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This Health Policy Update is an overview of state legislative activity to increase financial stability for families during the COVID-19 pandemic which may help to prevent adverse childhood experiences.

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.

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

Breastfeeding is considered the gold standard in postnatal care for both birthing persons and infants. Yet racial disparities in breastfeeding initiation and duration rates continue to persist. Effective intervention strategies require a multi-level approach that includes comprehensive legal, policy, and programmatic efforts.

This week might have marked the beginning of summer, but many policymakers and health officials have their eye on the upcoming school year and what that might mean in terms of getting students vaccinated against COVID-19. According to a recent MMWR, COVID-19 related hospitalizations among adolescents increased in March and April 2021, potentially related to increased circulation of new COVID-19 variants, changes in physical distancing, and a larger number of children returning to school or other in-person indoor activities. This increase indicates an urgent need for vaccination against COVID-19, which is currently authorized for use in youth as young as 12.

As the number of COVID-19 vaccinations grows, some states are looking at their vaccination rates to determine when to loosen measures that mitigate the spread of COVID-19, such as venue capacity limits, business closure times, and masking requirements. As vaccinations allow businesses to reopen and customers to return, questions have arisen about whether venues or services—especially those that bring people in close contact for long periods of times—such as retail stores, concert venues, entertainment venues, air travel, cruise ships, etc., can require patrons or customers to verify that they received a COVID-19 vaccine. So far, state policy makers have had mixed views on the issue.

Over the past several years, states and jurisdictions have continued to implement important policies to reduce tobacco and nicotine use, including increasing tobacco prices, expanding areas deemed “smoke-free,” limiting the sale of flavored tobacco products, and supporting tobacco cessation programs.

ASTHO Celebrates Women’s History Through the Decades ASTHO, association of state and territorial health officials, public health infrastructure, vice president, population health, health science, health system, public health workers, american women, career path, environmental health, public health mph, national women s history, international women s day, public health careers, health education specialist, week of march, history month, master of public health, black women, women s history week, women s history, public health work, public health leadership, woman president, public health practitioner, racism and sexism, public health system, women s history month, women leaders, women in public health Kimberlee Wyche Etheridge ASTHO | Celebrating ASTHO's past, present, and future of women in leadership. With a movie ticket costing $2.50 and gas hovering at $1.10 / gallon, the year 1984 ushered in many new eras. Apple debuted the Macintosh personal computer with its Superbowl commercial based on George Orwell’s dystopic novel in the Winter. Over the next generation, this technology would change the way we interact with the world. Prince’s Purple Rain and the accompanying concert-type movie were released, ushering in a new generation of forever fans. Space travel catapulted into the future with the launch of the space shuttle Discovery, which flew an additional 38 times. Childhood hunger took center stage with the release of the benefit song, “Do They Know It’s Christmas?” by Band Aid, which would sell millions of copies and raise millions of dollars. It was the Eighties—a key decade in U.S. history. It also marked a critical first in ASTHO’s history. ASTHO has a long history of pioneering women leaders. Below, you'll find several of them whose work has inspired mine. (Read the full list of ASTHO's women presidents.) 1980s After 42 years of public health work and leadership, ASTHO elected its first woman president—Kristine Moore Gebbie, DrPH, RN (alumni-WA)—in 1984. Gebbie was an educator who taught generations of nursing students around the world. She was a public health practitioner and served as Secretary of Washington State’s Department of Health. Her legacy highlights the importance of working across multiple levels of government and healthcare agencies, especially as it relates to preparedness. As ASTHO president, she was a trailblazer, best known for her commitment to work focused on AIDS. While in this role, she was tapped to serve as the first White House AIDS Policy Coordinator. She received numerous awards and accolades from many different organizations, including the American Nursing Diagnosis Association (NANDA). 1990s In 1992, Joycelyn Elders, MD (alumni-AR) also celebrated a first—becoming ASTHO’s first African American woman president. Elders served as the Director of the Arkansas Department of Health. Her public health accomplishments include reducing teen pregnancy in her state, increasing early childhood screenings as well as the percent of children immunized at 24 months. During her time in Arkansas, she was recruited to serve as Surgeon General, where she became the first African American—and only the second woman—to hold the post. She contended with both racism and sexism while in the job, and despite criticism and waning support from the administration, she stayed true to her public health beliefs. She fervently believed that poverty plays a critical role in public health crises such as teen pregnancy, and that education is as an essential strategy to breaking the cycle of poverty. She became the first person to be board certified in pediatric endocrinology. She has published more than 100 papers focused primarily on juvenile diabetes and adolescent health. 2000s Known for saving many lives by successfully cutting smoking rates by one-third during her time as Washington State Secretary of Health, Mary Selecky (alumni-WA) served as ASTHO president in 2003 and 2004. She holds the title as one of the nation’s longest serving secretaries of health having worked under three governors. During her time as the top state health official, Selecky moved Washington to become one of the first state health agencies to receive national accreditation. Childhood immunization rates in the state catapulted from among the bottom in the nation to in the top third. She worked to improve the state’s public health system after a 2001 earthquake. As ASTHO president, Selecky worked to elevate ASTHO’s status as a vital partner after the 9/11 terrorist attacks. She worked to ensure that public health preparedness funds were granted to health departments. 2010s Jewel Mullen, MD, MPH (alumni-CT) was serving as the Commissioner for the Connecticut Department of Public Health when she was elected President of ASTHO in 2014. During her time in Connecticut, Mullen focused on the state’s public health system, specifically chronic disease prevention programs and improving coordination between public health and medical care. She was also a crucial figure in bringing the community to the public health table. She created an Office of Health Equity Research, Evaluation and Policy while in her role to ensure integration of health equity in the states programming. Mullen used her ASTHO presidential challenge to highlight healthy aging and issue a call to action to help older adults live and age well in their communities. Through her Presidential Challenge, states committed to healthy and safe community environments, injury and falls prevention, empowered people, Alzheimer’s plan, active living, and clinical and community preventive services. Nicole Alexander-Scott, MD, MPH (alumni-RI) was elected ASTHO president in 2018. In that role, she led a presidential initiative encouraging state, local, tribal, and territorial health departments to build healthier, more resilient communities through community-led, place-based approaches. This initiative mobilized strategic investments to address socioeconomic and environmental determinants of health to transform systems and policies in ways to empower local communities. Alexander-Scott has also worked as a specialist in infectious diseases for children and adults. She is board certified in pediatrics, internal medicine, pediatric infectious diseases, and adult infectious diseases, and served as faculty at Brown University in pediatrics, medicine, and public health (with a focus on health services, policy, and practice). She continues to work with ASTHO to promote health equity. 2020s Rachel Levine, MD (alumni-PA) served as president of ASTHO in 2020. She is the first openly transgender woman to serve in the role. Levine is a pediatric and adolescent medicine physician and an educator. In 2015, while practicing clinical medicine at the Penn State Hershey Medical Center, she was nominated by the governor-elect to serve as Pennsylvania’s physician in general. Two years later, she was named as Pennsylvania Secretary of Health. Levine led the state through the COVID-19 public health response and helped the state respond to the growing opioid epidemic. While serving as ASTHO president, the White House nominated Levine to serve as Assistant Secretary for Health. She achieved another first when she was commissioned as the first woman four-star admiral in the U.S. Public Health Service Commissioned Corps. She remains a strong advocate for the well-being of LGBTQI+ youth. Continuing in this strong tradition of trailblazing women in leadership, Anne Zink, MD (SHO-AK) took the reins as ASTHO President in September 2022. Zink plans to focus her presidency on improving health information systems to empower the public, healthcare providers, and the public health workforce with the tools and information they need to promote individual and population health. There are others who have helped pave the way for future women leaders at ASTHO. This month of March, we celebrate all the past, present, and future women who have served as Presidents of ASTHO. We are because they were. ASTHO's Women Presidents: 2023  Anne Zink, MD, FACEP (SHO-AK) 2021  Rachel Levine, MD (alumni-PA) 2019  Nicole Alexander-Scott, MD, MPH (alumni-RI) 2015  Jewel Mullen, MD, MPH, (alumni-CT) 2009  Judith Monroe, MD (alumni-IN) 2007  Mary M. Hansen, RN, PhD (alumni-IA) 2006  Leah Devlin, DDS, MPH (alumni-NC) 2004  Mary C. Selecky (alumni-WA) 2003  Mary C. Selecky (alumni-WA) 2000  Patricia A. Nolan, MD, MPH (alumni-RI) 1993  Molly Coye, MD (alumni-CA) 1992  M. Joycelyn Elders, MD (alumni-AR) 1990  Suzanne Dandoy, MD (alumni-VA) 1985  Joan K. Leavitt, MD (alumni-OK) 1984  Kristine Gebbie, RN (alumni-WA) website 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.

In this infographic, ASTHO highlights some of the biggest takeaways, successes, and data collected from the Breastfeeding Learning Community.

ASTHO, with support from CDC, launched the first cohort of the Linking Pregnancy Risk Assessment Monitoring System and Clinical Outcomes Data Multi-Jurisdiction Learning Community in October 2021. This brief examines themes that emerged from conversations in the learning community about the challenges encountered during data linking activities and discussed lessons they learned.

A quick rundown of sessions and speakers at the 2022 ASTHO Public Health TechXpo.

States Stay Prepared by Supporting the Public Health Workforce Margaret Nilz, Christina Severin Learn how states use policy to support emergency preparedness and bolster the public health workforce. Public health — particularly public health preparedness — continues to experience workforce shortages, driven by longstanding systemic challenges such as chronic underfunding, high turnover, limited recruitment, and an aging workforce. While some jurisdictions report increased capacity to hire and train public health staff in recent years, they often rely on short-term or temporary funding streams, which limit long-term sustainability. State, local, tribal, and territorial health agencies have varying capacities to respond to public health emergencies, particularly in rural and underserved communities. Because a limited workforce can inhibit emergency preparedness efforts, jurisdictions recognize the importance of cultivating a resilient public health preparedness workforce to respond to future emergencies. In recent years, jurisdictions have pursued several policy interventions to bolster the public health preparedness workforce such as legislation supporting front-line clinical staff and first responders, and rulemaking and other executive powers to provide structural and financial support to critical personnel. Legislative Efforts Legislative efforts to increase benefits and support for health care and public health workers can help address the root causes of workforce challenges and lay the groundwork for sustainable, long-term investment in public health preparedness. Laws that establish standards and expectations for the preparedness workforce, including expansions of benefits or additional training, support workforce growth and retention. Since 2024, several jurisdictions expanded mental health benefits and related support for first responders and other preparedness personnel. Both Alaska (SB 103) and California (AB 2859) enacted legislation that allows peer support programs for emergency service personnel. In Alaska, the bill creates programs for entities such as law enforcement agencies, firefighters, and emergency dispatchers, while California’s bill creates programs to serve a variety of health care providers involved in emergency medical care, including physicians, nurses, paramedics, and emergency medical technicians (EMTs). Utah enacted HB 378, which requires the Department of Public Safety to annually distribute information about its critical incident stress management program to first responder agencies. The bill also requires first responder agencies to annually notify employees about the availability of mental health resources, including periodic screenings for employees and continued support for retired or separated first responders and their spouses. On a broader scale, Hawaii SB 3279 recently established a well-being project tasked with mental health trainings and support for several community organizations, including first responders, hospitals, and medical staff. In Washington, HB 2311 directs the state’s Criminal Justice Training Commission to develop resources for first responder wellness, including a peer support network for active and retired first responders and their families. States have also enacted legislation expanding traditional employment-related benefits, including Colorado (HB 24-1219), which expanded certain health benefits for firefighters to include part-time and volunteer firefighters, and Idaho HB 55, which allows retired public employees to volunteer with public employers without it being considered reemployment. In addition, Georgia HB 451 requires state and local entities to provide disability benefits for first responders who experience occupational or volunteer-related post-traumatic stress disorder. Finally, several jurisdictions enacted legislation to support education and training for their public health and health care workforce. For example, Kentucky HB 484 established an emergency medical service education grant program that provides tuition support for students pursuing paramedic certification, wage reimbursement to ambulance providers whose employees pursue certification, and funding for institutions planning to offer EMT, advanced EMT, and paramedic programs. Oklahoma HB 1696 expands eligibility for the Oklahoma Medical Loan Repayment program to include certified nurse practitioners. Two new laws in Puerto Rico require police officers with the Puerto Rico Police Bureau to be certified in first aid or immediate rescue (PC 0859) and adds seminars on sign language, suicide prevention, and conflict mediation to the Bureau’s continuing education training (PC 0543). Other Policy Levers: Beyond the Legislature Jurisdictions can also use non-legislative policy tools to enhance workforce capacity in public health preparedness. This includes rulemaking, where executive agencies use existing legal authority to adopt or amend regulations. Regulations have the force of law and can help support the public health workforce by establishing licensure standards, training requirements, and operational protocols. Wisconsin, following the enactment of AB 576 in 2024, is developing rules to establish a program for peer support and critical stress management teams in the state. And Utah recently adopted rules for its first responder mental health services grant, which helps these professionals pursue a degree or certification as a mental health provider. Government agencies can also leverage grants and contracts to fund and otherwise direct workforce development initiatives, support training programs, and expand capacity in targeted areas. Jurisdictions can strategically direct funds to address skill gaps and assist local, state, tribal, and territorial agencies build a more resilient workforce. One example of this is in Michigan, where in 2024 the state health agency issued a request for grant proposals to award up to $9 million in EMS workforce grants, building on similar awards to address EMS shortages in 2023. Executive orders are another policy option for jurisdictions to consider as they explore different pathways to workforce sustainability. Executive orders are issued by a jurisdiction’s chief executive (often the governor) and direct certain policy actions or activities. Generally, the power to issue an executive order comes from existing law or a jurisdiction’s constitution and, in most cases, does not require legislative approval or review. Several states have leveraged executive orders to advance the public health workforce and support preparedness activities more specifically. For example, Vermont and New Jersey have recently used executive orders to create or extend advisory councils on issues pertinent to public health preparedness. In 2024, Virginia’s governor issued an executive order formalizing the Office of First Responder Wellness, which provides training, counseling, and other resources to first responders in Virginia. In 2023, the governor of Maryland issued an executive order establishing a State of Preparedness directive if there is a risk of public emergency, and the actions state agencies must undertake to promote improved coordination and hazard planning. Key Takeaways Addressing public health emergency preparedness workforce challenges demands strategic, long-term policy solutions, but several implementation options are available. Health agencies can pursue a variety of policy interventions to support and prepare their public health workforce for future emergencies. ASTHO will continue to monitor this important issue and provide updates as appropriate. article yes

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.