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I think we all welcomed 2021 with open arms as we look to put the worst of 2020 behind us. We have all been through a lot—we have lost family members and friends to COVID-19, we have seen public health officials harassed and maligned, we sheltered-in-place, stayed home, and radically altered our day-to-day schedules, we have witnessed protests over police brutality and racial discrimination, and we have lived through (and still are living through) a presidential transition unlike any other. Despite all the challenges, turmoil, and changes wrought by 2020, the work of state and territorial public health continues. What is on our ASTHO horizon as we greet this new year and the opportunities and challenges it presents? Here are a few things on my mind as I look toward the future.

People who use electricity-dependent durable medical equipment (DME) at home—such as ventilators and oxygen concentrators—can face life-threatening consequences during a power outage. HHS reports that 2.7 million Medicare beneficiaries rely on electricity-dependent DME to live independently. This ASTHOBrief details the significant challenges that individuals who rely on electricity-dependent DME face during power outages and discuss recent efforts to increase support for this population.

On March 23, 2023, ASTHO President Anne Zink testified before the U.S. House of Representatives Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies.

On March 2, 2023, ASTHO announced that during the 2023 spring meeting, island health officials will also meet with Congress and the administration to urge them to strengthen island health systems and infrastructure.

On Dec. 15, 2021, ASTHO released its list of the top 10 state public health policy issues to watch in 2022. Although COVID-19 did not make the “official” list, it is woven into the management plan for nearly every trend. The 10 public health issues to watch in 2022 are public health authority, immunization, mental health, data privacy and modernization, health equity, the public health workforce, HIV, PFAS, e-cigarettes, and rural health.

On Sept. 28, 2022 ASTHO CEO Michael Fraser, PhD, attended the White House Conference on Hunger, Nutrition, and Health, a unique convening of advocates, lawmakers, and experts to end hunger, improve nutrition and physical activity, and reduce disparities.

On March 10, 2020, ASTHO member and Mississippi state health officer, Thomas Dobbs, MD, MPH, testified before a House subcommittee about the state of the COVID-19 response.

State and Local Health Officials at the Capitol to Urge Congress to Prioritize Funding for Public Health ARLINGTON, VA—Over 80 state, local, and territorial health officials from across the country will meet with members of congress on Capitol Hill together on March 13, 2019. The aim of their visits is to share the critical need to sustain investments in public health agencies that protect and promote the health of all Americans and prevent sequester cuts in the FY20 budget. This is the first-time members of the Association of State and Territorial Health Officials (ASTHO) and the National Association of County & City Health Officials (NACCHO) will combine their annual Hill Days to show a collective voice for governmental public health at the Capitol. Public health leaders are concerned about the impact of the potential $55 billion cut to non-defense discretionary spending that will happen in FY2020 if Congress does not act to prevent it. ASTHO and NACCHO strongly urge Congress to work in a bipartisan manner to raise FY2020 budget caps and provide needed funding for non-defense discretionary programs, and support increasing CDC’s budget 22 percent by FY22. “Our entire governmental public health system is strained. My colleagues are on the ground dealing with several measles outbreaks, the opioid epidemic, and natural disaster recovery, all while continuing the core work of disease prevention—especially at the community level. Unfortunately, we are consistently underfunded and must do more with less. As a nation, we must do better and prioritize investing in public health,” says Nicole Alexander-Scott, MD, MPH, ASTHO president and director of the Rhode Island Department of Health. “Every person and every community should have the opportunity to be as healthy as possible. As part of ASTHO’s President’s Challenge, additional federal resources will help equip health officials to mobilize community-led, place-based collectives to improve the way we live, work, and play.” “In the decade since the Great Recession, public health departments have lost about a fifth of their workforce due to funding issues and recovery has been slow at best. We see the impact of these resource losses on the health and well-being of our communities every day. In so many areas of public health, we know what works, but we don’t have the resources to ensure that all Americans, no matter where they live, have access to the same basic public health infrastructure, services, and protections,” says Kevin Sumner, NACCHO president and health officer/director for the Middle-Brook Regional Health Commission. “So much of our public health system operates silently in the background. By joining together on Capitol Hill, we will amplify our voice and spread the message of the importance of governmental public health in all sectors.” For more information on ASTHO’s advocacy priorities, visit http://www.astho.org/Advocacy-Materials. For more information about the President’s Challenge, visit http://www.astho.org/ASTHO-Presidents-Challenge/2019. For more information on NACCHO’s advocacy priorities, visit https://www.naccho.org/uploads/downloadable-resources/flyer_legislativeagenda_2019.pdf. ASTHO Press Release Boilerplate NACCHO Boilerplate website yes

ASTHO President Scott Harris, MD, MPH, Testifies to Congress Advocating for Sustainable and Predictable Public Health Funding ARLINGTON, VA — Scott Harris, MD, MPH, president of the Association of State and Territorial Health Officials (ASTHO) and state health officer for the Alabama Department of Public Health, testified today before the House Committee on Appropriations Subcommittee on Labor, U.S. Department of Health and Human Services (HHS), Education and Related Agencies. Harris emphasized the importance of providing sustainable and predictable federal funding for key programs and initiatives at the Centers for Disease Control and Prevention, Health Resources and Services Administration, and other federal health agencies that enhance our nation’s public health. In addition, he mentioned the challenges associated with the recent cancellation of COVID-19 grants by HHS. “Governmental public health agencies are on the front line protecting our nation and improving the health and well-being of the entire U.S. population. Our country continues to face many public health challenges, deaths associated with chronic diseases, the re-emergence of vaccine-preventable diseases, and opioid misuse,” says Harris. “To build long-term resilience, public health funding must be consistent, forward-looking, and rooted in community-driven initiatives that address the needs of people where they live.” ASTHO calls on Congress to provide stable and long-term financial support for public health agencies. Without consistent investment state, local, tribal and territorial health agencies will struggle to strengthen their infrastructure, build public trust and protect the health and safety of all Americans. We must have a firm commitment to lasting resources that ensure a healthier future for our communities. For more information about the hearing, please visit the committee YouTube channel and read Harris’s full testimony. ASTHO Press Release Boilerplate website yes

State and Territorial Health Leaders Convene on Capitol Hill to Advocate for Sustained Funding ARLINGTON, VA—The Association of State and Territorial Health Officials (ASTHO) leadership and public health officials will gather in Washington, D.C. from March 10-13 for the annual Spring Leadership Forum. Attendees will gather to discuss key policy issues, attend peer learning sessions, and advocate for critical funding on Capitol Hill. Health officials are expected to highlight the value of federal funding to public health agencies as well as infrastructure needs, with the looming expiration of federal funding on March 14. Specifically, ASTHO requests Congress provide $365 million in FY25 and invest $1 billion, which equates to about $3 per person in the United States, in FY26 for vital public health infrastructure. “This week, ASTHO members are meeting with Congress to advocate for adequate resources to sustain vital, life-saving public health operations,” says Joseph Kanter, MD, MPH, ASTHO CEO. “In-person meetings allow health officials to shed light on the impact of legislation on state-level health systems. Our goal is to foster bipartisan collaboration and advocate for Americans across the country who rely on federally funded programs to stay healthy.” Additionally, senior leadership from the five U.S. territories and three freely associated states (T/FAS) will participate in an island-tailored set of meetings with Congressional and federal agency partners. On Capitol Hill, ASTHO’s T/FAS members will discuss the impact of the recently renegotiated Compacts of Free Association, as well as emphasize the importance of territorial Medicaid funding and the challenges associated with the Section 1108b cap on territorial Medicaid funding. "ASTHO’s Spring Leadership Forum is a critical opportunity for U.S. territorial and freely associated state health officials to make our voices heard in Washington, D.C. We look forward to working with members of Congress and federal agencies on emerging federal and island public health priorities," says Dr. Esther Muña, CEO of the Commonwealth of the Northern Mariana Islands’ Commonwealth Healthcare Corporation, chair of the ASTHO Insular Affairs Committee, and Director on the ASTHO Board. ASTHO Press Release Boilerplate website yes

Policy & Advocacy Association of state and territorial health officials, astho, advocacy and policy, state and territorial health officials, public health agencies, federal government affairs, state health policy, public health policy, public health policies, public health officials, public health appropriations, public health programs, public health advocate, public health practice, public health legislation, states and territories, health policy, public health issues, public health leaders, public health lawyers, policy research and analysis, legislative tracking and analysis ASTHO’s federal and state government experts provide our members with guidance and education on public health policy development and legislation. ASTHO works closely with state and territorial health officials to shape laws, regulations, and administrative actions that drive improvement in governmental public health agencies. We ensure that decisions affecting our nation’s health and well-being incorporate the insights of state and territorial leaders. Our efforts include developing policy statements, legislative and legal analyses, technical assistance, and capacity-building activities. Our policy and advocacy work follows two critical paths: website

Federal Government Affairs Engaging in Government Affairs for Public Health Access timely information about public health related policies, and tap into the legislative and advocacy expertise of ASTHO’s Government Affairs team. ASTHO offers personalized legislative and advocacy expertise to our members. Additionally, ASTHO helps prepare them to provide testimony before Congress or participate in congressional briefings. We also provide congressional leaders and their staff with timely and relevant information regarding public health activities in their respective jurisdictions to guide their consideration of public health related policies. website

On Oct. 4, 2023, ASTHO responded to a Request for Information from the U.S. House of Representatives' Ways and Means Committee on the subject of improving access to healthcare and rural and underserved areas, including the island jurisdictions.

President Trump Releases FY27 Budget Proposal: April 2026 President Trump Releases FY27 Budget Proposal: April 2026 Learn how the Administrations FY27 budget proposal impact public health funding in this Legislative Alert. On April 3, the White House released President Trump’s FY27 discretionary budget proposal, which outlines the Administration’s funding priorities for the upcoming fiscal year beginning on October 1, 2026. The documents reflect the Administration’s planned HHS reorganization, proposed funding levels, and various policy and legislative proposals. As a reminder, Congress has the authority to approve, reject, or modify the Administration’s budget recommendations. Therefore, public health leaders must continue to educate and inform members of Congress about the impact of public health funding and the need for sustainable, predictable resources for governmental public health activities across federal, state, territorial, and local agencies. For additional information, please review the following documents: HHS Budget in Brief (PDF) Centers for Disease Control and Prevention (PDF) Administration for a Healthy America (PDF) Administration for Strategic Preparedness and Response (PDF) Centers for Medicare and Medicaid Services (PDF) Food and Drug Administration (PDF) Office of the Secretary: General Departmental Management (PDF) Environmental Protection Agency (PDF) It is challenging to conduct a detailed analysis of the budget proposal because many programs are eliminated, funding is consolidated or moved to different agencies. As a result, the ASTHO Government Affairs team cannot make a comprehensive comparison between FY26 enacted funding levels and the FY27 budget proposal. The information provided below is pulled directly from tables in the budget documents released by the Administration. Key Public Health Funding Proposals Overall, the budget proposes $111.1 billion in discretionary budget authority for HHS, a $15.8 billion or 12.5% decrease from the 2026 enacted level. Eliminates the Prevention and Public Health Fund, which provided $1.4 billion in funding across various CDC programmatic activities in FY26. Proposes establishment of the Administration for a Healthy America (AHA) (similar to the FY26 budget proposal) as part of a major reorganization of the Department of Health and Human Services. Specifically, it consolidates and relocates programs from across the Office of the Assistant Secretary for Health (OASH), the Health Resources and Services Administration (HRSA), the Substance Abuse and Mental Health Services Administration (SAMHSA), and from several CDC centers such as the National Center for Chronic Disease Prevention and Health Promotion, National Center for Injury Prevention and Control, and the National Center on Birth Defects and Developmental Disabilities. Establishes a new National Center for Chemicals and Toxins within CDC, to bring together complementary programs across HHS, to include: National Institute for Toxicological Research (from FDA) Agency for Toxic Substances and Disease Registry National Institute for Occupational Safety and Health (CDC) National Center for Environmental Health (CDC) National Institute for Environmental Health Sciences (from NIH) Establishes (similar to the FY26 budget proposal) a new $300 million grant program that consolidates hepatitis, STI, and tuberculosis grant funding into one program. The budget eliminates the following programs to reset the balance between federal and state responsibilities, among other reasons: Previously in CDC: Tobacco and Prevention Control Nutrition, Physical Activity, and Obesity School Health Vision and Eye Health Inflammatory Bowel Diseases Interstitial Cystitis Excessive Alcohol Use Chronic Kidney Disease Chronic Disease Education and Awareness Prevention Research Centers Heart Disease and Stroke Diabetes National Diabetes Prevention Program Oral Health Arthritis Epilepsy National Lupus Patient Registry Racial and Ethnic Approaches to Community Health (REACH) Million Hearts National Early Child Care Collaboratives Hospitals Promoting Breastfeeding Safe Motherhood/Infant Health Adverse Childhood Experiences Firearm Injury and Mortality Prevention Research Drowning Elderly Falls Other Injury Prevention Activities Injury Control Research Centers Previously in HRSA: Rural Hospital Flexibility Grants State Offices of Rural Health Rural Hospital Stabilization Pilot Program Rural Hospital Provider Assistance Program AIDS Education and Training Centers – Part F Dental Reimbursement Program – Part F Special Projects of National Significance Minority HIV/AIDS Fund Early Hearing Detection and Intervention Emergency Medical Services for Children Healthy Start Title X Family Planning Loan Repayment/Faculty Fellowships Scholarships for Disadvantaged Students Health Careers Opportunity Program Primary Care Training and Enhancement Oral Health Training Programs Medical Student Education Area Health Education Centers (AHEC) Geriatric Programs Mental and Behavioral Health Public Health/Preventative Medicine Advanced Nursing Education Nursing Workforce Diversity Nurse Education, Practice, and Retention Nurse Faculty Loan Repayment Public Health Reports Previously in SAMHSA: Seclusion and Restraint Mental Health Awareness Training Healthy Transitions Infant and Early Childhood Mental Health Children and Family Programs Consumer and Family Network Grants Mental Health System Transformation Project LAUNCH Primary and Behavioral Health Care Integration Primary and Behavioral Health Care Integration Tribal Training and Technical Assistance Center Mental Health Crisis Response Partnership Pilot Program Homelessness Prevention Programs Criminal and Juvenile Justice Program Assertive Community Treatment for Individuals with Severe Mental Illness Homelessness Prevention Programs Mental and Behavioral Health Minority AIDS Mental Health Minority Fellowship Program Tribal Behavioral Health Grants Interagency Taskforce on Trauma-Informed Care Eating Disorder Identification, Treatment, and Recovery Community Mental Health Services Block Grant Substance Use Treatment Minority AIDS SAT Minority Fellowship Program Substance Use Prevention, Treatment, and Recovery Services Block Grant State Opioid Response Grants Strategic Prevention Framework Substance Use Prevention Minority AIDS Sober Truth on Preventing Underage Drinking Minority Fellowship Program Tribal Behavioral Health Grants Drug Abuse Warning Network Behavioral Health Workforce Data and Development Hepatitis C Previously in OASH: Teen Pregnancy Prevention Kidney X Sexual Risk Avoidance Office of Adolescent Health Administration for a Healthy America The request proposes $17.5 billion for the Administration for a Healthy America (AHA). Primary Care $3 billion, for Health Centers, including $1.8 billion in discretionary funding and $1.1 billion in mandatory resources, a decrease of $3.5 billion. $59 million, or level funding, for the Organ Transplantation program. $41.3 million, a $11 million decrease, for the Cell Transplantation program and Cord Blood Stem Cell Bank program. $14 million, or level funding, for the National Hansen’s Disease program. $11 million, or level funding, for Rural Health Policy Development. $111 million, or level funding, for Rural Health Outreach Grants. $4 million, a $2 million increase, for Radiation Exposure Screening and Education Program. $12 million, or level funding, for the Black Lung Clinics program. $145 million, or level funding, for the Rural Communities Opioid Response program. $14 million, or level funding, for Rural Residency Planning and Development. $70 million, a $24.5 million increase including $20 million for chronic care telehealth centers of excellence, for the Office for the Advancement of Telehealth. $26 million, or level funding, for the Office of Disease Prevention and Health Promotion. $45 million, a $30 million decrease, for the Office of Minority Health. $19 million for a new Prevention Innovation Program. Chronic Disease and Health Prevention $448 million, a $985 million decrease, for chronic disease and prevention activities. $35 million, a $6.5 million decrease, for Alzheimer’s disease. $413 million, or level funding, for Cancer Prevention and Control. Injury Prevention and Control $588 million, a $173 million decrease, for Injury Prevention and Control (formerly in CDC). Specifically: $12 million, a $18 million decrease, for Comprehensive Suicide Prevention. $38 million for the Preventing Intimate Partner and Sexual Violence Program. This program replaces the Rape Prevention Education and Domestic Violence Prevention Enhancements and Leadership Through Alliances programs. $25 million, or level funding, for the National Violent Death Reporting System. $506 million, or level funding, for the opioid overdose prevention and surveillance. $8 million, or level funding, or traumatic brain injuries. HIV/AIDs $2.7 billion, a $923 million decrease, for HIV/AIDS programs. Specifically: $680.7 million, or level funding, for Part A- Emergency Relief Grants. $1.4 billion for Part B Comprehensive Care, which includes $900 million for the AIDS Drug Assistance program. $209 million, or level funding, for Part C Early Intervention Services. $78 million, or level funding, for Part D Women, Infants, Children, and Youth. $165 million, or level funding, for the Ryan White HIV/AIDS Ending HIV Epidemic. $220 million, or level funding, for the Ending HIV Epidemic initiative transferred from the CDC Domestic HIV Prevention and Research. $8 million, or level funding, for the Office of Infectious Disease and HIV/AIDS Policy. Maternal & Child Health $1.9 billion, a $561 million decrease, to support maternal and child health programs. $767 million, a $51 million decrease, for the Maternal and Child Health Block Grant. $17 million, or level funding, for the Alliance for Innovation for Maternal Health program. $10 million, or level funding, for the

November 2025 Federal Funding and Government Shutdown Update November 2025 Government Shutdown/Funding Update Learn about the Continuing Appropriations Act, 2026, that the Senate agreed to vote on to end the current government shutdown. On Nov. 9, 2025, the Senate agreed to vote on the Continuing Appropriations Act, 2026, to end the current government shutdown and fund portions of the federal government through a continuing resolution (CR) that would expire Jan. 30, 2026. The CR keeps current federal funding levels and applies to agencies such as CDC, HRSA, SAMHSA, and EPA. The rest of the federal government, including programs within the Department of Agriculture, FDA, the Department of Veterans Affairs, and the operations of Congress would be funded through full fiscal year appropriations bills expiring on Sept. 30, 2026. The bill also specifies a number of requirements related to federal workforce, state reimbursement, and spending which are detailed in the sections that follow. Outlook Considering the bipartisan support for this deal to end the government shutdown, the ASTHO Government Affairs team is tentatively optimistic that the Continuing Appropriations Act, 2026, will eventually become law. However, the current political environment is volatile and if anything changes, we will issue another legislative alert. After the Senate votes on the bill, which may be delayed due to negotiations on some agriculture provisions, the House will need to approve it by a simple majority vote. If the House fails to garner enough support, then the government shutdown will continue. Here is the full text of the bill, the text of various extenders, and a section-by-section summary of all sections by the Senate majority. Federal Workforce and State Finances Requires the return of all federal workforce levels prior to the current lapse of appropriations on Oct. 1, 2025. Requires that funds be apportioned to agencies at a rate that would prevent the furlough of any employee during the duration of the CR. Prevents agencies from overspending funds for grant programs during the CR period, unless funds are required to be spent for the programs during such period. It preserves the funding level for most grant programs, subject to Congress’s decision in the full-year appropriations acts. Explicitly states that agencies should spend money in the most limited way possible during the duration of the CR. Directs that funds provided by the CR are available to pay federal employees who were furloughed or excepted during the lapse. Requires reimbursement to states that carried out federal programs, to prevent a reduction in service, during the lapse. Prevents statutory PAYGO sequestration cuts to Medicare, agriculture, and other programs. Agriculture and FDA Specifically, Senators agreed to advance a three-bill package that includes FY26 funding for the Department of Agriculture and the Food and Drug Administration (Ag-FDA), the Department of Veterans Affairs, and the Legislative Branch. The Ag-FDA bill provides: A hemp products ban, which prevents the unregulated sale of intoxicating hemp-based or hemp-derived products, including Delta-8, from being sold online, in gas stations, and corner stores, while preserving non-intoxicating CBD and industrial hemp products. $8.2 billion for the Special Supplemental Nutrition Program for WIC. $460 million for the Commodity Supplemental Food Program to assist low-income seniors. $37.8 billion in mandatory funding for child nutrition programs, as requested by the Administration. $107 billion in mandatory funding for SNAP, as requested by the Administration. Reimbursement for both the SNAP and WIC contingency reserves to account for expenditures during the government shutdown. $7 billion (budget authority and user fees), a decrease of $70 million below FY25 enacted levels, for FDA. $1.2 billion for the Food Safety and Inspection Service. $4.1 billion to support rural development across the country including $1.4 billion to prioritize aging water and wastewater infrastructure. Public Health Provisions Other public health provisions in the bill include extending several programs through Jan. 30, 2026, including: Community health centers. National Health Service Corps and teaching health centers that operate general medical education programs. The Special Diabetes Program. Some of the authorities of the Pandemic and All Hazards Preparedness Act. Unfortunately, this bill did not include provisions to reauthorize HPP, PHEP, or other public health programs, which will need to be reauthorized in the new year. Extends Medicare telehealth flexibilities that were extended in the Consolidated Appropriations Act, 2023. The Sexual Risk Avoidance Education Program. The Personal Responsibility Education Program. Family-to-Family Health Information Centers. website yes

One Big Beautiful Bill Law Summary Learn how the recently passed One Big Beautiful Bill impacts key public health initiatives in this legislative alert. On July 4, 2025, President Trump signed the One Big Beautiful Bill Act (OBBBA) into law. This legislation was initially passed by the House on May 22 by a 215-214 vote and was received in the Senate and passed with an amendment by a 51-50 vote. The amended bill passed the House by a 218-214 vote on July 3. This budget package will have sweeping impacts across Medicaid, the Affordable Care Act (ACA), food nutrition programs, and more. The Congressional Budget Office (CBO) estimates the bill’s health provisions will result in 11.8 million people losing health coverage by 2034. The CBO also estimates that an additional 5.1 million people would lose health coverage due to two policy changes outside the bill including: 1) the final 2025 CMS marketplace rule implementing eligibility changes and 2) the expiration of the ACA expanded premium tax credits. In total, CBO estimates 16.9 million people could lose coverage. The new law may impact states in several ways: Increased Medicaid and ACA coverage loss for noncompliance with work requirements, eligibility changes (Medicaid), and limits on coverage for certain noncitizens (ACA and Medicaid). Limited ability to fund the state share of Medicaid and overall decreased federal funding for state Medicaid programs. Increased administrative burden for state eligibility staff and increased costs for technology systems to implement work requirements. Note: Not all provisions apply to U.S. territories, such as work requirements for expansion adults, financing (provider tax and state-directed payments), and certain eligibility changes. ASTHO is closely monitoring the anticipated impact. Resources The legislative text of the final bill is 870 pages and was modified throughout the legislative process. For more detailed information, we encourage state and territorial health officials to utilize these resources in addition to the summary of relevant public health provisions below. Full Text — H.R. 1 Congressional Budget Office — Information Concerning the Budgetary Effects of H.R. 1, as Passed by the Senate on July 1, 2025 Kaiser Family Foundation — Health Provisions in the 2025 Federal Budget Reconciliation Bill Rural Hospitals This provision was not included in the initial House-passed bill but was included in the Senate-amended (and ultimately enacted) legislation. This program seeks to address potential impacts of CBO-predicted reductions to Medicaid spending due to the Medicaid provisions in this legislation. Establishes the Rural Health Transformation Program: The Rural Health Transformation program appropriates $10 billion per fiscal year to the Centers for Medicare and Medicaid Services (CMS) for 2026-2030 ($50 billion over five years) to disperse to eligible states. States must submit an application to CMS by Dec. 31, 2025, that includes a detailed rural health transformation plan and a certification that includes specifics on the expenditure for the funding under the program. States selected for funding will receive payments for five years, and the amount each state receives is determined by the state’s rural population, the number of rural health facilities, and an analysis of the state hospitals. State Eligibility: States must submit an application that includes a rural health transformation plan detailing how the state will improve health care access and outcomes, prioritize the use of new technologies, initiate collaboration between rural health care providers, enhance the supply of health care providers through economic incentives, outline strategies for the long-term financial solvency of rural hospitals, and identify risk factors for rural hospital closure. The state must also certify that no funding would be spent on intergovernmental transfer, certified public expenditure, or any other expenditure to finance the non-federal share of expenditures required under any provision of law. Funds can be used toward a list of criteria, such as promoting evidence-based interventions to improve prevention and chronic disease management including technology-based solutions, paying providers for health care, recruiting and training rural health workforce, and other activities as designated by the Secretary. The bill does not specify which state agency should be the applicant and custodian of these funds. Medicaid Work Requirements Overview: Requires able-bodied adults aged 19-64 to work (or perform other qualifying activities) for at least 80 hours a month. There are mandatory exemptions for certain individuals (e.g., pregnant women, those with serious medical conditions, tribal members, parents/caregivers of a dependent child 13 years and under or with a disability). States may issue optional hardship waivers for specific individuals facing short-term hardship (e.g., inpatient care, related outpatient care, natural disasters, high unemployment rate within their county). Verification: States will be required to conduct a “look-back” to determine if an individual meets requirement within the three months prior to applying. States would be required to verify an individual's compliance with work requirements within one or more months of enrollment and one or more months before redetermination. Implementation Dates: June 1, 2026: HHS to release interim final rule with implementation requirements. Dec. 31, 2026 (or earlier at state option): States must implement work requirements. However, the final bill allows the Secretary to exempt states from compliance with new requirements until Dec. 31, 2028, if they demonstrate a good faith effort toward compliance. Funding: Provides $200M for HHS implementation funding and $200M for states in FY2026 (an increase from $50M and $100M, respectively, from the initial House version). Expansion Expansion FMAP for Emergency Medicaid: Effective Oct. 1, 2026, limits federal matching payments for Emergency Medicaid to the state’s regular FMAP for individuals who would otherwise be eligible for coverage through Medicaid expansion if not for their immigration status. Sunsetting increased FMAP incentive: Effective Jan. 1, 2026, states that newly adopt Medicaid expansion will no longer have provisions for the temporary incentive. In addition to the federal government providing 90% federal financing for the expansion population under a state’s Medicaid expansion, the American Rescue Plan Act provided states that expand Medicaid after March 2021 a temporary boost in FMAP — a two-year, five-percentage-point increase in FMAP for all non-expansion population. Modifying cost sharing requirements for certain expansion individuals under Medicaid: Effective Oct. 1, 2028, states are required to impose cost sharing of up to $35 per service on expansion adults with incomes 100-138% FPL. Exempts primary care, mental health, and substance use disorder services, along with services provided by federally qualified health centers (FQHCs), behavioral health clinics, and rural health clinics. Maintains the previous law that out-of-pocket costs cannot exceed 5% of family income. Provides $15M in implementation funding for 2026. The final legislation adds exemptions to cost-sharing services provided by FQHCs, behavioral health clinicals, and rural health clinics. Provider Taxes Freezes provider taxes at current levels by disallowing increases in any new provider taxes or increases on current tax amounts. Amends the hold harmless “safe harbor” threshold, which is currently 6%. In non-expansion states: Remains at 6%. In expansion states: Phases down hold harmless threshold from 6% to 3.5% by 0.5% annually starting in FY 2028. Exempts long-term care facilities. State Directed Payments Caps state directed payments for expansion states at 100% and non-expansion states at 110% of the Medicare rate. This may limit a state’s future options to incentivize high-quality care or improve access to care. Eligibility Coverage for Noncitizen Alien Medicaid Eligibility: Effective Oct. 1, 2026, Medicaid eligibility of qualified aliens who are humanitarian entrants (i.e., refugees, asylees, and humanitarian parolees), is cancelled, thus leaving Lawful Permanent Residents, certain Cuban/Haitian entrants, and Citizens of Freely Associated States in place as the only categories of noncitizens eligible for Medicaid. The final legislation includes language defining Alien Medicaid eligibility. The text restricts the definition of qualified immigrants for the purposes of Medicaid and CHIP eligibility. HHS system to prevent duplicate state enrollment: By Oct. 1, 2029, requires HHS to establish a system to prevent enrollment in multiple states. Requires states to update enrollee addresses using certain datasets by Jan. 1, 2027. Eligibility verification using Death Master File: By Jan. 1, 2028, requires states to use the SSA Death Master File to verify eligibility on a quarterly basis. Home equity cap for Long-Term Services and Supports: Effective Oct. 1, 2028, lowers the home equity cap for long-term services and supports eligibility to $1M. Limits on Retroactive Coverage: Effective Jan. 1, 2027, limits retroactive coverage to up to one month for the expansion population and two months for traditional enrollees and CHIP. Home and Community Based Services (HCBS) Effective July 1, 2028, allows states to expand home-and-community-based services program eligibility criteria and waive the requirement that individuals require nursing home level of care. This would allow a greater number of individuals with less severe needs to access HCBS programs; however, many states already face waitlists so may be unable to expand enrollment. The bill provides implementation funding including $50M in FY2026 and $100M in FY2027. CMS Eligibility/Long-Term Care Staffing Rule Delays Prohibits CMS from implementing or enforcing eligibility rules for Medicaid, CHIP,

Read a detailed summary of the FY26 Senate Appropriations Bill, which was released on July 31.

The bill provides $27.1 million to address shortfalls in Medicaid funding in the Northern Mariana Islands and extends critical autism-related programs.

March 2024 Federal Funding Update wic program, environmental protection agency, appropriation bills, food and drug administration, government affairs, government shutdown, synthetic nicotine, fiscal year, federal government, public health, house and senate, food and drug administration fda, tobacco free nicotine, synthetic nicotine products, spending levels, white house, government agency, spending bill, regulate tobacco products, astho, association of state and territorial health officials ASTHO | Congress must approve legislation to provide FY24 funding for a portion of the federal government. This week, Congress must approve legislation to provide FY24 funding for a portion of the federal government. Currently, the federal government is operating on a two-tiered continuing resolution. Funding for discretionary programs in the Agriculture Appropriation bill—Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and FDA—expires on March 8. On March 3, Congress released the legislative text of the Consolidated Appropriations Act, 2024, which proposes FY24 funding for six of the 12 appropriation bills. This package includes funding for EPA, the WIC program, the Supplemental Nutrition Assistance Program (SNAP), and FDA, among other critical programs. Importantly, this legislation includes full funding for the WIC program, a priority for ASTHO and other public health organizations. Funding for HHS discretionary programs (NIH, CDC, HRSA, SAMHSA) expires on March 22. Legislative text proposing funding for these programs has not been released. Outlook Given bipartisan negotiations, ASTHO’s government affairs team believes this bill will be signed into law, avoiding a partial government shutdown on March 8. Additionally, text for the remaining six appropriation bills, including funding for HHS, is expected to be released later this week, with approval needed before March 22. According to media reports, this specific package of legislation will face a very difficult road to approval by Congress. Resources Bill Text Legislative summaries (Majority and Minority) Joint Explanatory Statement—Agriculture, Rural Development, Food and Drug Administration, and Related Agencies Appropriation Act, 2024 Joint Explanatory Statement—Energy and Water Development and Related Agencies Appropriations Act, 2024 Joint Explanatory Statement—Interior, Environment, and Related Agencies Appropriations Act, 2024 Key Public Health Funding Highlights Agriculture Appropriation Bill $7.03 billion for the WIC program, an increase of $1.3 billion over FY23. This ensures the program is fully funded, and it increases funding for fruits and vegetables in the WIC Food Package to meet the President’s request. $122.4 billion ($3 billion to remain available through Sept. 30, 2026, for a contingency reserve) for SNAP, a decrease of $31.5 billion from FY23. $6.7 billion, level funding, for FDA. In addition, FDA is required to address drug and device shortages, among other critical priorities. Urges FDA’s Center for Tobacco Products to immediately remove any product containing synthetic nicotine from the market, regardless of whether such product is subject to the Premarket Tobacco Product Application process. Rescinds unspent COVID resources at FDA. Environmental Protection Agency This bill includes $9.2 billion for EPA, a reduction of $232 million. $4.4 billion for State and Tribal Assistance Grants. Within this amount, the bill includes $2.8 billion for Clean Water and Drinking Water State Revolving Funds and $1.4 billion in Community Project Funding. Compact of Free Association Pages 960-1048 of the bill text include a section amending Compacts of Free Association, which is important for territorial ASTHO members. The government affairs team will review this provision and provide additional analysis to our territorial members in the upcoming weeks. Other Public Health Programs Extends funding for the following programs through December 31, 2024: Community Health Centers National Health Service Corps Teaching Health Centers that Operate graduate medical education programs  Special Diabetes Program Authority for states and tribes to request temporary reassignment for federally funded personnel.  website yes