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PrEP is a powerful tool to reduce new HIV infections; expanding access to PrEP is a priority within the federal Ending the HIV Epidemic in the U.S. initiative. One way to increase access to PrEP is by allowing pharmacists to prescribe and dispense it.

This blog from ASTHO’s PH-HERO team touches on the importance of trauma-responsive leadership in the public health workforce.

Centering the Community’s Voice in State-Led Health Equity Initiatives health equity, public health departments, health outcomes, michigan public health institute, health disparities, underserved populations, marginalized communities, people of color, indigenous people, premature deaths, minority health, cultural competency, public health, life expectancy, improving health, american indians, health service, african american, native american, social determinants of health, sexual orientation, mortality rate, socioeconomic status, covid-19 pandemic, higher rates, alaska natives, group of people, racial groups, social economic, population health, department of health, astho, association of state and territorial health officials Lana McKinney, Jessica Fepelstein Establishing the community voice in health policy discussions. Over the past two years, ASTHO has worked directly with state public health departments and their communities to build capacity for improving health outcomes. These public health departments are building a culture of health equity through policies, practices, and quality improvement measures. This includes the Strategies to Repair Equity and Transform Community Health (STRETCH) Initiative—a 10-state learning community hosted by ASTHO, the CDC Foundation, and the Michigan Public Health Institute. STRETCH supports states in operationalizing health equity and preventing the constant pressures caused by negative health outcomes on their communities. For example, poverty can create constant pressures just as water pushes against a dam, which can build to the point of breaking and push people into poverty. Additionally, ASTHO supports state and territorial recipients of CDC’s COVID-19 Health Disparities grant to improve the health of high-risk and underserved populations disproportionately impacted by the COVID-19 pandemic. Health disparities impact the quality-of-life and financial well-being of communities, with the economic burden of health disparities increasing from $320 billion in 2014 to $451 billion in 2018. This includes associated costs of excess premature deaths, lost labor market productivity, and excess medical care for Americans of color as compared to their white counterparts. Events in recent years, such as the COVID-19 pandemic, revealed the pressures that Black, Indigenous, People of Color (BIPOC) and other marginalized communities experience because of health disparities. Aligned with the technical assistance received by public health departments, several states have taken concrete steps to achieve optimal health for all by supporting training of public health staff and increasing engagement of under-represented and underserved communities in the policy process. Promoting Staff Health Equity Training Ensuring that public health staff and other leaders are equipped with the knowledge, skills, and attitudes necessary to provide culturally competent and equitable care to all patients, regardless of their social background or identity can improve health outcomes. In recent years, states have worked to expand access to cultural competency and humility training for health system workers. Nevada enacted legislation (AB 267) requiring the state Board of Health to establish the frequency for medical facilities and dependent care facilities to conduct cultural competency training for employees who have direct patient contact. It also (1) requires the Office of Minority Health and Equity and Department of Health and Human Services to establish and maintain a public-facing list of approved courses for cultural competency training, and (2) require nurses, psychologists, marriage and family therapists, counselors, social workers, and behavioral analysts to complete a minimum of three hours of cultural competency training to successfully renew their license. At least four other states—Illinois (SB 2427), Massachusetts (S 1413), Virginia (SB 1440), and Vermont (H 512)—considered bills expanding access to cultural competency training for health care professionals. Vermont’s bill would implement the recommendations of the Health Equity Advisory Commission to provide training and continuing education for health care providers to improve cultural competency, cultural humility, and antiracism in Vermont’s health care system. Public health agencies can also promote health equity training by allocating funding and providing training. For example, the Arizona Department of Health Services leveraged funding from CDC’s COVID-19 Health Disparities grant to establish the Advancing Health Equity, Addressing Disparities (AHEAD AZ) program with the University of Arizona Center for Rural Health, which supports the health care and public health workforce, including support for Arizona’s 17 Critical Access Hospitals health equity strategic plans, and implementing a COVID-19 testing program that provided testing to communities most in need regardless of socioeconomic or immigration status, including those living in correctional facilities and unhoused people. Health Equity Commissions Health equity commissions play a critical role in advancing optimal health for all by bringing together experts, stakeholders, and policymakers to draw on evidence-based approaches that address the root causes of health disparities and to develop strategies to prevent them. At least two states proposed legislation related to health equity commissions in 2023. Colorado passed a law (SB 23-151) extending its Health Equity Commission through 2029. New Jersey is considering S 3136, which would establish and require a Commission on Health Equity to, among other things, recommend implicit bias training requirements for health care providers. Empowering Community Members to Engage in the Policy Process Hearing directly from community members, particularly those with lived experience, provides health agencies with unique insights into the community’s needs and daily life, and helps gain support from those most affected by the policy. There can be several barriers to holistic community engagement, particularly for community members who have fewer resources. Policymakers can take steps to lower these barriers by providing access to childcare, supporting transportation costs to a meeting, and/or compensating community members for their time and effort supporting the policy development process. In 2022, Washington enacted SB 5793 to compensate community members with lived experience for their time and expertise when serving on boards, commissions, councils, committees and other similar policymaking groups. The law directed the state’s Office of Equity to develop equity-driven compensation guidelines for all state agencies, which Washington’s Department of Health used to create and implement its Community Compensation Guidelines. These compensation guidelines outline how and when community members can be paid for their time and expenses when engaging in the policy process. Such methods are particularly valuable because the communities facing the most inequity are also the ones most systemically marginalized. Similarly, in 2023 Oregon’s legislature considered SB 694 to create a Task Force and Work Group Stipend Fund. The fund would provide for providing members who do not otherwise receive compensation for their participation to be compensated for their time and travel for task force or workgroup related work. ASTHO will continue to monitor policy developments supporting health equity programs and initiatives, providing relevant updates. Special thanks to Maggie Davis, JD, ASTHO’s director of state health policy, for her contributions to this blog. Additional Resources to Help Public Health Leaders Increase Community Engagement ASTHO’s Programmatic Health Initiatives and Strategies Georgia Health Policy Center’s Guide to Funding Navigation to help communities design and sustain equity-advancing investment. <!-- Strategies to Repair Equity and Transform Community Health (STRETCH) Initiative framework. --> website yes

While COVID-19 is still present and ever-changing, public health professionals must also grapple with new challenges such as monkeypox, increasing firearm homicide, and widespread heat waves. In the wake of such emergencies, public health preparedness is more critical than ever.

Reconciling the tension between public health and civil liberties is one of the most significant challenges of public health law and ethics. The Supreme Court of the United States historically upheld state authority to enact and enforce public health laws that temporarily limit a person’s civil liberties, such as quarantine and isolation powers that restrict a person’s freedom of assembly in order to prevent the spread of contagious disease. There have been many legal challenges to the public health orders issued to slow the spread of COVID-19—many of the claims asserting violations of First Amendment rights of assembly, association, and expression—but they’ve largely been rejected by the courts. However, courts have treated claims asserting violations of the free exercise of religion more favorably, which may indicate an impending shift in how courts analyze the impact state and territorial actions may have on religious organizations.

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

ASTHO notes the top state public health policy issues in an annual Legislative Prospectus series. ASTHO is publishing a prospectus for the top 10 policy issues to watch in 2022. This week we are featuring data modernization and privacy protections.

Explore how states are enacting legislation to help justice-involved people avoid overdose illness and death and foster a smooth transition after release.

States Amending Policies to Slow Congenital Syphilis Increases States Trying Policies that Increase Syphilis Testing Amelia Poulin State are exploring ways to slow the rapid increase of congenital syphilis cases by strengthening policies to require testing at key points during pregnancy. Syphilis among newborns, or congenital syphilis, is preventable. Yet the latest CDC data show that congenital syphilis cases have more than doubled (106%) from 2019-2023. In 2023 alone, there were nearly 4,000 cases of congenital syphilis resulting in 279 stillbirths and infant deaths. Timely testing and adequate treatment during pregnancy might have prevented up to 80% of these cases. Increases in congenital syphilis often mirror increases in syphilis among reproductive-aged women. From 2022 to 2023, the rate of syphilis (all stages) increased 6.8% among women aged 15–44 years; rates also increased in 39 states and Washington, D.C. CDC recommends testing pregnant women for syphilis at the first prenatal visit, as well as at 28 weeks gestation and delivery if they are at increased risk of infection. Syphilis testing recommendations extend to asymptomatic women who are at increased risk for infection as they may face additional barriers to health care. ASTHO’s policy-level interventions for states and territories suggest universal syphilis testing for pregnant women. Additionally, states have been taking action to increase access to syphilis testing for people, including those who are pregnant. The Syndemic Perspective A history of incarceration, sex work, drug use, and geography can all significantly increase risk for sexually transmitted infections (STIs), HIV, tuberculosis (TB), and more. Structural barriers, including housing instability, economic insecurity, stigma, and restricted health care access, create conditions that heighten vulnerability to multiple infections. These conditions do not occur in isolation but rather as part of a syndemic, where overlapping epidemics interact with and exacerbate one another. Health agencies may be positioned to address upstream and root cause issues recognizing and addressing the intersections of these disease areas and related structural and social issues (e.g., drug use and poverty). Health agencies carry a wealth of interdisciplinary expertise, with staff leading efforts around data collection and surveillance, policy, community mitigation, and more, all of which support capacity to identify root causes and design an evidence-based, multifaceted response. Policies that prioritize housing stability, harm reduction services, and access to comprehensive health care, including STI screening, can help mitigate these risks and improve health outcomes. Geography can also increase the chances of syphilis transmission. Some regions with limited health care infrastructure, provider shortages, and limited STI prevention program funding and capacity may have higher rates of infection. Rural areas and certain urban settings may lack accessible clinics or specialized services, creating significant barriers to timely testing and treatment. Rural areas and certain urban settings may lack accessible clinics or specialized services, creating significant barriers to timely testing and treatment. Social and economic differences across different geographic locations contribute to varying levels of disease burden. By adopting a syndemic framework, states can move beyond disease-specific interventions and implement comprehensive strategies that address upstream factors contributing to disease transmission. State Actions Several states have introduced or passed legislation to expand syphilis testing access, with a focus on increasing screening opportunities, mandating insurance coverage, and ensuring appropriate prenatal testing protocols. Syphilis Testing In 2024, Colorado enacted HB 24-1456, which gave the state’s Board of Health rulemaking authority over syphilis testing. This flexibility allows the state to adapt its public health response based on emerging epidemiological trends as new data on syphilis transmission and congenital infections become available. The 2025 legislative sessions have highlighted additional approaches to expanding access to syphilis testing. The New York legislature introduced S 2704, which would require health insurance coverage for certain approved STI home test kits. This policy would provide individuals who face barriers to in-person care a convenient and private way to get tested and stay healthy. Oregon is also addressing testing accessibility through HB 2943, which would require hospitals to test people for HIV and syphilis when they have blood tests done in the emergency department (ED). Since EDs often serve populations who do not routinely access preventive health care (e.g., people experiencing homelessness or struggling with substance use disorders), this legislation would strengthen the role of emergency settings in STI prevention and intervention. Perinatal Syphilis Testing Recognizing the importance of perinatal screening, several states have introduced legislation to add requirements for syphilis testing at key points in pregnancy. Tennessee recently enacted SB 1283, which requires that health care providers take a blood sample to screen for syphilis, hepatitis B, and hepatitis C at the first prenatal examination, ten days after the examination, and at delivery. This approach aligns with CDC recommendations and ensures infections are identified and treated in time to prevent congenital transmission. Similarly, Nebraska LB 41 would require testing for syphilis at the first examination, in the third trimester, and at birth (with the mother’s consent), reinforcing a multi-point screening strategy to detect and treat infections that may develop later in pregnancy. Missouri’s SB 178 would take a comprehensive approach to syphilis prevention during pregnancy by requiring an additional test at 28 weeks, a critical point for intervention. The legislation would also require treatment for mothers who test positive for an STI, reducing the risk of congenital infections. Additionally, it would expand Expedited Partner Therapy by allowing any health care professional authorized to prescribe medications to administer Expedited Partner Therapy as well as include other STIs in the treatment, enabling faster treatment for sexual partners who might otherwise go untreated and continue the cycle of transmission. Policy Considerations Expanding both syphilis and perinatal syphilis testing policies demonstrate a growing recognition of the need for proactive, evidence-based strategies to address the increasing rates of syphilis and congenital syphilis. However, the ability of policies to affect public health outcomes may depend on continued resource allocation, workforce training, and public awareness campaigns. State and territorial health agencies can consider additional measures, such as integrating syphilis screening into routine primary care visits and providing funding for community-based outreach. Conclusion These legislative actions represent various approaches states are taking to addressing syphilis. Implementing screening protocols aligned with current evidence may contribute to efforts to address syphilis and congenital syphilis. By leveraging legislative action and evidence-based interventions, states can improve health outcomes and reduce disparities in syphilis and other STIs. A comprehensive approach that includes additional testing, expanded health care access, and targeted interventions for populations at higher risk for infection or severe disease may ensure better health outcomes for parents and infants alike. ASTHO will continue to monitor and report on this important public health issue. article yes

This brief outlines some of the barriers that pregnant and postpartum women with opioid use disorder face, as well as examples of state legislation passed to address recovery program implementation, treatment funding and insurance coverage, and provider education.

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.

In the November 2020 election, voters in several states cast their ballots on proposals related to the use of legal and illicit drugs. These ballot proposals influence key public health issues such as tobacco control, substance use prevention and treatment, and mental health—many of them implemented by state health agencies. This post contains a brief summary of the proposals on ballots around the country.

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 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

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

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.

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

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.

This report contains lessons learned and examples of messaging strategies that were successful during cyanobacterial bloom responses, they were collected from 17 state health agency staff members across 12 states.

ASTHO Legislative Prospectus | Previewing 2025 state legislative actions on substance misuse and overdose prevention.