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

This report highlights how a six-state "payers cohort," through the ASTHO/CDC Heart Disease and Stroke Prevention Learning Collaborative, convened cross-sector teams which included payer partners, local health agency staff, academic institutions, community health workers, and other state‐ or local‐level stakeholders to support efforts to improve cardiovascular health outcomes, focusing on blood pressure control and reducing healthcare costs.

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.

Three ways policymakers are addressing access to care are through telehealth, safety net and emergency services, and adjusted reimbursement rates to Medicaid-enrolled providers.

In 2020, the COVID-19 pandemic exacerbated barriers to care and treatment for individuals experiencing opioid use disorder. Experts estimate a record-setting 90,000 people died of a drug overdose in 2020. Additionally, as the pandemic continues, it has understandably diverted attention, funds, and personnel usually focused on the opioid crisis. State and local public health departments are experiencing an all-time low in staffing, especially among Maternal and Child Health programs.

During the early months of the COVID-19 pandemic, the federal government enacted the Coronavirus Aid, Relief, and Economic Security (CARES) Act, temporarily expanding the use of telehealth technologies by removing various requirements and waiving certain restrictions. Many states also expanded telehealth access through changes to state Medicaid laws. These temporary policy changes created an uptick of telehealth use that improved access to care for millions of Americans—but questions remain about which policy changes will stick around beyond the pandemic. Currently, states are making decisions about what temporary policies to permanently implement and which policies to end without disrupting the delivery of care and further exacerbating health disparities.

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

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

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