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

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

Learn about the importance of exploring intermediaries that work alongside existing data platforms in addressing ongoing public health challenges.

Addressing the impact of substance use disorder on pregnant and postpartum individuals: a critical analysis of SUD policy, access to care, and lessons from the field.

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.

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 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.

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 communities transition from emergency response to long-term monitoring and recovery, the federal government and states are taking legislative action to improve emergency preparedness capabilities.

State and Federal Actions to Reduce Per- and Polyfluoroalkyl Substances’ Impact on Public Health safe drinking water act, per and polyfluoroalkyl substances, water supplies, contaminated groundwater, chemical companies, pfas contamination, forever chemicals, synthetic chemicals, maximum contaminant levels, industrial pretreatment program, polyfluoroalkyl substances pfas, chemical sales, chemical industry, bottled water, safe drinking water act sdwa, unregulated contaminants, companies in the world, united states, consumer products, 1996 amendments, national primary drinking water, surface water, water system, largest chemical companies, pfas strategic roadmap, primary drinking water regulations, pfas chemicals, pfoa and pfos, drinking water, testing for pfas, astho, association of state and territorial health officials Maggie Davis, Beth Giambrone State and Federal Actions to Reduce PFAS Impact on Public Health Since 2018, when the city of Stuart, Florida filed its lawsuit, communities across the United States have filed lawsuits against manufacturers that produce Per- and polyfluoroalkyl substances (PFAS), alleging that they contaminated groundwater and exposed residents to these harmful chemicals. In June 2023, manufacturer 3M agreed to pay at least $10.3 billion to settle the Stuart lawsuit and others across the country with public drinking water systems. Similarly, chemical companies DuPont, Chemours, and Corteva reached $1.18 billion settlement with local communities that have detected PFAS in their water supplies. PFAS are synthetic chemicals used in products like nonstick cookware and firefighting foam, which can migrate to soil, water, and air during production and use. Most of these chemicals remain in the environment without breaking down—hence the nickname “forever chemicals”—and can cause harmful health effects (e.g., higher risks of kidney or testicular cancer, and pre-eclampsia or high blood pressure among pregnant people) and are prevalent across the nation. Evidence shows the widespread nature of exposure to the chemicals and the economic costs of exposure. For example, a 2023 USGS study estimated that at least 45% of tap water nationwide could have one or more PFAS, while recent research estimates the annual cost of the disease burden attributable to long-chain (i.e., six or more carbon) PFAS exposure to be at least $5 billion. As communities seek restitution for PFAS contamination, federal and state policymakers are working to eliminate PFAS from ground water and drinking water and to mitigate exposure to these forever chemicals. Eliminating PFAS in Drinking Water Under the Safe Drinking Water Act, EPA has the authority to regulate the public drinking water supply in the United States. These regulations establish legally enforceable Maximum Contaminant Levels (MCLs) or Treatment Techniques and non-enforceable Maximum Contaminant Level Goals (MCLGs) for public water systems. EPA’s recently proposed PFAS National Primary Drinking Water Regulation could potentially add six different PFAS compounds to the list of regulated contaminants. Within the PFAS chemical family, PFOA and PFOS are proposed to each have MCLs of 4.0 parts per trillion (ppt), while PFNA, PFHxS, PFBS, and GenX would be regulated collectively as a mixture using EPA's Hazard Index approach. The proposed rule also could require public water systems to monitor and notify the public of PFAS levels and reduce the levels in drinking water if they exceed proposed standards. According to a survey conducted by the Environmental Council of the States, state guidelines vary; at least eleven states have established statewide MCLs for PFAS in drinking water. Some states prohibit their agencies from setting standards more stringent than federal ones and, in the absence of a federal standard, state agencies may hesitate to establish one that could easily be invalidated. In other cases, a lack of resources inhibits the agency’s capacity to set and enforce a PFAS standard. When a federal standard is established by EPA’s final rule, expected by the end of 2023, state primacy agencies will need to enforce the federal standard and adopt standards aligned with the federal standard or stronger within two years. Additional State Efforts to Reduce PFAS Exposure Even without MCLs, states are finding ways to mitigate the public’s exposure to PFAS. In 2023, states enacted legislation on banning PFAS in consumer products, increased requirements for testing and reporting of PFAS, and PFAS mitigation. Banning PFAS in Products Indiana enacted HB 1341 prohibiting fire departments from purchasing gear unless it contains a permanent label indicating whether it does or does not contain PFAS as of June 30, 2024. Minnesota’s HF 2310 prohibits selling or distributing products containing intentionally added PFAS beginning January 1, 2026. An exception may be made if the manufacturer submits information to the commissioner of the Pollution Control Agency such as the product, the amount of PFAS used, and the amount of PFAS in the product. The Oregon legislature enacted SB 543, which prohibits the selling or using polystyrene foam containers for prepared food, food containers containing intentionally added PFAS, and polystyrene packaging peanuts. Washington enacted HB 1047, which prohibits manufacturing, distributing, and selling cosmetic products with PFAS and other chemicals or chemical classes as of January 1, 2025. Testing/Reporting Indiana enacted HB 1219, establishing a pilot program that collects blood samples of previous or current firefighters, analyzes the samples for serum PFAS levels, and determines whether there are corresponding health implications associated with elevated serum PFAS levels. Maine’s LD 1248 requires bottlers who extract water from the state to sell as bottled water to test, regularly monitor, and report the presence of PFAS to the Department of Health and Human Services and post the results on a public-facing website. Sales of bottled water are prohibited if PFAS levels in the water source exceed the state or federal community water system standards, whichever is lower. Currently, Maine has an interim MCL standard of 20 ppt. Virginia’s HB 2189 directs the State Water Control Board to adopt regulations requiring industrial users of publicly owned treatment works to test waste streams for PFAS before and after cleaning, repairing, refurbishing, or processing items the user knows or reasonably should know uses PFAS chemicals. West Virginia’s HB 3189 requires its Department of Environmental Protection to identify and address sources of PFAS in raw sources of public drinking water systems. It also requires facilities to report the use of PFAS if they discharge to surface waters under a National Pollutant Discharge Elimination System (NPDES) permit or to a Publicly Owned Treatment Works under an industrial pretreatment program. Mitigation Connecticut enacted SB 100 establishing a PFAS testing account, which provides municipalities with grants or reimbursements for testing and remediating PFAS in drinking water. Maine enacted LD 289, which requires the state to purchase the real estate of a commercial farm found to be contaminated by PFAS before January 1, 2023 at the assessed fair market value but at no less than $20,000 per acre, and provides that the fair market value assessment cannot take PFAS contamination into consideration. Two enacted bills in Rhode Island (SB 724 and HB 5861) amend current law to add that if PFAS in drinking water exceed the state’s interim standard of 20 ppt, the state and the public water supply will enter into an agreement that requires dates for submittal of water treatment plans that will reduce the PFAS levels to or below the interim level. As more information emerges about the health effects of PFAS, states will be sure to continue their work to combat, mitigate, and report on their presence in the environment. ASTHO will continue to monitor and report on all legislative and regulatory activity around this issue. Special Thanks-Blog - State and Federal Actions to Reduce PFAS Impact on Public Health website yes

Accompanying an infusion of federal funding, states are considering several policy changes to strengthen the public health workforce and address challenges within the health care workforce.

As many state legislatures seek to expand vaccine exemptions, it’s important to understand the fundamental differences in exemption type and their impact on a community.

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.

As the U.S. continues to undertake the largest vaccination campaign in almost a century, it has required government at all levels to surge workforce capacity. The federal government, states, territories, and local jurisdictions are acting to meet the immediate demand for vaccination as well as expand the long-term vaccination workforce. Looking ahead, expansion of the vaccination workforce long-term will help support potential COVID-19 booster shots and expand vaccine access broadly.

Toxic stress contributes to a variety of negative outcomes for children. And unfortunately, COVID-19 has increased the likelihood of children experiencing childhood trauma, adverse childhood experiences (ACEs), and toxic stress. States and territories should have programmatic, and policy mechanisms to both prevent and mitigate the lifelong effects. A CDC Vital Signs Report found that preventing or mitigating ACEs could reduce depressive disorder by 44%, smoking by 33%, and unemployment by 15%.

Dental care and the oral health workforce have also been tremendously impacted by the COVID-19 pandemic. In the midst of stay at home orders, nationwide closures, and related employment loss, people have largely put their oral health on the back burner.

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 Are Innovating to Improve Indoor Air Quality Abe Kulungara Indoor air quality can significantly impact health and well-being—learn how states are using policy to address this issue. Whether at home, in the workplace, or in schools, the air we breathe inside is affected by improper ventilation, exposure to toxic chemical cleaning agents, buildup of moisture, and the presence of pests—all of which contribute to poor indoor air quality (IAQ). In addition, increases in extreme weather conditions (e.g., heat, hurricanes, flooding) can deteriorate buildings, reducing the physical barriers between outdoor and indoor spaces. And inadequate weatherization of schools and buildings can lead to indoor fungi and mold growth. Indoor air pollutants can have both short-term and long-term impacts on public health and well-being. Some examples of health outcomes (and their associated hazards) include: acute injury (carbon monoxide and other asphyxiants from combustion and safety hazards from improper design), cancer (asbestos and radon), infectious disease (COVID-19), as well as allergic disorders and asthma (mold and other products of damp indoor environments. Furthermore, poor IAQ in school can potentially affect comfort, concentration, and student performance. While the United States has made significant progress in improving outdoor environmental quality, improvements in indoor environments have been much slower, despite Americans spending approximately 90% of their lives indoors. In many cases, the responsibility for improving IAQ falls to individual states, resulting in a patchwork of regulations and varied approaches across the country. Indoor Air Quality at the Federal Level The federal government’s authority over indoor air quality is limited to federal buildings but there is no current comprehensive national regulation specifically focused on indoor air quality. Notwithstanding, federal laws and regulations addressing outdoor air quality can indirectly impact indoor air quality. For example, the Clean Air Act gives EPA the authority to establish and enforce National Ambient Air Quality Standards (NAAQS) for pollutants in outdoor air, such as ground-level ozone, particulate matter, and carbon monoxide. Improvements to ambient air quality will have an impact on indoor air quality as well. Even though the federal government’s role in IAQ is less direct, agencies including EPA have issued voluntary guidelines and best practices. This gap in federal regulations offers state and local governments the opportunity to set standards for their jurisdictions. The Model Clean Indoor Air Quality Act The Model Clean Indoor Air Quality Act (MCIAA) provides a framework for states to adopt and implement measures that are most relevant to their local needs and circumstances, much like the Model Food Code is used by states for food safety regulations. The Act consists of six main articles, each containing key sections designed to support a comprehensive mission of safeguarding and enhancing IAQ in public buildings through collaboration among public and private entities. The Act also presents extensive statutory language on IAQ and offers states the flexibility to choose the components that best suit their specific needs, priorities, and local conditions. By adopting the Model Act or portions of it, states can establish standards for ventilation, moisture control, hazardous materials use, and public education efforts. State Actions on Indoor Air Quality A growing number of states are proactively improving indoor air quality. Massachusetts recently introduced SD 2588, which incorporates language from MCIAA, while others are addressing IAQ issues more broadly, enacting legislation that prohibits smoking in indoor public spaces or responding to specific local challenges (e.g., mold, radon, volatile organic compounds ). At least five states are considering various bills relating to air quality in public schools. Massachusetts (SD 173 and SD 630) and New Jersey (S 1033) are establishing task forces or commissions to study indoor air quality. Connecticut (HB 5873), New York (A 2649) Virginia (HB 2618 and SB 1413) are establishing or amending indoor air quality standards for public schools. Massachusetts (HD 2890) is also prohibiting cleaning agents that could have an adverse effect on health. As states consider streamlining indoor air quality standards using the MCIAA, there are a large number of current statutes that improve IAQ. For example, Florida requires their Department of Health to have an IAQ testing and monitoring program to assess health risks from exposure to chemical, physical, and biological agents in the indoor environment. In Hawaii, the Department of Health is authorized to correct indoor air pollution problems in all buildings. The agency must establish and coordinate an IAQ assessment network involving state agencies and managers of publicly owned buildings to identify, evaluate, and resolve indoor air pollution problems. The statute also grants the agency the authority to implement a program for approving plans to construct, inspect, and monitor ventilation systems, as well as to provide IAQ information to managers, owners, and occupants of both public and private buildings. Other states, such as Washington and Oregon, have implemented programs that focus on IAQ in schools, acknowledging children’s unique vulnerabilities to poor air quality. ASTHO will continue to monitor and provide updates. 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

Support from postpartum doulas can can increase parental self-efficacy and adherence to treatment for those experiencing SUD, leading to lower rates of postpartum depression and, subsequently, improved health outcomes.