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Public health leaders are positioned to prevent illness from the "tripledemic” of COVID-19, Influenza, and RSV with approved vaccines and preventative antibody treatments.

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.

An increasing body of research finds racism can have a significant impact across one’s lifespan. Research shows that persistent exposure to racial discrimination may result in premature aging, poor health outcomes, and increased prevalence of certain chronic diseases. At every level of government, policymakers are seeking to acknowledge the systemic oppression of people of color that persists and to elevate racism as an urgent public health crisis comparable to other public health emergencies.

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.

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

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.

Public Health Approaches to Preventing Suicide and Promoting Mental Well-Being Public Health Approaches to Preventing Suicide Caitlin Langhorne Griffith, Arnelle Toffey Learn how to execute public health approaches to preventing suicide, which requires understanding the dynamics of policymaking and implementation. Despite ongoing prevention efforts, suicide remains a leading cause of death and disability among Americans of all ages, racial and ethnic groups, geographic regions, and socioeconomic statuses. While suicide affects populations at all levels, it continues to be the second leading cause of death in individuals under 44 and disproportionately impacts veterans, individuals with lower income and educational attainment, and residents in rural areas, among other groups. Approximately 6% of the U.S. population has a Serious Mental Illness (SMI) (e.g., bipolar disorder, major depressive disorder, and schizophrenia), and a 2022 study found that almost 10% of people who die by suicide had a known SMI. In addition, individuals with or without SMI can experience suicidal ideation or attempts. Factors such as adverse childhood experiences, limited access to health care, and economic instability can contribute to suicide risk. Public health approaches that expand treatment access and address the drivers of suicide risk can help foster mental well-being in communities and reduce the risk of individuals dying by suicide, including those with SMI. However, executing these approaches requires understanding the dynamics of evidence-based strategies in policymaking and implementation. Population-Based Approaches Expanding access to mental health care is critical for reducing risk and managing symptoms of mental illness, as only 50% of young adults (18 to 25 years old) and 53% of adults (26 to 49 years old) with any mental illness received treatment in 2024. However, barriers to mental health care — such as availability of providers, access to telehealth, cost, and other systemic factors — can prevent individuals from receiving treatment, especially during serious declines in mental health. Population-based approaches can fill this gap by focusing on non-clinical interventions and activities that address chronic stressors and other factors contributing to mental health declines, improving mental health outcomes. Examples of these policies include: Addressing structural determinants of suicide risk (e.g., economic security). Promoting access to clinical services (e.g., Medicaid expansion and state mental health parity laws). Limiting access to lethal means for suicide (e.g., child access prevention laws and access to high-risk medications). 988 Suicide & Crisis Lifeline State health agencies can also consider approaches that provide and enhance direct crisis support. The 988 Suicide & Crisis Lifeline is a nationwide hotline that provides emotional support to individuals experiencing suicide, mental health, or substance use crises. Since its launch in July 2022, call volumes have steadily risen in all states, and the Lifeline has been shown to improve callers' mental well-being as well as reduce suicide risk. Implementation of the 988 Lifeline occurs at both the state and local levels, resulting in variations in funding and infrastructure across communities. In the most recent legislative session, jurisdictions enacted legislation to fund and sustain 988, ensuring consistency in quality and access across all communities. For example, North Dakota SB 2200 allocates funding for 988 operations from a community health trust fund, while Texas HB 5342 established a trust fund outside of the state treasury to support the 988 Lifeline. States also enacted legislation either consolidating (Colorado SB 236) or ensuring interoperability with 988 and 911 emergency lines (Nebraska LB 362), streamlining services and accessibility for those in need of mental health support. In addition, 12 states have adopted a 988 telecom fee — similar to fees that support 911 infrastructure in every state — to create a sustainable financing source for 988. Adolescent Mental Health Support at School Schools are a critical setting to support adolescent mental health, particularly for children with serious emotional disturbances who are at elevated risk of suicide. Several states have mandated suicide prevention training requirements for school personnel as part of ongoing professional certification requirements. Federal funding — such as the Suicide Training and Awareness Nationally Delivered for Universal Prevention Act, which focuses on evidence-based programs for students — can help states and tribes establish/expand training for school staff and equip them with the education to recognize warning signs and connect students to resources, alongside student-directed programs that increase mental health literacy and foster peer support. In the 2025 legislative session, at least three states enacted legislation focused on preventing youth student suicide. Kentucky (HB 48) and Montana (SB 369) mandate training for school staff on suicide awareness and prevention, while Virginia HB 2055 requires school staff to provide materials to parents on suicide prevention (including the safe storage of firearms) if they believe a student is at imminent risk. At least three additional states enacted legislation that requires student identification cards to include mental health information and suicide crisis resources, including the 988 Lifeline (Colorado SB 326, Illinois HB 3000, New Jersey A 4897). Georgia HB 268 requires public schools to provide at least one hour of suicide awareness prevention and training to students in grades 6-12. Conversely, an Idaho bill (SB 1199) that would amend a 2024 law to allow minors to access medical treatment when calling the 988 Lifeline without parental consent passed the Senate but did not advance in the House. Jurisdictions have also incorporated policies that provide additional safeguards for adolescents and their use of the internet: Utah recently enacted SB 98, which requires the state Board of Education to create a video presentation for parents outlining the safety and legal issues students may encounter while using technology. Maryland's SB 310 expands the state's Youth Suicide Prevention School Program to include instruction to students on the relationship between gambling and youth suicide. At the federal level, Congress is considering the Kids Online Safety Act, which requires platforms, applications, and streaming services that connect to the internet to exercise care in creating and implementing design features to prevent and mitigate harm to minors. Looking Forward It is important to understand suicide prevention approaches nationwide, including how jurisdictions formalize and strengthen suicide prevention infrastructure as well as promote healthier environments. Strategies for policymakers include the following: Analyzing and comparing suicide prevention infrastructure laws nationwide to identify gaps and guide jurisdictional changes. Building protective environments that address upstream social and structural risk factors (e.g., access to clinical services and food insecurity), while advancing policies that reduce access to lethal means. Strengthening school-based prevention efforts by leveraging available funding to expand evidence-based programs, train school staff, establish student-directed programs, and connect students to needed resources. Promoting safer online spaces for youth with policies that limit harmful design features, strengthen parent engagement, and increase online platform transparency. Continuing investments in crisis services to expand and sustain programs like the 988 Lifeline. Prioritizing economic support policies to strengthen families and reduce ACEs, supporting healthier development and well-being. Leveraging these legal and policy frameworks can reduce suicide risk, support mental well-being, and build a stronger public health system for all. article yes

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

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

Preventing Hypertension Through State Policy Efforts Preventing Hypertension Through State Policy Efforts Beth Giambrone Learn how state legislatures are working to prevent hypertension through avenues like expanded access to care, insurance, and education. Nearly half of all U.S. adults live with hypertension, or high blood pressure. Often called a “silent killer” because it has no noticeable symptoms, hypertension significantly increases the risk of serious health problems, such as heart attack, stroke, and vision loss. It’s also one of the most expensive health conditions, with recent research showing that more than 10% of health care expenditures were associated with hypertension. Managing high blood pressure through a healthy diet, lifestyle changes, and medication (if necessary) are some of the most protective mechanisms against serious health effects. In recent years, state legislatures have started exploring ways to support residents in preventing and managing hypertension through expanded access to care, insurance coverage, and education. Access to Care Heart disease is the leading cause of death for women in the United States, accounting for about 20% of deaths in 2023. Focusing on heart health during key milestones such as pregnancy and menopause can provide a vital safety net in times of significant physical change. Pregnancy can act as a natural "stress test" for the heart, and approximately 10% of all pregnancies are affected by hypertensive disorders of pregnancy (e.g., chronic and gestational hypertension, preeclampsia, and eclampsia). In 2026, at least four states (Maryland, Pennsylvania, Tennessee, and Virginia) are considering bills that would establish pilot programs to improve maternal health for individuals receiving Medicaid, one activity being remote monitoring of blood pressure. Two bills in Florida (HB 1029 and SB 1508) would expand current home visiting programs (i.e., Healthy Start) to include expectant mothers and require the Department of Health to provide them with home blood pressure monitors. Meanwhile, New York companion bills (A 5529 and S 3881) would establish comprehensive care centers in Kings and Bronx Counties. These centers would provide prenatal through postpartum services as well as heart health care, while collaborating with local organizations and universities to research and close gaps in care. Like pregnancy, perimenopause and menopause cause hormonal shifts that make the heart and blood vessels more sensitive to change, increasing the risk for cardiovascular disease. North Carolina (SB 522) is considering a comprehensive bill that aims to improve care for women between the ages of 40 and 65. It would require health insurance to cover services the state deems essential for midlife care, including those that prevent cardiovascular disease. Insurance Coverage In addition, states are exploring how insurance coverage and regulation can support hypertension treatment and prevention, with several aiming to cover blood pressure monitors: Florida’s SB 736 would require the state’s Medicaid program to cover blood pressure monitoring devices for prescribed patients who participate in follow-up care. Minnesota companion bills (HF 2320 and SF 1963) would mandate that health plans cover one monitor every three years for people with uncontrolled blood pressure, and reimburse providers for patient training. Similarly, West Virginia’s SB 252 would provide blood pressure monitors to Medicaid enrollees with uncontrolled hypertension during pregnancy or the first postpartum year. Additionally, New York is considering legislation to reduce health insurance premiums when certain conditions are met. A 7177 would allow health insurers to offer premium reductions if the individual participates in a qualified wellness program (e.g., risk management) or programs that mitigate chronic disease, like hypertension, or promote physical fitness. Public Awareness and Education During this legislative session, several jurisdictions are also exploring public and school-based awareness of heart healthy activities. For example, Georgia’s HB 459 would authorize the Department of Health to implement a comprehensive campaign that includes developing educational materials, partnering with schools and colleges to educate students on cardiovascular disease (i.e., recognizing symptoms), and assisting community health centers with providing free or low-cost screenings. West Virginia is also considering two bills (SB 39 and SB 819) that would mandate 12-week nutrition and aerobic exercise programs for elementary students. Finally, Mississippi introduced a suite of bills (HB 1367, HB 192, and HB 1088) to standardize physical activity, improve nutrition standards, and mandate health curriculums across all grade levels, but the bills recently died in committee. Conclusion Policies aimed at improving heart health can go a long way in reducing hypertension and stopping the silent killer. ASTHO will continue to monitor policies that address hypertension as a core component of public health and provide any necessary updates. OE22-2203 PHIG article yes

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

ASTHO’s 2024 Legislative Session Update: Part One legislative session, state policy, data collection, domestic violence, health information exchange, data privacy, substance misuse, overdose prevention, sexually transmitted infections, reproductive health, contraceptive care, climate change, public health, protect data, user data, personal data, centers for disease control, disease control and prevention, social media, data management, primary care, health organizations, higher risk, family planning, data sources, astho, association of state and territorial health officials Lillian Colasurdo, Maggie Davis, Lana McKinney, JoAnne McClure This past December, ASTHO announced the top 10 public health state policy issues to watch for during the 2024 state and territorial legislative sessions. With at least 30 states concluding their regularly scheduled 2024 sessions, here is a brief update on five of the topics to watch. Data Collection and Exchange As expected, there was an increase in proposed legislation that specifically advances electronic health data access, encourages interoperability, and safeguards identifiable patient health records; this was particularly true for vital records. Hundreds of bills have been introduced this session addressing state vital records systems. The state of Illinois alone has already passed several bills, including HB 2856, which requires veteran status to be designated on death certificates, and HB 2841, which prohibits the assessment of fees to victims of domestic violence who are seeking a certified vital record (birth or death certificate) from the state. Other states such as Arizona (SB 1252) considered legislation that would require the Department of Health to provide vital records information on deceased individuals to the qualifying health information exchange (HIE). Arizona is one of eight jurisdictions (AZ, FL, IA, IL, NH, NJ, OK, and WV) that have proposed legislation addressing HIEs this session. Most of these bills increase requirements to connect to HIEs, but New Hampshire HB 1663 and Oklahoma HB 3556 would allow patients and health care providers to opt out of HIEs. As many states look to address health data privacy concerns, New Hampshire recently passed a constitutional amendment granting the explicit right to privacy and has introduced HB 1663, which would update many of the state’s privacy laws regarding medical records to conform with the constitutional requirements. Just next door, Maine considered legislation (LD 1902) that would strengthen privacy requirements for reproductive and gender-affirming patient health information. Finally, the launch of the new federal Trusted Exchange Framework and Common Agreement (TEFCA) led to the Florida legislature proposing SB 668, which, had it passed, would have required hospitals to make patient records available through a nationally recognized trusted exchange framework. It would also have required the Agency for Health Care Administration to adopt relevant rules. Substance Misuse and Overdose Prevention Measures to prevent substance misuse and reduce overdoses, namely increasing access to opioid antagonists, such as naloxone and regulating substances with the potential for misuse, are priorities this legislative season. ASTHO anticipated that states would consider legislation to reduce fatal overdoses including decriminalizing drug checking equipment, expanding naloxone access and distribution, establishing overdose prevention centers, and establishing state regulatory frameworks for commercial substances with the potential for misuse, including kratom and Delta-8. Current legislative priorities to expand access to naloxone include public spaces, such as libraries, schools, workplaces. Island jurisdictions along with at least four states—Colorado (HB 24-1003), Tennessee (SB 2141), Virginia (HB 732), and Wisconsin (AB 223)—passed legislation to provide greater access to and/or proper storage of naloxone in school settings. Additionally, Virginia passed HB 342 that requires naloxone access in state agency buildings. These legislative actions, along with the approval last year by the FDA of two non-prescription naloxone spray products for over-the-counter use, are collectively powerful policy shifts to expand access to naloxone. In an attempt to regulate substances with the potential for abuse or misuse, specifically kratom, eight states have considered legislation that would restrict the sale to people under the age of 18. Similarly, twelve states have considered legislation that would restrict the sale of kratom to those under the age of 21. At least 22 states have considered legislation that would compel specific labeling requirements for kratom. Of those, California (AB 2365) and New Jersey (A 1188) would require kratom products to be registered with the state health department annually and require lab testing of the product to meet certain qualifications. Preventing Sexually Transmitted Infections ASTHO has spotlighted the growing concerns of rising rates of sexually transmitted infections and state actions reducing congenital syphilis rates and expanding access to HIV prophylaxis (PrEP) and post-exposure prophylaxis (PEP). Rates of both syphilis and congenital syphilis continue to rise at an alarming rate, with more than 10 times as many babies being born with syphilis in 2022 than in 2012. Routine screening and timely and adequate treatment of pregnant people for syphilis, ideally more than 30 days before delivery, can effectively prevent this condition in newborns. Due to increasing cases, the American College of Obstetricians and Gynecologists recently updated their guidance for obstetrician–gynecologists and other obstetric care professionals advising serological screening for all pregnant individuals at the first prenatal visit and universal screening at the third trimester and at birth. During the 2024 legislative session at least two states—Missouri (SB 1260) and Maryland (HB 119)—are considering legislation that would require testing during pregnancy care at the third trimester for syphilis. Maryland’s legislature passed HB 119, which would require screening at the third trimester and at birth, as well as requiring the hospital to determine the syphilis status of the birthing parent before discharging the newborn. In 2023, New York enacted legislation (A 3007) that requires syphilis screening in the third trimester, and in the current legislative session they are considering S 2472, which would allow the state health department to provide education about congenital syphilis and screenings. At least six states have considered and passed legislation during the 2024 legislative session regarding expanded access for HIV prophylaxis (PrEP) and post-exposure prophylaxis (PEP). Of those considered, Georgia enacted HB 1028 to allow PEP to be issued by a standing order; Florida’s legislature passed HB 159 that would allow pharmacists to screen for HIV exposure, order, and dispense prevention drugs PEP and PrEP and sent it to the governor. Similarly, in Delaware the Senate chamber passed SB 194 that would permit pharmacists to provide PrEP and PEP pursuant to an approved protocol. Family and Reproductive Health Policymakers across all levels of government continued taking steps to make it easier for people to access contraceptives. In 2023, at least 14 states enacted laws in 2023 to facilitate expanding access to contraceptive care by either expanding the ability for pharmacists to dispense birth control without an individualized prescription and/or allowing pharmacists to dispense up to 12 months of contraceptives at once. So far in 2024, at least 13 jurisdictions considered legislation allowing pharmacists to dispense contraceptives without a prescription and at least 18 states considered legislation supporting access to 12 month supply of contraceptives. Following FDA’s July 2023 approval of Opill—the first over-the-counter (OTC) birth control pill—the drug is currently available in stores with several major pharmacies and health plans announcing that they will provide the medication at zero cost for many health plan sponsors. To further support access to Opill, at least two states (New Mexico and Wisconsin) issued standing orders for Opill to facilitate Medicaid coverage of the medication. Additionally, Maryland’s legislature passed SB 527 in March 2024, which requires community colleges to develop and implement a plan to provide students access to OTC contraception. In February 2024, New York enacted S 8096 allowing the commissioner of health to issue a standing order allowing a pharmacist to dispense self-administered hormonal contraceptives, effective retroactively to January 1, 2024. Under the new law, New York’s Commissioner of Health issued a standing order to allow pharmacists to dispense up to 12 months of self-administered hormonal contraceptives like birth control pills, vaginal rings, and contraceptive patches. Optimal Health for All ASTHO anticipates policymakers will take steps to improve collection of health disparities data, address inequities rural communities face in accessing care, and to support climate change adaptation planning efforts. So far in the 2024 legislative session, several states are considering bills to improve health care access and outcomes in rural areas. California is considering legislation (SB 945) that would build an integrated data dashboard to provide the public with information on the health impacts caused by wildfires and the effectiveness of forest health and wildfire mitigation on health outcomes. Additionally, California (AB 2342) is looking to ensure critical access hospitals on remote islands receive adequate funding through a dedicated annual supplement. New York is considering at least two bills that would promote rural health care access. First, New York S 8582 would create a pilot program to identify rural health zones and convene a rural health zone board

Though we’ve made progress on the number of HIV cases in the U.S, tens of thousands of Americans are diagnosed with HIV each year—a disproportionate number being people of color. In 2019, the federal government launched the Ending the HIV Epidemic: A Plan for America (EHE) with a goal of ending the HIV epidemic by 2030. EHE leverages four strategies to reduce the prevalence of HIV: diagnosis, treat, prevent, and respond. State efforts to reduce the incidence of HIV align with the federal plan, with many states passing legislation to enhance prevention and harm-risk reduction efforts.