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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

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

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.

In the November 2020 election, voters in several states cast their ballots on proposals related to the use of legal and illicit drugs. These ballot proposals influence key public health issues such as tobacco control, substance use prevention and treatment, and mental health—many of them implemented by state health agencies. This post contains a brief summary of the proposals on ballots around the country.

An increasing body of research finds racism can have a significant impact across one’s lifespan. Research shows that persistent exposure to racial discrimination may result in premature aging, poor health outcomes, and increased prevalence of certain chronic diseases. At every level of government, policymakers are seeking to acknowledge the systemic oppression of people of color that persists and to elevate racism as an urgent public health crisis comparable to other public health emergencies.

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

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.

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.

This blog post discusses mitigating risks of AI use in government agencies, emphasizing privacy, transparency, and ethical concerns.

ASTHO’s 2024 Legislative Session Update: Part One legislative session, state policy, data collection, domestic violence, health information exchange, data privacy, substance misuse, overdose prevention, sexually transmitted infections, reproductive health, contraceptive care, climate change, public health, protect data, user data, personal data, centers for disease control, disease control and prevention, social media, data management, primary care, health organizations, higher risk, family planning, data sources, astho, association of state and territorial health officials Lillian Colasurdo, Maggie Davis, Lana McKinney, JoAnne McClure This past December, ASTHO announced the top 10 public health state policy issues to watch for during the 2024 state and territorial legislative sessions. With at least 30 states concluding their regularly scheduled 2024 sessions, here is a brief update on five of the topics to watch. Data Collection and Exchange As expected, there was an increase in proposed legislation that specifically advances electronic health data access, encourages interoperability, and safeguards identifiable patient health records; this was particularly true for vital records. Hundreds of bills have been introduced this session addressing state vital records systems. The state of Illinois alone has already passed several bills, including HB 2856, which requires veteran status to be designated on death certificates, and HB 2841, which prohibits the assessment of fees to victims of domestic violence who are seeking a certified vital record (birth or death certificate) from the state. Other states such as Arizona (SB 1252) considered legislation that would require the Department of Health to provide vital records information on deceased individuals to the qualifying health information exchange (HIE). Arizona is one of eight jurisdictions (AZ, FL, IA, IL, NH, NJ, OK, and WV) that have proposed legislation addressing HIEs this session. Most of these bills increase requirements to connect to HIEs, but New Hampshire HB 1663 and Oklahoma HB 3556 would allow patients and health care providers to opt out of HIEs. As many states look to address health data privacy concerns, New Hampshire recently passed a constitutional amendment granting the explicit right to privacy and has introduced HB 1663, which would update many of the state’s privacy laws regarding medical records to conform with the constitutional requirements. Just next door, Maine considered legislation (LD 1902) that would strengthen privacy requirements for reproductive and gender-affirming patient health information. Finally, the launch of the new federal Trusted Exchange Framework and Common Agreement (TEFCA) led to the Florida legislature proposing SB 668, which, had it passed, would have required hospitals to make patient records available through a nationally recognized trusted exchange framework. It would also have required the Agency for Health Care Administration to adopt relevant rules. Substance Misuse and Overdose Prevention Measures to prevent substance misuse and reduce overdoses, namely increasing access to opioid antagonists, such as naloxone and regulating substances with the potential for misuse, are priorities this legislative season. ASTHO anticipated that states would consider legislation to reduce fatal overdoses including decriminalizing drug checking equipment, expanding naloxone access and distribution, establishing overdose prevention centers, and establishing state regulatory frameworks for commercial substances with the potential for misuse, including kratom and Delta-8. Current legislative priorities to expand access to naloxone include public spaces, such as libraries, schools, workplaces. Island jurisdictions along with at least four states—Colorado (HB 24-1003), Tennessee (SB 2141), Virginia (HB 732), and Wisconsin (AB 223)—passed legislation to provide greater access to and/or proper storage of naloxone in school settings. Additionally, Virginia passed HB 342 that requires naloxone access in state agency buildings. These legislative actions, along with the approval last year by the FDA of two non-prescription naloxone spray products for over-the-counter use, are collectively powerful policy shifts to expand access to naloxone. In an attempt to regulate substances with the potential for abuse or misuse, specifically kratom, eight states have considered legislation that would restrict the sale to people under the age of 18. Similarly, twelve states have considered legislation that would restrict the sale of kratom to those under the age of 21. At least 22 states have considered legislation that would compel specific labeling requirements for kratom. Of those, California (AB 2365) and New Jersey (A 1188) would require kratom products to be registered with the state health department annually and require lab testing of the product to meet certain qualifications. Preventing Sexually Transmitted Infections ASTHO has spotlighted the growing concerns of rising rates of sexually transmitted infections and state actions reducing congenital syphilis rates and expanding access to HIV prophylaxis (PrEP) and post-exposure prophylaxis (PEP). Rates of both syphilis and congenital syphilis continue to rise at an alarming rate, with more than 10 times as many babies being born with syphilis in 2022 than in 2012. Routine screening and timely and adequate treatment of pregnant people for syphilis, ideally more than 30 days before delivery, can effectively prevent this condition in newborns. Due to increasing cases, the American College of Obstetricians and Gynecologists recently updated their guidance for obstetrician–gynecologists and other obstetric care professionals advising serological screening for all pregnant individuals at the first prenatal visit and universal screening at the third trimester and at birth. During the 2024 legislative session at least two states—Missouri (SB 1260) and Maryland (HB 119)—are considering legislation that would require testing during pregnancy care at the third trimester for syphilis. Maryland’s legislature passed HB 119, which would require screening at the third trimester and at birth, as well as requiring the hospital to determine the syphilis status of the birthing parent before discharging the newborn. In 2023, New York enacted legislation (A 3007) that requires syphilis screening in the third trimester, and in the current legislative session they are considering S 2472, which would allow the state health department to provide education about congenital syphilis and screenings. At least six states have considered and passed legislation during the 2024 legislative session regarding expanded access for HIV prophylaxis (PrEP) and post-exposure prophylaxis (PEP). Of those considered, Georgia enacted HB 1028 to allow PEP to be issued by a standing order; Florida’s legislature passed HB 159 that would allow pharmacists to screen for HIV exposure, order, and dispense prevention drugs PEP and PrEP and sent it to the governor. Similarly, in Delaware the Senate chamber passed SB 194 that would permit pharmacists to provide PrEP and PEP pursuant to an approved protocol. Family and Reproductive Health Policymakers across all levels of government continued taking steps to make it easier for people to access contraceptives. In 2023, at least 14 states enacted laws in 2023 to facilitate expanding access to contraceptive care by either expanding the ability for pharmacists to dispense birth control without an individualized prescription and/or allowing pharmacists to dispense up to 12 months of contraceptives at once. So far in 2024, at least 13 jurisdictions considered legislation allowing pharmacists to dispense contraceptives without a prescription and at least 18 states considered legislation supporting access to 12 month supply of contraceptives. Following FDA’s July 2023 approval of Opill—the first over-the-counter (OTC) birth control pill—the drug is currently available in stores with several major pharmacies and health plans announcing that they will provide the medication at zero cost for many health plan sponsors. To further support access to Opill, at least two states (New Mexico and Wisconsin) issued standing orders for Opill to facilitate Medicaid coverage of the medication. Additionally, Maryland’s legislature passed SB 527 in March 2024, which requires community colleges to develop and implement a plan to provide students access to OTC contraception. In February 2024, New York enacted S 8096 allowing the commissioner of health to issue a standing order allowing a pharmacist to dispense self-administered hormonal contraceptives, effective retroactively to January 1, 2024. Under the new law, New York’s Commissioner of Health issued a standing order to allow pharmacists to dispense up to 12 months of self-administered hormonal contraceptives like birth control pills, vaginal rings, and contraceptive patches. Optimal Health for All ASTHO anticipates policymakers will take steps to improve collection of health disparities data, address inequities rural communities face in accessing care, and to support climate change adaptation planning efforts. So far in the 2024 legislative session, several states are considering bills to improve health care access and outcomes in rural areas. California is considering legislation (SB 945) that would build an integrated data dashboard to provide the public with information on the health impacts caused by wildfires and the effectiveness of forest health and wildfire mitigation on health outcomes. Additionally, California (AB 2342) is looking to ensure critical access hospitals on remote islands receive adequate funding through a dedicated annual supplement. New York is considering at least two bills that would promote rural health care access. First, New York S 8582 would create a pilot program to identify rural health zones and convene a rural health zone board

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.

Policy Trends Shaping Access to Care in 2026 Policy Trends Shaping Access to Care in 2026 Learn about policy trends shaping access to care in 2026, including supporting community health workers and improving rural health care. Public health agencies have a role in supporting access to care, which means assuring timely access to covered health care services provided by a qualified workforce. However, many communities experience challenges in accessing health care services, providers, facilities, or affordable care. Gaps in access to services that prevent chronic disease, address maternal health and behavioral health challenges, and other health goals undermine public health’s ability to improve community health. Strategies to improve access to care can include focused attention on underserved or at-risk communities or populations, including rural populations. To support access to comprehensive health care services, state legislatures continue to explore laws that strengthen clinical and community-based health workforces, support rural health care facilities, and promote access to care across the lifespan, including for women. Access to Supportive and Community-Based Health Services Community health workers (CHWs) are frontline public health workers who serve as a link between health and social services and the community, and can help address the social and behavioral health drivers of health outcomes. Many jurisdictions pursued policies to support CHWs by defining the workforce, establishing training or certification programs, and pursuing financial sustainability including through Medicaid programs. In 2025, more than a dozen states considered legislation related to CHWs, with several states enacting laws that recognize CHWs as providers and/or authorize Medicaid coverage and reimbursement. This includes Arkansas HB 1258, which establishes a state certification for CHWs, defines their role, and requires compensation for certified CHW services from both Medicaid and certain regulated health plans in the state. Montana (HB 850) and Oklahoma (SB 424) enacted bills to regulate CHWs but both bills were vetoed by their respective governors. In Oklahoma, the legislature overrode the veto. Rhode Island (S 0705) considered legislation that would require regulated health plans to cover CHW services, and Virginia enacted SB 981 which requires the health department to report on the status of the CHW workforce and future needs. Doulas are non-medical professionals who support individuals during pregnancy, birth, and the postpartum period. Doula care has been shown to reduce the rate of both cesarean sections and postpartum anxiety or depression, and may be cost effective, particularly for Medicaid programs. A majority of states are either pursuing or already offering doula coverage in their Medicaid programs. At least fourteen jurisdictions considered legislation in 2025 to recognize or provide coverage of doula services by Medicaid programs or private insurance. At least six states enacted laws regarding Medicaid coverage of doulas, including Louisiana (HB 454), Montana (SB 319), Utah (SB 284), and Vermont (S 53). In Maine, LD 1523 directs the health department to begin the rate development process for future coverage of doula services, establish a doula council to support that process and provide other advice to the department, and issue a report on the overall progress by February 2027. Arkansas (HB 1252) established a scope of practice for certified community-based doulas and requires compensation by both the Medicaid program and other health benefit plans in the state. Stabilizing and Growing Rural Health Care Access Rural communities face a number of health care challenges, including limited health care providers and financial strain on hospitals and other rural health care facilities. Several states explored strategic initiatives to support rural health care access, both broadly and for specific populations. California enacted SB 338 which establishes a virtual health hub to expand access to health services for farmworkers in rural communities. Iowa enacted HF 972, directing the health department to seek CMS approval for a hub-and-spoke model to support the state’s rural health providers. Finally, Texas enacted HB 18 which creates a rural hospital officers academy to support the education and development of these leaders, includes additional financial support for rural hospitals with obstetrics and gynecology services, and codifies current state programs and offices supporting rural hospitals. More than a third of U.S. counties are considered maternal care deserts, which are places where there are no obstetric providers or facilities. Several states enacted legislation to expand access to pregnancy and maternal health care in rural and underserved areas, including California which enacted SB 669 to create a pilot program for five rural hospitals to provide perinatal services on a standby basis. Arizona (HB 2332) will establish an advisory committee to make recommendations that will ensure the availability of “obstetrics, gynecology and maternal mental health services in low-volume, high-risk rural communities.” And in Connecticut, the governor signed several bills aimed at increasing access to maternal health care, including HB 7102 which requires the development of a strategic plan to increase the number of obstetric facilities in underserved areas of the state. Leg Prospectus-2026 - Access - Rural Health Expanding Support for Mid-Life Women's Health Care Women may experience a number of disruptive symptoms during perimenopause — the transition period before menopause — including difficulty sleeping, memory lapses, hot flashes, and general pain and discomfort. Following menopause, low hormone levels can increase the risk of chronic diseases like osteoporosis, heart disease, and stroke. Lack of knowledge about menopause and its wide range of symptoms, along with stigma, can prevent women from seeking treatment or other supports. Recognizing a growing need to address women's health across the entire lifespan, not just the reproductive years, state legislatures are exploring laws that address the menopause transition and its impacts through education and tailored health care access. In 2025, several jurisdictions — including Texas (HB 3961), Arizona (HB 2734), and Connecticut (AB 6593) — considered legislation directing the development, coordination, or distribution of educational programs and resources on menopause or perimenopause for women or providers, with Maine (LD 1079) enacting a measure requiring the health department to work to create and disseminate informational materials on perimenopause and menopause. Several other states have explored insurance coverage requirements, including New Jersey (A 5278/S 4148) and New York (A 5444) that would require certain health insurers and plans to cover menopausal and perimenopausal care and treatment. California (AB 432) would have required prescription coverage of drugs relevant to perimenopause and menopause care and treatment, and incentivize menopause-specific education for physicians, but the governor vetoed the bill and called for the state health and human services agency to propose policy changes for next year’s budget that address concerns about cost. Looking Ahead ASTHO expects states and territories to continue considering policies related to access to care, including legislation that: Increases coverage of and access to community-based health professionals like doulas, CHWs, and peer support specialists. Improves access to over-the-counter contraception. Recognizes telehealth's role in the health care system to ensure continued access to remote health care, particularly in rural communities. Supports access to reproductive care and women’s health services across the lifespan, including additional funding or other flexibilities to address anticipated changes in the federal funding landscape (e.g., Title X). OE22-2203 PHIG article yes

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.

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

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

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.

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.