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Centering the Community’s Voice in State-Led Health Equity Initiatives health equity, public health departments, health outcomes, michigan public health institute, health disparities, underserved populations, marginalized communities, people of color, indigenous people, premature deaths, minority health, cultural competency, public health, life expectancy, improving health, american indians, health service, african american, native american, social determinants of health, sexual orientation, mortality rate, socioeconomic status, covid-19 pandemic, higher rates, alaska natives, group of people, racial groups, social economic, population health, department of health, astho, association of state and territorial health officials Lana McKinney, Jessica Fepelstein Establishing the community voice in health policy discussions. Over the past two years, ASTHO has worked directly with state public health departments and their communities to build capacity for improving health outcomes. These public health departments are building a culture of health equity through policies, practices, and quality improvement measures. This includes the Strategies to Repair Equity and Transform Community Health (STRETCH) Initiative—a 10-state learning community hosted by ASTHO, the CDC Foundation, and the Michigan Public Health Institute. STRETCH supports states in operationalizing health equity and preventing the constant pressures caused by negative health outcomes on their communities. For example, poverty can create constant pressures just as water pushes against a dam, which can build to the point of breaking and push people into poverty. Additionally, ASTHO supports state and territorial recipients of CDC’s COVID-19 Health Disparities grant to improve the health of high-risk and underserved populations disproportionately impacted by the COVID-19 pandemic. Health disparities impact the quality-of-life and financial well-being of communities, with the economic burden of health disparities increasing from $320 billion in 2014 to $451 billion in 2018. This includes associated costs of excess premature deaths, lost labor market productivity, and excess medical care for Americans of color as compared to their white counterparts. Events in recent years, such as the COVID-19 pandemic, revealed the pressures that Black, Indigenous, People of Color (BIPOC) and other marginalized communities experience because of health disparities. Aligned with the technical assistance received by public health departments, several states have taken concrete steps to achieve optimal health for all by supporting training of public health staff and increasing engagement of under-represented and underserved communities in the policy process. Promoting Staff Health Equity Training Ensuring that public health staff and other leaders are equipped with the knowledge, skills, and attitudes necessary to provide culturally competent and equitable care to all patients, regardless of their social background or identity can improve health outcomes. In recent years, states have worked to expand access to cultural competency and humility training for health system workers. Nevada enacted legislation (AB 267) requiring the state Board of Health to establish the frequency for medical facilities and dependent care facilities to conduct cultural competency training for employees who have direct patient contact. It also (1) requires the Office of Minority Health and Equity and Department of Health and Human Services to establish and maintain a public-facing list of approved courses for cultural competency training, and (2) require nurses, psychologists, marriage and family therapists, counselors, social workers, and behavioral analysts to complete a minimum of three hours of cultural competency training to successfully renew their license. At least four other states—Illinois (SB 2427), Massachusetts (S 1413), Virginia (SB 1440), and Vermont (H 512)—considered bills expanding access to cultural competency training for health care professionals. Vermont’s bill would implement the recommendations of the Health Equity Advisory Commission to provide training and continuing education for health care providers to improve cultural competency, cultural humility, and antiracism in Vermont’s health care system. Public health agencies can also promote health equity training by allocating funding and providing training. For example, the Arizona Department of Health Services leveraged funding from CDC’s COVID-19 Health Disparities grant to establish the Advancing Health Equity, Addressing Disparities (AHEAD AZ) program with the University of Arizona Center for Rural Health, which supports the health care and public health workforce, including support for Arizona’s 17 Critical Access Hospitals health equity strategic plans, and implementing a COVID-19 testing program that provided testing to communities most in need regardless of socioeconomic or immigration status, including those living in correctional facilities and unhoused people. Health Equity Commissions Health equity commissions play a critical role in advancing optimal health for all by bringing together experts, stakeholders, and policymakers to draw on evidence-based approaches that address the root causes of health disparities and to develop strategies to prevent them. At least two states proposed legislation related to health equity commissions in 2023. Colorado passed a law (SB 23-151) extending its Health Equity Commission through 2029. New Jersey is considering S 3136, which would establish and require a Commission on Health Equity to, among other things, recommend implicit bias training requirements for health care providers. Empowering Community Members to Engage in the Policy Process Hearing directly from community members, particularly those with lived experience, provides health agencies with unique insights into the community’s needs and daily life, and helps gain support from those most affected by the policy. There can be several barriers to holistic community engagement, particularly for community members who have fewer resources. Policymakers can take steps to lower these barriers by providing access to childcare, supporting transportation costs to a meeting, and/or compensating community members for their time and effort supporting the policy development process. In 2022, Washington enacted SB 5793 to compensate community members with lived experience for their time and expertise when serving on boards, commissions, councils, committees and other similar policymaking groups. The law directed the state’s Office of Equity to develop equity-driven compensation guidelines for all state agencies, which Washington’s Department of Health used to create and implement its Community Compensation Guidelines. These compensation guidelines outline how and when community members can be paid for their time and expenses when engaging in the policy process. Such methods are particularly valuable because the communities facing the most inequity are also the ones most systemically marginalized. Similarly, in 2023 Oregon’s legislature considered SB 694 to create a Task Force and Work Group Stipend Fund. The fund would provide for providing members who do not otherwise receive compensation for their participation to be compensated for their time and travel for task force or workgroup related work. ASTHO will continue to monitor policy developments supporting health equity programs and initiatives, providing relevant updates. Special thanks to Maggie Davis, JD, ASTHO’s director of state health policy, for her contributions to this blog. Additional Resources to Help Public Health Leaders Increase Community Engagement ASTHO’s Programmatic Health Initiatives and Strategies Georgia Health Policy Center’s Guide to Funding Navigation to help communities design and sustain equity-advancing investment. <!-- Strategies to Repair Equity and Transform Community Health (STRETCH) Initiative framework. --> website yes

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.

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.

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.

State Policy Advances in Extreme Weather Preparedness Margaret Nilz Learn about recent policies that aim to improve extreme weather preparedness, boost community resilience, and ultimately protect public health. Extreme weather events are increasing in both frequency and severity — challenging public health systems, straining infrastructure, and risking lives. As states face rising temperatures, more intense wildfires, historic flooding, and stronger hurricanes, state legislatures are adopting forward-looking policies to improve preparedness. These policies aim to boost community resilience, protect public health, and modernize emergency responses across the country. They reflect a move toward proactive planning and investment, grounded in innovation and cross-sector collaboration. Strengthening Critical Infrastructure A growing area of legislative focus is pre-disaster planning and infrastructure resilience, with jurisdictions considering policies that proactively strengthen critical systems (e.g., infrastructure, energy, and communications). For example, in Maine, LD 1 creates the Office of Resilience, tasked with coordinating and implementing state policies to improve resistance to extreme weather events. It also increases homeowners’ access to home resiliency grants, establishes a revolving loan fund for county, municipal, and tribal hazard mitigation infrastructure projects, and invests in floodplain mapping improvements. Texas SB 75 establishes a Grid Security Commission, directs an evaluation of hazards to the state’s electric grid, and makes recommendations that ensure municipalities have energy, power, and fuel supplies in the event of a catastrophic power outage. Jurisdictions are also considering legislation that would: Amend procedures for cities and counties to finance post-disaster infrastructure repair and long-term climate adaptation projects (California SB 782). Require biennial emergency preparedness exercises as well as conduct disaster preparedness training in vulnerable areas (California AB 1200). Create a real-time, interoperable emergency communication platform to improve coordination across agencies during disasters (Texas HB 147). Addressing Wildfire Risk and Air Quality Jurisdictions are also paying close attention to growing wildfire threats and subsequent poor air quality. They’re moving beyond emergency response, ensuring systems/personnel are in place before a crisis unfolds and advancing wildfire mitigation strategies. Systems and Personnel Hawaii recently enacted HB 1064, establishing an Office of the State Fire Marshal. The office is tasked with increasing the state’s readiness for wildfires, including exploring opportunities to reduce wildfire risk and developing a statewide map that displays wildfire hazard zones. California is considering AB 1003, which would require the Department of Public Health to complete a plan that includes recommendations for counties during a significant air quality event by June 30, 2026. California is considering AB 1003, which would require the Department of Public Health to complete a plan that includes recommendations for counties during a significant air quality event by June 30, 2026. It would also require these plans to incorporate county-specific outreach, stakeholder communication, and implementation. These measures build critical infrastructure for training, staffing, and coordinated response. Mitigation Strategies California (SB 326) introduced policies that accelerate the implementation of ember-resistant zones, enhance risk modeling, and support local governments through grant funding for fire reduction efforts. New legislation (CA SB 629) also updates the state’s fire hazard severity maps and sets new criteria for safety zones, including annual defensible space inspections to help residents manage fuel loads around their homes. In Colorado, recently enacted laws support increased use of prescribed burns to improve forest health (SB 7) and empower local fire protection jurisdictions to mandate vegetation removal from private properties (HB 1009). Oregon enacted SB 85, which requires the State Fire Marshal to develop recommendations for community-based wildfire mitigation and submit them to the legislature by February 2, 2026. Two bills being considered in California would: Require the creation of a framework for wildfire mitigation and a wildfire risk forecast (SB 326). Update the state’s fire hazard severity maps and set new criteria for safety zones, including annual defensible space inspections to help residents manage fuel loads around their homes (SB 629). Together, these policies signal a shift from reactive firefighting to community-level risk reduction and long-term adaptation. Improving Flooding and Hurricane Preparedness Flooding, hurricanes, and coastal erosion remain central concerns for many states, particularly those already experiencing repeat disaster declarations. As flooding and coastal threats intensify, states are taking multi-pronged approaches to preparedness — investing in early warning systems, expanding access to mitigation funding, and examining the readiness of critical facilities. These policies can assist states in both major non-hurricane flood events and hurricane preparedness and response. Several states are working to improve community-level preparedness and emergency alert systems. Vermont recently enacted H 397, which expands the Governor’s authority in the anticipation of a flood event, increases municipal access to weather alert systems, and expands access to disaster recovery grants. Texas recently introduced HB 108, which requires the Division of Emergency Management to develop a flood preparedness guide for local organizations that includes structured guidance around training, communication, and post-disaster recovery. Alongside these efforts, states are strengthening long-term mitigation strategies through grant and buyout programs. Massachusetts (H 980) and New Jersey (A 5226) are considering legislation that would establish funding programs for municipalities to address flooding (i.e., through risk assessments and mitigation measures). In Virginia, recently enacted HB 2077 expands eligibility for the Virginia Community Flood Preparedness Fund to include federally and state-recognized tribes. Employing Innovation and Research Innovation continues to shape the next frontier of preparedness policy as jurisdictions pilot emerging technologies, promote cross-sector collaboration, and rethink how they can adapt infrastructure for a changing climate. In California, legislators are considering three bills that merge cutting-edge science with emergency responses: AB 270 directs the Department of Forestry and Fire Protection to assess whether autonomous firefighting helicopters could be transitioned to operational use in the state. SB 599 proposes improvements to atmospheric river forecasting, a key strategy in flood management. SB 223 would establish a centralized wildfire smoke and health data platform within the Department of Public Health to better inform public health decisions during smoke events. Additionally, jurisdictions are addressing the resilience of the built environment, balancing traditional engineering with nature-based approaches. Mississippi enacted HB 959, extending a program focused on wind hazard mitigation and grants to retrofit homes to July 2028. Additionally, Puerto Rico introduced PS 579 (en español), which establishes the use of natural mitigation structures (e.g., sand deposits and coral planting) as the first alternative to protect infrastructure affected by coastal erosion, flooding, or other events. In Conclusion The scale of today’s public health challenges requires long-term planning, robust infrastructure, and coordination across different sectors and levels of government. Investments in real-time data systems, interoperable communication, and resilient financing tools will be essential. This Preparedness Month, the increasing momentum behind jurisdiction-level policy action shows a clear understanding: Preparedness is public health. And by focusing on resilience, jurisdictions are not only preparing for the next emergency — they are actively creating a healthier, safer, and more climate-resilient future. ASTHO will continue to monitor and provide updates on extreme weather preparedness legislation. article yes

States Are Innovating to Improve Indoor Air Quality Abe Kulungara Indoor air quality can significantly impact health and well-being—learn how states are using policy to address this issue. Whether at home, in the workplace, or in schools, the air we breathe inside is affected by improper ventilation, exposure to toxic chemical cleaning agents, buildup of moisture, and the presence of pests—all of which contribute to poor indoor air quality (IAQ). In addition, increases in extreme weather conditions (e.g., heat, hurricanes, flooding) can deteriorate buildings, reducing the physical barriers between outdoor and indoor spaces. And inadequate weatherization of schools and buildings can lead to indoor fungi and mold growth. Indoor air pollutants can have both short-term and long-term impacts on public health and well-being. Some examples of health outcomes (and their associated hazards) include: acute injury (carbon monoxide and other asphyxiants from combustion and safety hazards from improper design), cancer (asbestos and radon), infectious disease (COVID-19), as well as allergic disorders and asthma (mold and other products of damp indoor environments. Furthermore, poor IAQ in school can potentially affect comfort, concentration, and student performance. While the United States has made significant progress in improving outdoor environmental quality, improvements in indoor environments have been much slower, despite Americans spending approximately 90% of their lives indoors. In many cases, the responsibility for improving IAQ falls to individual states, resulting in a patchwork of regulations and varied approaches across the country. Indoor Air Quality at the Federal Level The federal government’s authority over indoor air quality is limited to federal buildings but there is no current comprehensive national regulation specifically focused on indoor air quality. Notwithstanding, federal laws and regulations addressing outdoor air quality can indirectly impact indoor air quality. For example, the Clean Air Act gives EPA the authority to establish and enforce National Ambient Air Quality Standards (NAAQS) for pollutants in outdoor air, such as ground-level ozone, particulate matter, and carbon monoxide. Improvements to ambient air quality will have an impact on indoor air quality as well. Even though the federal government’s role in IAQ is less direct, agencies including EPA have issued voluntary guidelines and best practices. This gap in federal regulations offers state and local governments the opportunity to set standards for their jurisdictions. The Model Clean Indoor Air Quality Act The Model Clean Indoor Air Quality Act (MCIAA) provides a framework for states to adopt and implement measures that are most relevant to their local needs and circumstances, much like the Model Food Code is used by states for food safety regulations. The Act consists of six main articles, each containing key sections designed to support a comprehensive mission of safeguarding and enhancing IAQ in public buildings through collaboration among public and private entities. The Act also presents extensive statutory language on IAQ and offers states the flexibility to choose the components that best suit their specific needs, priorities, and local conditions. By adopting the Model Act or portions of it, states can establish standards for ventilation, moisture control, hazardous materials use, and public education efforts. State Actions on Indoor Air Quality A growing number of states are proactively improving indoor air quality. Massachusetts recently introduced SD 2588, which incorporates language from MCIAA, while others are addressing IAQ issues more broadly, enacting legislation that prohibits smoking in indoor public spaces or responding to specific local challenges (e.g., mold, radon, volatile organic compounds ). At least five states are considering various bills relating to air quality in public schools. Massachusetts (SD 173 and SD 630) and New Jersey (S 1033) are establishing task forces or commissions to study indoor air quality. Connecticut (HB 5873), New York (A 2649) Virginia (HB 2618 and SB 1413) are establishing or amending indoor air quality standards for public schools. Massachusetts (HD 2890) is also prohibiting cleaning agents that could have an adverse effect on health. As states consider streamlining indoor air quality standards using the MCIAA, there are a large number of current statutes that improve IAQ. For example, Florida requires their Department of Health to have an IAQ testing and monitoring program to assess health risks from exposure to chemical, physical, and biological agents in the indoor environment. In Hawaii, the Department of Health is authorized to correct indoor air pollution problems in all buildings. The agency must establish and coordinate an IAQ assessment network involving state agencies and managers of publicly owned buildings to identify, evaluate, and resolve indoor air pollution problems. The statute also grants the agency the authority to implement a program for approving plans to construct, inspect, and monitor ventilation systems, as well as to provide IAQ information to managers, owners, and occupants of both public and private buildings. Other states, such as Washington and Oregon, have implemented programs that focus on IAQ in schools, acknowledging children’s unique vulnerabilities to poor air quality. ASTHO will continue to monitor and provide updates. article yes

ASTHO staff identified a range of evidence-supported policies considered by state legislatures that could prevent ACEs. This report synthesizes these research and policy proposals and is intended for public health practitioners and policymakers who are considering adopting similar policies.

An ASTHO blog article on leave policies to support better work/life balance.

Across the nation, public health agencies have mounted herculean efforts to stem the COVID-19 pandemic while addressing a pre-existing HIV epidemic and an opioid crisis that is serving as a source for many new HIV outbreaks. Tackling these public health crises simultaneously presents significant challenges as overdose deaths have spiked in the past year while HIV resources have been diverted leading to lower testing rates, fewer prescriptions for as pre-exposure prophylaxis (PrEP) and a decrease in HIV treatment, all of which will are likely to increase the number of acute HIV infections.