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States Pursue Policy Options to Support Access to Over-the-Counter Contraception State Policy to Support Over-the-Counter Contraception Access Christina Severin Learn about state policy options that can help to support over-the-counter contraception access including levers within Medicaid programs. Effective contraceptive care improves maternal health outcomes by helping individuals plan if and when they become pregnant. Additionally, some contraceptive methods may reduce the risk of certain cancers and protect against sexually transmitted infections. While the most effective methods generally require a visit to a health care provider, over-the-counter (OTC) options may address certain barriers to accessing contraception (e.g., taking time off work for a medical appointment and lack of health insurance or access to health care providers/settings). The New Age of Nonprescription Oral Contraceptives A significant change in the marketplace of OTC options occurred in 2023 when FDA approved the first daily non-prescription oral contraceptive. This progestin-only pill —known as Opill — is considered both safe and highly effective at preventing pregnancy when taken correctly. Opill reached stores in early 2024 and has a suggested retail price of about $20 per month or $50 for a three-month supply. While OTC oral contraceptives like Opill may improve access among individuals not currently using contraception or those using a less effective method, high out-of-pocket costs can be a barrier. One way to limit out-of-pocket costs is to require private health insurance coverage of contraception without cost-sharing. ACA requires most private health insurance plans to do this, but it does not extend to all health insurances or contraceptives. For OTC contraceptives, the landscape is even more complex: While plans are encouraged to cover OTC emergency contraception at no cost and without a prescription, it is not required. HHS and the Departments of Labor and Treasury issued a proposed rule in 2023 that would have required broader coverage of OTC contraception without a prescription or cost-sharing, but the rule was later withdrawn. Without a federal mandate, states can pursue coverage requirements through the health insurance products they regulate. Jurisdictions can also support OTC contraception access in their Medicaid programs. While Medicaid requires coverage of family planning supplies without cost-sharing, jurisdictions have some flexibility in how they design this benefit, and the scope of coverage depends on jurisdiction and state plan-specific factors. Jurisdictions also have flexibility in determining how they provide prescription drug coverage for contraceptive medications and what OTC products are covered. State Legislative Action Legislation is one way for states to promote access to OTC contraceptives, including hormonal contraceptives, through state-regulated plans and provider scope of practice considerations. Since 2024, several states have enacted laws requiring coverage of OTC hormonal contraception, including Delaware (SB 232), which directs insurance carriers to cover FDA-approved OTC contraception with or without a prescription, and Maine (LD 163), which requires coverage of nonprescription oral hormonal contraception. At least two states have clarified the role of pharmacists in supporting access to OTC contraceptives. Massachusetts (HB 4800) allows pharmacist dispensing of OTC oral contraception per a standing order and provides liability protections, while California (AB 50) allows pharmacists to furnish self-administered OTC hormonal contraception without complying with the state’s protocols for prescription-only oral contraceptives. States have also enacted laws to explore or support broader access to OTC contraception, including at least three bills enacted in Maryland since 2024: HB 367/SB 527 requires community colleges to develop an OTC contraception access plan and allows the health department to serve as a resource, including for consultation on vending machine access. HB 1171/SB 944 allows local health department registered nurses to dispense OTC contraception. SB 674/HB 939 creates a collaborative tasked with studying and making recommendations on OTC contraceptive access, with a final report due to the governor and legislature by Jan. 1, 2027. Other Policy Levers Legislation isn’t the only policy lever available to jurisdictions looking to support OTC contraception access. A number of states have taken executive actions to improve access, including (but not exclusively) through Medicaid. While jurisdictions already have the flexibility to support OTC contraceptive access in their Medicaid programs, Medicaid rules require a prescription even for OTC products, which may present a barrier for some individuals. One potential solution is to use standing orders, which allow individuals direct access to OTC products at a pharmacy, without having to visit a separate provider for a prescription first. To ease access to OTC hormonal contraception specifically, several states have recently utilized standing orders that facilitate Medicaid coverage, including Wisconsin, Massachusetts, and New Mexico. Additionally, in 2024, North Carolina announced that it was removing barriers to OTC oral contraception, and would cover condoms and spermicide as OTC products. Outside of Medicaid, several other states have taken action to support access to OTC hormonal contraception: In 2024, the Governor of Arizona issued an executive order directing the Department of Administration to designate Opill and OTC hormonal contraception as a no-cost essential health benefit for state employees, among other actions to expand coverage and access. Also in 2024, Pennsylvania issued guidance to health insurers encouraging coverage of OTC hormonal contraception and highlighting two insurers intending to comply with the guidance. Finally, Michigan’s health agency, in partnership with the Governor’s office, implemented a Take Control of Your Birth Control campaign. This initiative distributed OTC contraception at hundreds of community sites across the state, with a stated goal of connecting individuals to insurance coverage, including Medicaid. While the campaign recently ended, the state distributed more than 400,000 OTC contraceptive resources (e.g., condoms, emergency contraception, and oral contraceptives) and saw an increased number of Medicaid applications. Jurisdictions can play a significant role in connecting public health and health care industry leadership, providers, and other experts — promoting awareness, increasing utilization, and encouraging connection to existing resources. Related Content - Blog - State Policy to Support OTC Contraception Access article yes

State and federal actions to expand the doula workforce and improve maternal health.

Health Agencies Keeping Cottage Foods Safe Heather Tomlinson Rows of homemade jams at the local farmer’s market and a neighbor’s birthday cake on social media have something in common: they are both cottage (or homestead) food products. Cottage foods are home-based, home-made food products prepared outside of a commercial kitchen and sold to the public. Cottage food producers operate on a small scale, often from a home kitchen, selling goods locally. Although cottage foods provide opportunities to small, locally owned businesses, they also create complexity in selling food products to the public that are not inspected and may not meet basic food safety standards. And while home kitchens are not considered food establishments in the FDA Food Code, states are able to define “food establishments” by amending provisions in their food code adoption process or enacting legislation or regulations. In addition to regulating, state health agencies can play a role in keeping cottage foods safe through education, training, and other mechanisms. Cottage Food Regulation Currently, all 50 states and Washington, D.C. allow the sale of cottage food products directly to consumers. Several foodborne illnesses have been linked to products improperly prepared at home, such as botulism outbreaks in home-canned products and E.coli contamination of jerky. Many foodborne illnesses can be prevented by safely preparing, processing, and storing foods, processes often outlined by health regulations. Health agencies use a variety of tools to regulate cottage food production. Types of Foods: The types of foods permitted can vary across jurisdictions with some allowing only non-time/temperature controlled for safety (TCS) foods (e.g., baked goods, jams, candies), while others allow a wide range of products including TCS foods and items that require specialized processes (e.g., pickled vegetables). Some jurisdictions may use an exhaustive or illustrative list outlining permitted foods, while others limit specific food production processes but allow all other food items. Licensing and Inspection: Cottage food producers must follow a variety of rules in the form of permits, licenses, and registration. Although cottage foods are exempt from many inspection requirements, at least fifteen states require an initial inspection of home kitchens before they can sell items. All states allow the investigation of foodborne illness complaints; some states require annual licensure. Food Safety Training: States can require a food safety course to ensure that all cottage food producers understand the basic food safety requirements. Sales Caps: Gross sales caps limit the scale of operations allowed without full food safety precautions. After a cottage food operation exceeds their gross sales cap, they would be required to register as a food establishment and permitting rules would take effect. Sales Venues: States typically only allow direct-to-consumer sale of cottage foods (e.g., farmers’ markets) but some states permit online sales. Federal food safety regulations, which prohibit cottage foods, apply when food products are sold across state lines. Cottage food sales, whether in-person or online, should remain within the state they were created to avoid violating federal regulations. Labeling: All states have a labeling requirement for cottage foods. These labels can vary but typically include the food producer’s name and address, the product name, an ingredients list, allergens, product weight, date of production, and a disclaimer identifying that the product was prepared in a home kitchen that is not inspected. Recent Cottage Foods Legislation in the States Legislators often face tension in weighing the balance between maintaining food safety regulations and supporting small cottage food businesses by reducing the entry barriers (e.g., leasing commercial kitchen space). In recent years, there has been an increase in legislation expanding cottage food parameters ranging from product and preparation inclusions to modifying the gross sales cap. The Arizona House of Representatives passed and the Senate is currently considering HB 2864, which would expand the state’s cottage food item list to include precut and processed freeze-dried fruits and vegetables. Arizona enacted HB 2042, which expands the definition of cottage foods to include foods that require time and temperature control if they're exempt under federal regulations. The Hawaii legislature passed HB 2144 which is now awaiting action from the Governor, which would expand the definition of cottage foods to include pickled products and non-hazardous products that do not contain dried meat or seafood, permit the sale of products in retail stores, and allow for customer delivery via third party vendors or shipping. Several states have introduced legislation to increase the gross sales cap for those who qualify as a cottage food producer. Mississippi (MS SB 2638) and Washington (WA SB 5107) introduced bills that proposed to increase the annual gross sales cap, but both failed in session. There has also been legislation surrounding cottage food preemption. Massachusetts is considering S 2761, which would establish a cottage food regulatory framework and prohibit local health agencies from being able to establish their own cottage food regulations. Microenterprise Home Kitchens In expanding cottage food production, there has been increased legislation on microenterprise home kitchens. Microenterprises typically allow the production of more types of foods, including fully prepared hot meals, but also require stricter regulations (such as preparing and selling the food on the same day). Minnesota (MN SF 4501) and Hawaii (HI HB 1591) have introduced legislation that would allow microenterprise home kitchens and establish a regulatory framework for licensing and safety standards. Raw Milk Considerations Raw milk is an animal milk that has not gone through pasteurization (process of heating milk to a specific temperature for a set period of time) to kill harmful bacteria. Raw milk can carry dangerous bacteria that can cause food poisoning and has recently been shown to test positive for the recent highly pathogenic avian influenza (HPAI) virus. As of March 2024, 30 states allow the interstate sale of raw milk. This session, West Virginia passed legislation (WV HB 4911) and at least six states, Michigan (MI HB 5603), Hawaii (HI HB 1989), Missouri (MO HB 1711), Massachusetts (MA S 43), Louisiana (LA HB 467), and New Jersey (NJ A 1086), considered legislation that would allow unpasteurized, raw milk to be sold to consumers. How State Health Agencies Can Keep Cottage Foods Safe Health agencies consider cottage food inclusions based on food production risks. For instance, many agencies will allow baked goods but do not permit pickling due to the botulism risk associated with pickling. Health agencies evaluate food science to educate their legislatures on the considerations of cottage foods and where they would recommend public health regulations. Health agencies also ensure cottage food guidance is easily accessible and written in plain language, so producers have the needed information to follow regulations. Relevant information may include the permitted products, how to become a cottage food producer, and food safety considerations when preparing home-made foods. For example, the Illinois Department of Health, in collaboration with a diverse collection of stakeholders, created a robust cottage food guide to help producers and regulators understand state requirements and cottage food safety standards. Author card spacing 4 State policy surrounding cottage foods is constantly evolving. ASTHO will continue monitoring these changes and provide relevant updates. website yes

How states are using 1115 waivers to improve health equity for people on Medicaid.

To address the youth tobacco epidemic, jurisdictions filed lawsuits against JUUL to end their marketing practices aimed at youth and to obtain compensation from the financial toll experienced by communities.

National HIV Testing Day is observed each year on June 27, the goal is to encourage people to get tested and know their HIV status. Recent legislation on this topic speaks to its prioritization and importance; themes include: consent for HIV testing, site-specific processes for routine screening, increased access to testing.

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.

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.

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.

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

In response to the COVID-19 pandemic, states are using their emergency powers to authorize a variety of social distancing measures. This post is a summary of executive orders that have led to the closure of many businesses and nonprofit organizations, as well as proposed state legislation to provide economic assistance to businesses impacted by 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

Learn how state legislation is expanding access to drug checking equipment and screening in this Health Policy Update.

State Policies Promote the Importance of Defibrillators and CPR astho, association of state and territorial health officials, automated external defibrillators, heart disease, cpr training, defibrillators and cpr, cardiac arrest, coronary artery disease, sudden cardiac arrest, ventricular fibrillation, heart failure, heart muscle, perform cpr, heart attack, shocks to the heart, heart problem, electrical system, blood vessels, united states, automated external defibrillators, call 911, heart rhythm, cardiopulmonary resuscitation, chest pain, pump blood, cardiac arrest occurs, blood flow Lana McKinney Health Policy Update | Reviewing state policies that promote increased access to Automated External Defibrillators and use of CPR. Heart disease remains the leading cause of death in the United States for men, women, and most ethnic groups—even during the COVID-19 pandemic. And while overall rates of death from heart disease have declined over the past couple of decades, non-Hispanic Black persons are more likely to die from heart disease than other racial and ethnic groups. Additionally, more than 400,000 cardiac arrests occur annually outside a hospital setting.  CDC recently revised its Best Practices for Heart Disease and Stroke, highlighting strategies to improve cardio- and cerebrovascular health. One goal is to increase public access to automated external defibrillators (AEDs). Early use of AEDs by bystanders or emergency medical technicians during out-of-hospital cardiac arrest has been shown to improve survival rates to greater than 50%; those rates can triple if CPR is performed within the first few minutes of cardiac arrest.  Policies to develop and maintain public access to AEDs and CPR training are crucial. Across the country, state legislatures are enacting or considering legislation related to AEDs and CPR that enhance bystander response to cardiac events and improve the chance of survival of persons who experience cardiac arrest. As policymakers develop and adopt these measures, they should also consider health equity and data implications. Legislative Actions to Increase AED Access and CPR Training  So far in 2023, several states have introduced legislation to require the placement of AEDs in certain publicly accessible locations, including highway rest areas (WV HB 3038), county government buildings (MA HD 1842), all public safety vehicles (MA SD 2342), hotels (NJ A 5105), urgent care and retail health clinics (NJ S 1768), and health clubs (MA HD 2574). Additionally, at least four states—Massachusetts (HD 774), Mississippi (HB 203), Missouri (HB 426), and New York (S 1698)—have introduced legislation requiring AEDs in schools this year. New York also proclaimed a CPR-AED Awareness Week. Although relatively uncommon, an estimated 2,000 children each year die from sudden cardiac arrest. As of 2021, 39 states and Washington D.C. required CPR training for high school students. In 2023, at least four states have introduced bills to expand CPR certification and AEDs training. These include a bill to further expand high school education on CPR and AEDs (OK SB 236), and a bill that requires every public and charter school in the state to (1) have at least one employee with a valid CPR certification and (2) to provide annual CPR training for all high school personnel and students (AZ HB 2421).  In Colorado, SB 23-023 encourages each public school to provide CPR and AED instruction to students in grades nine through 12. West Virginia introduced SB 469 to establish a revolving loan fund that provides funding for CPR instruction to high school students. Meanwhile, California legislators are considering   AB 245 to update school-based CPR and first aid training by adding a requirement to rehearse the appropriate responses to the signs and symptoms of concussions, heat illness, and cardiac arrest. Challenges of Equity in CPR and AED training   As the evidence base about the impact AEDs and CPR have as lifesaving measures for cardiac arrest continues to build, the equitable distribution of AEDs equipment, its maintenance, and training for AEDs must also be considered.  Strategies that optimize the location of public access AEDs based on the risk of cardiac arrest associated with the site can help improve accessibility. Such registries can inform the public and emergency dispatchers of the location of publicly accessible AEDs to facilitate use during an emergency. Registries may also contribute to improving AED readiness by informing owners and managers when batteries and pads need replacing.  In 2018, CDC issued a report providing evidence about the training of responders, and the placement and maintenance of AEDs. While jurisdictions recognize the importance of AED devices, their affordability is a continuing concern.  Further Considerations  Understanding how to best measure and influence cardiac event outcomes and their contributing factors is critical to informing policy decisions. There are several ongoing challenges to understanding the national epidemiology of cardiac arrest, including the incidence and outcomes of out-of-hospital cardiac arrest and the reporting of such events. Additional knowledge is needed about out-of-hospital cardiac arrest key components such as geographic incidence, risk factors, and the impacted populations.  Valid data can advance and improve health outcomes by providing appropriate resource allocation and evidence-based service provision. Despite being one of the leading causes of death, there are currently no nationwide standards for surveillance to monitor the incidence and outcomes of cardiac arrest. Public health officials can help policymakers by reviewing their jurisdictions’ current AED laws and by increasing awareness of the positive impact AED policies and CPR training have on responding to a cardiac arrest. Bystanders can improve the survival rate of a person who is experiencing sudden cardiac arrest with increased public access to AEDs and additional CPR training.  Overall, additional policy actions to support AED availability and CPR training will continue to improve health outcomes. It is important to continue to acknowledge American Heart Month and all the improvements policy makes to save lives. Special thanks to ASTHO’s Erin Bayer, Senior Director of Chronic Disease Prevention and Health Improvement and Andy Baker-White, Senior Director of State Health Policy, and Erin Gabert of the American Heart Association for their contributions to this blog post. article yes

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

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.

Across the nation, public health agencies have mounted herculean efforts to stem the COVID-19 pandemic while addressing a pre-existing HIV epidemic and an opioid crisis that is serving as a source for many new HIV outbreaks. Tackling these public health crises simultaneously presents significant challenges as overdose deaths have spiked in the past year while HIV resources have been diverted leading to lower testing rates, fewer prescriptions for as pre-exposure prophylaxis (PrEP) and a decrease in HIV treatment, all of which will are likely to increase the number of acute HIV infections.