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Under the Tenth Amendment, states have the power to protect the health and welfare of their populations, including the authority to implement isolation and quarantine orders to limit the spread of disease. This post is an examination of state public health authority for isolation and quarantine.

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.

Three ways policymakers are addressing access to care are through telehealth, safety net and emergency services, and adjusted reimbursement rates to Medicaid-enrolled providers.

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.

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: data privacy and modernization, reproductive health, health equity, strengthening public health agencies, and immunization.

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

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

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

Over the past several years, states and jurisdictions have continued to implement important policies to reduce tobacco and nicotine use, including increasing tobacco prices, expanding areas deemed “smoke-free,” limiting the sale of flavored tobacco products, and supporting tobacco cessation programs.

Do Cottage Foods Really Come from a Cottage? Beth Giambrone Even if you're not familiar with the term "cottage foods," chances are you have purchased them—think getting a loaf of bread from your weekend farmers market or cookies from a friend's home-based baking business. In some cases, they can also be sold online. So, what exactly are they? Cottage foods are home-based, home-made food products prepared outside a commercial kitchen and sold to the public. Cottage food producers operate at a small scale, often from a home kitchen, selling goods in the jurisdiction where they are created. Cottage foods are exempt from many state food and safety regulations, with supporters of expanding cottage food laws asserting that existing laws burden small business and restrict competition and consumer freedom. Those opposing the expansion of cottage foods argue the need to ensure food safety and to protect consumers from food borne illness. Here's a primer on cottage foods and how they're regulated. What's the difference between a cottage food kitchen and a commercial kitchen? Commercial kitchens (sometimes known as shared use kitchens) are large, industrial spaces where food can be produced in high volumes; they can also be rented out for shared use. While every state subjects commercial kitchens to food safety inspection and regulations, a few states require inspection of microenterprise or home kitchens producing cottage foods. Does the government have a role in regulating cottage foods? While several federal agencies regulate commercial food products—such as USDA for meat processing and FDA for produce—cottage foods are not subject to federal regulation because they are typically only sold within a state and not across state lines. At the state level, cottage food producers are subject to the health and safety laws and regulations of the state in which they are operating. Some states require cottage food producers to register their business or to have training and/or certification in safe food handling. Currently, all 50 states and Washington D.C. have some sort of cottage food law in place. Under most state laws, cottage food producers are exempt from food safety laws that apply to food establishments. These exempt rules are usually based on the type of food product produced, the point of sale, and the labeling requirements associated with the food. Although cottage food producers are exempt from certain requirements, all states allow the Department of Health to investigate complaints related to foodborne illness and fine producers if there are violations. Since the 2020 legislative sessions, at least 17 states (Alabama, Arkansas, California, Connecticut, Florida, Iowa, Illinois, Maryland, Missouri, Mississippi, New Hampshire, New Jersey, Oklahoma, Tennessee, Utah, West Virginia, and Wyoming) considered bills related to cottage foods, often centering around product sales, food products, and labeling. An overview of the conditions and a snapshot of the laws passed in states are below. What are common cottage food products? Most state laws limit which food products can be produced and sold as cottage foods. And while specific allowable foods vary state to state, some common restrictions on the type of food sold include foods requiring temperature control (e.g., meat and dairy products) and fermented or pickled foods. Foods such as dairy-free baked goods (e.g., breads and biscuits), candies, and jams are popular cottage food products. Over the last few years, states have expanded the types of foods that qualify to be a cottage food. In 2021, Illinois enacted SB 2007, amending the types of foods permissible under the cottage food law from a delineated list of canned foods (e.g. jams and syrups) to a general standard that mirrors the FDA definition of "low-acid canned food." The New Jersey legislature passed A 3991 in 2022 to exempt raw, unprocessed honey from the state's cottage food regulations. The bill is currently awaiting action by the governor. Oklahoma enacted its "Homemade Food Freedom Act" (HB 1032) in 2021. This new law allows any packaged food or beverage (excluding alcoholic beverages, unpasteurized milk, or cannabis products) to be considered a cottage food rather than only baked goods made without meat or fresh fruits. Additionally, the law allows beekeepers who produce less than 500 gallons of honey per year to qualify for the state's food freedom exemptions if the honey is produced from hives located in the state and sold directly to the consumer. Similarly, the 2022 "Tennessee Food Freedom Act" (HB 813/SB 693) broadly expands the types of homemade foods eligible for sale under the cottage food law to include any non-time/temperature-controlled food item or non-alcoholic beverage. What limitations do states place on cottage food sales? Most states limit cottage food producers to direct-to-consumer sales, such as at a farmers market or roadside stand. More than half of states allow online and direct-to-consumer sales as long as they are to in-state consumers only. While the producer is usually required to deliver the products, at least five states allow delivery by a third party. Several states have considered allowing the sale of cottage food in retail settings. In 2020, Wyoming enacted HB 84, which increased the gross sales cap for producers and allowed producers of non-temperature controlled foods (e.g., jams, vegetables, dried soup mixes) to use third-party vendors like a retail shop rather than solely relying on gross sales. Furthermore, the Wyoming legislature expanded the use of third-party vendors to include the sale of eggs in 2021 by enacting HB 118. A 2021 Arkansas law (HB 248) also allows for the sale of cottage food products at retail stores. Additionally, many states define cottage foods based on the number of items sold or the annual gross sales. The gross sales cap limits vary greatly across states, ranging from $3,000 to $250,000. At least twenty states have no gross sales limit. At least one state (Ohio) places a limit on meals sold per week from home kitchens. What are common labeling requirements for cottage foods? Most states require cottage food producers label their goods. While specific labeling requirements vary state to state, producers generally must provide the name of the product, a list of ingredients, known allergens (e.g., nuts), contact information of the producer, and a statement declaring the product was made in a kitchen exempt from licensing and inspection regulations. In some states, cottage food producers are allowed to use an identification number in place of contact information on product labels. Maryland enacted HB 1017 in 2020, which allows cottage food producers to use a unique identification number issued by the Department of Health in lieu of the business name and address. Arkansas HB 248 (referenced above) also allows producers to use an identification number. What's next? State policy surrounding cottage foods is constantly evolving, with more foodstuffs exempt from state food and safety regulations increasing the risk of foodborne illness outbreaks necessitating a public health response. ASTHO will continue monitoring these changes and provide relevant updates. website yes

As the number of COVID-19 vaccinations grows, some states are looking at their vaccination rates to determine when to loosen measures that mitigate the spread of COVID-19, such as venue capacity limits, business closure times, and masking requirements. As vaccinations allow businesses to reopen and customers to return, questions have arisen about whether venues or services—especially those that bring people in close contact for long periods of times—such as retail stores, concert venues, entertainment venues, air travel, cruise ships, etc., can require patrons or customers to verify that they received a COVID-19 vaccine. So far, state policy makers have had mixed views on the issue.

State issued documents, such as birth certificates, are often required to navigate daily life. Vital records policy is a complex and evolving issue with many of the processes and procedures left to jurisdictional policy-makers.