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Looking to the future, states are improving access to care, providing subsidies for tuition costs, expanding hours of licensed facilities, increasing access, and meeting the needs of both parents and children.

Vaccines are one of the greatest public health achievements of the last century, as well as some of the most powerful and cost-effective tools to prevent disease, disparities, disability, and death among children and adults. The COVID-19 pandemic and the unprecedented development and distribution of the vaccines against the novel coronavirus have generated much focus on state laws related to vaccinations. As state and territorial legislatures prepare to convene in the coming weeks, we can already identify several topics within vaccine law that policymakers across the country will consider.

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.

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

ASTHO's 2024 Legislative Session Update: Part Two Beth Giambrone, Maggie Davis, Christina Severin ASTHO's Public Health Legislative Update on Tobacco, Mental Health, Environmental Health, Workforce, and Containing Infectious Disease By the end of April, at least 36 states will have concluded their regularly scheduled 2024 sessions, with several states passing laws on important public health issues. Earlier this month, ASTHO provided a brief update on five of the top 10 public health state policy issues to watch during the 2024 state and territorial legislative sessions; this update examines the remaining five. Containing the Spread of Infectious Disease Public health agencies have a responsibility to keep their communities safe and healthy by maintaining foundational public health services including identifying, containing, and preventing the spread of communicable disease. ASTHO supports maintaining and guaranteeing robust public health legal authorities allowing public health leaders to meet their responsibilities for containing the spread of infectious disease. Following the COVID-19 pandemic, state and territorial legislatures considered many bills to change public health agency’s legal authorities to meet their responsibility, a trend that ASTHO anticipated continuing into 2024. So far, at least 28 states have considered, and at least two legislatures passed, bills relating to public health authority to address the spread of infectious disease in 2024. For example, the Hawaii legislature passed SB 3122, expanding public health authority by providing the state health official broad authority to issue standing orders for people 18 years and older to receive evidence-based services recommended by the U.S. Preventative Services Task Force. In March, however, Utah enacted HB 405, which limits local public health official’s authority to issue an isolation or quarantine order to specific conditions unless the local legislative body agrees that a new, drug resistant, or reemerging pathogen likely to cause high mortality or morbidity needs containment. Environmental Health Under the Safe Drinking Water Act, the EPA has the authority to set national standards for public drinking water. These standards establish legally enforceable Maximum Contaminant Levels (MCLs) and non-enforceable Maximum Contaminant Level Goals for public water systems. In April 2024, EPA released a final rule establishing legally enforceable MCLs for six PFAS compounds that occur in drinking water. Public water systems have until 2027 to complete initial monitoring and inform residents of the levels of PFAS in their water, and until 2029 to act if their drinking water levels exceed the MCLs. To date in 2024, at least four states have enacted or are considering legislation that would aid in monitoring and remediating PFAS in drinking water. Virginia recently enacted HB 1085/SB 243, which requires that the Department of Health notify the Department of Environmental Quality (DEQ) of any results from their monitoring of public water systems that show MCL exceedances, at which time requires DEQ to implement a plan to prioritize and conduct assessments of the public water system's raw water source(s). The Rhode Island House of Representatives passed H 7439, which would require the Department of Environmental Management to determine the maximum number of PFAS detectable by standard laboratory methods, and specifies the types of water systems that will be required to monitor untreated drinking water for those PFAS by June 1, 2025. Massachusetts is considering H 853, which would require the Department of Environmental Protection to maintain a list of municipalities where PFAS levels exceed the MCL and provide vouchers to homes in those municipalities to purchase home water filtration equipment. Strengthening the Public Health Workforce With several successes in 2023, ASTHO anticipated legislatures to continue considering legislation to strengthen the public health and health care workforces that represent the communities they serve during the 2024 legislative sessions. One strategy is establishing career pathway programs that provide students training and support to pursue public health careers. At least six states have considered, and three have passed, bills creating or strengthening a career pathway program during the current legislative sessions. At least two states have enacted programs to address health care provider shortages in April. Maine’s legislature passed LD 2268, which would allow internationally trained physicians to receive a limited license to practice medicine and address provider shortages in rural areas of the state. Washington enacted SB 5582, directing community and technical colleges to develop a plan in consultation with local workforce development councils and health care employers to train more nurses over the next four years. In May, Hawaii’s legislature passed HB 1827 appropriating funds to support public high school health care workforce certificate programs to support graduates seeking entry-level positions in the health care industry. Supporting Mental Health Children and adolescents continue to experience mental health issues, with teen girls reporting significant challenges. Schools can play an important role in supporting the mental health of all students through direct services or policies that address prevention, education or coordination. In 2024, a number of jurisdictions considered legislation related to youth mental health, through training requirements for staff and students, and support for treatment flexibility in the school setting. At least six jurisdictions considered bills related to mental health education for students, including specific suicide and violence prevention content. Virigina enacted HB 603, which requires school health instruction to include information about common mental health challenges, helpful coping strategies, the importance of seeking help from a professional or other adult, and available school resources. Several jurisdictions, including Virginia (HB 224), Minnesota (HF 4363) and Missouri (HB 2471), also considered establishing or amending suicide prevention and related mental health training programs for teachers and other school staff. Finally, several jurisdictions considered legislation to explore or otherwise support using telehealth services in schools for mental health services. Minnesota is considering legislation that would create a pilot program to determine whether the availability of telehealth services in schools increases mental health access (SF 4236) as well as a requirement to provide space at secondary schools for students to receive telehealth mental health services (HF 3542). New York is currently considering S 8976, which would authorize telehealth services in schools to be delivered by licensed providers, while Maryland enacted HB 522 in April, which requires school districts to develop guidelines to allow telehealth appointments at schools starting in the 2025-26 school year. Tobacco and Nicotine Products According to the American Lung Association, 22 states do not have comprehensive smoke-free laws that help protect against the dangers of second-hand smoke in a variety of settings (e.g., multi-family homes, public spaces, restaurants), or reduce the number of people who start smoking. At least 16 states have introduced legislation aimed at creating, promoting, or expanding smoke-free environments. Connecticut recently enacted SB 132, which expands their clean indoor air act to prohibit vaping at dog race tracks. The Maryland legislature passed HB 238/SB 244, which would update their Clean Indoor Air Act to prohibit vaping in public indoor areas, indoor places of employment, and mass transportation. In addition, the Alabama Senate recently passed SB 37, which would prohibit vaping in public places. In addition, at least 14 states have introduced legislation to either prohibit or further restrict the sale of flavored tobacco products, including menthol products. For example, bills introduced in Hawaii (HB 2441/SB 3130), Minnesota (HF 2177/SF 2123), and New Jersey (S 1947) would prohibit the sale of flavored tobacco products, including menthol, within their jurisdiction. In addition, a bill in New York (A 699/S4477) would ban the sale of flavored smokeless tobacco products within five hundred feet of a public or private school. ASTHO’s state health policy team continues to monitor these important public health issues and will provide relevant updates. website yes

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

Sustaining DMI: Medicaid Advanced Planning Document Process How state Medicaid agencies can request enhanced federal funding for Medicaid Enterprise Systems and related activities. Why is the Advanced Planning Document process important? Based on information from the Government Accountability Office (GAO), the Centers for Medicare & Medicaid Services (CMS), and the Federal Register, the Advanced Planning Document (APD) process is a procedure through which states develop a plan of action for their Medicaid information technology (Medicaid IT) projects. These plans are for designing, implementing, or operating Medicaid Enterprise Systems (MES) projects. State Medicaid agencies (SMAs) submit completed APDs to CMS—specifically a designated state officer in the Center for Medicaid and Children’s Health Insurance Program (CHIP) Services (CMCS) Data and Systems Group (DSG)—to request federal financial participation for their activities. The state officer reviews APDs to assess whether states’ requests for federal financial participation for designing, developing, implementing, or maintaining MES activities contribute to the economic and efficient operation of Medicaid and meet specific technical and operational criteria defined in statute, regulation, or sub-regulatory guidance. A state that receives federal financial participation can see increased access to stable federal funding to support MES activities. In addition, APDs are used to monitor a state’s project performance and outcomes. What are the three types of APDs? There are three types of APDs: Planning, Implementation, and Operational (Table 1). Table - Resource - Sustaining DMI: Medicaid Advanced Planning Document Process What are the major steps for states in the APD process? To request enhanced federal funding for MES, SMAs must complete the APD template that aligns with where they are in the development of their project (for example, design or maintenance) and submit it to the designated CMCS DSG state officer. The APD process contains five major steps and can take many months to complete: Meet with key state contacts and decision-makers. Based on information from the Public Health Informatics Institute’s information and tip sheets, before developing the APD, the SMA should identify and engage key state contacts and decision makers to solicit their input about the proposed project and secure their and their staff’s collaboration to complete and submit the APD to the CMCS DSG state officer. The state health agency (SHA) should work closely with the SMA during this process to ensure that they provide needed support to the SMA. For example, the SHA may gather information for the SMA to include in the APD or advise on how to complete particular sections of the APD. During this process, the SMA and SHA should consult with their respective agency leadership to discuss the type of technological solutions Public Health maintains, Public Health’s relationship with the state Medicaid program, and the opportunity to align systems to reduce overall state costs and improve state efficiency through the APD process. The SMA and SHA should also engage the MES lead, who can offer critical information about current MES components and component certification needed to complete the APD. In addition, GAO recommends states involve their chief information official in overseeing Medicaid IT projects because they can play a critical role in decision making related to IT budgets, management, and oversight. Next, the SMA and SHA should engage the CMCS DSG state officer to develop a strong understanding of how the APD can support the Medicaid program and serve a public health interest. Coordinating with the state project management office can help integrate the diverse parties and processes needed to develop and submit the APD for approval. It can also help ensure that states develop a comprehensive and flexible timeline for the APD process, stay aware of approaching deadlines, and meet ad hoc requirements. Develop the appropriate APD. Next, based on 45 C.F.R. § 95.610(c), the SMA and SHA should identify which of the three types of APDs to submit to the CMCS DSG state officer. Planning APDs are recommended for large and complex projects, such as statewide projects. However, if a state can identify a clear and easy pathway to integrate a public health information technology system with a current MES procurement or development phase, it can forgo developing a Planning APD and directly develop or update an existing Implementation APD. For example, if a state is looking to integrate its counties’ public health data into its MES at once, it should develop a Planning APD as the project is large and affects all counties in the state. However, if a state already has most of its counties’ public health data in its MES but is looking to add a single county’s data to its MES using the same process it previously and successfully used to add the other counties’ data, it may not need to submit a Planning APD. If a state has already successfully integrated its counties’ public health data into its MES and is looking to make major technology upgrades and improvements, it should submit an Operational APD. Regardless of the type of APD the state submits, the SMA and SHA should work together to ensure the request meets the Conditions for Enhanced Funding (see separate document Conditions for Enhanced Funding: The Basics). Submit the APD for approval and be available for revisions. Based on information from CMS, GAO, and the Office of Child Support and Enforcement, the state should then submit the APD to the designated CMCS DSG state officer. The SMA and SHA should plan to receive questions and revision requests from the CMCS DSG state officer and ensure that the state has staff capacity to answer questions and revise and resubmit. Approval conditions can be found at 45 C.F.R. § 307.15, but approval criteria might vary by Medicaid IT project and other factors. If approved, implement the plan. Next, the state can carry out the plan described in its Planning and Implementation APDs. After the Medicaid IT project has been operating for at least six months, states can request system certification from CMS. According to CMS, certification is required to receive the enhanced 75 percent federal financial participation for operations. The certification process includes states submitting to CMS an intake form, a certification request letter, and supplemental materials with information on its system. CMS may then start its review to assess whether the state’s system meets certification requirements. If approved, monitor and report progress and submit other APDs as needed. Based on 45 C.F.R. § 95.610(c) and 45 C.F.R. § Part 95 Subpart F and information from CMS, CMCS, Office of Child Support and Enforcement, as the state continues with its Medicaid IT project, it should adhere to monitoring and reporting requirements for enhanced federal funding. It also should submit annual APDs as required. If the state wants to make any major changes to the Medicaid IT project in concept, scope, cost allocation approach, timeline, and other key areas, it must develop and submit an as-needed APD. An as-needed APD is due no later than 60 days after the occurrence of the change. State examples: Medicaid Enterprise System projects Based on information from Alvarez & Marsel, state MES projects will vary based on factors such as the maturity of a state’s technology infrastructure, its specific data needs, and its available resources. As such, projects to design, implement, or operate MES can range in size, complexity, and timeline. For example, the Alabama MES Modernization Program, the Wyoming Integrated Next Generation System Project, and the Florida Health Care Connections project all seek to transform their singular Medicaid Management Information Systems (MMIS) into modular, multi-vendor MES, but differ in approach. In addition, Arizonia and Hawaii are collaborating to modernize their shared MES. For more information on state MES projects, see the Medicaid Enterprise System Solution/Module Contract Status Report. This webpage lists states’ MMIS and Eligibility and Enrollment contract information for their MES projects. It also lists contact information for state officers to reach out to learn more about states’ MES projects. 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.