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As COVID-19 emerged and spread in the U.S., people working and residing in long-term care facilities have experienced a significant burden of COVID-19 cases and deaths. As of Oct. 8, deaths associated with these facilities account for 40% of total COVID-19 deaths in the U.S. Health officials have taken measures to improve their funding and capacity.

Anticipating a rapid deployment of COVID-19 vaccines as they are authorized, the CDC developed COVID-19 Vaccination Program Operational Guidance in collaboration with state and local jurisdictions to outline how each jurisdiction will make an authorized vaccine widely available. In addition to the operational plans, there is a legal framework of federal and state laws supporting the distribution and administration of the FDA-authorized vaccines.

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.

Several states and territories, as well as many local governments, are going beyond recommendations and requiring individuals to wear face coverings when they are in public settings and spaces (i.e. grocery stores, retail stores, restaurants, public and private transportation services, parks, etc.). Ongoing research and evidence suggests the relationship between mandatory face coverings and declines in daily COVID-19 growth rates is statistically significant.

How New Laws Support Telehealth and Access to Health Care How New Laws Support Telehealth and Access to Health Care Ashley Cram Learn how federal and state policies are improving access to health care by supporting telehealth. Telehealth strengthens the health system by reducing barriers to access to health care and extending services to underserved communities. Federal and state policies — many born out of the COVID-19 pandemic — have increased the use of telehealth by patients and providers. This includes expanded reimbursement to allow more providers to deliver telehealth services in more locations and through more modalities. This Health Policy Update summarizes recent federal and state laws and policies that impact telehealth delivery and access to care. Federal Laws and Policies Rural Health Transformation Program Enacted as part of the One Big Beautiful Bill Act in July 2025, the Rural Health Transformation Program appropriates $10 billion per fiscal year for the Centers for Medicare & Medicaid Services (CMS) to award to eligible states looking to improve rural health care. CMS encouraged state applicants to focus on select strategies, including investment in technology platforms that enhance care delivery. This includes tools and resources that support telehealth overall and remote patient monitoring (RPM), which is a way for providers to monitor and support patients through the use of devices that support data collection and transmission. Applicants that participate in interstate licensure compacts are also incentivized throughout the five-year program period by being awarded additional points for participation, which may lead to states pursuing compact legislation in the coming years. Medicare Telehealth Flexibilities Set to Expire During the COVID-19 pandemic, CMS issued numerous flexibilities that authorized broader telehealth use to expand access to care. Flexibilities included expansion of certain audio-only services, geographic areas and patient locations, and additional provider types eligible to deliver telehealth services. Current policy authorizes these pandemic-related telehealth flexibilities through January 30, 2026. Without permanent extension of these flexibilities, Medicare coverage for telehealth services beyond January 30, 2026, telehealth will again be limited to patients living in rural areas and to certain services, providers, and facilities. Physician Fee Schedule Changes CMS establishes the annual Medicare Physician Fee Schedule (PFS), which sets payment policy for health care services provided by physicians and other professionals to Medicare beneficiaries. The 2026 PFS includes new codes for RPM that allow providers to tailor monitoring frequency and engagement levels to meet patient needs. These codes, and the expansion of RPM, allow providers to effectively monitor health indicators such as weight, blood pressure, blood glucose, and respiratory flow rates, to manage health issues. By regularly monitoring a patient’s health status, a provider can reduce the risk of adverse health outcomes and emergency department visits. Additionally, the PFS streamlined the process for adding eligible telehealth services for reimbursement by removing distinction between permanent and provisional services and focusing review on whether services can be delivered via telehealth. State Legislation Impacting Telehealth Delivery States are also developing policy solutions to enable broader access to telehealth services, including expansion of audio-only and RPM services. Audio-only telehealth services are the use of communications technology, without a visual component, to deliver synchronous health care services. This modality can ensure continuity of and access to care for patients who live in areas with limited broadband and/or those who lack access to a video-enabled device. In 2025, at least four states enacted laws related to audio-only telehealth services. This includes at least three states that extended coverage that would have otherwise expired. In Hawaii, SB 1281 extended the expiration of the state’s coverage of certain audio-only behavioral health services through 2027, while Minnesota (HF 2) took a similar approach to audio-only telehealth services, including certain behavioral health and substance use disorder services, through July 1, 2027. Similarly, Maryland (SB 372/HB 869) removed the sunset date for coverage of audio-only telehealth services. And more broadly, Missouri (SB 79) clarified the state’s telehealth definition to include audio-only technologies. RPM uses digital devices to monitor a patient’s health by collecting and sharing health information with providers. RPM is particularly effective for management of chronic conditions, allowing providers to engage in shared decision making with patients and prevent adverse health outcomes through more regular monitoring. In recent years, several states enacted legislation to expand access to RPM including two bills in Louisiana. Enacted in 2024, HB 896 established the Louisiana RPM program for Medicaid patients with chronic conditions and a history of high-cost services, with the goal of improved care coordination and reduced costs. Then in 2025, SB 70 expanded these criteria to include pregnant and postpartum women and infants following discharge from the NICU. In Maryland, HB 553 specifies that the Medicaid program must cover the equipment and provider oversight of blood pressure monitoring for eligible recipients, including pregnant and postpartum individuals and those with chronic health conditions. Lastly, Virginia enacted SB 843 which directs the state Medicaid agency to develop a plan and cost estimate for expanding Medicaid eligibility for RPM for patients with chronic conditions. State and territorial health agencies can encourage public health programs to incorporate telehealth and propose policy solutions that enable broader utilization of telehealth modalities across the entire jurisdiction. States that are interested in expanding access to telehealth can visit ASTHO’s Telehealth Project Initiation and Scoping Assessment to conduct a review and identify opportunities to expand access to telehealth, particularly related to policy, infrastructure, and funding. UD3OA22890-13-00 article yes

ASTHO Legislative Prospectus | Previewing 2025 state legislative actions on data modernization and privacy.

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

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.

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.

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.

As many state legislatures seek to expand vaccine exemptions, it’s important to understand the fundamental differences in exemption type and their impact on a community.

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 report identifies and breaks down seven core value areas that emerge from taking a health in all policies approach to policymaking and programming.

Learn about state regulation of hemp, following federal deregulation and public health challenges including adverse effects of hemp products.

State and Federal Actions to Reduce Per- and Polyfluoroalkyl Substances’ Impact on Public Health safe drinking water act, per and polyfluoroalkyl substances, water supplies, contaminated groundwater, chemical companies, pfas contamination, forever chemicals, synthetic chemicals, maximum contaminant levels, industrial pretreatment program, polyfluoroalkyl substances pfas, chemical sales, chemical industry, bottled water, safe drinking water act sdwa, unregulated contaminants, companies in the world, united states, consumer products, 1996 amendments, national primary drinking water, surface water, water system, largest chemical companies, pfas strategic roadmap, primary drinking water regulations, pfas chemicals, pfoa and pfos, drinking water, testing for pfas, astho, association of state and territorial health officials Maggie Davis, Beth Giambrone State and Federal Actions to Reduce PFAS Impact on Public Health Since 2018, when the city of Stuart, Florida filed its lawsuit, communities across the United States have filed lawsuits against manufacturers that produce Per- and polyfluoroalkyl substances (PFAS), alleging that they contaminated groundwater and exposed residents to these harmful chemicals. In June 2023, manufacturer 3M agreed to pay at least $10.3 billion to settle the Stuart lawsuit and others across the country with public drinking water systems. Similarly, chemical companies DuPont, Chemours, and Corteva reached $1.18 billion settlement with local communities that have detected PFAS in their water supplies. PFAS are synthetic chemicals used in products like nonstick cookware and firefighting foam, which can migrate to soil, water, and air during production and use. Most of these chemicals remain in the environment without breaking down—hence the nickname “forever chemicals”—and can cause harmful health effects (e.g., higher risks of kidney or testicular cancer, and pre-eclampsia or high blood pressure among pregnant people) and are prevalent across the nation. Evidence shows the widespread nature of exposure to the chemicals and the economic costs of exposure. For example, a 2023 USGS study estimated that at least 45% of tap water nationwide could have one or more PFAS, while recent research estimates the annual cost of the disease burden attributable to long-chain (i.e., six or more carbon) PFAS exposure to be at least $5 billion. As communities seek restitution for PFAS contamination, federal and state policymakers are working to eliminate PFAS from ground water and drinking water and to mitigate exposure to these forever chemicals. Eliminating PFAS in Drinking Water Under the Safe Drinking Water Act, EPA has the authority to regulate the public drinking water supply in the United States. These regulations establish legally enforceable Maximum Contaminant Levels (MCLs) or Treatment Techniques and non-enforceable Maximum Contaminant Level Goals (MCLGs) for public water systems. EPA’s recently proposed PFAS National Primary Drinking Water Regulation could potentially add six different PFAS compounds to the list of regulated contaminants. Within the PFAS chemical family, PFOA and PFOS are proposed to each have MCLs of 4.0 parts per trillion (ppt), while PFNA, PFHxS, PFBS, and GenX would be regulated collectively as a mixture using EPA's Hazard Index approach. The proposed rule also could require public water systems to monitor and notify the public of PFAS levels and reduce the levels in drinking water if they exceed proposed standards. According to a survey conducted by the Environmental Council of the States, state guidelines vary; at least eleven states have established statewide MCLs for PFAS in drinking water. Some states prohibit their agencies from setting standards more stringent than federal ones and, in the absence of a federal standard, state agencies may hesitate to establish one that could easily be invalidated. In other cases, a lack of resources inhibits the agency’s capacity to set and enforce a PFAS standard. When a federal standard is established by EPA’s final rule, expected by the end of 2023, state primacy agencies will need to enforce the federal standard and adopt standards aligned with the federal standard or stronger within two years. Additional State Efforts to Reduce PFAS Exposure Even without MCLs, states are finding ways to mitigate the public’s exposure to PFAS. In 2023, states enacted legislation on banning PFAS in consumer products, increased requirements for testing and reporting of PFAS, and PFAS mitigation. Banning PFAS in Products Indiana enacted HB 1341 prohibiting fire departments from purchasing gear unless it contains a permanent label indicating whether it does or does not contain PFAS as of June 30, 2024. Minnesota’s HF 2310 prohibits selling or distributing products containing intentionally added PFAS beginning January 1, 2026. An exception may be made if the manufacturer submits information to the commissioner of the Pollution Control Agency such as the product, the amount of PFAS used, and the amount of PFAS in the product. The Oregon legislature enacted SB 543, which prohibits the selling or using polystyrene foam containers for prepared food, food containers containing intentionally added PFAS, and polystyrene packaging peanuts. Washington enacted HB 1047, which prohibits manufacturing, distributing, and selling cosmetic products with PFAS and other chemicals or chemical classes as of January 1, 2025. Testing/Reporting Indiana enacted HB 1219, establishing a pilot program that collects blood samples of previous or current firefighters, analyzes the samples for serum PFAS levels, and determines whether there are corresponding health implications associated with elevated serum PFAS levels. Maine’s LD 1248 requires bottlers who extract water from the state to sell as bottled water to test, regularly monitor, and report the presence of PFAS to the Department of Health and Human Services and post the results on a public-facing website. Sales of bottled water are prohibited if PFAS levels in the water source exceed the state or federal community water system standards, whichever is lower. Currently, Maine has an interim MCL standard of 20 ppt. Virginia’s HB 2189 directs the State Water Control Board to adopt regulations requiring industrial users of publicly owned treatment works to test waste streams for PFAS before and after cleaning, repairing, refurbishing, or processing items the user knows or reasonably should know uses PFAS chemicals. West Virginia’s HB 3189 requires its Department of Environmental Protection to identify and address sources of PFAS in raw sources of public drinking water systems. It also requires facilities to report the use of PFAS if they discharge to surface waters under a National Pollutant Discharge Elimination System (NPDES) permit or to a Publicly Owned Treatment Works under an industrial pretreatment program. Mitigation Connecticut enacted SB 100 establishing a PFAS testing account, which provides municipalities with grants or reimbursements for testing and remediating PFAS in drinking water. Maine enacted LD 289, which requires the state to purchase the real estate of a commercial farm found to be contaminated by PFAS before January 1, 2023 at the assessed fair market value but at no less than $20,000 per acre, and provides that the fair market value assessment cannot take PFAS contamination into consideration. Two enacted bills in Rhode Island (SB 724 and HB 5861) amend current law to add that if PFAS in drinking water exceed the state’s interim standard of 20 ppt, the state and the public water supply will enter into an agreement that requires dates for submittal of water treatment plans that will reduce the PFAS levels to or below the interim level. As more information emerges about the health effects of PFAS, states will be sure to continue their work to combat, mitigate, and report on their presence in the environment. ASTHO will continue to monitor and report on all legislative and regulatory activity around this issue. Special Thanks-Blog - State and Federal Actions to Reduce PFAS Impact on Public Health website yes

Adopting a public health approach to substance use by implementing harm reduction policies across all levels of government can help communities address the overdose crisis. This post analyzes e

The COVID-19 pandemic has negatively impacted youth mental health, particularly as a result of school closures, social isolation, family economic hardship, fear of family loss or illness, and reduced access to healthcare. However, states have many strategies to choose from to improve youth mental health and reduce suicide.

On the 32nd anniversary of the ADA, this blog post explores state legislation around the country that supports people living with disabilities.