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Breastfeeding is considered the gold standard in postnatal care for both birthing persons and infants. Yet racial disparities in breastfeeding initiation and duration rates continue to persist. Effective intervention strategies require a multi-level approach that includes comprehensive legal, policy, and programmatic efforts.

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 Questions are being raised about whether USPSTF recommendations will be rescinded or downgraded and, if so, what the impact would be on states and territories.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in the future, it cannot review newer data on preventive services, meaning existing recommendations could become outdated and USPSTF can’t make recommendations for new services.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

Reconciling the tension between public health and civil liberties is one of the most significant challenges of public health law and ethics. The Supreme Court of the United States historically upheld state authority to enact and enforce public health laws that temporarily limit a person’s civil liberties, such as quarantine and isolation powers that restrict a person’s freedom of assembly in order to prevent the spread of contagious disease. There have been many legal challenges to the public health orders issued to slow the spread of COVID-19—many of the claims asserting violations of First Amendment rights of assembly, association, and expression—but they’ve largely been rejected by the courts. However, courts have treated claims asserting violations of the free exercise of religion more favorably, which may indicate an impending shift in how courts analyze the impact state and territorial actions may have on religious organizations.

The opioid crisis continues to claim the lives of thousands across the United States and has cost the economy billions in health care, mortality, and criminal justice costs. In 2018, it’s estimated that 67,367 people died of overdose, with opioids (prescription opioids, heroin, and other synthetic opioids other than methadone) made up almost 70% of overdose deaths. Provisional data for the twelve-month period ending December 2019 shows that there were 71,130 overdose deaths, with 50,178 overdose deaths attributed to opioids. The COVID-19 pandemic has also exacerbated the drug overdose crisis. Data shows that in the time of continued lockdowns and social distancing that overdose rates have increased, indicating a sustained need to support people with substance use disorder.

Conditioning school attendance on student vaccinations is an evidence-based way of maintaining and increasing vaccine coverage. State law establishes school vaccination requirements which apply not only to public schools but often to private schools and childcare facilities as well. All states allow an exemption for those where a vaccine poses a medical risk. Several states also allow non-medical exemptions, often based on an asserted religious, philosophical, or personal belief of the parents or child opposing vaccinations. However, a few states have recently abolished all non-medical exemptions.

May is Mental Health Awareness Month and the importance of continued mental health promotion and suicide prevention efforts during the COVID-19 pandemic. As we address the physical effects of COVID-19 through social distancing, mask wearing, and vaccination, we still need to prioritize mental health and well-being during and after the pandemic. A recent Morbidity and Mortality Weekly Report found increases in adults reporting symptoms of anxiety or depression (36.4% to 41.5%) and unmet mental health care need (9.2% to 11.7%) between Aug. 2020 to Feb. 2021.

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.

This Health Policy Update is an overview of state legislative activity to increase financial stability for families during the COVID-19 pandemic which may help to prevent adverse childhood experiences.

In the current legislative cycle, there are several policy strategies that support the development and integration of community health workers into the public health workforce, including dedicated federal funding and state laws supporting workforce development programs, certification standards, and Medicaid coverage.

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.

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.

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.

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.

States and territories have broad powers to protect public health and safety, including powers to prevent and control the spread of communicable disease typically exercised by state and territorial health departments. This authority is an essential tool in the fight to keep the public safe and healthy.

State and territorial health agencies continue to be challenged by the opioid epidemic, which has been exacerbated by the COVID-19 pandemic. Addressing the opioid crisis requires a robust public health response, which could be helped by resources from pending and future opioid settlement funds.

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.

Responsible for planting, growing, harvesting, processing, and preparing the food we eat, agricultural workers are essential workers during the COVID-19 response to keep the U.S. food supply chain operating efficiently. But farmworkers are particularly vulnerable to COVID-19 due to lack of physical distancing, lack of access to health insurance and sick leave, and poor access to clean water for handwashing throughout the work day.

States Stay Prepared by Supporting the Public Health Workforce Margaret Nilz, Christina Severin Learn how states use policy to support emergency preparedness and bolster the public health workforce. Public health — particularly public health preparedness — continues to experience workforce shortages, driven by longstanding systemic challenges such as chronic underfunding, high turnover, limited recruitment, and an aging workforce. While some jurisdictions report increased capacity to hire and train public health staff in recent years, they often rely on short-term or temporary funding streams, which limit long-term sustainability. State, local, tribal, and territorial health agencies have varying capacities to respond to public health emergencies, particularly in rural and underserved communities. Because a limited workforce can inhibit emergency preparedness efforts, jurisdictions recognize the importance of cultivating a resilient public health preparedness workforce to respond to future emergencies. In recent years, jurisdictions have pursued several policy interventions to bolster the public health preparedness workforce such as legislation supporting front-line clinical staff and first responders, and rulemaking and other executive powers to provide structural and financial support to critical personnel. Legislative Efforts Legislative efforts to increase benefits and support for health care and public health workers can help address the root causes of workforce challenges and lay the groundwork for sustainable, long-term investment in public health preparedness. Laws that establish standards and expectations for the preparedness workforce, including expansions of benefits or additional training, support workforce growth and retention. Since 2024, several jurisdictions expanded mental health benefits and related support for first responders and other preparedness personnel. Both Alaska (SB 103) and California (AB 2859) enacted legislation that allows peer support programs for emergency service personnel. In Alaska, the bill creates programs for entities such as law enforcement agencies, firefighters, and emergency dispatchers, while California’s bill creates programs to serve a variety of health care providers involved in emergency medical care, including physicians, nurses, paramedics, and emergency medical technicians (EMTs). Utah enacted HB 378, which requires the Department of Public Safety to annually distribute information about its critical incident stress management program to first responder agencies. The bill also requires first responder agencies to annually notify employees about the availability of mental health resources, including periodic screenings for employees and continued support for retired or separated first responders and their spouses. On a broader scale, Hawaii SB 3279 recently established a well-being project tasked with mental health trainings and support for several community organizations, including first responders, hospitals, and medical staff. In Washington, HB 2311 directs the state’s Criminal Justice Training Commission to develop resources for first responder wellness, including a peer support network for active and retired first responders and their families. States have also enacted legislation expanding traditional employment-related benefits, including Colorado (HB 24-1219), which expanded certain health benefits for firefighters to include part-time and volunteer firefighters, and Idaho HB 55, which allows retired public employees to volunteer with public employers without it being considered reemployment. In addition, Georgia HB 451 requires state and local entities to provide disability benefits for first responders who experience occupational or volunteer-related post-traumatic stress disorder. Finally, several jurisdictions enacted legislation to support education and training for their public health and health care workforce. For example, Kentucky HB 484 established an emergency medical service education grant program that provides tuition support for students pursuing paramedic certification, wage reimbursement to ambulance providers whose employees pursue certification, and funding for institutions planning to offer EMT, advanced EMT, and paramedic programs. Oklahoma HB 1696 expands eligibility for the Oklahoma Medical Loan Repayment program to include certified nurse practitioners. Two new laws in Puerto Rico require police officers with the Puerto Rico Police Bureau to be certified in first aid or immediate rescue (PC 0859) and adds seminars on sign language, suicide prevention, and conflict mediation to the Bureau’s continuing education training (PC 0543). Other Policy Levers: Beyond the Legislature Jurisdictions can also use non-legislative policy tools to enhance workforce capacity in public health preparedness. This includes rulemaking, where executive agencies use existing legal authority to adopt or amend regulations. Regulations have the force of law and can help support the public health workforce by establishing licensure standards, training requirements, and operational protocols. Wisconsin, following the enactment of AB 576 in 2024, is developing rules to establish a program for peer support and critical stress management teams in the state. And Utah recently adopted rules for its first responder mental health services grant, which helps these professionals pursue a degree or certification as a mental health provider. Government agencies can also leverage grants and contracts to fund and otherwise direct workforce development initiatives, support training programs, and expand capacity in targeted areas. Jurisdictions can strategically direct funds to address skill gaps and assist local, state, tribal, and territorial agencies build a more resilient workforce. One example of this is in Michigan, where in 2024 the state health agency issued a request for grant proposals to award up to $9 million in EMS workforce grants, building on similar awards to address EMS shortages in 2023. Executive orders are another policy option for jurisdictions to consider as they explore different pathways to workforce sustainability. Executive orders are issued by a jurisdiction’s chief executive (often the governor) and direct certain policy actions or activities. Generally, the power to issue an executive order comes from existing law or a jurisdiction’s constitution and, in most cases, does not require legislative approval or review. Several states have leveraged executive orders to advance the public health workforce and support preparedness activities more specifically. For example, Vermont and New Jersey have recently used executive orders to create or extend advisory councils on issues pertinent to public health preparedness. In 2024, Virginia’s governor issued an executive order formalizing the Office of First Responder Wellness, which provides training, counseling, and other resources to first responders in Virginia. In 2023, the governor of Maryland issued an executive order establishing a State of Preparedness directive if there is a risk of public emergency, and the actions state agencies must undertake to promote improved coordination and hazard planning. Key Takeaways Addressing public health emergency preparedness workforce challenges demands strategic, long-term policy solutions, but several implementation options are available. Health agencies can pursue a variety of policy interventions to support and prepare their public health workforce for future emergencies. ASTHO will continue to monitor this important issue and provide updates as appropriate. article yes

Learn how strengthening collaboration and utilization of opioid settlement funds can help address overdose.

Policymakers seek to prevent the spread of COVID-19 by focusing on non-congregate sheltering and alternative housing for unhoused populations.