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Strengthening Maternal and Infant Health Data in the U.S. Territories ASTHO, association of state and territorial health officials, maternal and infant health data, U.S. territories, public health, surveillance programs, pregnancy risk assessment monitoring system, improving the health, live births, health problems, reproductive health, federal government, toggle the centers for disease control and prevention cdc, risk assessment monitoring system, assessment monitoring system prams, pregnancy risk assessment monitoring, maternal and infant health, information collected, table of contents, population based, health status, supreme court, prams data, toggle the table, risk factors, prenatal care, collecting information Stephany Strahle The U.S. territories—Puerto Rico (PR), U.S. Virgin Islands (USVI), Guam, Commonwealth of the Northern Mariana Islands (CNMI), and American Samoa—are largely excluded from most statistical data systems in the United States. This gap leaves island health leaders, national partners, and federal agencies without the surveillance necessary to inform timely and robust public health programs and policies. This is also seen in critical maternal and child health surveillance programs like the Pregnancy Risk Assessment Monitoring System (PRAMS), Maternal Mortality Review Committees, and the Pregnancy Mortality Surveillance System, which either do not include or only recently included territories in their scope of coverage. This incomplete information creates challenges in identifying the aspects health systems need to address to reduce adverse maternal and infant health outcomes. Applying a life course perspective to maternal and infant health data reveals gaps in public health systems that impact outcomes before, during, and after birth. PRAMS provides vital insights into these lived experiences and pregnant people’s interactions with health care services. PRAMS data can also be linked to other administrative datasets, such as Medicaid, child welfare services, and Community Healthy Start programs, to provide a broader understanding of determinants of health across the life course for both the birthing parent and their child. With the breadth of contextual experiences that PRAMS captures in its data and the potential for data linkage projects to explore outcomes and their contributing factors, U.S. territories can leverage this wealth of information to assess the needs of their pregnant communities and their children. Despite its development in 1987, PRAMS has been implemented in only two territories, PR and CNMI, within the past decade. This brief highlights the work of these two islands and the potential to gain further insights into maternal and infant health outcomes using data linkage methods. Island Expansion of Maternal and Infant Health Surveillance Using PRAMS Since beginning PRAMS data collection in 2017, PR has made considerable strides in providing their communities with comprehensive reports on various topics. In 2021, one in eight live births was preterm in PR—the U.S. average is one in 10 live births. This outcome is one example of a potential research area in PR that could leverage PRAMS linkages to clinical administrative data sources to investigate contributing factors. In a special project conducted from 2016 to 2018, PRAMS served as an avenue for assessment of Zika awareness among pregnant people and their partners. Moreover, PRAMS informed numerous reports and educational materials on topics ranging from dental care to lactation and opioid use during pregnancy. Linking PRAMS to other administrative datasets could illuminate more information about health care utilization and access among pregnant people in PR. Although limited research exists on maternal and infant health outcomes in CNMI, available evidence reveals disparities in preterm birth among the territory’s indigenous Chamorro and Carolinian communities and Asian and Pacific Islander groups. Since CNMI started administering PRAMS in 2021, strong relationships with entities outside the territory (e.g., the Hawaii Department of Health) have facilitated PRAMS implementation by helping navigate Internal Review Board regulations and applications—both of which are necessary to conduct PRAMS collection and potential research using PRAMS data, like data linkage projects. Moreover, the CNMI PRAMS team’s deep familiarity with their communities could help identify local administrative data sources that, when linked to PRAMS, capture priority areas for improved health care and social service delivery. Considerations for Future Maternal and Infant Health Data Exploration With the existing gaps in surveillance data available for maternal and infant health, this recent implementation of PRAMS and the potential for data linkages to other data sources could provide enhanced insights for U.S. territories. The following considerations can inform best practices to optimize this data. Building Partnerships to Support a Linked Maternal and Infant Health Data Network To build capacity for further data exploration, building partnerships with other agencies and PRAMS jurisdictions can facilitate the information-sharing necessary to navigate data use agreements and other considerations before successfully linking data. Leveraging these connections can also supply more avenues to administer educational tools about PRAMS and perinatal services, linking their pregnant populations to the services they need. A robust web of partnerships can create a network of linked data capturing the life course perspective to inform high-quality programs for the ongoing care of pregnant people and their infants. Leveraging Community Input and Data on Social Determinants of Health Territories are uniquely positioned to leverage closer community ties to examine how data linkages can inform initiatives that improve experiences surrounding pregnancy and the life course after birth. As with PR, integrating the voices of pregnant people, their families, and the people providing their care into their advisory committees allows for better identification of what communities need. Active engagement ensures agencies can be efficient with their linkage efforts by tailoring their projects to high-priority maternal and infant health outcomes. Moreover, to foster community awareness about PRAMS and possible linked data sources, territories could create dashboards such as those created by Washington D.C.’s PRAMS program to provide a comprehensive and interactive view of the data. Data on social determinants of health collected through PRAMS—such as insurance coverage throughout pregnancy and postpartum as well as access to social support and a wide range of services—can also be leveraged for potential data linkage to identify inequities in health outcomes and the delivery of care. website yes

Centralizing Administrative Functions, with Lessons Learned from Guam Megan Drake-Pereyra Centralizing administrative functions, such as procurement or grants management, is a strategy many organizations utilize. Having administrative functions concentrated with a specific team rather than dispersed or managed within separate teams can work well. There is potential for standardized processes and procedures, increased efficiency and quality, more control and accountability, and consistent data collection and monitoring. This brief details how health departments can utilize existing, evidence-based frameworks to centralize administrative functions and build off lessons learned from others, such as the Guam Department of Public Health and Social Services (Guam DPHSS). Getting Started Considerations When transitioning from a decentralized structure to a centralized structure, it is important to clearly outline the what, why, how, and benefits. Consider the following components to kickstart success: Leadership vision: Start with the leader’s visionary perspective. When the leader allocates sufficient time and consistently reinforces the vision, it allows for the necessary decisions, trust, and support to be established during the transition. Data-driven design: Use data and existing information, such as current standard operating procedures or process diagrams, to understand the decentralized process differences/similarities, and guide effective centralized processes and procedures. Role clarity: Clearly outline and define the new centralized infrastructure, purpose, roles, responsibilities, expectations, and procedures. This helps everyone understand and follow the new processes more consistently, with better results. Performance measures: Establish and use performance measures from the outset (e.g., team knowledge, skills, competency, process time and quality, outcomes, impact, etc.), for insight into the value, or return on investment, of the centralized model. This will help indicate the quantity, quality, and impact of programs/processes. Documentation: Capture and share decisions, vision, goals, structure, standard operating procedures, and relevant details in writing for new team members and users of the centralized functions. Communication: Transparently share plans, timelines, and additional knowledge to maximize utilization and value. Additionally, anticipate and proactively address resistance to change to help everyone embrace and adhere to the new, centralized approach. The Plan-Do-Study-Act Method Change management, quality planning, and process improvement models can also support organizational and process change. For example, the quality improvement methodology, Plan-Do-Study-Act (PDSA), offers an effective framework for centralizing administrative functions and complements many of the aforementioned considerations: Step one, plan, relies on leaders to decide the vision, scope, structure, roles/responsibilities, goals, and purpose of the centralized team. Here leaders establish and reinforce the leadership vision, using existing data to guide the design of the new centralized team. Step two, do, is dedicated to onboarding centralized team members, defining their work processes and procedures, and ensuring effective communication with all stakeholders. This requires thorough documentation and strong communications plans. Step three, study—an often overlooked but crucial building step—is for testing the processes, procedures, roles, and responsibilities, to confirm and build confidence that this centralized structure will yield the desired results. Performance measures provide clarity into what is working well and what is not. Step four, act, is for launching and rolling out the structure, ongoing monitoring of performance, and continuing to educate and coach for successful, sustainable improvements. Lessons Learned from Guam Guam DPHSS, a joint health and social services agency, is working to centralize its administrative functions to reduce inefficiencies and redundancies as well as improve quality and consistency. This has been a big change for Guam DPHSS, but leadership vision, documentation, role clarity, and communication have proven to be key throughout the process. In 2021, Guam DPHSS established a centralized Office of Grants Management (OGM). In its early stages, programmatic teams saw OGM as a regulatory body that would audit and direct their work, while OGM’s true objective was to provide support and ease administrative burden, allowing program staff to focus on accomplishing their goals and deliverables. By clarifying and documenting the vision, roles, and responsibilities as well as focusing on communication, the OGM built trust, addressed specific concerns, and established a shared vision of their role as supportive and helpful. In 2023, Guam DPHSS began the process of establishing a centralized Procurement Management Office (PMO). While Guam DPHSS reorganized and co-located staff into the new, centralized PMO, Guam was undergoing a governmentwide business process improvement (BPI) project focused on procurement—presenting an opportunity for Guam DPHSS to involve new PMO staff and other key DPHSS team members in improving its functions and centralizing the procurement process. Through the BPI project, which utilized PDSA, DPHSS clarified roles and responsibilities, defined work processes and procedures, and developed training and communications plans that supported process improvement and centralization of procurement functions. Guam DPHSS has learned many lessons throughout their journey to create a centralized OGM and PMO, including that change of this magnitude is hard—more specifically, balancing change management while ensuring maintenance of key operations. Ultimately, they found that the aforementioned considerations and methods for getting started were critical in supporting the change to centralized administrative functions. Establishing the Ideal Structure for Administrative Functions Determining if and how centralized administrative functions will work for an organization is multifaceted. An organization’s culture, size, infrastructure (including technology and systems), and workforce and skills all play crucial roles in shaping the ideal structure. The methods and considerations noted previously can help health departments determine and support the best path forward for each unique organization. ASTHO has several additional resources and tools that can support administrative change and improvement. Visit the ASTHO STAR Center to learn more. website yes

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.

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

Improving Grants Management in the U.S. Virgin Islands: Q&A with Tatia Monell-Hewitt Improving Grants Management in the U.S. Virgin Islands Anya Groner Learn about how the U.S. Virgin Islands Department of Health streamlined grants management, as explained by its Chief Finance Officer Tatia Monell-Hewitt. Public health agencies have an important role in piecing together federal and local funding to support a comprehensive, cohesive array of programs and services for their communities. Optimal management of these funds ensures communities maintain access to these crucial initiatives. In the U.S. Virgin Islands (USVI), decentralized and inefficient processing coupled with high staff turnover caused delays in grant procurement that, at times, caused funds to go unspent. In the aftermath of Hurricanes Irma and Maria, Category 5 storms that devastated the islands in 2017, USVI Governor Albert Bryan Jr. sought assistance to manage and spend the federal funds available for the massive recovery process. In collaboration with ASTHO and the Department of the Interior, the territorial government began a three-year business process improvement initiative to streamline grants management. Nine agencies, including the governor’s office, came together to establish official grant and financial management systems, ensuring that federal funding could be accessed faster once approved. By maintaining a long-term vision, consistency of effort, and steadfast support from leadership and staff, USVI has been highly successful in streamlining the grants management process. Since the new system launched in 2023, initial sample data showed a range of 25-64% reductions across agencies in the time to set up federal grants, which enables the health agency to begin work sooner – highlighting what is possible with continual improvement. Furthermore, communication channels established through the business process improvement initiative have enabled interagency collaboration. This initiative built the foundations for improving grants management in USVI, and the Department of the Interior awarded additional funds to continue interagency communication, collaboration, and improvement to sustain the gains. In this interview, the USVI Department of Health’s Chief Finance Officer Tatia Monell-Hewitt discusses how changes to USVI’s grants management process and increased interagency collaboration impact public health. What prompted the update to USVI's grants management process? Was there a particular event or series of events? The update was prompted by the USVI’s Department of Health’s successful Business Process Improvement initiative in 2019-2021, along with a broader recognition of inefficiencies and inconsistencies in how federal grants were being managed across government agencies. An analysis of several grants conducted by ASTHO throughout government agencies revealed that, in some cases, the setup process from the receipt of a Notice of Award (NOA) to having the budget available online, could take up to 255 days or the better part of a year. These delays significantly hindered program execution and the timely drawdown of funds. The findings highlighted the urgent need for a streamlined and standardized grants management process. What were some of the biggest changes that you made to the grant process, and why are they so valuable? The most impactful changes include adoption of a standardized federal grant planning and setup process across the nine agencies defined as receiving the NOA to having an approved budget online. We moved from paper to an electronic process to improve transparency, speed, and accountability, and agreed to/established defined time frames for each step. Lastly, the creation of the Federal grant community of practice allowed for ongoing training, problem identification and resolution, and building process consistency across and within agencies. These improvements reduce delays, increase first-time accuracy, and enhance compliance, ultimately allowing agencies to deliver services to the community more quickly and effectively. The grants management process is often invisible to the public. Have USVI residents noticed the quicker turnaround? Yes! A more efficient grants management process has strengthened community trust in the U.S. Virgin Islands public health system. Improved customer satisfaction, faster service delivery, increased outreach participation, and more responsive agency communication have made a real difference. The community sees that the department is being a responsible steward of federal funds, which builds confidence in our ability to serve and protect. How did the improvements to the grants management process impact health agencies in particular? The Department of Health benefits from clearer roles and responsibilities in grant execution. That translates to quicker access to funding. A key example is the Epidemiology and Laboratory Capacity grant. The budget was approved and online within 30 days of the NOA. This enabled a swift response to the dengue outbreak that began in December 2024 on St. Thomas and St. John. Using real-time surveillance from the dengue dashboard, the epidemiology team targeted mosquito control efforts in hotspot communities. Supported by case mapping and proactive prevention strategies, the combined efforts — surveillance, lab testing, provider education and resource deployment — helped contain the outbreak and safeguard public health. How have partnerships strengthened health access and preparedness? Has that culture of collaboration and communication across government agencies continued in other projects? Absolutely. Agencies such as the Department of Health, Department of Human Services, Department of Finance, Department of Justice, and the Office of Management and Budget now coordinate processes, resolve issues collaboratively, and share training initiatives. Strong partnerships ensure that the Department of Health can align financial resources quickly to support health programs and improve access to care and emergency preparedness. Shared accountability has enabled timely and effective service delivery for the community. Have other improvements to grants management and agency coordination resulted from the business process improvement initiative? Definitely. The process has led to a uniform process across departments. Shared expectations include ongoing performance measures, a focus on timelines, a standard operating procedure checklist, and shared tools such as Adobe Acrobat Sign. Regular communication and updates shared in the community of practice meetings have made the grants management process more efficient, trainable, and adaptable to new challenges. What does the Department of Health’s grants management data collection show, and how does it use this data for continued improvement? The Department of Health uses a scorecard to track critical metrics such as milestone completion times, low spending rates, slow drawdowns, and the number of corrections needed. This data driven approach has helped us identify bottlenecks, guide training, and informed standard operating procedures. It has also highlighted programs that consistently manage their grants well. How do you see this work continuing over the long term? This work is built for long term sustainability. We’ve set up continuous education using the-train-the-trainer model, ongoing performance reviews and interagency meetings, and accountability by the community of practice and the cross-agency leadership team. We have a shared vision of efficiency and citizen-focused service delivery. What about this work are you most proud of? I am most proud of how multiple agencies came together to build a unified, efficient system. We've significantly shortened the time between the NOA and getting the budget online. We’ve established timeframes for each step of the grant procurement process — two days to receive the NOA, 10 days to adjust the spending plan, three days to obtain financial codes, seven days to submit the budget, and three days to get the budget online. That’s 25 days total for the entire grant turnaround. That alone has enabled us to serve our community much faster, which is what matters most. CDC-HHS - $1,000,000 article yes

For Emman Parian, Strong Partnerships Are at the Heart of Public Health Strong Partnerships Are at the Heart of Public Health Anya Groner Learn about Immunization Program Manager Emman Parian's approach to public health success: strong partnerships and collaboration. As immunization program manager for the Commonwealth Healthcare Corporation (CHCC) in the Commonwealth of the Northern Mariana Islands (CNMI), Emman Parian and his team work closely with a range of organizations: school systems, government agencies, private businesses, other Pacific Island jurisdictions, and national partners including ASTHO and the Association of Immunization Managers. Maintaining relationships through effective and regular communication sustains those networks and the communities they serve. Thus, the immunization program meets with partners regularly, basing the meeting frequency on partner’s roles and preferences. They also encourage off-island partners to visit in person so they can better understand the CNMI context. According to Parian, they rely on each other for their successes — a lesson he has learned throughout his public health career. Developing a Knack for Community Engagement In less than a decade, Parian has built an impressive career in public health. His journey began in 2018 as a student intern in public health at CHCC. Though he initially planned to become a nurse, his role offering support to community members with hypertension identification and control changed his trajectory. He was able to support people trying to navigate which services they could utilize to improve their health. When his internship ended, participants reported that his calls helped them manage their blood pressure and inspired them to make changes in their nutrition, medication compliance, and regular clinical visits — demonstrating Parian’s impact and providing him with fulfillment.   The Commonwealth Healthcare Corporation Immunization team attend a professional development workshop.   Discovering the Power of Collaboration The power of personal interactions inspired Parian to pursue a bachelor’s degree in health care management and a master’s degree in public health. When the COVID-19 pandemic began, he was shadowing CHCC’s CEO, Esther Muña, and corporate quality and performance manager, Halina Palacios, getting a front row seat as the organization’s leadership team developed their initial response to the pandemic. From this position, he learned effective strategies for addressing public health crises, like leveraging partnerships and building community trust, as well as approaches for successful workforce development. Eventually, he landed a permanent position as a vaccine specialist, managing storage, handling, and distribution of vaccines for the jurisdiction, then becoming the vaccine program coordinator overseeing the COVID-19 vaccination program for several years. Parian attributes his success to the supportive culture at CHCC where program managers and leadership regularly collaborate to align their missions for the benefit of the community. Making Advancements Through Outreach These days, Parian is a leader at CHCC, working as the immunization program manager for CNMI. Post-pandemic, vaccine hesitancy is on the rise. Parian’s team is responding by building trust through relationship-building activities and education. Emman Parian 1 - Strong Partnerships Are at the Heart of Public Health The team regularly visits villages, schools, health programs, and community centers, and even runs Saturday clinics/outreach events to ensure that all community members have the opportunity to get vaccinated. Efforts like these are particularly important given CNMI’s geography, which includes 14 islands, with three populated islands (Saipan, Tinian, and Rota). Even so, CNMI is in a better position to respond to future public health emergencies post-pandemic due to their expanded and improved partnerships and collaboration.   Parian attends a regional meeting with other Pacific Island managers and staff in Saipan.   Leading with Open Communication As a manager, Parian emulates the leadership models that he encountered early in his career. Open communication enabled Parian’s rise in the field, and he encourages discussion among his team. Whether feedback is positive or negative, Parian takes it into consideration. For him, leadership doesn’t mean dictating what your team does but instead working alongside them and being open-minded. That approach resonates. Emman Parian 2 - Strong Partnerships Are at the Heart of Public Health Building a leadership approach that works is important, as turnover can hinder programs due to lost institutional knowledge and a constant need to retrain employees. But lately, there’s less turnover. Parian notes that young people are increasingly invested in health care careers, a shift he attributes to recent health crises. Like him, they have a drive for outreach work and find fulfillment in it. Positioned for Future Public Health Success Strong collaboration builds the sustainability and infrastructure necessary for CHCC to succeed in their public health efforts. Should a new health crisis emerge, CHCC will be able to coordinate with partners to quickly identify resources, technical assistance, and subject matter experts. With strong teams and partnerships in place, Parian believes CHCC is ready for the future. article yes

Learn about the art of storytelling in public health and how to tell stories to secure support/funding for critical public health initiatives.

Puerto Rico Program Supports Vulnerable Populations ASTHO Island Support Learn how Puerto Rico addresses social determinants of health and promotes equity among vulnerable populations. The Puerto Rico Department of Health’s Health Equity Program implemented an innovative initiative to support diverse institutions, with the goal of addressing social determinants of health and promoting health equity among vulnerable populations. This provided opportunities for a wide range of sectors including private non-profit organizations, universities, and hospitals. The project evolved throughout its duration, demonstrating the power of local funding and the importance of flexibility in program administration. Project Kickoff Grant Awarding and Training Process During the second request for proposal, 30 organizations expressed interest in submitting applications. However, given the detailed and rigorous rubric, six applied, of which four grants were awarded. The team scored the proposals based on the rubric, and allocated funds to support vulnerable populations such as individuals living in rural areas, people with disabilities, pregnant women, and older adults. Implementation and Best Practices Once the Health Equity Program awarded grants, they designed a detailed work plan, including key indicators for monitoring and tracking the progress of beneficiary organizations. They implemented a SharePoint-based system for the submission of reports and documentation. In addition, they held monthly meetings to ensure cohesion and effective communication among all stakeholders. This collaborative approach enabled efficient and transparent monitoring processes. “It was a collaborative process since the institutions know their populations best. We just wanted to ensure a systematic and consistent plan because these matters are crucial for project progress and monitoring.” — Miguel Cruz, PhD, Co-Principal Investigator Project Evolution The program initially funded one institution and due to its positive impact, additional opportunities emerged to provide funding for up to four additional institutions. The main topic revolved around health literacy as a strategy to reach health equity among people living in rural areas, older adults, people experiencing homelessness, individuals with functional diversity, and those experiencing a mental health challenge. These four new institutions covered the west, central, and other rural areas broadening coverage within traditionally underserved communities. Administrative Flexibility and Communication Strategies Administratively, the program had to be flexible during pre-award and award processes, ensuring compliance with state and federal regulations. This included revising announcements and creating plans. Additionally, the program created documentation, like templates, and provided technical assistance to clarify compliance guidelines to ensure transparency and proper use of funds. The program implemented effective communication strategies to inform institutions about funding opportunities, including announcements via mass media and the Department of Health’s official social media platforms. They also created an external technical committee as an official communication channel to evaluate proposals. For this purpose, the creation of a detailed rubric facilitated its proper, unbiased, and timely assessment. Technological Challenges and Solutions One key challenge throughout the project was the use of technology to receive, process, and manage documentation. To mitigate obstacles, a SharePoint webpage facilitated electronic documentation acquisition between each subgrantee and the program. Additionally, the program provided clear instructions and developed a Q&A guide based on the needs that various institutions identified. In case of new inquiries, the Health Equity Program also shared responses collectively to ensure all organizations received consistent information, enabling them to complete the process smoothly and with equal opportunity. Lessons Learned A final evaluation of the process revealed that anticipating challenges was key to the project’s success. However, there are still areas for improvement: One of these is the optimization of financial processes by the organizations. It is critical to submit evidence of fund use in a timely manner and ensure accuracy in reconciling invoices within the allocated period. Organizations should also align internal processes with the parameters set when they receive funds. Adhering to these parameters can streamline the process on the Department of Health's side. Although beneficiaries get an assigned accounting professional, the documentation must still go through the Fiscal Office for review. Another challenge faced by institutions was retaining participants in the training sessions provided as part of the grant. Therefore, mechanisms need to be in place to ensure active and continuous participation in future interventions. The Health Equity Program also identified the opportunity to standardize the evaluation processes for organizations. While each institution worked on diverse projects, evaluations were based on their respective work plans and progress reports. However, a standardized evaluation process could improve efficiency in future interventions. Sustainability and Recommendations Many institutions that received funds have used them as a starting point to develop larger initiatives while others have used them to develop internal resources (i.e., digital libraries, trainings). “Organizations used this funding as seed money for projects that are now receiving greater financial support. Others have developed internal resources that allow them to continue addressing key health issues. For instance, they have optimized the use of digital libraries, expanded training reach, and replicated projects funded by this grant in other municipalities.” — Miguel Cruz, PhD, Co-Principal Investigator For other agencies looking to implement similar programs, the recommendation is clear: Streamline efforts to maintain consistency and coherence. Additionally, explore other agency or office supports for fostering an organizational culture that prioritizes continuous monitoring and process improvement, emphasized Cruz, PhD. Conclusion Clear, transparent communication and flexible administration with a focus on health equity generate a positive impact on vulnerable populations — as evidenced by increased knowledge, improved participant skills, attitude changes, inclusion in services, greater technology use among older adults, and enhanced equity skills among workers. This project demonstrates how health departments can collaborate with other sectors to address social determinants and ensure equitable access to resources. article yes

Ripple Effect: What USPSTF Recommendations Mean for State and Territorial Health Law What USPSTF Recommendations Mean for State and Territorial Health Law Andy Baker-White This Health Policy Update highlights how U.S. states and territories are using policy to codify important public health recommendations. The United States Preventive Services Task Force (USPSTF) is a volunteer panel of national experts that issues evidence-based letter-grade recommendations on clinical preventive services. Under the Affordable Care Act, services with an A or B grade must be covered by most private health insurance plans without cost-sharing, with similar requirements for Medicaid enrollees and Medicare beneficiaries. An estimate by the Department of Health and Human Services concluded that in 2020, these services reached approximately 264 million Americans. States and territories implement these recommendations through statutes and rules. ASTHO identified over 200 state and territorial laws referencing the USPSTF, including in insurance statutes, Medicaid rules, disease-specific laws, and state employee health plan requirements. Over the past year, the stability of USPSTF recommendations has come into question. The U.S. Supreme Court's June 2025 ruling in Kennedy v. Braidwood confirmed the HHS Secretary’s authority to block USPSTF recommendations and remove task force members. News reports in July 2025 indicated that HHS Secretary Kennedy intended to remove all USPSTF members, and in May 2026 fired the chair and vice-chair of the task force. Questions are being raised about whether USPSTF recommendations will be rescinded or downgraded and, if so, what the impact would be on states and territories. In addition, if the USPSTF fails to convene in the future, it cannot review newer data on preventive services, meaning existing recommendations could become outdated and USPSTF can’t make recommendations for new services. To meet these challenges, states and territories are taking steps to ensure the continued scientific basis for preventive health services within their own law. Dynamic References to USPSTF Recommendations States and territories often use dynamic references to USPSTF recommendations in regulating health plan coverage of preventive services. This allows the jurisdiction to automatically require coverage for the most current USPSTF recommendations. Laws in West Virginia (state employee health plans), Oregon (regulated health plans), Hawaii (health director standing orders), and Alaska (adult Medicaid enrollees) use this approach. While dynamic references allow jurisdictions to stay up to date with the recommendations, if the task force withdraws any guidance, then those preventive services would no longer require no-cost coverage without additional action from those jurisdictions. Some jurisdictions address this by specifying that certain USPSTF guidance changes will not apply. For example, Guam’s law requires continued no-cost coverage for colorectal cancer screenings and authorizes the health director to adjust diabetes screening recommendations if USPSTF recommendations cease. Illinois specifies that the 2009 USPSTF recommendations for breast cancer screening and mammography are not to be considered current because national medical bodies created differing recommendations for screening. Another way jurisdictions avoid the unpredictability of using dynamic references is locking in the date of the USPSTF recommendations that are used for coverage requirements. For example, Massachusetts requires its state employee health plan to cover USPSTF A and B recommendations that were in effect by July 1, 2023. Using a version of USPSTF recommendations from a specific date maintains a base level of coverage regardless of future changes, though adopting new recommendations or removing outdated recommendations would require separate action. During this year’s legislative sessions, several states enacted or proposed legislation to remove dynamic USPSTF references. For example, Maryland passed legislation (HB 637 and SB 385) to lock in the USPSTF A and B recommendations that were in effect on December 31, 2024. Washington enacted HB 2242 requiring coverage of USPSTF A and B recommendations in effect on June 30, 2025, as well as recommendations adopted by the state insurance commissioner. A bill passed in Delaware, HB 338, would require the use of the USPSTF recommendations from January 1, 2025. Overall, however, neither dynamic nor fixed references to USPSTF recommendations address how jurisdictions can keep up with new scientific data and advances in preventive services in the absence of ongoing USPSTF review and recommendations. To fill this need, some states have enacted legislation that creates processes for reviewing data and establishing recommendations. For example, the new Maryland law mentioned above also authorizes the state’s health secretary to adopt preventive service recommendations that have not been recommended by or that differ from USPSTF. The new process requires notice and a 30-day comment period, an analysis by the Maryland Health Care Commission, and citations to the authoritative medical body upon which the recommendation is based. Disease-Specific Statutes: USPSTF Grades as Care Standards and Thresholds Many states also use USPSTF grades as thresholds for specific preventive services, establishing the standard of care, or issuing standing orders. For example, Arkansas law defines "follow-up colonoscopy" by reference to a colorectal screening assigned an A or B grade by the USPSTF, while Nevada’s law directs primary care providers to use criteria set out in USPSTF recommendations to screen adult women for BRCA mutations. In Hawaii, the state health director is authorized to issue public health standing orders for current USPSTF A and B recommended services, and in Idaho the law uses USPSTF guidance for applying ocular antibiotic prophylaxis to newborns as the standard for medical practice in the state. Some states are considering legislation to distance preventive service coverage requirements from USPSTF recommendations. For example, while New Jersey's current law requires no-cost coverage for colorectal cancer screenings in accordance with the method and frequency recommended by the USPSTF, introduced legislation (A4916 and S4254) would remove the reference to USPSTF recommendations and instead authorize one screening per year for persons aged 33 or older. More broadly, Hawaii considered legislation (HB 1898 and SB 3133) that would have authorized the state’s health department to “make recommendations relating to clinical preventive service recommendations of the [USPSTF] Force that have been assigned a grade of A or B as of July 1, 2025” and require no-cost coverage for the department’s recommendations. However, this legislation did not pass. State Employee Benefit Plans USPSTF recommendations may also be used to establish preventive health services covered by state employee health plans. A West Virginia statute requires the state’s employee health plans to cover mammograms consistent with "current guidelines from the United States Preventive Services Task Force," while the health plan document further states that preventive services are "subject to change as USPSTF…recommendations are updated.” In Ohio, a regulation requires state employee health benefits include all USPSTF-recommended tobacco cessation services and authorizes the state health director to update covered services if USPSTF guidance changes. Missouri law requires full coverage of USPSTF graded A and B recommended prescription and prescribed over-the-counter drugs for state plan members. The Path Forward USPSTF recommendations have helped millions of Americans receive critical health services at no cost, and states and territories have built practices, programs, and standards on that foundation. From adopting fixed-date references to establishing state-level recommendation authority to creating new state review bodies, legislative activity this year reflects a broad effort to address ripple effects from potential future changes to or lack of USPSTF guidance. Health officials may be asked to assess their jurisdiction’s laws and their use of USPSTF recommendations, and coordinate with insurance commissioners, Medicaid directors, and employee benefits administrators to confirm consistent agency interpretation and identify where action is needed. ASTHO will continue to monitor these policies as they develop. article yes

Partnership as the Foundation for Advancing Adolescent Health in American Samoa Partnership Advances Adolescent Health in American Samoa Gabby Ruiz Learn how American Samoa advances adolescent health in American Samoa through collaboration among state and local health and education agencies. Cross-sector partnerships are essential to advancing adolescent health, particularly in school-based settings. The intersection between public health, education, and clinical health is vital to the delivery of integrated services. In the United States, it is estimated that children in grades K-12 spend at least 1,231 hours each year in school, not including time dedicated to clubs or extracurricular activities. When schools function as trusted environments where health and learning meet, they become powerful access points for early identification of needs, preventive services, and supportive relationships. The public health sector brings expertise in prevention, population-level data, and community engagement. Meanwhile, the education sector provides youth engagement and the ability to creatively embed health into learning environments by leveraging diverse resources. When sectors work in isolation, resources are used inefficiently and adolescents may experience gaps in care, fragmented supports, and inconsistent access to essential services. With support from CDC’s Division of Adolescent and School Health, ASTHO leads the Leadership Exchange for Adolescent Health Promotion Plus Community of Practice, an initiative that promotes collaboration among state and local health and education agencies to strengthen health education, connect schools to services, and foster safe, supportive learning environments. This initiative provides a space for teams to share ideas, troubleshoot challenges, and build sustainable partnerships. Through this effort, the American Samoa team built a strong partnership between the Department of Health and the Department of Education to expand and enhance effective communication about sexual and reproductive health to reduce risk taking behaviors and promote protective factors. Peer-to-Peer Learning as a Catalyst for Youth Engagement Grounded in the belief that young people are often the most trusted messengers for their peers, the American Samoa team launched the Students Promoting Education, Awareness, and Knowledge (SPEAK) project: a student-led, peer mentor collaborative effort between the American Samoa Department of Education (ASDOE), the American Samoa Department of Health (ASDOH), and youth peer leaders. The project builds a network of trained peer educators who engage students on topics such as healthy relationships, personal responsibility, privacy, consent, HIV, STI, and pregnancy prevention. SPEAK peer leaders are students in grades 10 through 12, with two or more representatives from each grade level. High school counselors help identify students suited for this role, which includes: Co-creating educational materials that reflect their identities (i.e., their values, abilities, and lived experiences). Fostering safe spaces for support and dialogue. Managing online platforms that allow youth to ask questions anonymously. Collaborating with schools, communities, and health care providers to develop and promote educational campaigns through social media channels. SPEAK promotes student leadership, shared accountability, and open, stigma-free dialogue. Forging Strong Relationships Alignment and Sustainability From the beginning, ASDOH and ASDOE committed to building a unified team to support adolescent sexual and reproductive health. This collaboration became one of their greatest strengths. The team noted that establishing a shared vision early on helped them maintain momentum through challenges. Donation Ape, ASDOE Program Director, played a pivotal role in bridging agencies and strengthening the network that supported the project’s success. While Ape’s dedication and tenacity have been key to nurturing this partnership, both sides of the team are working to ensure that this partnership is sustainable. “With the right network, we were able to do it.” — Donation Ape, ASDOE Program Director Thoughtful Health Education In addition to coordinating across school systems and community partners, long-standing cultural values that emphasize privacy around family and personal matters made open discussion of adolescent health topics more challenging. Prior to SPEAK, students were not receiving structured health education in this area. ASDOE staff and leadership initially expressed understandable concerns about ensuring any peer-led approach would be age-appropriate, culturally respectful, and aligned with community standards. A key strategy for addressing these concerns was thoughtfully engaging youth alongside educators, families, and community stakeholders to help demonstrate the need and shape a solution to delivering health education. “When you see young people not just as children but as contributors to society, you start to see what’s possible.” — Fatih Seiuli, Health Educator, ASDOH Key Considerations for State and Territorial Health Agencies American Samoa’s experience offers key insights for other jurisdictions seeking to strengthen adolescent health through school-based partnerships: Integrate public health into education, clinical health, and mental and behavioral health to ensure a more holistic and sustainable cross-sector approach. Together, these sectors form a coordinated system that has the capacity to address pertinent adolescent health concerns. In addition, youth hold a critical role in their own care, and engaging them as part of these cross-sector partnerships is essential to adolescent health program uptake and understanding. Involve essential community voices by engaging key stakeholders and end users early on. Creating a peer educator network and creating space for youth-led engagement ensures programs reflect young people’s lived realities — increasing relevance and reach, and fostering trust and ownership among students who may otherwise feel disconnected from traditional health messages. Adapt curricula with cultural responsiveness. Integrate bilingual materials and tailor them to the unique needs of communities — expanding reach across cultural contexts and addressing stigma or other social and structural barriers. Additionally, ensure the framing of the program is appropriate for audiences and helps to overcome cultural barriers. Looking Ahead American Samoa’s journey demonstrates how intentional partnerships, youth leadership, and culturally grounded approaches can advance adolescent health in meaningful and sustainable ways. Their work reinforces that collaboration is a critical strategy that serves as the foundation for lasting impact. ASTHO will continue supporting jurisdictions through the Leadership Exchange for Adolescent Health Promotion Plus Community of Practice by fostering connections, strengthening multi-sector partnerships, and creating spaces where teams can learn from one another. As American Samoa’s experience shows, meaningful progress in adolescent health is possible when sectors and systems align around a shared purpose. Reviewed by - Akbarali, Mackie, Vance article yes

Learn about legislation in island areas from the past year to strengthen infrastructure, prevention strategies, health care oversight, and more.

Strengthening Public Health Workforce Capacity in Island Jurisdictions Strengthening Public Health Workforce Capacity in Island Jurisdictions A.C. Rothenbuecher, Allison Budzinski, Marta McMillion, Melissa Sever Guam and CNMI leveraged support from ASTHO to improve their public health workforce planning — learn more in this blog post. Strategic workforce planning helps public health agencies stay prepared, attract and retain the right talent, and build flexible systems that can handle change. When done well, it leads to better services, stronger performance, and a healthier work environment. It also saves money by reducing turnover and helps agencies respond to health emergencies or challenges as they arise. A Learning Collaborative Approach For U.S territories and freely associated states, where geography, connectivity, and resources pose unique challenges, strategic planning is especially important. With support from the Public Health Infrastructure Grant (PHIG), the Association of State and Territorial Health Officials (ASTHO) and the Public Health Accreditation Board (PHAB) launched a nine-month Island-Centric Workforce Planning Learning Collaborative to offer support as island health departments strengthen their workforce planning efforts. This pilot included workforce teams from Guam’s Department of Public Health and Social Services and the Commonwealth of the Northern Mariana Island’s (CNMI) Commonwealth Healthcare Corporation, Division of Public Health Services. The learning collaborative gave participating island health departments a chance to build on their strengths while getting tailored support for workforce planning. Through expert guidance, peer sharing, and coaching — both online and in person — participants worked through each step of ASTHO’s Workforce Planning Guide and explored essential workforce components aligned with PHAB’s Standards and Measures for Accreditation. The collaborative took a “start with what you have” approach, building on previous workforce planning efforts, existing data, and plans in both Guam and CNMI while leveraging resources from several national partners in the process. From Resources to Results: Putting Workforce Tools to Work Before the learning collaborative began, ASTHO, PHAB, and the University of Nebraska Medical Center (UNMC) teamed up to streamline and align their workforce planning resources. Early coordination ensured the tools complemented each other and avoided duplication. The ASTHO Workforce Planning Guide served as the foundation, while PHAB’s Workforce Plan Template gave health departments a clear structure to build upon. UNMC’s Public Health Workforce Planning: A Practical Guide and workforce data from the de Beaumont Foundation’s Public Health Workforce Interests and Needs Survey (PH WINS) helped ground planning efforts with practical guidance for facilitators and up-to-date data reflecting current needs and priorities. Callout 1 - Blog - Strengthening Public Health Workforce Capacity in Island Jurisdictions Collaboration Across Islands: Sharing Challenges and Solutions Over the course of the learning collaborative, Guam and CNMI’s public health teams built strong relationships by sharing challenges, exchanging ideas, and celebrating progress. Common issues like limited workforce capacity helped them relate to one another, while differences in structure and resources sparked creative solutions. The peer relationships and connections that were built and strengthened during the collaborative continue. On-Site Support ASTHO visited both jurisdictions to meet with leaders, review progress, and plan next steps — reinforcing the value of ongoing partnerships in workforce development. During the visits, participants revisited the Workforce Planning Cycle, layered in the latest PH WINS data, refined draft plan sections, clarified alignment with PHAB workforce standards, and considered the sustainability of their work beyond the collaborative. The hands-on sessions blended facilitation, coaching, and dedicated writing time, allowing participants to make measurable progress on their plans. What Guam and CNMI Achieved Through the learning collaborative, Guam and CNMI made meaningful progress in their strategic workforce planning efforts. Some near-term successes include: Active Workforce Committees: Both jurisdictions formed or maintained dedicated teams to lead workforce planning efforts. Steps Toward Accreditation: Each agency advanced efforts towards PHAB recognition related to a core domain, “Maintain a Competent Public Health Workforce.” Smart Use of Data: Each agency used human resource, workforce, and PH WINS data to guide decisions and improve planning. Stronger Capacity: Teams gained valuable skills and knowledge to support long-term workforce efforts. Customized Action Plans: Each agency created tailored plans aligned with their unique goals and needs. While Guam and CNMI achieved many similar milestones, each jurisdiction brought its own strengths and strategies to the table. Their different approaches offer valuable lessons for tailoring workforce planning and technical assistance to local needs. Guam emphasized structural development and broad departmental engagement, while CNMI leaned into data-driven decision-making and sustained leadership support. Callout 2 - Blog - Strengthening Public Health Workforce Capacity in Island Jurisdictions What Other Jurisdictions Can Learn The Island-Centric Workforce Learning Collaborative offers practical lessons for other jurisdictions focusing on workforce planning: Start with leadership support and clear roles across teams. Utilize and adapt existing tools and frameworks, like the PHAB Workforce Planning Template, the ASTHO Workforce Planning Guide, and UNMC’s Public Health Workforce Planning: A Practical Guide to jumpstart planning. Request tailored coaching and technical assistance through national organizations such as ASTHO and PHAB. Leverage workforce data, such as PH WINS, to inform decisions and progress. Collaborate across partners to benefit from diverse expertise. Celebrate your wins to build momentum and morale. What’s Next for Workforce Development in CNMI and Guam The success of the Island-Centric Workforce Learning Collaborative highlights what’s possible when public health agencies are supported with the right tools, partnerships, and local context. Guam and CNMI’s progress show that even in resource-limited settings, meaningful change is achievable. Special Thanks - Blog - Strengthening Public Health Workforce Capacity in Island Jurisdictions OE22-2203 PHIG article yes

Learn how territorial and freely associated state health agencies can support community health workers and their vital work in this brief.

Collecting and sharing data are crucially important to improving health equity, because those datasets inform effective policymaking. Despite having some of the most challenging population health outcomes, the U.S. island areas are often absent within federal public health datasets.Federal, island, and nonprofit partners should prioritize efforts to increase their inclusion.

Learn how increasing the use of indirect cost rates in the territories and freely associated states can help improve public health financing in these jurisdictions.

Establishing an Office of Health Equity or Minority Health Learn how to establish, structure, and fund a health equity or minority health office. A dedicated office of health equity or minority health can provide a focus on cross-cutting efforts and strategies that help to improve services, outreach, and engagement with marginalized communities. This report delves into the typical scope for setting up a health equity or minority health office, including how to establish, structure, and fund it—providing a blueprint to island areas working to build one or considering establishing one in the future. In addition, it explores lessons learned from state offices of health equity or minority health, including California, Michigan, Nebraska, Nevada, New Jersey, New York, Ohio, Vermont, and Washington. Get the Report (PDF) website yes

This report aims to highlight the unique vector-borne disease challenges faced by Island Areas and to dive into the key components of a mosquito control program, that are relevant to these unique jurisdictions.

Learn more about current and upcoming public health trends through ASTHO's annual Environmental Scan.

Engage in meaningful dialogue in island grantor/grantee relationships, with support from these sample questions and comments.

Leveraging the NIH Bookshelf to Showcase Health Agency Research Island Areas Workgroup, Data Capacity Subgroup Learn how to submit your health agency research to the NIH Bookshelf to increase visibility and expand reach. If you’re looking to strengthen ties with the academic community and increase the visibility of your public health agency’s published population health reports, consider submitting them to the National Institute of Health’s Bookshelf platform. This free, searchable collection feeds into the PubMed database and accepts “gray literature,” or research produced outside of traditional commercial or academic publications. It is a great opportunity for public health agencies to expand their reach. Application and Review Process Submit content Initial screening Scientific review Technical review Publication Before submitting your content, make sure it meets Bookshelf requirements: Is your content: Full text (a full report, not just an abstract or data) with an executive summary or abstract? Aligned with at least one of the subjects priotitized by Bookshelf? Written in English? Accessible via a PDF/Word Document or online via a web link? While drafting the document, did you undergo some sort of peer review process? (E.g., an advisory council reviewed, offered feedback, and approved the final draft.) The peer review process must be publicly documented within the content, in a separate document, or via a description on the website. If you answered yes to the previous questions, follow these steps to apply: Download and complete the application for a single title or application spreadsheet for multiple titles. Complete publisher information sheet (if you are new to submitting to Bookshelf). Email your application to bookshelf@ncbi.nlm.nih.gov. Other information you will include in your application: Title of content. PDF/Word Document or URL where content can be accessed. Publishing information (name, management, qualifications, policies). Short author/editor biographies or CVs (1-2 pages). Resources for writing a professional CV (PH resume and examples). Copyright information. Abstract or summary. If you have questions about the application process or the suitability of your content, please contact bookshelf@ncbi.nlm.nih.gov. Note: If you have been publishing related content for at least two years, Bookshelf may review your content as a collection. This means any future materials may be added to the collection without an additional application. Once you have submitted your content: Initial Screening: Bookshelf staff checks that your application is complete and meets the minimum submission requirements. If Bookshelf staff have questions, they will contact you. Be ensure the project point of contact is responsive to inquiries, as timely responses are critical to moving your application forward without delays. If all submission requirements have been met, your content will move into the Scientific Quality Review. Scientific Quality Review: Bookshelf staff will assess whether your content meets the platform’s scientific standards (e.g., whether its content is substantive and valuable). Your content will either pass or fail this review; there is no opportunity to revise in response to feedback. If rejected, you may resubmit the content after two years. If your content passes this review, it will move to the technical review. Technical Review: Bookshelf staff will assess whether your content meets the platform’s technical requirements (e.g., an XML document with proper formatting and accessibility). This is typically the longest stage of the process, as there can be some back and forth between Bookshelf staff and applicants, as applicants strive to address any technical issues with the content. An applicant can contract with a commercial vendor to produce the necessary XML document, if needed. If your content is accepted: Bookshelf will give you an opportunity to preview the content. Make sure you’re comfortable with how the content looks, as this preview represents how the content will look on the platform. Ensure there are no typos or formatting issues! Sign the participation agreement, discussing questions with NIH Bookshelf staff as relevant. Celebrate your success, and share the link with peers and partners! Additional Resources from NIH How to Include Content in Bookshelf: Summarizes the Bookshelf application process. Bookshelf Copyright Notice: Summarizes relevant copyright restrictions that apply to Bookshelf. NLM Retention Policy: Summarizes the National Library of Medicine’s retention policies, which apply to Bookshelf. Background This product was created by the Island Areas Workgroup (IAW) — Data Capacity Subgroup. Established in October 2021, IAW brings together representatives from island jurisdictions, federal agencies, and trusted partners to address key administrative challenges impacting health outcomes in island jurisdictions, including efforts to strengthen procedures and organizational policies affecting health financing, data capacity, and workforce development. The Data Capacity Subgroup drafted this resource to support territorial and freely associated state public health leadership and researchers in their efforts to expand the reach of local population health data and research. OE22-2203 and PW-24-0080 article yes