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Learn how state and territorial legislatures can bolster or restrict public health legal authority, with examples from early COVID-19 as well as 2024.

Policymakers all over the country have used legislation about farmers markets and sugar-sweetened beverages to help curb many of the negative impacts of food environments.

Each September marks National Preparedness Month. This year, public health emergency preparedness professionals look back on 20 years since the 9/11 attacks—the event that effectively launched the preparedness field—while actively responding to COVID-19.

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

The COVID-19 pandemic has impacted both the physical and mental health well-being of youth. Disruptions in both their home and school life have put youth at risk for poor mental health outcomes that include increased anxiety, depression, and risk of suicide. This Mental Health Month we examine state and territorial legislation that addresses youth mental health.

Learn how Hawaii and Iowa have leveraged policy change to improve overdose prevention.

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

Policy Trends Shaping Public Health Funding and Administration in 2026 Policy Trends Shaping Public Health Funding in 2026 Learn about policy trends shaping public health funding and administration in 2026, including increased funding for behavioral health and other areas. Decades of underinvestment in the nation’s public health system have impacted agencies’ ability to respond to health challenges. The COVID-19 pandemic revealed the fragility of a chronically under-resourced sector tasked with responding to a global emergency. While public health has received influxes of funding through the CARES Act and American Rescue Plan Act over the last five years, both were temporary injections of funding in response to COVID-19. There have been efforts to provide longer term funding for public health improvements through the Public Health Infrastructure Grant and the Prevention and Public Health Fund, but this funding faces an uncertain future: There have been multiple reductions in federal funding to the Prevention and Public Health Fund since its creation in 2010. Moreover, state public health agencies are preparing for the possibility of federal funding being reduced or cancelled. This, coupled with balanced budget requirements, is driving states to explore ways to improve their public health investments while bolstering infrastructure — focusing on health departments’ core services, and ensuring access to quality public health programs at the state and local levels. Increased Funding for Public Health In 2025, 47 states enacted or will enact budget bills. While overall nationwide funding for public health in FY26 was roughly equivalent to FY25, at least half of the state health departments had some form of increased funding (e.g., Medicaid, provider reimbursement rates, and specific public health initiatives and programs). For example: Behavioral Health: Colorado SB 25-206 included a $1.6 million increase in funding to provide behavioral health services in primary care settings. Certification: Illinois SB 2510 includes a $6 million increase to support licensing, inspecting, and certifying health care facilities for compliance with state and federal regulations. Maternal and Child Health: Georgia HB 68 provided a nearly $3 million increase in funding to expand a pilot program that provides home visits in at-risk and underserved communities during pregnancy and early childhood. Rural Health: Arizona’s budget bills include $4 million to expand access to health care through the development of rural medical residency programs. School-Based Health Centers: Delaware HB 225 appropriates funding to develop school-based health centers in elementary schools with more than 90% of students classified as low-income, multilingual learners, or underrepresented minorities. Leg Prospectus-2026 - Funding - Rural Health Improved Public Health Administration Several states passed legislation restructuring their public health systems. Nevada enacted SB 494, dividing the previous Department of Health and Human Services into two separate agencies. The bill gives the new health agency, called the Nevada Health Authority, the authority to oversee health programs (e.g., Medicaid and the Children's Health Insurance Program), manage health care compliance and consumer health services, and develop policy that improves health care access and cost efficiency. Hawaii’s HB 1120 formally gives the Department of Health the authority to prevent, address, and abate any issues that pose a threat to public health and/or environmental health, such as toxic materials, vector-borne diseases, and climate change. More than half of U.S. state health agencies are decentralized or largely decentralized, meaning many public health services are provided by city, county, or regional health departments that are separate from the state health agency. In 2025, at least two states enacted legislation enhancing local health departments’ abilities to provide core public health services: Utah SB 172 requires the Department of Environmental Quality to enter into cooperative agreements with local health departments to prevent and respond to potential health and safety threats from the environment. It also establishes a governance committee of state and local health department personnel to evaluate proposed policy changes affecting local health departments and ensure allocated resources meet the minimum performance standard. Washington HB 1946 modifies the membership requirements for local health boards, allowing federally recognized tribes with reservation or trust lands in the board’s jurisdiction to have members on the board. It also allows urban Indian organizations recognized by the Indian Health Service that provide services within that jurisdiction to have members. Looking Ahead ASTHO anticipates states and territories will continue considering and adopting legislation to provide state funding for public health and improve public health infrastructure, including those that: Create contingency plans or rainy-day funds in the event of reduced federal funding. Establish partnerships with neighboring states to share health data. Promote sharing services and resources within local health departments. Leverage regionalization as a tool to consolidate and share scarce public health resources. Adapt the funding and management of public health grants to ensure efficiency. Improve public health data systems to promote greater efficiency. OE22-2203 PHIG article yes

Good news and bad news on tobacco use: smoking rates are down but e-cigarette use continuing rapid rise among youth. Read how states are combating the problem.

Ripple Effect: What USPSTF Recommendations Mean for State and Territorial Health Law What USPSTF Recommendations Mean for State and Territorial Health Law Andy Baker-White This Health Policy Update highlights how U.S. states and territories are using policy to codify important public health recommendations. The United States Preventive Services Task Force (USPSTF) is a volunteer panel of national experts that issues evidence-based letter-grade recommendations on clinical preventive services. Under the Affordable Care Act, services with an A or B grade must be covered by most private health insurance plans without cost-sharing, with similar requirements for Medicaid enrollees and Medicare beneficiaries. An estimate by the Department of Health and Human Services concluded that in 2020, these services reached approximately 264 million Americans. States and territories implement these recommendations through statutes and rules. ASTHO identified over 200 state and territorial laws referencing the USPSTF, including in insurance statutes, Medicaid rules, disease-specific laws, and state employee health plan requirements. Over the past year, the stability of USPSTF recommendations has come into question. The U.S. Supreme Court's June 2025 ruling in Kennedy v. Braidwood confirmed the HHS Secretary’s authority to block USPSTF recommendations and remove task force members. News reports in July 2025 indicated that HHS Secretary Kennedy intended to remove all USPSTF members, and in May 2026 fired the chair and vice-chair of the task force. Questions are being raised about whether USPSTF recommendations will be rescinded or downgraded and, if so, what the impact would be on states and territories. In addition, if the USPSTF fails to convene in the future, it cannot review newer data on preventive services, meaning existing recommendations could become outdated and USPSTF can’t make recommendations for new services. To meet these challenges, states and territories are taking steps to ensure the continued scientific basis for preventive health services within their own law. Dynamic References to USPSTF Recommendations States and territories often use dynamic references to USPSTF recommendations in regulating health plan coverage of preventive services. This allows the jurisdiction to automatically require coverage for the most current USPSTF recommendations. Laws in West Virginia (state employee health plans), Oregon (regulated health plans), Hawaii (health director standing orders), and Alaska (adult Medicaid enrollees) use this approach. While dynamic references allow jurisdictions to stay up to date with the recommendations, if the task force withdraws any guidance, then those preventive services would no longer require no-cost coverage without additional action from those jurisdictions. Some jurisdictions address this by specifying that certain USPSTF guidance changes will not apply. For example, Guam’s law requires continued no-cost coverage for colorectal cancer screenings and authorizes the health director to adjust diabetes screening recommendations if USPSTF recommendations cease. Illinois specifies that the 2009 USPSTF recommendations for breast cancer screening and mammography are not to be considered current because national medical bodies created differing recommendations for screening. Another way jurisdictions avoid the unpredictability of using dynamic references is locking in the date of the USPSTF recommendations that are used for coverage requirements. For example, Massachusetts requires its state employee health plan to cover USPSTF A and B recommendations that were in effect by July 1, 2023. Using a version of USPSTF recommendations from a specific date maintains a base level of coverage regardless of future changes, though adopting new recommendations or removing outdated recommendations would require separate action. During this year’s legislative sessions, several states enacted or proposed legislation to remove dynamic USPSTF references. For example, Maryland passed legislation (HB 637 and SB 385) to lock in the USPSTF A and B recommendations that were in effect on December 31, 2024. Washington enacted HB 2242 requiring coverage of USPSTF A and B recommendations in effect on June 30, 2025, as well as recommendations adopted by the state insurance commissioner. A bill passed in Delaware, HB 338, would require the use of the USPSTF recommendations from January 1, 2025. Overall, however, neither dynamic nor fixed references to USPSTF recommendations address how jurisdictions can keep up with new scientific data and advances in preventive services in the absence of ongoing USPSTF review and recommendations. To fill this need, some states have enacted legislation that creates processes for reviewing data and establishing recommendations. For example, the new Maryland law mentioned above also authorizes the state’s health secretary to adopt preventive service recommendations that have not been recommended by or that differ from USPSTF. The new process requires notice and a 30-day comment period, an analysis by the Maryland Health Care Commission, and citations to the authoritative medical body upon which the recommendation is based. Disease-Specific Statutes: USPSTF Grades as Care Standards and Thresholds Many states also use USPSTF grades as thresholds for specific preventive services, establishing the standard of care, or issuing standing orders. For example, Arkansas law defines "follow-up colonoscopy" by reference to a colorectal screening assigned an A or B grade by the USPSTF, while Nevada’s law directs primary care providers to use criteria set out in USPSTF recommendations to screen adult women for BRCA mutations. In Hawaii, the state health director is authorized to issue public health standing orders for current USPSTF A and B recommended services, and in Idaho the law uses USPSTF guidance for applying ocular antibiotic prophylaxis to newborns as the standard for medical practice in the state. Some states are considering legislation to distance preventive service coverage requirements from USPSTF recommendations. For example, while New Jersey's current law requires no-cost coverage for colorectal cancer screenings in accordance with the method and frequency recommended by the USPSTF, introduced legislation (A4916 and S4254) would remove the reference to USPSTF recommendations and instead authorize one screening per year for persons aged 33 or older. More broadly, Hawaii considered legislation (HB 1898 and SB 3133) that would have authorized the state’s health department to “make recommendations relating to clinical preventive service recommendations of the [USPSTF] Force that have been assigned a grade of A or B as of July 1, 2025” and require no-cost coverage for the department’s recommendations. However, this legislation did not pass. State Employee Benefit Plans USPSTF recommendations may also be used to establish preventive health services covered by state employee health plans. A West Virginia statute requires the state’s employee health plans to cover mammograms consistent with "current guidelines from the United States Preventive Services Task Force," while the health plan document further states that preventive services are "subject to change as USPSTF…recommendations are updated.” In Ohio, a regulation requires state employee health benefits include all USPSTF-recommended tobacco cessation services and authorizes the state health director to update covered services if USPSTF guidance changes. Missouri law requires full coverage of USPSTF graded A and B recommended prescription and prescribed over-the-counter drugs for state plan members. The Path Forward USPSTF recommendations have helped millions of Americans receive critical health services at no cost, and states and territories have built practices, programs, and standards on that foundation. From adopting fixed-date references to establishing state-level recommendation authority to creating new state review bodies, legislative activity this year reflects a broad effort to address ripple effects from potential future changes to or lack of USPSTF guidance. Health officials may be asked to assess their jurisdiction’s laws and their use of USPSTF recommendations, and coordinate with insurance commissioners, Medicaid directors, and employee benefits administrators to confirm consistent agency interpretation and identify where action is needed. ASTHO will continue to monitor these policies as they develop. article yes

Learn how states can leverage policy to reduce ACEs and improve children's well-being in this Health Policy Update.

Reviewing states' efforts to reduce children's exposure to lead.

Federal and state legislation can play a role in promoting positive infant mental health by providing funding and policies that support early intervention, caregiver assistance, and the creation of nurturing environments conducive to their emotional well-being.

There are a number of court cases playing out across the country that could affect the options state and territorial health officials have to limit the spread of disease and promote health and well-being.

While communities transition from emergency response to long-term monitoring and recovery, the federal government and states are taking legislative action to improve emergency preparedness capabilities.

A mid-session legislative update on five of ASTHO's top 10 public health state policy issues to watch in 2023: tobacco, HIV, mental health, PFAS, and opioids.

Accompanying an infusion of federal funding, states are considering several policy changes to strengthen the public health workforce and address challenges within the health care workforce.

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.

The ASTHO State Health Policy team provides brief updates on 5 of the ten state health policy issues to watch in 2022: mental and behavioral health, rural health, e-cigarettes and flavored tobacco products, HIV and PFAS.

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.