Board to advise the Department of Health on solutions to increase participation in the WIC program, including increasing access to WIC-authorized stores for participants. Jurisdictions also enacted legislation ensuring students receive healthy school meals through farm-to-school programs. New Hampshire HB 1678 created a pilot program that incentivizes school districts to buy food for school meals that come from local farms and producers. Virginia HB 830/SB 314 established a Farm to School Program Task Force within the Department of Education to increase farm-to-school school programs within the state, including programs where public schools purchase and feature locally produced food prominently in school meals and learning opportunities related to local food and agriculture. Ensuring Students are Fed At the beginning of the 2023-2024 school year, eight states, including California, Colorado, Maine Massachusetts, Michigan, Minnesota, New Mexico, and Vermont, provided free school meals to all public-school students regardless of income. In 2023, Illinois (HB 2471) and Washington (HB 1238) also enacted legislation to provide universal free school meals or expand access to free school meals for public school students. The programs in both states are subject to funding. In 2024, at least two jurisdictions enacted legislation to study and report on the cost and impact of providing free breakfast and lunch to all public-school students. Maryland (SB 579) required the Department of Education to submit a report on the cost of providing free meals to all public school students by December 1, 2024, while Virginia (SB 283) directed the Superintendent of Public Instruction to explore the impact of offering free school meals to all students and identify options to eliminate student and school meal debt and leverage federal and state programs to provide school meals. Virginia’s report was published in November 2024 and, while noting the significant costs and sustainability concerns associated with free school meals for all students, it included several strategies for maximizing existing meal programs in the state. A number of jurisdictions have also expanded eligibility requirements or updated student meal program policies in recent legislative sessions. Two states enacted legislation requiring all public schools to provide a free breakfast and lunch to students who qualify for a reduced-price meal under the Federal School Breakfast Program and Federal School Lunch Program: Louisiana in 2023 (HB 282) and Delaware in 2024 (HB 125). New Jersey (A5684) took a similar approach and also expanded state-based income eligibility criteria to allow more students to receive free meals at school. In 2023, North Dakota (HB 1494) enacted a law requiring schools participating in the federal school lunch program to adopt and publish a school meals policy that prohibits schools from taking action against students who lack funds or have unpaid meal balances, such as taking away a student’s food if they have already been served, requiring the student to work to pay off the debt, or limiting participation in school activities due to an unpaid balance. Several states also enacted legislation to benefit students during the non-school months through summer food programs. In 2023, Maine enacted LD 947, which requires summer food service program rules to allow for maximum flexibility under federal law for mealtimes and packaging of meals to send home with students. That same year, as part of a broader piece of human services legislation, California (AB 120) required the State Department of Social Services to maximize participation in the Summer EBT program, which provides funding to families with school-aged children to buy groceries during the summer. And in 2024, Hawaii (HB 2430) and New Hampshire (SB 499) enacted legislation authorizing participation in the Summer EBT program. ASTHO will continue to monitor and report on this important issue. article yes

2026 State Legislative Session Update 2026 State Legislative Session Update Learn about state legislation from FY26 focused on hot public health topics in this Health Policy Update. ASTHO’s 2026 Legislative Prospectus Series announced the top five public health state policy issues to watch this year. With at least 30 states scheduled to conclude their legislative sessions by the end of May, state legislatures focused on many of these public health topics. Expanding Access to Care As expected, a number of states considered legislation to expand access to care, including policies that promote community-based services and rural health care access. Doula birthing support services continue to be a topic for state legislatures with at least a dozen states considering legislation to expand coverage or access. Oregon enacted SB 1568, expanding coverage for birth and postpartum doulas and lactation counselors. Virginia enacted two bills that support access to doulas: HB 328 requires the Bureau of Insurance to select a new essential health benefits benchmark plan that includes doula care coverage starting in 2029, while HB 838 expands Medicaid coverage to include incentive payments for doulas to provide linkage to care visits in the postpartum period. For other licensed health care professionals, interstate compacts allow health care professionals licensed in one member state to practice in another without additional credentials. This year, legislatures have considered more than 100 health care professional compact bills so far, with at least six states enacting legislation: Arizona (HB 2190), North Dakota (HB 1622), and South Dakota (HB 1146) adopted the Physician Assistant Licensure Compact. New Mexico adopted the Interstate Medical Licensure Compact (SB 1) and the Social Work Licensure Compact (HB 50). Mississippi (SB 2543) adopted the Dentist and Dental Hygienist Compact. Washington (HB 2088) adopted the Dietitian Licensure Compact. Finally, at least two states enacted legislation to expand telehealth. Virginia HB 1284 specifies that its Medicaid provider-to-provider consultation provision includes services provided via telehealth, and Kentucky HB 424 eases the requirements for social worker telehealth practice. Behavioral Health Legislatures are also continuing to explore policies that address mental health and substance misuse. This includes legislation that supports people across the care continuum, explores the use of psychoactive substances in mental health treatment, and regulates emerging substances. At least seven states have enacted legislation to establish or enhance the continuity of care for people in a behavioral health crisis. This includes Maine LD 1216, which requires the Department of Health and Human Services to establish crisis intervention support services in all counties. Virginia enacted HB 453, which specifically allows amendments to the state’s Marcus Alert plan supporting the state’s comprehensive crisis system and requires state agencies and local partners to align their policies accordingly. States also continue to promote the availability of opioid reversal drugs through legislative action. Virginia SB 257/HB795 requires certain health insurance plans to include at least one opioid antagonist with limited cost-sharing on their drug formularies. Kansas HB 2534 requires schools to stock naloxone and establish polices to support its administration, and Utah SB 87 clarified its immunity provisions for administering opioid antagonists and will allow expired — but still effective — opioid antagonists to be dispensed and administered in certain situations. Another trend this legislative session is the legalization and regulation of use, medical study, and reclassification of certain psychedelic drugs for therapeutic purposes. Several states considered legislation to allow psilocybin for therapeutic purposes, including Oregon HB 4040, which already allows psilocybin service centers and expanded its licensing criteria for psilocybin service facilitators. At least 23 states considered, and five states (Mississippi SB 2056, South Dakota HB 1099, Utah SB 83, Virginia SB 379, and West Virginia SB 906) enacted legislation that would automatically reschedule psilocybin or certain formulations, pending federal approval and/or rescheduling. Finally, at least 10 states considered bills to support access or research into ibogaine, which is being studied in relation to PTSD and substance use disorder. States include Washington (SB 5204), Oregon (HB 4110), Tennessee (SB 2149/HB 2075), Louisiana (SB 43), Oklahoma (HB 3834), and Georgia (HB 1296), with Mississippi enacting HB 314 to allow the state health department to participate in a consortium supporting clinical trials for ibogaine drug development. A number of states are also taking action to address kratom, a plant-based substance with the potential for serious side effects, including substance use disorder and withdrawal symptoms. As of January 2026, 31 jurisdictions regulate kratom, with at least five states enacting legislation this year. New York (A 9472/S 8814), Virginia (HB 360), and West Virginia (SB 985) established or enhanced prohibitions on selling kratom to people under 21, while Nebraska (LB 901) enacted an excise tax on kratom products. Utah enacted two bills (HB 385 and SB 45) that regulate processors and retailers and New York mandated warning labels on certain kratom products (A 9443/S 8780). Healthy Food and Chronic Disease States continue to prioritize chronic disease by advancing policies recognizing the importance of prevention and how food impacts health. In 2026, a number of states considered legislation to address food insecurity, improve school nutrition, and promote chronic disease screening and prevention. At least 10 states considered legislation to limit ultra-processed foods or promote access to healthy foods, with Nebraska LB 940 prohibiting public schools from offering foods that contain certain color additives and Tennessee SB 2423/HB 1853 taking a similar approach but for any artificial food dye. States are also exploring ways to accommodate student dietary preferences. Minnesota (SF 2970), New Jersey (S 1676), New York (A 1834), and Washington (S 5878) introduced legislation that would mandate plant-based options in school cafeterias. Illinois enacted HB 1607, creating a health department task force to review state efforts to eliminate food deserts and requiring a report with recommendations by January 2028. Finally, state legislatures are taking action to support access to early detection and chronic disease management through insurance regulation. Mississippi enacted HB 565 to require Medicaid and other health plans to cover biomarker testing for the diagnosis, treatment, management, or monitoring of patients when supported by medical evidence. Additionally, Oregon enacted SB 1527, which limits out of pocket costs for medically necessary cervical cancer screenings and follow-up examinations. Finally, Alabama (SB 19) will prohibit certain insurance plans from imposing cost-sharing for prostate cancer screening of all men over 50 and younger men at high risk. Infectious Disease Prevention With recent changes to the membership and recommendations of the Advisory Committee on Immunization Practices (ACIP), a number of state legislatures have considered changes to vaccine policy in 2026. Several states enacted legislation to modify the role of ACIP, including Colorado (SB 26-032), Connecticut (HB 5044), Maine (LD 2146), Maryland (HB 637), New Mexico (HB 156), Oregon (SB 1598), Vermont (H 545), and Washington (HB 2242). Many of these bills address other components of vaccine policy, including: Vaccine Schedule Recommendations: Colorado, Connecticut, Maryland, New Mexico, Vermont, and Washington substitute or add state health agencies and/or organizations like the American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American Academy of Family Physicians, and American College of Physicians as sources for vaccine recommendations. Insurance Coverage: Connecticut, Maryland, New Mexico, Oregon, Vermont, and Washington require health insurance plans to cover vaccines recommended by health agencies or other organizations, rather than ACIP alone. Pharmacist Scope of Practice: Maryland and Vermont substitute or remove ACIP recommendations as an authority for pharmacists to administer vaccines, and Colorado allows pharmacists to prescribe vaccines independently. Funding: Colorado, Maine, and Vermont expand vaccine purchasing programs to include vaccines recommended by bodies other than ACIP. Liability Protections: Colorado, Maine, and Vermont include liability protections for certain providers administering vaccines according to state or medical organization recommendations. Public Health Funding Legislatures in thirty-one states, the District of Columbia, and three U.S. territories will enact budgets for the 2027 fiscal year, while legislatures in three more states will enact biennial budgets for the 2027 and 2028 fiscal years. With reductions in federal funding, states continue to find ways to leverage state funds to invest in public health and public health infrastructure while adhering to balanced budget requirements. Eleven states have enacted FY 2027 budgets and three states enacted biennial budgets for FY 2027-FY 2028, with several states increasing public health funding, including Kansas (HB 2513), New Mexico (HB 2), and Wyoming (SF 0001). Additionally, three states passed FY 2027 supplemental budgets featuring public health provisions: Maine LD 2212 appropriates funding to support access to affordable prescription drugs in rural and underserved areas, Washington SB 6003 increases funding for the state’s Drinking Water State Revolving Fund, and Nebraska LB 1071 shifts funds to children’s health insurance, community-based aging services, and mental health operations. States have also

During the 2023 legislative session, a number of states enacted policies that advance ACEs prevention measures and support families in ensuring safe places for their children to live, grow, and play.

State efforts to reduce firearm injury and death with safe storage policies.

Recent legislation at both the state and federal levels has significantly affected the ability of health care providers to serve patients virtually and across state lines.

Research confirms that strengthening economic supports can improve parental mental health, children’s health, education, and social outcomes.

How the Emergence of Xylazine Impacts Overdose Prevention Policy overdose prevention policy, overdose crisis, fatal overdoses, emergence of xylazine, illicit drug supply, toxicological testing, withdrawal symptoms, xylazine test strips, drug paraphernalia laws, drug checking, legislative action, drug supply, substance use disorders, controlled substance, opioid use disorder, centers for disease control, health care, harm reduction services, psychoactive substances, department of public health, illegal drug, type of drug, opioid crisis, prescription opioid, astho, association of state and territorial health officials JoAnne McClure, Victoria Pless How states are considering overdose policy changes as xylazine continues to emerge in the illicit drug market. Developing and adopting policies to reduce fatal overdoses can help public health leaders address the ever evolving and complex national overdose crisis. More than 109,000 fatal overdoses occurred in 2022, with the majority involving illicitly manufactured fentanyl. Adding to the overdose challenge is the emergence of xylazine, a non-opioid tranquilizer (i.e., sedative), that is being increasingly mixed with fentanyl in the illicit drug supply. As of November 2022, xylazine was found in the illicit drug supply in 48 of 50 states and Puerto Rico. Xylazine is currently associated with one in ten fatal fentanyl (11%) overdoses, a near-threefold increase from 2.9% in 2019. Toxicological testing for xylazine is not uniform and, as a result, its involvement in fatal overdoses may be underestimated. Some states have taken initiatives such as Indiana (HB 1286) and South Carolina, to improve the consistency of toxicological testing for xylazine. With xylazine’s addition to the overdose crisis, states are beginning to adopt laws to better regulate the supply of xylazine and detect its presence in the illicit drug supply. What is Xylazine? Xylazine, also known as “tranq” or “tranq dope,” is a central nervous system depressant causing drowsiness, slowed breathing, reduced heart rate, and hypotension, which can increase the risk of a fatal overdose. Xylazine is approved for veterinary use in the United States but is not FDA-approved for human medicine. Xylazine, can be added to substances that are ingested orally, snorted, sniffed, or—mostly commonly—injected intravenously, and has been added to or used to cut heroin and fentanyl to prolong their effects. People who use drugs may be unaware of xylazine’s presence, which can put them at a higher risk of fatal overdose. Xylazine use is associated with skin ulcers, lesions, abscesses that left untreated, can lead to amputation. People who develop a physical dependency on xylazine may develop severe withdrawal symptoms. Although symptoms of xylazine use and opioid use are similar—making it difficult to differentiate whether someone has used one or both substances—overdose reversal agents (e.g., naloxone) do not counteract the effects of xylazine. Public health leaders still recommend that naloxone be administered for a suspected opioid overdose because xylazine has been detected in substances alongside fentanyl. For a person experiencing a xylazine-involved overdose, public health leaders emphasize the need to seek treatment beyond naloxone. In addition to public health’s work to address xylazine in the illicit drug supply, some state and territorial legislatures are expanding or protecting access to xylazine test strips as well as steps to limit access to xylazine through the state drug schedule. Legalizing Drug-Checking Equipment Drug-checking equipment, such as fentanyl test strips, are evidence-based interventions that allow a person who uses drugs to test their supply for an adulterated substance. State drug paraphernalia laws historically prohibited drug checking equipment, limiting the possession, distribution and use of items like fentanyl test strips. To make fentanyl test strips more widely available to prevent overdose, legislatures rapidly changed their laws to either explicitly legalize fentanyl test strips or generally legalize drug checking equipment. As of July 5, 2023 more than 33 jurisdictions legally authorize the use of fentanyl test strips, 12 of which (Alaska, Colorado, Guam, Maine, Maryland, Nebraska, New York, the Commonwealth of the Northern Mariana Islands, Pennsylvania, South Carolina, Utah, and Vermont) generally authorize the possession and use of drug-checking equipment. Similar to fentanyl, people may not know whether they are exposed to xylazine when using other substances, increasing the risk for harm. New test strips can detect the presence of xylazine, however state drug paraphernalia laws that criminalize drug checking equipment may limit the accessibility of xylazine test strips to prevent overdose. In 2023, at least three states—Illinois (HB 3203), New Hampshire (HB 287), and Utah (SB 86)—enacted legislation to authorize or decriminalize use of drug-checking equipment for fentanyl and xylazine, ensuring that xylazine test strips are lawful and able to be distributed. Additionally, states that previously passed legislation to allow for fentanyl-specific drug checking are amending their statutes to include all drug checking to ensure the legal possession of xylazine test strips. For example, Delaware enacted (SB 189) that specifically legalized xylazine test strips. Two other states—Vermont (H 222) and New Jersey (SB 3957)—enacted laws expanding the authorization of fentanyl test strips to allow for all harm reduction supplies, including drug checking equipment, which would permit the use of xylazine test strips. The Question of Scheduling Drugs are scheduled based on their acceptable medical use and potential for misuse and severe psychological and/or physical dependence, with drugs in Schedule I being the most tightly regulated. Xylazine is not a controlled substance under the federal Controlled Substance Act so it is not DEA scheduled or controlled. Nevertheless, xylazine is subject to FDA regulation under the federal Food, Drug, and Cosmetic Act and state law. Prior to 2023, only two states directly or indirectly scheduled xylazine. Florida codified xylazine as a Schedule I substance in 2016, and xylazine could fall under Massachusetts’ Schedule VI designation, which applies to prescription drugs. As state and territorial leaders take steps to schedule xylazine, policymakers should consider whether scheduling or other criminal penalties will deter people from seeking care if they fear being arrested for unknowingly testing positive for exposure or xylazine use. Another consideration for leaders before scheduling xylazine is whether scheduling will also make possession of test strips illegal under the jurisdiction's drug paraphernalia law. In 2023 at least nine states–Delaware (SB 189), Illinois (HB 3873), Louisiana (HB 106), Michigan (HB 4913), New Jersey (A 5448), New York (A 5914), Oklahoma (SB 668), Rhode Island (HB 5922), and West Virginia (SB 546)—considered legislation to schedule xylazine as a controlled substance. Of those, Delaware, Rhode Island, and West Virginia enacted laws scheduling xylazine in 2023. In addition to legislative action, at least two governors (Ohio and Pennsylvania) took executive action to schedule xylazine. ASTHO’s overdose prevention and state health policy teams continue to monitor these important public health issues. website yes

ASTHO staff identified a range of evidence-supported policies considered by state legislatures that could prevent ACEs. This report synthesizes these research and policy proposals and is intended for public health practitioners and policymakers who are considering adopting similar policies.

Assessment of Foundational Capabilities Assessment of Foundational Capabilities in Public Health Grace Gorenflo, Brian Lentes, Melissa Touma, Anna Bradley Learn how state health departments are implementing the Foundational Public Health Services model to bolster their public health work in this report. The Foundational Public Health Services model serves as the core framework for defining cross-cutting capabilities essential for public health departments to deliver a minimum standard of service. This report compiles examples and assessments from 25 states to illustrate the implementation and progress of these foundational capabilities. Highlighting the importance of public health infrastructure, the report also includes a summary of state activities, showcases models and strategies for modernization and transformation, and reference tools such as cost assessments, legislation, and funding mechanisms used to strengthen public health systems nationwide. Dive into the full report to access these resources. Download the Report (PDF) article yes

Learn how federal and state policies are lessening the presence and negative health effects of PFAS in water and consumer products.