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State Policy Trends in Cybersecurity and Public Health Preparedness Maggie Nilz Learn how states are including cybersecurity in their emergency preparedness work in this Health Policy Update. Cybersecurity is an increasingly important component of public health preparedness as state cybersecurity policy intersects with public health agency responsibilities. Public health agencies rely on interconnected digital systems and critical infrastructure for disease surveillance, laboratory reporting, emergency communications, and health data management, making cybersecurity critical to maintaining these functions. Beyond compromising sensitive data and potentially harming patients, cyber incidents can disrupt essential public health services, including emergency response operations. Health care data breaches have steadily increased over the last 15 years, highlighting growing risks for government and health systems. A recent report showed that more than 7,000 health care data breaches were reported to the Department of Health and Human Services since 2009, and reported HIPAA data breaches in 2023 were nearly double the number recorded in 2018. Meanwhile, preparedness capacity has lagged: as of 2022, only 13% of local health departments reported being prepared for cyber-related disruptions, and recent scans show cybersecurity is rarely included in emergency preparedness planning. In response at the federal level, HHS recently announced it is undoing a 2024 reorganization by returning department-wide technology responsibilities to the Office of the Chief Information Officer while refocusing the Office of the National Coordinator for Health Information Technology on improving nationwide health IT interoperability and data sharing. In recent years, state and territorial legislatures have begun to address these gaps by incorporating cybersecurity into preparedness, health care oversight, and statewide governance structures. These legislative trends signal a need to integrate cybersecurity into emergency operations plans, strengthen cross-sector coordination, and safeguard the continuity of public health services. Some of the most recent policies considered and enacted by legislatures treat cyber incidents as emergencies, expand reporting requirements, and strengthen cyber governance. Cyber Incidents Are Being Built into Emergency Preparedness Frameworks In response to these growing threats, jurisdictions have begun incorporating cyber response into emergency plans and strategies, reinforcing cybersecurity as essential to preparedness. These developments highlight growing awareness that cyber incidents can disrupt critical services, much like natural disasters. In 2025, New York enacted S 7672, which requires municipal entities and public authorities report cybersecurity incidents and demands for ransom to the state Division of Homeland Security and Emergency Services. In addition, it directs the Director of the Office of Information Services to establish cybersecurity training and protection standards for state systems as well as require cybersecurity training for state and local government employees. Virginia is currently considering HB 83, which would establish a volunteer Cyber Civilian Corps within the state IT agency to provide rapid assistance during cybersecurity incidents affecting municipalities, nonprofits, education, and critical infrastructure. Preparedness efforts also extend beyond legislation to executive action. In February 2026, Minnesota Governor Tim Walz authorized $1.2 million in state disaster assistance to support response efforts and restore critical systems in response to a cyber incident that disrupted digital services in Saint Paul on July 29, 2025. Additionally, the National Governors Association has included cybersecurity as a primary consideration for planning and preparedness in their latest edition of the Public Health Emergency Playbook. Health care and Public Health Critical Sectors Are Facing New Cyber Requirements Beyond emergency response frameworks, jurisdictions are also adopting cybersecurity reporting and planning requirements for health care and public health organizations. Companion bills in Tennessee (HB 511/SB 555) would require health care providers and facilities to notify their contracted health insurers of cybersecurity incidents. In Maine, LD 2103 would require hospitals to adopt cybersecurity plans to protect patient data and maintain operations, and must include cybersecurity training for employees and board members. New Jersey is looking to adopt and implement a more comprehensive cybersecurity plan across all sectors. This session, legislators have introduced at least two cyber security bills: A 3231 would require “sensitive businesses” (defined as those engaged in financial, essential infrastructure, or health care industries) to report cybersecurity incidents to the New Jersey Cybersecurity and Communications Integration Cell (NJCCIC) when they are aware of their occurrence and would require NJCCIC to conduct a cybersecurity audit within 30 days of notification. A 3283 would require the same “sensitive businesses” to implement cybersecurity programs in accordance with standards adopted by NJCCIC and certify compliance annually. As states expand reporting and cybersecurity requirements, these obligations may intersect with public health reporting and continuity planning. States Are Strengthening Government Cyber Governance and Coordination In addition to sector-specific requirements, jurisdictions are also strengthening the governance structures responsible for coordinating cybersecurity, improving their ability to respond to large-scale incidents affecting public systems. Legislation enacted recently in Texas and California aim to improve coordination among state government by establishing a state agency centralizing cybersecurity incident prevention and response (Texas HB 150) and mandating the development of a cybersecurity playbook to strengthen information sharing (California AB 979). A 2024 bill enacted in Puerto Rico (PC 1530) requires commonwealth agencies to develop and implement a cybersecurity program, which must include a yearly risk assessment as well as vulnerability assessment. At least three jurisdictions are currently considering bills strengthening established cybersecurity programs, with two states recently passing legislation. Utah recently enacted a bill authorizing the Utah Cyber Center to conduct voluntary cybersecurity risk assessments for critical infrastructure and coordinate with government entities on infrastructure safety (HB 165). Utah also enacted legislation creating a specific funding stream for the Center to use for various activities, including implementing a statewide cybersecurity plan and conducting assessments for governmental entities (SB 123). Kansas enacted HB 2574, which would require chief information security officers for the executive, legislative, and judicial branches to adopt cybersecurity programs based on a nationally recognized standard for governmental entities. Finally, Florida recently passed SB 7024, which would expand the state’s public record exemption to include risk assessments, information related to cybersecurity breaches, and information related to data protection, ensuring the confidentiality of sensitive cybersecurity information held by state agencies; the bill is with the governor for final consideration. Key Takeaways for Preparedness Leaders Cybersecurity is critical for preparedness across multiple policy areas, and requires new planning, coordination, and oversight responsibilities. By including cyber incidents into disaster frameworks, standards for health care organizations, and governance, preparedness leaders may find themselves more directly engaged in integrating cybersecurity into emergency operations, exercises, and cross-sector partnerships. For state and territorial health agencies beginning to incorporate cybersecurity into their preparedness plans, agencies such as the Cybersecurity and Infrastructure Security Agency provide jurisdictional support and resources to guide this work. article yes

Explore how states are enacting legislation to help justice-involved people avoid overdose illness and death and foster a smooth transition after release.

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.

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

States Reassessing Vaccine Policy and Public Health Powers Shalini Nair, Andy Baker-White Review of state policies to weaken vaccine requirements and reduce public health powers. Immunization is a key pillar of public health, crucial for protecting communities and preventing infectious diseases from spreading. State and territorial health officials and their departments play critical roles in setting and implementing immunization requirements, managing disease surveillance and outbreak response, and ensuring access to vaccines. In recent years, however, the immunization landscape has evolved as legislative changes alter public health authority and access to vaccines. As these challenges persist, public health officials must be informed and prepared to navigate the dynamic policy environment to ensure immunization programs’ continued effectiveness at protecting public health. The True Cost of Vaccine Skepticism and Misinformation In the years since the pandemic, rates of routine vaccinations among U.S. children have steadily declined; there has simultaneously been an increase in non-medical exemptions. While reasoning behind personal decisions about vaccination are not always clear, increasing prominence of vaccine-related myths is a significant contributor to this phenomenon. Perhaps the most glaring consequence of this decrease is best illustrated by the 2025 measles outbreak and the first measles-associated deaths in more than a decade. Previously considered to have been eliminated, measles is now under threat of resurgence as vaccine rates fall below the thresholds to uphold herd immunity. Health officials are also seeing declines in coverage for several other vaccine preventable diseases like pertussis, mumps, hepatitis, and even polio. Legislation Restricts Innovation and Sows Doubt About Vaccine Components The use of mRNA technology expanded in 2020 following its breakthrough success in COVID-19 vaccines. These mRNA vaccines prevented more than 120 million additional COVID-19 infections and 3.2 million additional deaths. Researchers are currently assessing mRNA technology to address pandemic influenza, HIV, Zika, and even cancer. During 2025 sessions, at least seven states introduced legislation to ban or limit using mRNA vaccines. Iowa’s SF 360 sought to prohibit any “gene-based vaccines” (i.e., those developed using mRNA or DNA technology); the bill was based on a widely debunked myth that mRNA vaccines can interact with and alter human DNA (they can’t). New York’s A 4798 would prevent administering COVID-19 mRNA vaccines until the department of health conducts a risk-benefit analysis. Several states have introduced legislation to prohibit selling — or require labeling foods that contain — vaccine or vaccine material. This bill is based on another common internet rumor that mRNA vaccines are being introduced into the food supply via livestock and produce (they aren’t). Nonetheless, Utah enacted a bill (HB 84) requiring that food intended for human consumption that contains a vaccine or vaccine material be designated as a drug. Similar bills were introduced in Florida (HB 525), Alabama (HB 316), and Tennessee (SB 616, HB 1100). Vaccine Authority’s Shifting Landscape While the federal government plays an important role in putting forth policy recommendations, the ultimate power to impose or revoke vaccine requirements and determine exemptions outside of health emergencies rests with states. In many jurisdictions, state health agency expertise determines the vaccines required for school enrollment. These decisions, while ultimately at the feet of state health officials, rely heavily on input from experienced, knowledgeable, and skilled agency staff. Recent legislative actions in several states seek to shift authority for determining school-based immunization requirements solely to the legislature. Idaho’s new law (H 290) removes the state board of health’s authority to determine which immunizations are required for daycare and school enrollment, as well as the manner and frequency of their administration. The bill also repeals a former law establishing the Idaho Childhood Immunization Policy Commission, created in 2010 to issue recommendations to the legislature and board of health. A similar effort in Maine (LD 727) would remove health department authority to determine school vaccine requirements as part of a larger repeal effort responding to the 2019 law disallowing vaccine exemptions based on religious or philosophical grounds. In New Hampshire, existing statutes define required immunizations for school attendance and allow the state health official to add to this list via the rulemaking process. Recently, lawmakers introduced a bill (HB 357) that would remove this add-on ability. If passed, existing commissioner-led requirements for vaccines such as varicella, hepatitis B, and Hib would expire in June 2026 and no future amendments could occur under this authority. Several other bills introduced in Texas (HB 468, HB 3304, SB 94, SB 117, HB 3852), West Virginia (SB 108, HB 2203), and North Carolina (HB 89) target shifting authority and/or modifying vaccine requirements for certain school types. Evidence-Based Policy as the Path Forward State and territorial health agencies are foundational to preventing the spread of infectious diseases through vaccine education and administration. ASTHO has identified public health expertise in developing vaccination policy as one of three recommended strategies that prioritize evidence-based public health authority and support agencies to protect and improve health. As this landscape further evolves, ASTHO will continue tracking legislative and executive action on this important public health issue. article yes

ASTHO Legislative Prospectus | Prevention 2025 state legislative action on infectious disease control and prevention.

Policy Trends Shaping Access to Care in 2026 Policy Trends Shaping Access to Care in 2026 Learn about policy trends shaping access to care in 2026, including supporting community health workers and improving rural health care. Public health agencies have a role in supporting access to care, which means assuring timely access to covered health care services provided by a qualified workforce. However, many communities experience challenges in accessing health care services, providers, facilities, or affordable care. Gaps in access to services that prevent chronic disease, address maternal health and behavioral health challenges, and other health goals undermine public health’s ability to improve community health. Strategies to improve access to care can include focused attention on underserved or at-risk communities or populations, including rural populations. To support access to comprehensive health care services, state legislatures continue to explore laws that strengthen clinical and community-based health workforces, support rural health care facilities, and promote access to care across the lifespan, including for women. Access to Supportive and Community-Based Health Services Community health workers (CHWs) are frontline public health workers who serve as a link between health and social services and the community, and can help address the social and behavioral health drivers of health outcomes. Many jurisdictions pursued policies to support CHWs by defining the workforce, establishing training or certification programs, and pursuing financial sustainability including through Medicaid programs. In 2025, more than a dozen states considered legislation related to CHWs, with several states enacting laws that recognize CHWs as providers and/or authorize Medicaid coverage and reimbursement. This includes Arkansas HB 1258, which establishes a state certification for CHWs, defines their role, and requires compensation for certified CHW services from both Medicaid and certain regulated health plans in the state. Montana (HB 850) and Oklahoma (SB 424) enacted bills to regulate CHWs but both bills were vetoed by their respective governors. In Oklahoma, the legislature overrode the veto. Rhode Island (S 0705) considered legislation that would require regulated health plans to cover CHW services, and Virginia enacted SB 981 which requires the health department to report on the status of the CHW workforce and future needs. Doulas are non-medical professionals who support individuals during pregnancy, birth, and the postpartum period. Doula care has been shown to reduce the rate of both cesarean sections and postpartum anxiety or depression, and may be cost effective, particularly for Medicaid programs. A majority of states are either pursuing or already offering doula coverage in their Medicaid programs. At least fourteen jurisdictions considered legislation in 2025 to recognize or provide coverage of doula services by Medicaid programs or private insurance. At least six states enacted laws regarding Medicaid coverage of doulas, including Louisiana (HB 454), Montana (SB 319), Utah (SB 284), and Vermont (S 53). In Maine, LD 1523 directs the health department to begin the rate development process for future coverage of doula services, establish a doula council to support that process and provide other advice to the department, and issue a report on the overall progress by February 2027. Arkansas (HB 1252) established a scope of practice for certified community-based doulas and requires compensation by both the Medicaid program and other health benefit plans in the state. Stabilizing and Growing Rural Health Care Access Rural communities face a number of health care challenges, including limited health care providers and financial strain on hospitals and other rural health care facilities. Several states explored strategic initiatives to support rural health care access, both broadly and for specific populations. California enacted SB 338 which establishes a virtual health hub to expand access to health services for farmworkers in rural communities. Iowa enacted HF 972, directing the health department to seek CMS approval for a hub-and-spoke model to support the state’s rural health providers. Finally, Texas enacted HB 18 which creates a rural hospital officers academy to support the education and development of these leaders, includes additional financial support for rural hospitals with obstetrics and gynecology services, and codifies current state programs and offices supporting rural hospitals. More than a third of U.S. counties are considered maternal care deserts, which are places where there are no obstetric providers or facilities. Several states enacted legislation to expand access to pregnancy and maternal health care in rural and underserved areas, including California which enacted SB 669 to create a pilot program for five rural hospitals to provide perinatal services on a standby basis. Arizona (HB 2332) will establish an advisory committee to make recommendations that will ensure the availability of “obstetrics, gynecology and maternal mental health services in low-volume, high-risk rural communities.” And in Connecticut, the governor signed several bills aimed at increasing access to maternal health care, including HB 7102 which requires the development of a strategic plan to increase the number of obstetric facilities in underserved areas of the state. Leg Prospectus-2026 - Access - Rural Health Expanding Support for Mid-Life Women's Health Care Women may experience a number of disruptive symptoms during perimenopause — the transition period before menopause — including difficulty sleeping, memory lapses, hot flashes, and general pain and discomfort. Following menopause, low hormone levels can increase the risk of chronic diseases like osteoporosis, heart disease, and stroke. Lack of knowledge about menopause and its wide range of symptoms, along with stigma, can prevent women from seeking treatment or other supports. Recognizing a growing need to address women's health across the entire lifespan, not just the reproductive years, state legislatures are exploring laws that address the menopause transition and its impacts through education and tailored health care access. In 2025, several jurisdictions — including Texas (HB 3961), Arizona (HB 2734), and Connecticut (AB 6593) — considered legislation directing the development, coordination, or distribution of educational programs and resources on menopause or perimenopause for women or providers, with Maine (LD 1079) enacting a measure requiring the health department to work to create and disseminate informational materials on perimenopause and menopause. Several other states have explored insurance coverage requirements, including New Jersey (A 5278/S 4148) and New York (A 5444) that would require certain health insurers and plans to cover menopausal and perimenopausal care and treatment. California (AB 432) would have required prescription coverage of drugs relevant to perimenopause and menopause care and treatment, and incentivize menopause-specific education for physicians, but the governor vetoed the bill and called for the state health and human services agency to propose policy changes for next year’s budget that address concerns about cost. Looking Ahead ASTHO expects states and territories to continue considering policies related to access to care, including legislation that: Increases coverage of and access to community-based health professionals like doulas, CHWs, and peer support specialists. Improves access to over-the-counter contraception. Recognizes telehealth's role in the health care system to ensure continued access to remote health care, particularly in rural communities. Supports access to reproductive care and women’s health services across the lifespan, including additional funding or other flexibilities to address anticipated changes in the federal funding landscape (e.g., Title X). OE22-2203 PHIG article yes

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

ASTHO's 2024 Legislative Session Update: Part Two Beth Giambrone, Maggie Davis, Christina Severin ASTHO's Public Health Legislative Update on Tobacco, Mental Health, Environmental Health, Workforce, and Containing Infectious Disease By the end of April, at least 36 states will have concluded their regularly scheduled 2024 sessions, with several states passing laws on important public health issues. Earlier this month, ASTHO provided a brief update on five of the top 10 public health state policy issues to watch during the 2024 state and territorial legislative sessions; this update examines the remaining five. Containing the Spread of Infectious Disease Public health agencies have a responsibility to keep their communities safe and healthy by maintaining foundational public health services including identifying, containing, and preventing the spread of communicable disease. ASTHO supports maintaining and guaranteeing robust public health legal authorities allowing public health leaders to meet their responsibilities for containing the spread of infectious disease. Following the COVID-19 pandemic, state and territorial legislatures considered many bills to change public health agency’s legal authorities to meet their responsibility, a trend that ASTHO anticipated continuing into 2024. So far, at least 28 states have considered, and at least two legislatures passed, bills relating to public health authority to address the spread of infectious disease in 2024. For example, the Hawaii legislature passed SB 3122, expanding public health authority by providing the state health official broad authority to issue standing orders for people 18 years and older to receive evidence-based services recommended by the U.S. Preventative Services Task Force. In March, however, Utah enacted HB 405, which limits local public health official’s authority to issue an isolation or quarantine order to specific conditions unless the local legislative body agrees that a new, drug resistant, or reemerging pathogen likely to cause high mortality or morbidity needs containment. Environmental Health Under the Safe Drinking Water Act, the EPA has the authority to set national standards for public drinking water. These standards establish legally enforceable Maximum Contaminant Levels (MCLs) and non-enforceable Maximum Contaminant Level Goals for public water systems. In April 2024, EPA released a final rule establishing legally enforceable MCLs for six PFAS compounds that occur in drinking water. Public water systems have until 2027 to complete initial monitoring and inform residents of the levels of PFAS in their water, and until 2029 to act if their drinking water levels exceed the MCLs. To date in 2024, at least four states have enacted or are considering legislation that would aid in monitoring and remediating PFAS in drinking water. Virginia recently enacted HB 1085/SB 243, which requires that the Department of Health notify the Department of Environmental Quality (DEQ) of any results from their monitoring of public water systems that show MCL exceedances, at which time requires DEQ to implement a plan to prioritize and conduct assessments of the public water system's raw water source(s). The Rhode Island House of Representatives passed H 7439, which would require the Department of Environmental Management to determine the maximum number of PFAS detectable by standard laboratory methods, and specifies the types of water systems that will be required to monitor untreated drinking water for those PFAS by June 1, 2025. Massachusetts is considering H 853, which would require the Department of Environmental Protection to maintain a list of municipalities where PFAS levels exceed the MCL and provide vouchers to homes in those municipalities to purchase home water filtration equipment. Strengthening the Public Health Workforce With several successes in 2023, ASTHO anticipated legislatures to continue considering legislation to strengthen the public health and health care workforces that represent the communities they serve during the 2024 legislative sessions. One strategy is establishing career pathway programs that provide students training and support to pursue public health careers. At least six states have considered, and three have passed, bills creating or strengthening a career pathway program during the current legislative sessions. At least two states have enacted programs to address health care provider shortages in April. Maine’s legislature passed LD 2268, which would allow internationally trained physicians to receive a limited license to practice medicine and address provider shortages in rural areas of the state. Washington enacted SB 5582, directing community and technical colleges to develop a plan in consultation with local workforce development councils and health care employers to train more nurses over the next four years. In May, Hawaii’s legislature passed HB 1827 appropriating funds to support public high school health care workforce certificate programs to support graduates seeking entry-level positions in the health care industry. Supporting Mental Health Children and adolescents continue to experience mental health issues, with teen girls reporting significant challenges. Schools can play an important role in supporting the mental health of all students through direct services or policies that address prevention, education or coordination. In 2024, a number of jurisdictions considered legislation related to youth mental health, through training requirements for staff and students, and support for treatment flexibility in the school setting. At least six jurisdictions considered bills related to mental health education for students, including specific suicide and violence prevention content. Virigina enacted HB 603, which requires school health instruction to include information about common mental health challenges, helpful coping strategies, the importance of seeking help from a professional or other adult, and available school resources. Several jurisdictions, including Virginia (HB 224), Minnesota (HF 4363) and Missouri (HB 2471), also considered establishing or amending suicide prevention and related mental health training programs for teachers and other school staff. Finally, several jurisdictions considered legislation to explore or otherwise support using telehealth services in schools for mental health services. Minnesota is considering legislation that would create a pilot program to determine whether the availability of telehealth services in schools increases mental health access (SF 4236) as well as a requirement to provide space at secondary schools for students to receive telehealth mental health services (HF 3542). New York is currently considering S 8976, which would authorize telehealth services in schools to be delivered by licensed providers, while Maryland enacted HB 522 in April, which requires school districts to develop guidelines to allow telehealth appointments at schools starting in the 2025-26 school year. Tobacco and Nicotine Products According to the American Lung Association, 22 states do not have comprehensive smoke-free laws that help protect against the dangers of second-hand smoke in a variety of settings (e.g., multi-family homes, public spaces, restaurants), or reduce the number of people who start smoking. At least 16 states have introduced legislation aimed at creating, promoting, or expanding smoke-free environments. Connecticut recently enacted SB 132, which expands their clean indoor air act to prohibit vaping at dog race tracks. The Maryland legislature passed HB 238/SB 244, which would update their Clean Indoor Air Act to prohibit vaping in public indoor areas, indoor places of employment, and mass transportation. In addition, the Alabama Senate recently passed SB 37, which would prohibit vaping in public places. In addition, at least 14 states have introduced legislation to either prohibit or further restrict the sale of flavored tobacco products, including menthol products. For example, bills introduced in Hawaii (HB 2441/SB 3130), Minnesota (HF 2177/SF 2123), and New Jersey (S 1947) would prohibit the sale of flavored tobacco products, including menthol, within their jurisdiction. In addition, a bill in New York (A 699/S4477) would ban the sale of flavored smokeless tobacco products within five hundred feet of a public or private school. ASTHO’s state health policy team continues to monitor these important public health issues and will provide relevant updates. website yes

During the 2023 legislative session, a number of states enacted policies that advance ACEs prevention measures and support families in ensuring safe places for their children to live, grow, and play.

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