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In-depth analysis on state health policy surrounding immunization. This is part of ASTHO's annual legislative prospectus series.

Learn about the importance of immunization information systems to public health in this Health Policy Update.

The opioid epidemic has exacerbated the shortage of board-certified forensic pathologists, presenting a major workforce challenge for public health systems.

ASTHO, in collaboration with CDC, provided full-time disability and preparedness specialists to 17 jurisdictions to better meet the needs of people with disabilities. In this brief, specialists share their thoughts on why people living with disabilities may be hesitant to get the COVID-19 vaccine and some approaches public health officials can take to address vaccine hesitancy in people living with disabilities.

Board-certified forensic pathologists play a critical role in public health by investigating death so as to better serve the living. Despite forensic pathology’s contribution to public health surveillance, prevention, and response, the discipline remains largely under-resourced and over strained. These briefs spotlight the critical role that international medical graduates play in minimizing forensic pathology workforce shortages and spotlights a local effort to address financial disincentives for medical graduates entering the field and highlights federal funding opportunities and resources for state partners looking to minimize forensic pathology workforce shortages.

This report analyzes way that public health officials can mitigate the impact of disasters on pregnant people, neonates, and infants through a variety of policies, including policies related to preparing for, responding to, and recovering from a public health emergency.

As the Delta variant spreads across the country and increases the number of COVID-19 cases, the strain it is placing on the nation’s health system continues to grow. The surge of COVID-19 patients is contributing to a shortage of the medications and equipment used to treat the disease. As these limitations grow, decisions will need to be made as to which patients receive resources and care and which patients don’t. To guide these decisions, policies called crisis standards of care are often established to maximize resource benefit and ensure they are distributed equitably.

This June marked the 40-year anniversary of the first five cases of what later became known as AIDS reported in CDC’s Morbidity and Mortality Weekly Report. Since then, more than 32 million people have died from the disease worldwide and nearly 38 million currently live with the HIV virus (including 1.2 million people in the United States). Over that period, tremendous strides have been made in HIV testing, prevention strategies, and treatment of individuals living with the virus to ensure that they can lead healthier and longer lives. While these advancements have led to significant progress in reducing HIV/AIDS-related deaths and new infection rates, HIV/AIDS continues to be a persistent problem in the United States. The federal government and state legislatures are taking significant steps toward ending the HIV epidemic, including steps to reduce new infections, combating stigma, and advancing access to care and HIV prevention

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.

Geographic Information Systems and other data visualization tools have become integral parts of public health decision-making workflows and provide crucial support to topic areas such as environmental health, the COVID-19 pandemic response, and chronic disease investigation and prevention.

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

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.

Outcomes and Implications of ACIP’s Vote on the Hepatitis B Vaccine for Newborns Implications of ACIP Vote on Hepatitis B Vaccine for Newborns Susan Kansagra, Andy Baker-White, Kim Martin, Jessica Baggett Learn about the outcomes and implications of the December 2025 ACIP vote on the hepatitis B vaccine for newborns. On Dec. 4 and 5, the Advisory Committee on Immunization Practices (ACIP) held a long-anticipated meeting featuring two major topics of discussion: the hepatitis B birth dose and the pediatric vaccine schedule. The committee voted on two questions related to the pediatric hepatitis B vaccine schedule, both of which passed. To briefly summarize the outcome of the meeting, ACIP shifted from recommending a universal birth dose of the hepatitis B vaccine for all newborns to individualized decision-making for newborns born to HBsAg-negative mothers. There was no change to the recommendation for infants born to HBsAg-positive mothers or whose HBsAg status is unknown. CDC has not yet adopted these changes. In the meantime, many states are taking actions to provide clarity to providers and promote public confidence in the vaccine. How States Are Taking Action In response to (and in some cases before) the new ACIP recommendations, several states issued recommendations, guidelines, standing orders, executive directives, and health alerts for providers to provide clarity. States Recommending or Encouraging the Full Vaccine Series Some states are issuing their own guidance and recommendations for the hepatitis B vaccine series or encouraging providers to adhere to the series as is it was before the new ACIP recommendations: The Northeast Public Health Collaborative released a consensus statement before the ACIP meeting recommending the hepatitis B vaccine birth dose and a schedule that aligns with clinical recommendations. Collaborative members also issued statements reaffirming their adherence to established hepatitis B vaccine recommendations, including Connecticut, Maine, Maryland, Massachusetts, New Jersey, New York, Pennsylvania, and Rhode Island. Maryland also released guidance for parents and caregivers about its childhood immunization recommendations. States in the West Coast Health Alliance issued statements supporting the universal birth dose of the hepatitis B vaccine. These states include California, Hawaii, Oregon, and Washington. Many individual states also issued statements affirming the recommendation for the continued use of the hepatitis B vaccine birth dose, including Arizona, Colorado, Illinois, Michigan, New Mexico, and Vermont. States Issuing Standing Orders and Executive Directives At least two states issued a standing order or executive directive related to the hepatitis B vaccine: The Maryland Department of Health issued a standing order to ensure hepatitis B vaccine access for infants and children in the state. The standing order authorizes qualified health care providers to administer the hepatitis B vaccine and outlines the policies and procedures for administering the vaccine. In New Jersey, the acting health commissioner issued an executive directive recommending the hepatitis B vaccine birth dose and full series. States Issuing Public Health Alerts and Advisories Well before the recent ACIP meeting, the Maine CDC issued a health advisory to providers recommending the hepatitis B vaccine birth dose and full series. Since the ACIP meeting, at least two other states have released provider advisories. Maryland issued a letter to providers laying out the state’s hepatitis B vaccine recommendations, and New Hampshire issued a health alert with a continued recommendation for the full hepatitis B vaccine series and birth dose. In addition, Vermont sent a guidance letter to the providers in the state’s vaccine program. States Reexamine State Statutes and Agency Rules Linking to ACIP Recommendations Over the last several months, many states have proposed and enacted legislation to move away from sole reliance on ACIP recommendations. More recently, Massachusetts adopted H 4761, authorizing the health commissioner — in consultation with a newly established committee on immunization recommendations — to review and issue alternative standards to ACIP recommendations. States are also proposing changes to agency rules related to school and childcare immunization requirements. For example, Colorado’s health department has issued a proposed rule to modify the state’s standards for school and childcare immunization requirements and to align its rules with recent changes to state statute. Additional Considerations for States If CDC adopts the proposed ACIP recommendations, states can consider the following actions. Hepatitis B Screening States should continue to work with health care providers to close gaps in hepatitis B screening and follow-up for infants of HBsAg-positive mothers. Data show the most common cause of perinatal infection occurs when a mother with hepatitis B gives birth and the infant does not receive follow-up postexposure prophylaxis. Insurance Coverage While public and private insurance, including the Vaccines for Children program, are still required to cover the hepatitis B vaccine, such as any birth doses given to infants of HBsAg-negative mothers under shared clinical decision-making, states can consider creating additional coverage requirements. Some states have passed policies on insurance coverage, and other states have proposed legislation related to other vaccine coverage. Implementation of Shared Clinical Decision-Making While health care providers and parents have the flexibility to determine their approach for infants of HBsAg-negative mothers (i.e., continuing to recommend/give a birth dose), ACIP recommendations that rely on shared clinical decision-making have increased provider questions on how to have and document these conversations. States can work with medical associations, provider boards, and health care partners to ensure clinicians understand how to apply shared clinical decision-making recommendations. This includes educating staff in birthing hospitals, community clinics, and pediatric practices on how to counsel parents and document informed discussions. Jurisdictions can also develop or adapt educational materials and decision aids that clearly outline benefits, risks, timing, and follow-up options to support both providers and parents. More information on shared clinical decision-making is available from CDC and Common Health Coalition. States can also encourage providers and birthing institutions to examine workflows, Immunization Information System documentation, and follow-up to ensure scheduling of future doses. Implications for Vaccine Supply States can examine vaccine supply through the Vaccines for Children program to understand how the new recommendations impact supply of single antigen hepatitis B vaccines. If a significant percentage of the population receives vaccines on a different timetable, it could impact supply and timing for other vaccinations, given the reliance on combination vaccines for hepatitis B dose two and three, which can include DTaP, polio, and Hib vaccines. Supplemental Resources Common Health Coalition: Vaccine Resources December 2025 ACIP Meeting: Hepatitis B Updates for Health Leaders (PDF) Vaccine Integrity Project – Hepatitis B by Centers for Infectious Disease Research and Policy Understanding the Benefits of Vaccines: Common Questions by HealthyChildren.org Childhood Vaccinations (PDF) by Your Local Epidemiologist Hep B Birth Dose Media Toolkit by Hepatitis B Foundation Reframing the Conversation About Child and Adolescent Vaccinations by Frameworks Institute CDC: ACIP Shared Clinical Decision-Making Recommendations ACIP Meeting Materials for Public Posting: Hepatitis B Birth Dose Briefing Document (PDF) Hepatitis B Birth Dose Vaccination (PDF) article yes

Recap the state legislative sessions in 2025 thus far, spanning maternal health, infectious disease, and other important public health issues.

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

Learn about wastewater as a tool for detecting arboviruses and complementary surveillance effort, with insights from Arizona.

This episode will focus on the burden of seasonal and pandemic flu, and highlight key planning activities and strategies that federal, state, and local public health agencies are doing to combat flu and keep communities healthy.

Though we’ve made progress on the number of HIV cases in the U.S, tens of thousands of Americans are diagnosed with HIV each year—a disproportionate number being people of color. In 2019, the federal government launched the Ending the HIV Epidemic: A Plan for America (EHE) with a goal of ending the HIV epidemic by 2030. EHE leverages four strategies to reduce the prevalence of HIV: diagnosis, treat, prevent, and respond. State efforts to reduce the incidence of HIV align with the federal plan, with many states passing legislation to enhance prevention and harm-risk reduction efforts.

Policymakers seek to prevent the spread of COVID-19 by focusing on non-congregate sheltering and alternative housing for unhoused populations.