ASTHO Legislative Prospectus | Previewing 2025 state legislative actions on data modernization and privacy.
Policy Trends Shaping Behavioral Health in 2026 Policy Trends Shaping Behavioral Health in 2026 Learn about the policy trends shaping behavioral health in 2026, including improving access to naloxone, mobile crisis units, and more. Public health efforts remain focused on reducing mental health-related harms and preventing substance use disorder and overdose. In 2024, an estimated 23.4% of U.S. adults — about 61.5 million people or more than one in five — experienced a mental illness, underscoring the widespread and urgent nature of mental health challenges nationwide. After years of rising fatalities, the United States saw its first notable decline in overdose deaths in 2023, followed by a nearly 24% decrease in 2024, with approximately 87,000 deaths reported over a 12-month period. While this progress is promising, overdose is still a leading cause of death in the United States, underscoring the need for sustained prevention, treatment, and recovery efforts. To continue strengthening behavioral health systems and advancing overdose prevention, state and territorial legislatures are considering measures that promote mobile crisis units, support access to overdose prevention tools and treatment, and address the increased use of unregulated substances. Mobile Crisis Response Over the past decade, federal and state policy has emphasized community-based behavioral health crisis response. Building on early local models, the 2021 American Rescue Plan Act created a new Medicaid option for states to fund mobile crisis intervention services with a time-limited enhanced federal matching rate. States also integrated mobile crisis teams into broader crisis response systems aligned with the 988 Suicide and Crisis Lifeline. As implementation expands, state legislatures are considering measures to strengthen service coordination, sustain funding beyond the enhanced federal match period, and address workforce and capacity needs. During the 2025 legislative session, at least 13 states considered and six enacted measures related to behavioral health mobile crisis services. Rhode Island (HB 6118) will require insurance coverage for mobile response and stabilization services for children and adolescents under 18. In Washington, HB 1813 directs additional planning and coordination among service providers to promote access to crisis stabilization services for Medicaid enrollees. Leg Prospectus-2026 - SBH - SAMHSA CMS Naloxone Availability Naloxone is a life-saving medication that quickly reverses opioid overdoses. Approved for over-the-counter sale by FDA in 2023, its expanded availability has increased opportunities for timely intervention. To support access for people at risk for overdose, many states are advancing policies to make naloxone available in public settings — such as schools, libraries, and community centers — to empower bystanders to respond to and prevent overdose deaths. At least eight states have considered legislation to increase naloxone availability with a focus on youth. Colorado enacted SB 25-164 to advance youth overdose prevention, clarifying access to naloxone in school communal areas, like buses, and giving the state board of health authority to establish what entities can receive naloxone for distribution. Michigan is considering SB 404, which would require schools receiving naloxone from the health department to adopt policies regarding administration and explicitly limit liability of school employees administering naloxone. Montana enacted SB 503, which extends liability protections for those who administer expired opioid antagonists — like naloxone — including in schools. Leg Prospectus-2026 - SBH - MOUD Therapeutic Substances for Mental Health Diagnoses Psilocybin and ibogaine are naturally occurring psychoactive substances being studied for their potential to treat mental health and/or substance use disorders. As interest in their therapeutic applications grows, several states are considering legislation to expand access for clinical research and regulated therapeutic use. In 2025, more than two dozen states considered and seven states passed measures related to psilocybin. Arizona (SB 1555), Colorado (HB 25-1063), and Nebraska (LB 72) enacted laws that would allow psilocybin prescribing pending FDA approval, though this approval has not occurred. Iowa (HF 383) and Virginia (SB 1135) passed similar provisions but both governors vetoed the bills, citing the need to wait for FDA approval and DEA rescheduling before taking state-level action. At least 10 states considered legislation to study ibogaine or fund clinical trials exploring its potential to treat PTSD, depression, opioid use disorder, and related conditions. Washington considered SB 5204, which would support the study of ibogaine-assisted therapy for adults with opioid use disorder. And several states — including Nevada (AB 378), New York (S 4664), and Oregon (HB 3817) — considered legislation focused on supporting research and trials that improve the health of veterans and first responders. Finally, Texas enacted SB 2308 to establish a consortium focused on ibogaine research and trials to support FDA approval of the drug for treatment of various mental health and substance use disorders. Kratom Regulation Public health leaders are examining ways to reduce the potential misuse of unregulated substances, including kratom, a product derived from the leaves of a tropical tree that can act as both a stimulant and sedative, and that carries the risk of addiction and abuse. Kratom is not a scheduled drug under federal law, but the FDA has reiterated that there are no legally marketed drugs containing kratom and that it is not an appropriate dietary supplement or approved food additive. While FDA explores a scheduling action for 7-OH, a concentrated byproduct of kratom, a number of state legislatures are considering measures to regulate kratom products. At least 34 states considered and 11 states passed legislation regarding kratom in 2025, including Louisiana (SB 154) which criminalizes the possession and distribution of kratom. Another six states — Colorado (SB 25-072), Mississippi (HB 1077), Nebraska (LB 230), Rhode Island (SB 792), South Carolina (S 221), and South Dakota (HB 1056) — passed legislation restricting the sale of kratom to people under the age of 21 and establishing product labeling standards. Looking Ahead ASTHO anticipates states and territories to continue considering and adopting laws to prevent substance misuse and overdose and reduce mental health-related harms, including those that: Enhance support and capacity for behavioral health mobile crisis units and improve care coordination and entry across the behavioral health care continuum. Expand coverage for peer support specialists and establish baseline standards for peer support specialists in treatment and social support recovery services. Develop measures to study and decriminalize some psychoactive substances for potential mental health and substance use treatment. Develop innovative policies to link recently incarcerated persons to substance use disorder treatment. Improve access to medications for opioid use disorder by expanding telehealth availability, prohibiting prior authorization requirements, and ensuring comprehensive insurance coverage. Explore state regulatory frameworks for commercially available substances with the potential for misuse, including kratom and hemp-derived cannabinoids like Delta-8. OE22-2203 PHIG article yes
ASTHO Legislative Prospectus | Prevention 2025 state legislative action on infectious disease control and prevention.
This report analyzes way that public health officials can mitigate the impact of disasters on pregnant people, neonates, and infants through a variety of policies, including policies related to preparing for, responding to, and recovering from a public health emergency.
This toolkit is designed to support public health leaders in leveraging the policy development process to achieve health equity in their jurisdiction.
Public Health Approaches to Preventing Suicide and Promoting Mental Well-Being Public Health Approaches to Preventing Suicide Caitlin Langhorne Griffith, Arnelle Toffey Learn how to execute public health approaches to preventing suicide, which requires understanding the dynamics of policymaking and implementation. Despite ongoing prevention efforts, suicide remains a leading cause of death and disability among Americans of all ages, racial and ethnic groups, geographic regions, and socioeconomic statuses. While suicide affects populations at all levels, it continues to be the second leading cause of death in individuals under 44 and disproportionately impacts veterans, individuals with lower income and educational attainment, and residents in rural areas, among other groups. Approximately 6% of the U.S. population has a Serious Mental Illness (SMI) (e.g., bipolar disorder, major depressive disorder, and schizophrenia), and a 2022 study found that almost 10% of people who die by suicide had a known SMI. In addition, individuals with or without SMI can experience suicidal ideation or attempts. Factors such as adverse childhood experiences, limited access to health care, and economic instability can contribute to suicide risk. Public health approaches that expand treatment access and address the drivers of suicide risk can help foster mental well-being in communities and reduce the risk of individuals dying by suicide, including those with SMI. However, executing these approaches requires understanding the dynamics of evidence-based strategies in policymaking and implementation. Population-Based Approaches Expanding access to mental health care is critical for reducing risk and managing symptoms of mental illness, as only 50% of young adults (18 to 25 years old) and 53% of adults (26 to 49 years old) with any mental illness received treatment in 2024. However, barriers to mental health care — such as availability of providers, access to telehealth, cost, and other systemic factors — can prevent individuals from receiving treatment, especially during serious declines in mental health. Population-based approaches can fill this gap by focusing on non-clinical interventions and activities that address chronic stressors and other factors contributing to mental health declines, improving mental health outcomes. Examples of these policies include: Addressing structural determinants of suicide risk (e.g., economic security). Promoting access to clinical services (e.g., Medicaid expansion and state mental health parity laws). Limiting access to lethal means for suicide (e.g., child access prevention laws and access to high-risk medications). 988 Suicide & Crisis Lifeline State health agencies can also consider approaches that provide and enhance direct crisis support. The 988 Suicide & Crisis Lifeline is a nationwide hotline that provides emotional support to individuals experiencing suicide, mental health, or substance use crises. Since its launch in July 2022, call volumes have steadily risen in all states, and the Lifeline has been shown to improve callers' mental well-being as well as reduce suicide risk. Implementation of the 988 Lifeline occurs at both the state and local levels, resulting in variations in funding and infrastructure across communities. In the most recent legislative session, jurisdictions enacted legislation to fund and sustain 988, ensuring consistency in quality and access across all communities. For example, North Dakota SB 2200 allocates funding for 988 operations from a community health trust fund, while Texas HB 5342 established a trust fund outside of the state treasury to support the 988 Lifeline. States also enacted legislation either consolidating (Colorado SB 236) or ensuring interoperability with 988 and 911 emergency lines (Nebraska LB 362), streamlining services and accessibility for those in need of mental health support. In addition, 12 states have adopted a 988 telecom fee — similar to fees that support 911 infrastructure in every state — to create a sustainable financing source for 988. Adolescent Mental Health Support at School Schools are a critical setting to support adolescent mental health, particularly for children with serious emotional disturbances who are at elevated risk of suicide. Several states have mandated suicide prevention training requirements for school personnel as part of ongoing professional certification requirements. Federal funding — such as the Suicide Training and Awareness Nationally Delivered for Universal Prevention Act, which focuses on evidence-based programs for students — can help states and tribes establish/expand training for school staff and equip them with the education to recognize warning signs and connect students to resources, alongside student-directed programs that increase mental health literacy and foster peer support. In the 2025 legislative session, at least three states enacted legislation focused on preventing youth student suicide. Kentucky (HB 48) and Montana (SB 369) mandate training for school staff on suicide awareness and prevention, while Virginia HB 2055 requires school staff to provide materials to parents on suicide prevention (including the safe storage of firearms) if they believe a student is at imminent risk. At least three additional states enacted legislation that requires student identification cards to include mental health information and suicide crisis resources, including the 988 Lifeline (Colorado SB 326, Illinois HB 3000, New Jersey A 4897). Georgia HB 268 requires public schools to provide at least one hour of suicide awareness prevention and training to students in grades 6-12. Conversely, an Idaho bill (SB 1199) that would amend a 2024 law to allow minors to access medical treatment when calling the 988 Lifeline without parental consent passed the Senate but did not advance in the House. Jurisdictions have also incorporated policies that provide additional safeguards for adolescents and their use of the internet: Utah recently enacted SB 98, which requires the state Board of Education to create a video presentation for parents outlining the safety and legal issues students may encounter while using technology. Maryland's SB 310 expands the state's Youth Suicide Prevention School Program to include instruction to students on the relationship between gambling and youth suicide. At the federal level, Congress is considering the Kids Online Safety Act, which requires platforms, applications, and streaming services that connect to the internet to exercise care in creating and implementing design features to prevent and mitigate harm to minors. Looking Forward It is important to understand suicide prevention approaches nationwide, including how jurisdictions formalize and strengthen suicide prevention infrastructure as well as promote healthier environments. Strategies for policymakers include the following: Analyzing and comparing suicide prevention infrastructure laws nationwide to identify gaps and guide jurisdictional changes. Building protective environments that address upstream social and structural risk factors (e.g., access to clinical services and food insecurity), while advancing policies that reduce access to lethal means. Strengthening school-based prevention efforts by leveraging available funding to expand evidence-based programs, train school staff, establish student-directed programs, and connect students to needed resources. Promoting safer online spaces for youth with policies that limit harmful design features, strengthen parent engagement, and increase online platform transparency. Continuing investments in crisis services to expand and sustain programs like the 988 Lifeline. Prioritizing economic support policies to strengthen families and reduce ACEs, supporting healthier development and well-being. Leveraging these legal and policy frameworks can reduce suicide risk, support mental well-being, and build a stronger public health system for all. article yes
The COVID-19 pandemic has exasperated challenges around access to nutritious and affordable foods. In response, the federal government has taken action to increase funding and access to programs to strengthen food security.
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.
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.
States Support Postpartum Health with Medicaid Expansions astho, association of state and territorial health officials, 2023 state legislative session, medicaid expansions, postpartum health, the consolidated appropriations act, national women s health week, postpartum coverage, affordable care act, premium tax credits, affordable care, 12 weeks, united states, extended postpartum coverage, health a priority, medicaid program, national women s health, mother s day, 2023 legislative, vaginal birth, physical activity, women s health week, postpartum care, coverage for 12 months, 60 days, state plan amendment, care act, postpartum depression, health care Sowmya Kuruganti National Women’s Health Week reminds us that postpartum care is critical for the long-term health of the birthing parent and baby. National Women’s Health Week’s 2023 theme—Women’s Health, Whole Health: Prevention, Care and Wellbeing—is a reminder that postpartum care is critical for the long-term health of the birthing parent and baby. The first year after pregnancy can be full of physical, emotional, and mental health challenges that have long-term or even life-threatening health impacts without timely diagnosis and treatment. In September 2022 CDC reported that 23% of pregnancy-related deaths occur from seven to 42 days postpartum, and 30% of deaths occur 43-365 days postpartum. Among all pregnancy-related deaths occurring from 2017 to 2019, approximately 84% were deemed preventable. Black and American Indian and Alaskan Native <!--(AI/AN)--> women have two to three times higher rates of pregnancy-related death compared to white women. These disparities, like others, are driven by social and economic factors that are rooted in structural and systemic racism and discrimination. Health insurance coverage is one such factor that supports positive maternal health outcomes by facilitating access to care before, during, and after pregnancy. In the United States, 40% of births are covered by Medicaid, which is the primary source of health coverage and access to care for those of low income. Organizations like ASTHO and the Association of Maternal and Child Health Programs support extending Medicaid coverage through one-year postpartum to combat disparities in maternal health outcomes. Federal Legislation for Postpartum Coverage under Medicaid For the majority of states that have adopted Medicaid expansion under the Affordable Care Act (ACA), all people with income up to 138% of the federal poverty level (FPL) are eligible for Medicaid. In states without Medicaid expansion, pregnant people can be eligible for coverage during pregnancy and up to 60 days postpartum under federal law. After 60 days postpartum, these people may lose coverage for the rest of the year-long postpartum period based on general state Medicaid eligibility requirements. Prior to 2021, states could extend Medicaid coverage to postpartum people through a section 1115 demonstration waiver or through state funds. The enactment of the 2021 American Rescue Plan Act, gave states another option to extend Medicaid coverage to 12 months postpartum via state plan amendment for five years. So far in 2023, CMS has approved the State Plan Amendments for five states (Alabama, Arizona, Colorado, Oklahoma, and Rhode Island) implementing a 12-month postpartum expansion. To date, a total of 33 states have expanded Medicaid coverage to 12 months postpartum via Section 1115 demonstration waiver or state plan amendment. 2023 State Legislative Session Depending on states rules for modifying Medicaid coverage the legislature may need to direct the health department to submit a state plan amendment. So far in 2023, three states enacted legislation related to expanding coverage to 12 months postpartum. In Mississippi, SB 2212 authorizes the state’s Division of Medicaid to provide 12 months continuous postpartum coverage to people who qualify. Utah’s SB 133 extends coverage for 12 months postpartum for women eligible for Medicaid during pregnancy. In Wyoming, HB 4 temporarily extends Medicaid coverage for qualifying pregnant women for 12 months postpartum, ending March 31, 2027. Other states introduced bills to extend postpartum coverage during this session. The Alaska Legislature passed legislation (SB 58) directing the Department of Health to submit a state plan amendment extending postpartum coverage to 12 months, and to raise the household income level for eligibility to 225% of the FPL. The bill is currently awaiting action by the governor. Iowa introduced legislation (SF 57) to enact postpartum coverage for 12 months postpartum by Medicaid State Plan Amendment. This would extend the current 60-day postpartum coverage for Medicaid beneficiaries. The Missouri legislature passed (SB 45) that would extend MO HealthNet postpartum coverage from 60 days to 12 months postpartum for women who are either currently receiving or eligible to receive aid to families with dependent children, or eligible to receive benefits via the income eligibility standard. Pregnant women eligible for MO HealthNet and receiving mental health treatment for postpartum depression, related mental health conditions, or substance abuse treatment within sixty days of giving birth would remain eligible for benefits for those services for an additional 12 months. The bill is currently awaiting action by the governor. Nebraska introduced legislation (LB 419) to extend postpartum coverage for 12 months postpartum that would extend the current 60 day postpartum coverage. Texas introduced legislation (HB 12) to extend postpartum coverage to 12 months; it has passed in the House and is now pending in the Senate. Its passage would significantly change the current coverage structure, which uses state funds to provide postpartum people a limited package of postpartum services through the Healthy Texas Women program under HB 133, and subsequently submitted 1115 waivers to draw down federal funds for the program and extend coverage to six months postpartum. Wisconsin introduced companion bills (AB 114/SB 110) extending postpartum coverage for 12 months postpartum for women eligible for Medicaid during pregnancy. This action would extend coverage from the current 60 days and amend the previous 90-day Section 1115 Waiver submitted in 2021. Studies have demonstrated numerous benefits of extending Medicaid coverage for postpartum people and, given these positive impacts, ASTHO expects that more states will take action to extend Medicaid to 12 months postpartum. ASTHO will continue to monitor and report on this essential maternal public health issue. website yes
Public health agencies are working to reduce dementia risk and to optimize the health and well-being of people living with dementia and their caregivers.
In an effort to help meet demand, some states and territories have joined interjurisdictional licensing compacts that allow a mental health care provider licensed in one state to provide care in another state—without needing to gain licensure in multiple states. These agreements also offer guidance on patient privacy for services rendered remotely or from out-of-state.
States have identified different strategies to implement healthy eating approaches and reduce obesity at the school and community levels, as well as through food labeling at grocery stores and food markets.
During the 2022 state legislative sessions, at least 20 states considered bills that would require a religious exemption to a vaccine requirement. As state legislatures continue considering vaccine protocols for COVID-19, HPV, and other diseases—along with what types of exemptions should be given—courts are reconsidering what type of vaccine requirements are constitutional.
ASTHO notes the top state public health policy issues in an annual Legislative Prospectus series. ASTHO is publishing a prospectus for the top 10 policy issues to watch in 2022. This week we are featuring data modernization and privacy protections.
Recap the state legislative sessions in 2025 thus far, spanning maternal health, infectious disease, and other important public health issues.
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
How the Emergence of Xylazine Impacts Overdose Prevention Policy overdose prevention policy, overdose crisis, fatal overdoses, emergence of xylazine, illicit drug supply, toxicological testing, withdrawal symptoms, xylazine test strips, drug paraphernalia laws, drug checking, legislative action, drug supply, substance use disorders, controlled substance, opioid use disorder, centers for disease control, health care, harm reduction services, psychoactive substances, department of public health, illegal drug, type of drug, opioid crisis, prescription opioid, astho, association of state and territorial health officials JoAnne McClure, Victoria Pless How states are considering overdose policy changes as xylazine continues to emerge in the illicit drug market. Developing and adopting policies to reduce fatal overdoses can help public health leaders address the ever evolving and complex national overdose crisis. More than 109,000 fatal overdoses occurred in 2022, with the majority involving illicitly manufactured fentanyl. Adding to the overdose challenge is the emergence of xylazine, a non-opioid tranquilizer (i.e., sedative), that is being increasingly mixed with fentanyl in the illicit drug supply. As of November 2022, xylazine was found in the illicit drug supply in 48 of 50 states and Puerto Rico. Xylazine is currently associated with one in ten fatal fentanyl (11%) overdoses, a near-threefold increase from 2.9% in 2019. Toxicological testing for xylazine is not uniform and, as a result, its involvement in fatal overdoses may be underestimated. Some states have taken initiatives such as Indiana (HB 1286) and South Carolina, to improve the consistency of toxicological testing for xylazine. With xylazine’s addition to the overdose crisis, states are beginning to adopt laws to better regulate the supply of xylazine and detect its presence in the illicit drug supply. What is Xylazine? Xylazine, also known as “tranq” or “tranq dope,” is a central nervous system depressant causing drowsiness, slowed breathing, reduced heart rate, and hypotension, which can increase the risk of a fatal overdose. Xylazine is approved for veterinary use in the United States but is not FDA-approved for human medicine. Xylazine, can be added to substances that are ingested orally, snorted, sniffed, or—mostly commonly—injected intravenously, and has been added to or used to cut heroin and fentanyl to prolong their effects. People who use drugs may be unaware of xylazine’s presence, which can put them at a higher risk of fatal overdose. Xylazine use is associated with skin ulcers, lesions, abscesses that left untreated, can lead to amputation. People who develop a physical dependency on xylazine may develop severe withdrawal symptoms. Although symptoms of xylazine use and opioid use are similar—making it difficult to differentiate whether someone has used one or both substances—overdose reversal agents (e.g., naloxone) do not counteract the effects of xylazine. Public health leaders still recommend that naloxone be administered for a suspected opioid overdose because xylazine has been detected in substances alongside fentanyl. For a person experiencing a xylazine-involved overdose, public health leaders emphasize the need to seek treatment beyond naloxone. In addition to public health’s work to address xylazine in the illicit drug supply, some state and territorial legislatures are expanding or protecting access to xylazine test strips as well as steps to limit access to xylazine through the state drug schedule. Legalizing Drug-Checking Equipment Drug-checking equipment, such as fentanyl test strips, are evidence-based interventions that allow a person who uses drugs to test their supply for an adulterated substance. State drug paraphernalia laws historically prohibited drug checking equipment, limiting the possession, distribution and use of items like fentanyl test strips. To make fentanyl test strips more widely available to prevent overdose, legislatures rapidly changed their laws to either explicitly legalize fentanyl test strips or generally legalize drug checking equipment. As of July 5, 2023 more than 33 jurisdictions legally authorize the use of fentanyl test strips, 12 of which (Alaska, Colorado, Guam, Maine, Maryland, Nebraska, New York, the Commonwealth of the Northern Mariana Islands, Pennsylvania, South Carolina, Utah, and Vermont) generally authorize the possession and use of drug-checking equipment. Similar to fentanyl, people may not know whether they are exposed to xylazine when using other substances, increasing the risk for harm. New test strips can detect the presence of xylazine, however state drug paraphernalia laws that criminalize drug checking equipment may limit the accessibility of xylazine test strips to prevent overdose. In 2023, at least three states—Illinois (HB 3203), New Hampshire (HB 287), and Utah (SB 86)—enacted legislation to authorize or decriminalize use of drug-checking equipment for fentanyl and xylazine, ensuring that xylazine test strips are lawful and able to be distributed. Additionally, states that previously passed legislation to allow for fentanyl-specific drug checking are amending their statutes to include all drug checking to ensure the legal possession of xylazine test strips. For example, Delaware enacted (SB 189) that specifically legalized xylazine test strips. Two other states—Vermont (H 222) and New Jersey (SB 3957)—enacted laws expanding the authorization of fentanyl test strips to allow for all harm reduction supplies, including drug checking equipment, which would permit the use of xylazine test strips. The Question of Scheduling Drugs are scheduled based on their acceptable medical use and potential for misuse and severe psychological and/or physical dependence, with drugs in Schedule I being the most tightly regulated. Xylazine is not a controlled substance under the federal Controlled Substance Act so it is not DEA scheduled or controlled. Nevertheless, xylazine is subject to FDA regulation under the federal Food, Drug, and Cosmetic Act and state law. Prior to 2023, only two states directly or indirectly scheduled xylazine. Florida codified xylazine as a Schedule I substance in 2016, and xylazine could fall under Massachusetts’ Schedule VI designation, which applies to prescription drugs. As state and territorial leaders take steps to schedule xylazine, policymakers should consider whether scheduling or other criminal penalties will deter people from seeking care if they fear being arrested for unknowingly testing positive for exposure or xylazine use. Another consideration for leaders before scheduling xylazine is whether scheduling will also make possession of test strips illegal under the jurisdiction's drug paraphernalia law. In 2023 at least nine states–Delaware (SB 189), Illinois (HB 3873), Louisiana (HB 106), Michigan (HB 4913), New Jersey (A 5448), New York (A 5914), Oklahoma (SB 668), Rhode Island (HB 5922), and West Virginia (SB 546)—considered legislation to schedule xylazine as a controlled substance. Of those, Delaware, Rhode Island, and West Virginia enacted laws scheduling xylazine in 2023. In addition to legislative action, at least two governors (Ohio and Pennsylvania) took executive action to schedule xylazine. ASTHO’s overdose prevention and state health policy teams continue to monitor these important public health issues. website 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.
The ASTHO State Health Policy team provides brief updates on 5 of the ten state health policy issues to watch in 2022: public health authority, immunization, data privacy and modernization, public health workforce, and health equity.