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These resources provide core insights into the rulemaking process for creating laws to advance public health.

How New Laws Support Telehealth and Access to Health Care How New Laws Support Telehealth and Access to Health Care Ashley Cram Learn how federal and state policies are improving access to health care by supporting telehealth. Telehealth strengthens the health system by reducing barriers to access to health care and extending services to underserved communities. Federal and state policies — many born out of the COVID-19 pandemic — have increased the use of telehealth by patients and providers. This includes expanded reimbursement to allow more providers to deliver telehealth services in more locations and through more modalities. This Health Policy Update summarizes recent federal and state laws and policies that impact telehealth delivery and access to care. Federal Laws and Policies Rural Health Transformation Program Enacted as part of the One Big Beautiful Bill Act in July 2025, the Rural Health Transformation Program appropriates $10 billion per fiscal year for the Centers for Medicare & Medicaid Services (CMS) to award to eligible states looking to improve rural health care. CMS encouraged state applicants to focus on select strategies, including investment in technology platforms that enhance care delivery. This includes tools and resources that support telehealth overall and remote patient monitoring (RPM), which is a way for providers to monitor and support patients through the use of devices that support data collection and transmission. Applicants that participate in interstate licensure compacts are also incentivized throughout the five-year program period by being awarded additional points for participation, which may lead to states pursuing compact legislation in the coming years. Medicare Telehealth Flexibilities Set to Expire During the COVID-19 pandemic, CMS issued numerous flexibilities that authorized broader telehealth use to expand access to care. Flexibilities included expansion of certain audio-only services, geographic areas and patient locations, and additional provider types eligible to deliver telehealth services. Current policy authorizes these pandemic-related telehealth flexibilities through January 30, 2026. Without permanent extension of these flexibilities, Medicare coverage for telehealth services beyond January 30, 2026, telehealth will again be limited to patients living in rural areas and to certain services, providers, and facilities. Physician Fee Schedule Changes CMS establishes the annual Medicare Physician Fee Schedule (PFS), which sets payment policy for health care services provided by physicians and other professionals to Medicare beneficiaries. The 2026 PFS includes new codes for RPM that allow providers to tailor monitoring frequency and engagement levels to meet patient needs. These codes, and the expansion of RPM, allow providers to effectively monitor health indicators such as weight, blood pressure, blood glucose, and respiratory flow rates, to manage health issues. By regularly monitoring a patient’s health status, a provider can reduce the risk of adverse health outcomes and emergency department visits. Additionally, the PFS streamlined the process for adding eligible telehealth services for reimbursement by removing distinction between permanent and provisional services and focusing review on whether services can be delivered via telehealth. State Legislation Impacting Telehealth Delivery States are also developing policy solutions to enable broader access to telehealth services, including expansion of audio-only and RPM services. Audio-only telehealth services are the use of communications technology, without a visual component, to deliver synchronous health care services. This modality can ensure continuity of and access to care for patients who live in areas with limited broadband and/or those who lack access to a video-enabled device. In 2025, at least four states enacted laws related to audio-only telehealth services. This includes at least three states that extended coverage that would have otherwise expired. In Hawaii, SB 1281 extended the expiration of the state’s coverage of certain audio-only behavioral health services through 2027, while Minnesota (HF 2) took a similar approach to audio-only telehealth services, including certain behavioral health and substance use disorder services, through July 1, 2027. Similarly, Maryland (SB 372/HB 869) removed the sunset date for coverage of audio-only telehealth services. And more broadly, Missouri (SB 79) clarified the state’s telehealth definition to include audio-only technologies. RPM uses digital devices to monitor a patient’s health by collecting and sharing health information with providers. RPM is particularly effective for management of chronic conditions, allowing providers to engage in shared decision making with patients and prevent adverse health outcomes through more regular monitoring. In recent years, several states enacted legislation to expand access to RPM including two bills in Louisiana. Enacted in 2024, HB 896 established the Louisiana RPM program for Medicaid patients with chronic conditions and a history of high-cost services, with the goal of improved care coordination and reduced costs. Then in 2025, SB 70 expanded these criteria to include pregnant and postpartum women and infants following discharge from the NICU. In Maryland, HB 553 specifies that the Medicaid program must cover the equipment and provider oversight of blood pressure monitoring for eligible recipients, including pregnant and postpartum individuals and those with chronic health conditions. Lastly, Virginia enacted SB 843 which directs the state Medicaid agency to develop a plan and cost estimate for expanding Medicaid eligibility for RPM for patients with chronic conditions. State and territorial health agencies can encourage public health programs to incorporate telehealth and propose policy solutions that enable broader utilization of telehealth modalities across the entire jurisdiction. States that are interested in expanding access to telehealth can visit ASTHO’s Telehealth Project Initiation and Scoping Assessment to conduct a review and identify opportunities to expand access to telehealth, particularly related to policy, infrastructure, and funding. UD3OA22890-13-00 article yes

Government Shutdown Effects on Public Health: Lessons from the 2025 and 2018-2019 Closures Catherine Jones Learn about the government shutdown effects on public health, with insights from the 2025 and 2018-2019 closures. When the federal government shuts down, it exposes vulnerabilities in our public health ecosystem. It also brings to light the critical role state and territorial health departments play to protect the health of their jurisdictions. While the political dynamics behind each shutdown may vary, the consequences are unfailingly disruptive. Some federal agencies and programs continue under mandatory or advance appropriations, but the day-to-day machinery that keeps the federal public health system functioning — workforce, oversight, and technical assistance — is impacted. Federal employees from shuttered agencies are either furloughed or required to work without pay if their roles are deemed essential to public safety, as with certain functions of HHS and FDA, among others. The effects of a shutdown can be temporary or long-lasting. In the past, Congress enacted guardrails to reduce the harm of future funding lapses, but the unpredictable nature of each shutdown ensures that disruption, loss, and hardship follow. A comparison of the 2025 and 2018-2019 shutdowns displays this impact — with the 2025 impasse becoming the longest shutdown in U.S. history, surpassing the 35-day record set during the December 2018 to January 2019 closure. Key Differences Between the Shutdowns The 2018-2019 shutdown, which was sparked over a funding fight for the U.S-Mexico border wall, spared HHS because the FY2019 Labor-HHS-Education Appropriations Act had already been enacted before the funding lapse. As a result, core public-health agencies — including CMS, CDC, HRSA, and SAMHSA — continued operating. However, the programs funded through the Agriculture-FDA appropriations bill (e.g., SNAP, WIC, and FDA) were impacted, but the disruptions were somewhat contained: FDA paused some food and drug inspections, while SNAP and WIC administrators worked to stretch timing buffers to sustain benefits. The 2025 shutdown, by contrast, impacted HHS. Disputes over the Continuing Appropriations and Extensions Act, 2026, (H.R. 5371), also known as a continuing resolution (CR) — compounded by an acrimonious stalemate over extending the Affordable Care Act premium tax credits (analyses show premiums could more than double in 2026 without extensions) and reversing Medicaid cuts in the One Big Beautiful Bill — placed health care directly in the shutdown’s epicenter. After 14 failed attempts to move the CR in the Senate, the measure was revised to extend federal funding through Jan. 30, 2026, and to reverse the Reductions in Force (RIFs) enacted during the lapse in appropriations. This CR was combined with three additional minibus appropriations packages, which included the Agriculture-FDA bill that funds SNAP and WIC through FY2026. On Nov. 10, the Senate narrowly mustered the 60 votes needed for passage, with eight Democratic senators joining in support. The bill then cleared the House on Nov. 12 with a 222-209 vote, and President Trump signed it the same day. The result of the 43-day shutdown was a deeper and more systemic breakdown. Furloughs and RIFs swept across agencies. Staffing gaps impacted CDC, SAMHSA, and CMS operations, while lawsuits proliferated over withheld pay, suspended contracts, and SNAP payment distribution. As of now, ACA subsidies remain unresolved, and the full repercussions of the 2025 shutdown continue to emerge. A Closer Look at the Shutdown Impacts Furloughs In 2025, the HHS contingency plan anticipated furloughing roughly 41% of its workforce, with CDC and NIH hit hardest — about 64% and 75% of staff, respectively. During the 2018-2019 shutdown, about 48% of HHS staff were furloughed, with CDC at 61% and NIH at 76%. After the 2018-2019 shutdown, Congress enacted the Government Employee Fair Treatment Act of 2019, ensuring that all furloughed federal employees receive retroactive back pay once operations resume. The current CR provides a provision requiring the payment of federal employees who are furloughed or excepted during the lapse. Government contractors, unlike direct federal employees, are not guaranteed back pay after shutdowns. RIFs During the 2025 shutdown, CDC issued more than a thousand layoff notices, some later rescinded, while SAMHSA reported significant workforce losses. There were no RIFs during the 2018-2019 shutdown. In AFGE v. Donald J. Trump, federal-worker unions challenged the administration’s issuance of mass layoff notices during the 2025 shutdown, arguing that RIFs during a funding lapse violate the Antideficiency Act and are “arbitrary and capricious.” A federal judge issued a preliminary injunction blocking further RIFs for hundreds of employees. This case is currently ongoing. To note, as part of the revised aforementioned CR, RIFs issued during this shutdown were reversed, returning to status quo workforce levels prior to the lapse of appropriations. WIC WIC entered October 2025 with funds from Section 32, providing $300 million as a bridge. Nationally, on average, WIC (a discretionary program) needs about $150 million per week to serve approximately 7 million women, infants, and children. To support access, several states tapped emergency funds and reallocated resources to food banks. In early November, the Trump Administration transferred $450 million from unused customs revenue to fund WIC. During the 2018-2019 shutdown, WIC continued to operate without gaps using prior-year funds. SNAP Roughly 42 million Americans currently rely on SNAP benefits. SNAP is considered mandatory spending, which allows payments to continue temporarily during a shutdown, but when a lapse exceeds 30 days, disruption risk escalates. During the 2025 shutdown, EBT payment delays triggered widespread litigation. In Coalition of States v. U.S. Department of Agriculture, over 25 states sued USDA for suspending benefits despite available contingency funds, citing violations of the Food and Nutrition Act and the Administrative Procedure Act. Federal courts issued temporary restraining orders protecting millions of beneficiaries. The administration appealed to the Supreme Court to halt payments, and the Court granted the request. During the 2018-2019 shutdown, SNAP participants received benefits in December 2018 and January 2019. February benefits were also distributed in late January to avoid disruptions; these were not additional benefits. Tribal Health In 2025, the Indian Health Service remained open due to FY2026 enacted advance appropriations. This funding was in part a reaction to the dire consequences of the 2018-2019 shutdown in which the Tribal and Urban health programs reported having to limit health care services and resources, due to Indian Health Service employees having to work without pay or being furloughed. Unique Implications of the 2025 Shutdown As previously noted, because Congress fully funded HHS in 2018-2019 there was minimal impact on public health programs. However, the length and scope of the 2025 shutdown did impact HHS directly. For example: Mental health: Mental and behavioral health access contracted sharply as SAMHSA’s state-support network lost nearly two-thirds of its staff, due to shutdown RIFs as well as earlier rounds of layoffs and retirements. At-home care and telehealth: During the 2025 government shutdown, hospitals nationwide faced delayed Medicare reimbursements and the temporary suspension of hospital-at-home programs, which had become vital for managing capacity during workforce shortages. Telehealth expansion and remote monitoring efforts were also paused, causing many patients to pay out of pocket. U.S. territories: The pause on SNAP and the Nutrition Assistance Program (NAP) funding in November had disproportionate impacts on the U.S. territories, as higher percentages of their populations depend on SNAP and NAP (20%-40%). In three territories, legislatures passed bills to fund partial or full SNAP and NAP benefits for November. Implications for the Future of Public Health The 2025 shutdown underscored that lapses in government funding disrupt the public health ecosystem. A fully functioning system relies on steady collaboration from federal, state, local, and tribal health departments. The depth of the 2025 crisis has ignited bipartisan discussion about structural fixes to prevent governing by brinkmanship. Proposed congressional legislation includes bills to stabilize federal pay with automatic funding, contain congressional travel and adjournment until appropriations are complete, guarantee pay for federal workers and contractors, prevent disruption to SNAP and WIC programs, and ensure reimbursement to states. Padding Block - Large Related Contnet - Blog - Government Shutdown Effects on Public Health article yes

Learn about the importance of exploring intermediaries that work alongside existing data platforms in addressing ongoing public health challenges.

Read about deference to ACIP vaccine recommendations in state and territorial vaccine policy, following recent changes to the committee.

Downstream Effects of CDC Adopting ACIP Recommendations for COVID-19 and MMRV Vaccines Downstream Effects of CDC Adopting ACIP Recommendations Susan Kansagra, Andy Baker-White, Meredith Allen, Kimberly Martin, Ericka McGowan Learn about the downstream effects of CDC adopting ACIP recommendations for COVID-19 and MMRV vaccines, as states examine how their policies and laws intersect. On Oct. 6, CDC adopted the recommendations that the Advisory Committee on Immunization Practices (ACIP) made in September — specifically, individual-based decision-making for COVID-19 vaccine and separate measles, mumps, and rubella vaccine, and the varicella vaccine in toddlers. The adoption of these recommendations now sets in motion a cascade of other processes that influence access to vaccines. In addition, several states have begun to examine how their state level policy and laws intersect with ACIP recommendations given the delay in adoption and the uncertainty of the process going forward. COVID-19 Vaccine Recommendation CDC adopted the recommendation for shared clinical decision-making for the COVID-19 vaccine for those six months and older. The adoption of this ACIP recommendation has a ripple effect on coverage and access: It enables states to begin ordering COVID-19 vaccine under the Vaccines for Children program. It allows state Medicaid programs that link coverage to ACIP recommendations to cover the cost of the vaccine. It enables pharmacists to provide the COVID-19 vaccine under the federal PREP act declaration — as opposed to or in addition to state law, which varies by state. Many state health departments issued standing orders and executive orders to enable pharmacists to administer in the meantime. It requires health insurers to cover the cost of the vaccine, as the Affordable Care Act ties insurance coverage requirements to ACIP recommendations. Though, prior to the meeting, health insurers indicated they would do so anyway this year. MMRV Recommendation The CDC also adopted the recommendation for separate varicella (V) and measles, mumps, rubella (MMR) vaccines rather than the MMRV vaccine (combined measles, mumps, rubella, varicella) for children under four years. As background, current guidance allows either MMRV or MMR + V to be administered to children 12-47 months. However, because of a small but higher risk of febrile seizures for dose one, they are recommended to be administered separately (MMR + V), unless families express a preference for MMRV. Only about 15% of children currently receive MMRV for the first dose, and the general consensus is that this decision will result in some changes but not significantly impact access to vaccines: The adoption of this recommendation means that VFC will no longer cover MMRV for children under four, but it continues to cover separate MMR and V vaccines. Since many state Medicaid plans tie vaccine coverage to ACIP recommendations, coverage of MMRV by state Medicaid will vary depending on this language, though separate MMR and V vaccines would continue to be covered. Private insurers can choose to cover MMRV and will likely continue to in the short term but are not required to. They are required to cover separate MMR and V vaccines. How States Are Preparing for the Future As it stands now, ACIP recommendations, particularly for respiratory viral season, are not that different than prior years – with influenza, RSV, and the COVID-19 vaccine recommended (the latter with shared clinical decision making). However, the delayed and unpredictable process has led many states to examine how closely they are tied to ACIP in law, regulation, or practice. Over 600 statutes across U.S. states and territories reference ACIP — whether for pharmacist vaccine authority, school entry, health care worker or other requirements. States have considered a variety of actions to ensure they maintain access to vaccinations for their jurisdictions including: Passing or introducing legislation that allows the state health department to use ACIP guidance from previous years or recommendations from other bodies (e.g., medical provider organizations) in state law, as it relates to school entry, pharmacist authority, and others. Issuing standing orders and executive orders to enable pharmacists to administer vaccines in the absence of ACIP recommendations. Examining Medicaid state plan language to determine how to interpret requirements when ACIP is referenced and considering updates to that language (e.g., North Carolina). Issuing state requirements for insurers on vaccine coverage (e.g., Oregon, California, Hawaii). Examining use of state funds to purchase vaccines. Supplemental Resources Tracking State Actions on Vaccine Policy and Access by KFF Vaccine Resources by the Common Health Coalition States Take Action to “Immunize” Vaccine Access by Mandy Cohen, Julian Polaris, and Liz Dervan Vaccine Integrity Project — Fall Immunization Information by the Center for Infectious Disease Research and Policy Special Thanks - Blog - Downstream Effects of CDC Adopting ACIP Recommendations Padding Block - Large Related Content - Blog - Downstream Effects of CDC Adopting ACIP Recommendations article yes

Federal, State, and Stakeholder Perspectives on the Rural Health Transformation Fund Perspectives on the Rural Health Transformation Fund Catherine Jones Explore federal, state, and stakeholder perspectives on the Rural Health Transformation Fund, shared at a discussion hosted by ASTHO and Cornerstore Government Affairs teams. In early July, ahead of final votes on the One Big Beautiful Bill Act (full text H.R.1), Senate Majority Leader John Thune (R-SD), joined by Senators Susan Collins (R-ME) and Lisa Murkowski (R-AK), secured a $50 billion funding line for a new Rural Health Transformation Program (RHTP). This five-year mandatory fund is designed with two primary goals: To stabilize vulnerable rural hospitals, health centers, clinics, and their workforces. To improve access, affordability, modernization, and health outcomes for rural residents, who on average experience higher rates of chronic disease, shorter lifespans, and lower earning power compared to urban populations. To help states better understand how to apply and utilize RHTP dollars, ASTHO partnered with Cornerstone Government Affairs to host a discussion on Sept. 4 featuring two expert panels. Participants included representatives from Centers for Medicare & Medicaid Services (CMS) and HRSA, congressional staff, state health departments, and experts from the National Rural Health Association and National Association of Medicaid Directors. Lively discussions provided valuable insights into the application process, how states might deploy funds to build and sustain rural health programs, and the realities of delivering care on the ground. Panel One: Federal Perspectives Application Tips The first order of business was to provide potential applicants with essential information they need to apply. CMS is working quickly to release the Notice of Funding Opportunity in early September. Applications will be due in November, with funding decisions finalized by Dec. 31. This is a one-time application for the five-year mandatory fund, with dollars allocated evenly across FY26 to FY30 ($10 billion per year). Importantly, the RHTP fund is separate from — and unaffected by — FY26 Labor Health and Human Services, and Education discretionary appropriations outlined by the Senate and House, and any continuing resolutions. The $50 billion program will be divided into two parts. $25 billion will be distributed evenly among states that apply and have successful applications. The remaining $25 billion will be allocated at CMS’s discretion based on factors such as a state’s rural population, the number of rural health care facilities, and state policies and policy commitments. States will not be required to provide matching funds. In anticipation of the application deadline, many state health departments have been mobilizing over the past weeks. Health officials are convening task forces, launching working groups and public hearings, and issuing Requests for Information and surveys to shape projects and spending plans. These efforts are focused on aligning with CMS’s strategic goals, including making rural America healthy again, providing sustainable access to care, workforce development, innovative care delivery, and technology modernization. Program Insights Panelists also highlighted how RHTP differs from existing rural health programs. The Federal Office of Rural Health Policy, for example, funds initiatives focused on quality improvement, hospital technical assistance programs for operational challenges, and targeted pilot programs to test the feasibility of ideas related to community needs. By contrast, RHTP will provide states with a large, flexible infusion of funds to augment existing and novel rural health care efforts. States will also be permitted to use RHTP dollars for one-time investments (e.g., electronic health record systems, diagnostic equipment, and network-building initiatives). Panelists emphasized the importance of tailoring approaches to state and community needs, noting that Tribal communities face especially severe challenges, requiring intentional engagement. The first session concluded with a focus on Alaska, where 73.7% of hospitals are in rural areas — a key driver of Senator Murkowski’s strong advocacy for the fund. Her legislative director noted the state’s persistent struggles with connectivity, limited primary care access, workforce shortages, and low patient volume. Previous funding formulas, which relied heavily on hospital bed counts or numbers of health care facilities, often disadvantaged Alaska and similar states. RHTP, structured as a cooperative agreement, gives states both predictability and flexibility: dollars they can count on, combined with broad authority to design solutions in partnership with CMS protocols and assistance. CMS has existing protocols for grant management, and Congress will likely ask for clear reporting requirements as they monitor the successful implementation of the fund. Panel Two: State and Stakeholder Perspectives Rural Health Challenges To align visions with on-the-ground realities, health department leaders from Pennsylvania and Mississippi described their extensive efforts underway to gather input and identify priorities that are both sustainable and impactful, underscoring the importance of community engagement in shaping state strategies. Panelists noted that states are working through a broad list of rural health challenges, including: Maternal and child health. Behavioral health. Substance use disorder. Emergency medical services. Transportation barriers. Aging populations. Specialist shortages. Data modernization (including cybersecurity, AI, broadband, training, and administrative support). Telehealth. Workforce shortages. Hospital, clinic and federally qualified health care center closures. Payment models (public and private). Improving health information exchanges and electronic heath records were also mentioned as universal goals. RHTP is designed with flexibility to tackle these issues and to craft solutions (some of them can be shelf-ready, such as technology or prevention kits) to respond to the diverse needs of rural communities. Aligning Programs Panelists were asked how they are working with partners to achieve alignment for their programs. All concurred that strategic planning is essential, with an emphasis on local partnerships and regional collaborations. It was stressed that rural health care should ideally be delivered as close to the community level as possible, supported by a robust ecosystem. Speakers agreed that the financial health of rural areas is inseparable from the health of their hospitals and clinics. It was underscored that local residents are deeply invested in their communities and want to see them thrive. Transforming rural health care systems will require large-scale collaborations at a local level, which are built on trust, a shared vision, and a clear understanding of the long-term goals. The challenges of chronic disease, which occurs and leads to death at significantly higher rates in rural areas, surfaced. Panelists agreed that tackling this issue requires major investments in ancillary professions — such as nutritionists, physical therapists, and community health workers — alongside a renewed emphasis on primary care services and alleviating the acute shortage of primary care physicians. According to the American Medical Association, roughly 65% of rural areas face a shortage of primary care providers, and only 4%-5% of incoming medical students now come from rural backgrounds. Some solutions noted by the panelists were extending medical student rotations in rural settings from a few weeks to 12 or more, coupled with financial and professional incentives. Encouragingly, research shows that students from rural areas are far more likely to return home as practicing physicians. Final Words Panelists overwhelmingly agreed that RHTP represents an unprecedented opportunity for states — though, notably, not for U.S. territories or Washington, D.C. — to expand access, raise the quality of rural health care, and ultimately improve both quality of life and life expectancy for their rural residents. The $50 billion fund is not only a lifeline but also a testing ground, and if implemented successfully, it could serve as a model to pave the way for future federal investments of this magnitude in rural health. For more information on RHTP, please email MAHARural@cms.hhs.gov. Participants Part One: Federal Senator Lisa Murkowski and Angela Ramponi, MPH, Legislative Director Emily Chen, MBA, Senior Advisor, Office of the Administrator, Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services Tom Morris, MPA, Associate Administrator for Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services Moderated by Carlos Jackson, Principal, Cornerstone Government Affairs Part Two: State and Stakeholder Daniel Edney, MD, FACP, FASAM, State Health Officer, Mississippi State Department of Health Debra Bogen, MD, FAAP, Secretary of Health, Pennsylvania Department of Health Zil Joyce Dixon Romero, State Government Affairs Manager, National Rural Health Association Lindsey Browning, Deputy Executive Director of Programs, National Association of Medicaid Directors Moderated by Susan Kansagra, MD, MBA, Chief Medical Officer, ASTHO article yes

Learn about public health strategies for preventing chronic disease that intersect with themes in MAHA report including nutrition and physical activity.

Good news and bad news on tobacco use: smoking rates are down but e-cigarette use continuing rapid rise among youth. Read how states are combating the problem.

Cases of sepsis and septic shock can be prevented with strong health policies as shown in New York. Several states have taken action to enact mandatory early detection and treatment protocols.

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

Learn about the importance of immunization information systems to public health in this Health Policy Update.

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

Learn how states can leverage policy to reduce ACEs and improve children's well-being in this Health Policy Update.

Legislative Snapshot: Suicide Prevention Infrastructure and AI Chatbots Legislative Snapshot: Suicide Prevention Infrastructure and AI Chatbots JoAnne Deehr Suicides continue to be a critical public health issue — learn how states are leveraging policy to improve suicide prevention. Suicide remains a persistent public health challenge, affecting people of all ages, racial and ethnic groups, geographic regions, and income levels in the United States. Despite ongoing prevention efforts, more than 49,300 Americans died by suicide in 2023. National suicide rates steadily rose from 2003 until 2018 and have remained high since then, reflecting an enduring and widespread impact. While all communities are affected by suicide, certain demographics face higher risks. Disproportionately higher rates of suicide are seen among elderly Americans, Veterans, individuals with lower income, less education, and those living in rural areas. People in certain industries, such as mining, construction, and public safety, are also at elevated risk. At the same time, emerging technologies like chatbots powered by artificial intelligence (AI) have raised new considerations related to safety, oversight, and appropriate use in mental health settings, underscoring the need for thoughtful state approaches to suicide prevention. Policymakers are responding to these challenges in multiple ways, including establishing state suicide prevention infrastructure and regulating AI chatbot use in mental health. Suicide Prevention Infrastructure Legislation Suicide prevention efforts are most effective when states and territories have dedicated infrastructure — such as suicide prevention offices, coordinators, commissions, and fatality review processes — to support coordination, surveillance, and implementation of evidence-based strategies. These structures enable state and territorial health agencies to identify populations and communities at increased risk, align partners across public health, health care, and public safety, and pursue sustainable funding for suicide prevention and crisis system improvements. ASTHO’s Suicide Prevention Offices and Committees Legal Map highlights the varied policy approaches states have taken to establish this infrastructure and identifies which states had statutory suicide prevention structures in place as of January 1, 2025. During the 2025 legislative session, states considered at least 30 bills related to establishing suicide prevention offices, coordinators, advisory bodies, and suicide fatality reviews. Five of these bills were enacted, including Delaware’s HB 54 which establishes the state’s Office of Suicide Prevention. Delaware also enacted HB 87, expanding membership in the state’s Suicide Prevention Coalition to include someone who has experienced suicidal ideation or survived a suicide attempt and someone who has lost a loved one to suicide. Conversely, Oklahoma enacted SB 676, repealing the section of the state’s Suicide Prevention Act that established the Oklahoma Suicide Prevention Council, which was slated to sunset in 2020. The council was originally tasked with identifying issues and promoting strategies to prevent suicide, and providing technical assistance on best practices for identifying people at risk of suicide. The Department of Mental Health and Substance Abuse Services still serves as the leading agency for implementing the remainder of tasks outlined in the Act. Illinois and Texas enacted legislation establishing advisory bodies focused on suicide prevention among first responders. In Texas, HB 1593 creates a committee to study suicide prevention and peer support programs within fire departments and requires a report with recommendations by September 2026. In Illinois, HB 2551 reconstitutes the First Responders Suicide Prevention Task Force, and increases membership in the task force to include a member from an organization that provides mental health training and support to first responders and two members who represent organizations that advocate on behalf of public safety telecommunicators, such as 911 operators and dispatchers. The bill also charges the task force with developing a final report by December 2026. Both bodies are scheduled to sunset in January 2027. Currently, Wisconsin has several types of fatality review teams operating through voluntary efforts with no law formally establishing or governing these teams. Wisconsin is considering SB 192, which would formally establish processes for reviewing fatalities, including deaths by suicide. It would also direct the Department of Health Services to establish a fatality review program comprised of established local teams and authorize the department to establish state fatality review teams. AI Chatbots While states continue to strengthen suicide prevention infrastructure, policymakers are beginning to turn their attention to emerging mental health considerations related to AI. Since emerging in the 1950s, AI has evolved from rule-based systems to today's machine learning and natural language processing applications, powering everything from data analysis to interactive chatbots. Recent AI advances enable chatbots to simulate human conversation so convincingly that users may forget they are interacting with a machine. However, these systems lack genuine empathy and cannot substitute for professional mental health treatment. Their tendency to be excessively agreeable creates particular dangers for people experiencing suicidal ideation, leading some states to explore regulations governing AI chatbot use in mental health and suicide prevention contexts. At least 19 states considered legislation regulating the use of AI for mental health related reasons to promote user safety. At least five bills were enacted, including California SB 243, which requires chatbot platform operators to disclose that users are interacting with AI if confusion could occur, develop protocols to prevent and respond to suicidal ideation or self-harm, and report annually on safety measures to the state Office of Suicide Prevention. The California legislature also passed AB 1064, which the Governor subsequently vetoed due to concerns that its broad restrictions on AI companion chatbots for minors could limit access to potentially beneficial tools. Illinois and Nevada passed legislation that largely prohibits AI from providing behavioral health services. Illinois HB 1806 restricts the use of AI for therapy or psychotherapy unless delivered by a licensed professional who is required to inform the patient, or their legal representative, in writing and receive consent. The law also prohibits licensed professionals from allowing AI to make independent therapeutic decisions or interact directly with clients and allows the use of AI only for administrative or supplemental tasks under professional oversight. Nevada AB 406 similarly prohibits AI systems from providing or representing themselves as offering professional mental or behavioral health care, prohibits AI from performing the functions of a school counselor, psychologist, or social worker in public schools, and allows licensed professionals to use AI only for administrative or supportive purposes, with oversight to ensure accuracy and safety. New York and Utah passed laws requiring mental health chatbots to clearly disclose that they are not human. As part of their annual budget, New York S 3008 mandates that AI companion systems capable of simulating human-like interactions detect suicidal ideation or self-harm, provide crisis referrals, and regularly disclose that users are interacting with AI rather than a person. Utah HB 452 requires AI-driven mental health chatbots to provide clear disclosures and limits advertising and data practices. At the federal level, on December 11, 2025, the White House issued an executive order seeking to establish a national policy framework for artificial intelligence and create a “minimally burdensome” federal approach. The order also directs the Department of Justice to form an AI Litigation Task Force to identify and challenge state AI laws deemed in conflict with this federal policy, and the Department of Commerce to limit eligibility for certain federal funds for states that take a non-preferred approach. The scope and criteria of these federal actions, including their impact on state laws aimed at suicide prevention, have not been clearly defined. Advancing suicide prevention will require states and territories to take comprehensive approaches that address both systemic gaps within state infrastructure and emerging technologies. ASTHO will continue to monitor these policy developments and provide relevant updates. Reviewed by - Baker-White, Maffey article yes

States Pursue Policy Options to Support Access to Over-the-Counter Contraception State Policy to Support Over-the-Counter Contraception Access Christina Severin Learn about state policy options that can help to support over-the-counter contraception access including levers within Medicaid programs. Effective contraceptive care improves maternal health outcomes by helping individuals plan if and when they become pregnant. Additionally, some contraceptive methods may reduce the risk of certain cancers and protect against sexually transmitted infections. While the most effective methods generally require a visit to a health care provider, over-the-counter (OTC) options may address certain barriers to accessing contraception (e.g., taking time off work for a medical appointment and lack of health insurance or access to health care providers/settings). The New Age of Nonprescription Oral Contraceptives A significant change in the marketplace of OTC options occurred in 2023 when FDA approved the first daily non-prescription oral contraceptive. This progestin-only pill —known as Opill — is considered both safe and highly effective at preventing pregnancy when taken correctly. Opill reached stores in early 2024 and has a suggested retail price of about $20 per month or $50 for a three-month supply. While OTC oral contraceptives like Opill may improve access among individuals not currently using contraception or those using a less effective method, high out-of-pocket costs can be a barrier. One way to limit out-of-pocket costs is to require private health insurance coverage of contraception without cost-sharing. ACA requires most private health insurance plans to do this, but it does not extend to all health insurances or contraceptives. For OTC contraceptives, the landscape is even more complex: While plans are encouraged to cover OTC emergency contraception at no cost and without a prescription, it is not required. HHS and the Departments of Labor and Treasury issued a proposed rule in 2023 that would have required broader coverage of OTC contraception without a prescription or cost-sharing, but the rule was later withdrawn. Without a federal mandate, states can pursue coverage requirements through the health insurance products they regulate. Jurisdictions can also support OTC contraception access in their Medicaid programs. While Medicaid requires coverage of family planning supplies without cost-sharing, jurisdictions have some flexibility in how they design this benefit, and the scope of coverage depends on jurisdiction and state plan-specific factors. Jurisdictions also have flexibility in determining how they provide prescription drug coverage for contraceptive medications and what OTC products are covered. State Legislative Action Legislation is one way for states to promote access to OTC contraceptives, including hormonal contraceptives, through state-regulated plans and provider scope of practice considerations. Since 2024, several states have enacted laws requiring coverage of OTC hormonal contraception, including Delaware (SB 232), which directs insurance carriers to cover FDA-approved OTC contraception with or without a prescription, and Maine (LD 163), which requires coverage of nonprescription oral hormonal contraception. At least two states have clarified the role of pharmacists in supporting access to OTC contraceptives. Massachusetts (HB 4800) allows pharmacist dispensing of OTC oral contraception per a standing order and provides liability protections, while California (AB 50) allows pharmacists to furnish self-administered OTC hormonal contraception without complying with the state’s protocols for prescription-only oral contraceptives. States have also enacted laws to explore or support broader access to OTC contraception, including at least three bills enacted in Maryland since 2024: HB 367/SB 527 requires community colleges to develop an OTC contraception access plan and allows the health department to serve as a resource, including for consultation on vending machine access. HB 1171/SB 944 allows local health department registered nurses to dispense OTC contraception. SB 674/HB 939 creates a collaborative tasked with studying and making recommendations on OTC contraceptive access, with a final report due to the governor and legislature by Jan. 1, 2027. Other Policy Levers Legislation isn’t the only policy lever available to jurisdictions looking to support OTC contraception access. A number of states have taken executive actions to improve access, including (but not exclusively) through Medicaid. While jurisdictions already have the flexibility to support OTC contraceptive access in their Medicaid programs, Medicaid rules require a prescription even for OTC products, which may present a barrier for some individuals. One potential solution is to use standing orders, which allow individuals direct access to OTC products at a pharmacy, without having to visit a separate provider for a prescription first. To ease access to OTC hormonal contraception specifically, several states have recently utilized standing orders that facilitate Medicaid coverage, including Wisconsin, Massachusetts, and New Mexico. Additionally, in 2024, North Carolina announced that it was removing barriers to OTC oral contraception, and would cover condoms and spermicide as OTC products. Outside of Medicaid, several other states have taken action to support access to OTC hormonal contraception: In 2024, the Governor of Arizona issued an executive order directing the Department of Administration to designate Opill and OTC hormonal contraception as a no-cost essential health benefit for state employees, among other actions to expand coverage and access. Also in 2024, Pennsylvania issued guidance to health insurers encouraging coverage of OTC hormonal contraception and highlighting two insurers intending to comply with the guidance. Finally, Michigan’s health agency, in partnership with the Governor’s office, implemented a Take Control of Your Birth Control campaign. This initiative distributed OTC contraception at hundreds of community sites across the state, with a stated goal of connecting individuals to insurance coverage, including Medicaid. While the campaign recently ended, the state distributed more than 400,000 OTC contraceptive resources (e.g., condoms, emergency contraception, and oral contraceptives) and saw an increased number of Medicaid applications. Jurisdictions can play a significant role in connecting public health and health care industry leadership, providers, and other experts — promoting awareness, increasing utilization, and encouraging connection to existing resources. Related Content - Blog - State Policy to Support OTC Contraception Access article yes

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