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Support for programs and policies that encourage positive mental health in early childhood and provides support for parents and caregivers to have the best chance to improve mental health across the life course.

This guide captures the experiences and best practices of state and local public health agencies and their partners who are currently in the Cardiff Model implementation phase.

Alabama shares six ways a cross-cutting approach successfully impacted its PHIG workplan implementation.

Sandra Powell, deputy director of Rhode Island Department of Health, how her department was able to increase the number of permanent positions to meet critical public health needs.

In the late fall of 2021, ASTHO leadership visited select jurisdictions in the Pacific and the Atlantic for the first time since COVID-19 curtailed travel to these regions. It was a fantastic to reconnect with our leadership and dedicated staff. Unsurprisingly, we heard about the jurisdictions’ challenges, including chronic ones related to funding and infrastructure, as well as new challenges resulting from the global pandemic.

Economic security and well-being, job stability, access to safe and affordable housing, access to healthy and nutritious foods, and access to resources to manage mental and physical health—all of these things impact individual, family, and community health. The COVID-19 pandemic has fundamentally impacted each of these social determinants of health for many Americans. Furthermore, some communities and industries have faced harder economic impacts than others, including households with low incomes, non-white households, and households with children. Human services and public health leaders can collaborate to make sure we are rebuilding systems and programs in a way that creates healthier, more resilient families and communities.

Over the years evidence has expanded on community health workers (CHWs) improving outcomes and even reducing disparities in heart disease and many other public health priority areas. However, their presence in state and local public health workforce is still modest. A number of efforts have sought to expand the role of CHWs in medical care settings by developing reimbursement through third party payers, along with including them in managed care contracts and incorporating them in state Medicaid plans. The experience and lessons of the COVID-19 pandemic could substantially change the way we practice public health in the future, and provides opportunities to expand the role and presence of CHWs in the state and local public health workforce.

The opioid crisis continues to claim the lives of thousands across the United States and has cost the economy billions in health care, mortality, and criminal justice costs. In 2018, it’s estimated that 67,367 people died of overdose, with opioids (prescription opioids, heroin, and other synthetic opioids other than methadone) made up almost 70% of overdose deaths. Provisional data for the twelve-month period ending December 2019 shows that there were 71,130 overdose deaths, with 50,178 overdose deaths attributed to opioids. The COVID-19 pandemic has also exacerbated the drug overdose crisis. Data shows that in the time of continued lockdowns and social distancing that overdose rates have increased, indicating a sustained need to support people with substance use disorder.

ASTHO and PIHOA Praise Approval of Medicaid Funding Fix for U.S. Territories ARLINGTON, VA—This week, Congress approved legislation to extend Medicaid funding for two years for the U.S. territories in their fiscal year 2020 appropriations bills and extenders package. Esther Muña, the chief executive officer of the Commonwealth Healthcare Corporation, Association of State and Territorial Health Officials (ASTHO) board member, and Emi Chutaro, executive director of the Pacific Island Health Officer’s Association (PIHOA), issued the following statements applauding the bipartisan and bicameral extenders package. The legislation avoided devastating cuts to the territories’ health care services for their most vulnerable residents, scheduled to take place at the end of the year—widely called the “Medicaid Cliff.” “The U.S. territories face unique healthcare and public health challenges and the support provided through the Medicaid program allows us to care for Americans who live on these islands in their communities,” says Chutaro. “It is vital that we prioritize public health for Americans living in the U.S. territories,” says Nate Smith, secretary of health at the Arkansas Department of Health and ASTHO president. “Ensuring access to care is essential to protect and ensure health equity among and well-being within this population. As state health officials, we know that what benefits the territories will help us in our quest to bring optimal health to all.” “We are grateful for the bipartisan and bicameral legislation which provides a two-year increase in funds and federal match for the Medicaid program in the U.S. territories," says Muña. “The increased funding will allow the health care and public health systems in the U.S. territories to further improve access and quality of care to the population. This funding continues to be vital to all of the U.S. territories, and while we are grateful for this temporary fix, we must find a long-term solution to Medicaid funding to provide stability to our system of care. In the upcoming year, we look forward to working collaboratively with Congress and the Trump Administration to further bolster health care and public health systems to build healthy and resilient communities throughout the U.S. territories.” ASTHO Press Release Boilerplate PIHOA Boilerplate website yes

State and Local Health Officials at the Capitol to Urge Congress to Prioritize Funding for Public Health ARLINGTON, VA—Over 80 state, local, and territorial health officials from across the country will meet with members of congress on Capitol Hill together on March 13, 2019. The aim of their visits is to share the critical need to sustain investments in public health agencies that protect and promote the health of all Americans and prevent sequester cuts in the FY20 budget. This is the first-time members of the Association of State and Territorial Health Officials (ASTHO) and the National Association of County & City Health Officials (NACCHO) will combine their annual Hill Days to show a collective voice for governmental public health at the Capitol. Public health leaders are concerned about the impact of the potential $55 billion cut to non-defense discretionary spending that will happen in FY2020 if Congress does not act to prevent it. ASTHO and NACCHO strongly urge Congress to work in a bipartisan manner to raise FY2020 budget caps and provide needed funding for non-defense discretionary programs, and support increasing CDC’s budget 22 percent by FY22. “Our entire governmental public health system is strained. My colleagues are on the ground dealing with several measles outbreaks, the opioid epidemic, and natural disaster recovery, all while continuing the core work of disease prevention—especially at the community level. Unfortunately, we are consistently underfunded and must do more with less. As a nation, we must do better and prioritize investing in public health,” says Nicole Alexander-Scott, MD, MPH, ASTHO president and director of the Rhode Island Department of Health. “Every person and every community should have the opportunity to be as healthy as possible. As part of ASTHO’s President’s Challenge, additional federal resources will help equip health officials to mobilize community-led, place-based collectives to improve the way we live, work, and play.” “In the decade since the Great Recession, public health departments have lost about a fifth of their workforce due to funding issues and recovery has been slow at best. We see the impact of these resource losses on the health and well-being of our communities every day. In so many areas of public health, we know what works, but we don’t have the resources to ensure that all Americans, no matter where they live, have access to the same basic public health infrastructure, services, and protections,” says Kevin Sumner, NACCHO president and health officer/director for the Middle-Brook Regional Health Commission. “So much of our public health system operates silently in the background. By joining together on Capitol Hill, we will amplify our voice and spread the message of the importance of governmental public health in all sectors.” For more information on ASTHO’s advocacy priorities, visit http://www.astho.org/Advocacy-Materials. For more information about the President’s Challenge, visit http://www.astho.org/ASTHO-Presidents-Challenge/2019. For more information on NACCHO’s advocacy priorities, visit https://www.naccho.org/uploads/downloadable-resources/flyer_legislativeagenda_2019.pdf. ASTHO Press Release Boilerplate NACCHO Boilerplate website yes

The second half of Public Health Review's story on the opioid epidemic explores how coalitions in Kentucky are driving prevention efforts, what public health practitioners in West Virginia are doing to identify and care for newborns who have been exposed prenatally to addictive drugs, and how one federal agency is working to ensure that rural communities get access substance abuse and mental health services.

Public Health Organizations Unite in Call to Restore State and Local Emergency Funding and Approve Emergency Supplemental for Zika ARLINGTON, VA—As the weather warms and the threat of Zika virus intensifies, state and local health agencies are faced with the dilemma of a significant funding cut, as documented in two new reports released by the Association of State and Territorial Health Officials (ASTHO), the National Association of County and City Health Officials (NACCHO), the Association of Public Health Laboratories (APHL), and the Council of State and Territorial Epidemiologists (CSTE). Absent dedicated funding from Congress to prepare and respond to the threat of Zika virus, the Centers for Disease Control and Prevention (CDC) last month announced it will need to reprogram $44.25 million from the Public Health Emergency Preparedness (PHEP) fund to help combat Zika. State and local health agencies depend on PHEP funding to prepare and respond to health emergencies, everything from natural disasters to terrorist or mass casualty events. Preparing for and responding to emerging infectious disease is also a primary use of PHEP funding, meaning state and local health agencies will have less capability to find, control, and mitigate localized outbreaks of Zika as a result of the reallocation. ASTHO, in cooperation with CSTE, APHL, and NACCHO, asked their members what the consequences of the PHEP reprogramming would be, should the cuts take effect on July 1. The results raise significant concern showing that state and local emergency response will be compromised. Major findings from the surveys include the following. Community Preparedness Will Suffer the Most Both state (77%) and local (75%) respondents listed “Community Preparedness” as the area that will be most negatively affected. Scenario planning and training exercises will be curtailed or eliminated. Volunteer recruitment and training will slow or cease. Community partnerships and contracts with specialized vendors will be compromised. Laboratory Testing and Surveillance Capacity Will Diminish More than 70 percent (72%) of state respondents said they expect that functional preparedness programs, including disease surveillance, epidemiology, lab services, and mosquito control, would be negatively affected. Labs would be forced to delay or eliminate new equipment purchases or scheduled equipment maintenance. Public Health Staff Cuts State and local agencies suffered significant job losses—up to 20 percent—during and after the Great Recession that started in late 2007, and they have not come close to adding that number back since. Both state and local survey respondents report likely staffing cuts as a result of the PHEP reprogramming. Almost two-thirds (64%) of local health agencies responding to the survey said they expect to lose at least one health preparedness staff person. There is significant fear that this could worsen significantly if the reprogramming continues in future years as the threat of Zika is not expected to abate in the short term. Zika Response at State and Local Level Will Be Compromised as a Result of the Reallocation State and local health agency leaders are unified in saying the reduction of PHEP funding will harm their ability to respond to and control Zika once it establishes itself in the U.S. Our capacity to identify localized outbreaks and our capability to control and eliminate virus transmission will be slower. Local agency responders cited the following concerns: A decrease in staffing, Medical Reserve Corps (MRC) unit, or volunteer sustainability. A reduction in opportunities to provide staff trainings as well as plan and conduct exercises. An inability to conduct surveillance or epidemiologic investigations. At the state level, 61 percent of respondents say decreased PHEP funding in their state will significantly harm their ability to prepare for and respond to Zika. One respondent wrote: “The PHEP funding in [our state] is the resource we have for providing a response to Zika, and any other novel communicable disease. By reducing this funding you are reducing our ability to respond to a Zika event in [our state].” All public health sectors—federal, state, and local—have worked hard to build and sustain an all-hazards preparedness infrastructure that can deliver on their mission to protect and enhance the health and well-being of their constituents. However, large-scale emergencies, such as the 2009 influenza pandemic, Ebola, and Zika, require sufficient and reliable core funding to maintain a solid and ready public health infrastructure and additional emergency funds to provide the enhanced protections and services those living in the United States deserve and expect. Robbing the fund that sustains the all-hazards infrastructure to pay for large, widespread emergencies, no matter how necessary, ensures that infrastructure will deteriorate. Dedicated emergency funding that will enable all public health sectors to prepare for and respond to Zika is essential. ASTHO Press Release Boilerplate NACCHO Boilerplate APHL Boilerplate CSTE Boilerplate website yes

While the Biden Administration and Congress have no shortage of immediate health issues to focus on, improving maternal health outcomes—particularly Black maternal morbidity and mortality—have become a priority for federal lawmakers. To make sense of what’s going on, ASTHO staff partnered with the Association of Maternal and Child Health Programs (AMCHP) to outline the seven things to know happening on the federal level right now.

One of tools presidents have to implement and drive their strategy are executive actions. Executive orders and presidential memoranda carry the force of law and allow presidents to move quickly, deliver a clear message, organize the functioning of the executive branch, and spotlight critical issues with declarations of commemorative observances.

As the response to COVID-19 transitions from response to recovery, advocacy efforts continue to intensify on Capitol Hill, to help shape negotiations on the fifth emergency supplemental package.

ASTHO and NAMD Letter Urging Congress to Fully Fund Medicaid and CHIP in U.S. Territories Dear Chair Wyden, Chair Rodgers, Ranking Member Crapo, and Ranking Member Pallone: Strong, sustainably funded Medicaid and Children's Health Insurance Programs (CHIP) are crucial to addressing health care challenges in the U.S. territories. On behalf of the Association of State and Territorial Health Officials (ASTHO) and the National Association of Medicaid Directors (NAMD), we urge Congress to ensure the fiscal stability of the territories’ Medicaid programs by lifting the annual Section 1108(g) allotment cap for all territories and authorizing a permanent 83% Federal Medical Assistance Percentage (FMAP) for Puerto Rico. Robust Medicaid and CHIP are critical components of strong and resilient territorial health systems. The five U.S. territories—American Samoa, Guam, the Commonwealth of the Northern Mariana Islands (CNMI), Puerto Rico, and the U.S. Virgin Islands (USVI)—vary dramatically in population, health care system capacity, and Medicaid program structure. Despite these differences, they share common challenges, including significantly higher rates of poverty (ranging from 16.8 percent in Guam to 54.6 percent in American Samoa in 2019, compared to 10.5 percent in the United States), higher rates of chronic health conditions, and a lack of health care infrastructure. Medicaid and CHIP programs are crucial to addressing these challenges. Chronic underfunding has impaired territories’ capacity to serve their residents, who are U.S. citizens or U.S. nationals. Historically, the territories have faced two statutory funding challenges: 1) A low, fixed FMAP rate that is not tied to per capita income (as is the case in the states), and 2) Annual funding caps. Prior to FY 2023, Congress supplemented low annual funding amounts with short-term additional investments. The short-term nature of this funding limited territories’ ability to plan, undertake large investments, and efficiently deliver services. In the Consolidated Appropriations Act of 2023, Congress permanently increased the FMAP for American Samoa, Guam, USVI, and CNMI to 83% and authorized a 76% FMAP for Puerto Rico through 2027. NAMD and ASTHO applaud and fully support this structural means of addressing longstanding needs. Congress should continue to build on this foundation by extending the permanent 83% FMAP to Puerto Rico to ensure all U.S. territories have access to sustainable Medicaid and CHIP funding. Over and above this FMAP adjustment, Congress must also address the constraints caused by the allotment cap on the territories’ Medicaid and CHIP funding, established by Section 1108(g) of the Social Security Act. When a territory reaches this cap, they are responsible for funding their Medicaid agency solely with local dollars. Due to challenges generating sufficient local funds, many territories have been forced to cut services after reaching these allotment caps, drastically limiting their ability to offer services and destabilizing local health care providers. For example, CNMI expects to hit its FY 2024 cap by July, leaving the CNMI government with more than two months of unmatched Medicaid costs. Congress should eliminate the annual Section 1108(g) allotment cap to ensure sustained access to high-quality public health and health care services in the U.S. territories. Sustainable, equitable funding will allow territorial programs to make long-term, cost-effective investments that support high-quality and innovative Medicaid programs. The Consolidated Appropriations Act of 2023 directed American Samoa, Guam, CNMI, and USVI to develop four-year strategic plans focused on workforce, program integrity, systems development, and financing. The four territories developed comprehensive plans with ambitious goals, including developing electronic eligibility and enrollment, MMIS, and T-MSIS systems, launching initiatives to expand local provider workforces and territory administrative capacity, and strengthening program integrity processes. These plans are evidence of the momentum and energy that territory leaders bring to their reform agendas. Technical assistance from CMS and other agencies will remain a critical resource for capacity-building efforts in the territories. In addition to lifting the statutory allotment cap and providing Puerto Rico with a permanent 83% FMAP, Congress should also consider providing the territories with targeted, project-specific enhancements to their administrative match rates to facilitate necessary technical assistance and change management. These structural improvements will strengthen the impact of Medicaid dollars allotted to the territories. Thank you for your previous support of the Medicaid programs in the U.S. territories and your ongoing attention to this important issue. If you have any questions or require additional information, please reach out to Jeffrey Ekoma (senior director of government affairs at ASTHO, jekoma@astho.org) and Jack Rollins (director of federal policy at NAMD, Jack.Rollins@MedicaidDirectors.org). Sincerely, Joseph Kanter, MD, MPH Chief Executive Officer, ASTHO Kate McEvoy, Esq. Executive Director, NAMD website yes

Fortunately, looking at the ASTHO Directors of Public Health Preparedness (DPHP) peer group and seeing the great work of public health emergency preparedness and response programs across the nation, we recognize that there is much to be celebrated this month—but also much more work that needs to be done.

CDC-funded program will accelerate data exchange between healthcare and public health to drive timely, data-informed public health action

ASTHO and NAMD Call on Congress to Fully Fund Medicaid and CHIP in U.S. Territories ARLINGTON, VA—In a joint letter to Congress, the Association of State and Territorial Health Officials (ASTHO) and the National Association of Medicaid Directors (NAMD) urged Congress to fully fund Medicaid and Children's Health Insurance Programs (CHIP) in the U.S. territories. ASTHO and NAMD request that Congress lift the annual Section 1108(g) allotment cap for all territories and authorize a permanent 83% Federal Medical Assistance Percentage (FMAP) for Puerto Rico. “ASTHO recognizes the importance of permanent, sustainable, and equitable Medicaid financing for all U.S. territories,” says Joseph Kanter, MD, MPH, ASTHO CEO. “ASTHO respectfully requests Congress make changes to territorial Medicaid funding structures to help our nation’s territories ensure the same access to essential public health and health care services available to citizens in mainland United States.” “Unlike the states, the U.S. territories face an annual cap on their Medicaid funding,” says Kate McEvoy, Executive Director of NAMD. “This has impaired the territories’ capacity to provide needed health care to Medicaid-eligible U.S. citizens and nationals. It has also held the territories back from making the structural investments in care delivery and value-based payment reform, workforce, IT systems, and program integrity that are crucial to high performing and innovative Medicaid programs.” Chronic underfunding has impaired territories’ capacity to serve the needs of their residents, who are U.S. citizens or U.S. nationals. By acting today, Congress can improve health and ensure equity for all. Learn more in the joint letter. ASTHO Press Release Boilerplate NAMD Boilerplate website yes