Public Health Policy Issues to Watch in 2021

January 07, 2021|2:08 p.m.| ASTHO Staff

With many of the state and territorial legislatures reconvening over the next few weeks, we can look forward to new (and not-so-new) legislation start to crop up that will impact public health. To help navigate the new legislative sessions, ASTHO’s "2021 Legislative Prospectus" series highlights eight priority policy areas jurisdictions will address during this year. Each prospectus in the series provides a brief overview of the issue, the issue’s impact on health, and recent legislative trends aimed at addressing the issue. This year, ASTHO developed prospectuses on COVID-19, e-cigarettes, HIV, influenza, maternal mortality and morbidity, neonatal abstinence syndrome (NAS), polyfluoroalkyl substances (PFAS), and rural health. Below is a brief summary of the COVID-19 legislative prospectus, as well as previews of the remaining seven topics which are to be featured and released in future ASTHO health policy updates.

COVID-19: An Extraordinary Public Health Challenge
In 2020, the COVID-19 pandemic caused great disruption to daily life and has led to the loss of over 300,000 lives—a number that continues to grow. Every state and territory exercised its emergency powers to implement necessary public health measures to slow the spread of the disease and increase the capacity of the healthcare system. Fact-based measures like stay-at-home orders, school and business protocols, gathering limits, and face mask requirements—while effective at reducing activities associated with the community spread of disease—were seen by some as a government overreach and faced legal challenges and resistance among community members.

Although many actions taken to address the pandemic were done through executive emergency powers, states and territories also enacted legislation to facilitate the pandemic response by procuring personal protective equipment (PPE), conducting testing, and implementing contact tracing programs. With concerns of government overreach in some COVID-19 response policies, a few legislatures considered measures to curtail executive branch emergency powers and public health authority. While legislative efforts to limit public health powers largely failed in 2020, there were successful judicial challenges to public health interventions in state and federal courts.

In addition to legislation related to PPE supply, COVID-19 testing, contact tracing, and public health authority, ASTHO expects legislatures in 2021 to consider bills that address issues related to the COVID-19 vaccines. This includes vaccine requirements; immunity passports; data collection and usage; expanding the scope of practice of healthcare providers to administer COVID-19 vaccines; and addressing the mental health impact of the pandemic on the public health and healthcare workforce.

Annual Flu Vaccinations: Vital to Public Health
While the 2019-2020 flu season resulted in approximately 5 million fewer flu illnesses than the season before, a decline possibly associated with COVID-19 mitigation measures, reduced flu testing, and lower numbers of people seeking treatment during the pandemic, there were still higher rates of infection, hospitalization, and death for children under five than in recent seasons. Recent studies show vaccination reduces the risk of flu by 40 to 60% and getting the annual flu vaccine not only reduces the risk of illness and death, but also lowers the risk of hospitalization and time away from school or work. For these and a variety of other public health-related reasons, the CDC recommends an annual flu vaccination for individuals six months and older. Legislative trends for flu vaccinations include requirements to educate high-risk populations about the seasonal flu and expanding access to the flu vaccine by allowing pharmacists to administer it to children. Additional trends will include flu vaccine requirements for children attending childcare facilities and requirements that employees of childcare and adult residential facilities receive annual flu vaccinations.

E-cigarettes and JUULs: Stopping a New Epidemic
In 2020 states and territories continued to adopt policies to reduce youth use of e-cigarettes and other vaping products. These efforts were even more important with new research showing that e-cigarette use is associated with a higher risk of a COVID-19 diagnosis. Last year, 14 states raised the minimum age of tobacco sales to 21, joining the federal government and the 36 other states and territories with similar laws. California became the second state to end the sale of all flavored tobacco products, including e-cigarettes, and voters in Colorado and Oregon approved ballot measures imposing price increases on e-cigarette and vaping products. ASTHO expects further legislation to prevent youth e-cigarette use in 2021. Other likely tobacco legislation this year includes sales restrictions on tobacco products with specific nicotine concentrations; prohibitions on the bulk sale of e-cigarette products; and the incorporation of e-cigarettes in the definition of tobacco products.

HIV: Ending the Epidemic
States have increasingly started implementing evidence-based policies to prevent future HIV cases in recent years. These policies include improving access to treatment, notably pre-exposure prophylaxis (PrEP), the pill that prevents at-risk people from contracting HIV in the first place. States have also worked to establish programs to prevent the spread of infectious diseases, such as syringe service programs and establishing comprehensive sex education programs. In 2021, ASTHO expects states to increase access to preventive treatments and services for minors, as well as amend criminal and public health statutes to decriminalize certain actions by people who are HIV-positive to reduce stigma, encourage testing, and expand routine testing and service programs to high-prevalence areas and high-risk populations.

Maternal Mortality and Morbidity: Preventing a Crisis
The U.S. has one of the highest rates of maternal mortality among high-income countries. To reverse this trend, state policymakers have established Maternal Mortality Review Committees (MMRCs), widened the scope of existing MMRCs (e.g., to include examinations of maternal morbidity as well as maternal mortality), and required legislative reports and recommendations by the MMRCs. In 2021, ASTHO anticipates legislatures to consider and adopt policies to expand the type of information available for review by MMRCs, improve screening and treatment for postpartum depression and substance use, include health equity considerations in the MMRC process, and create mental health advisory councils for interagency coordination and policy implementation.

Neonatal Abstinence Syndrome: Impact of the Opioid Epidemic
One of the many unfortunate outcomes of the opioid epidemic is an increase in cases of neonatal abstinence syndrome (NAS), when a baby is exposed to illicit and prescription drugs while in utero. In recent years states have started standardizing NAS screening and treatment for mothers and newborns, adding NAS to the list of notifiable conditions, and aligning NAS treatment interventions with child abuse and neglect laws. ASTHO anticipates that 2021 legislative trends will include the development of standardized NAS clinical definitions, guidelines to diagnose and treat NAS, license requirements for specialized NAS treatment facilities, and treatment programs addressing the mother-infant dyad.

Polyfluoroalkyl Substances (PFAS): Regulating Toxic Compounds
PFAS are manmade chemicals used in products such as nonstick cookware, water-repellent clothing, stain resistant fabrics, cosmetics, and firefighting foam. During production and use, PFAS can migrate into soil, water, and air, where they do not break down. Repeated exposure to PFAS can cause these chemicals to build up in people and animals, and there is evidence that exposure to PFAS may lead to harmful health effects. Over the past few years, state legislatures have taken a variety of approaches to address PFAS contamination, such as the assessing or monitoring the presence of PFAS and health effects; setting quality standards; restricting the use, sale, or distribution of PFAS; PFAS remediation and response activities; and calls for federal support. In 2021, ASTHO expects to see legislative trends around the use of PFAS chemicals in food and product packaging, the advancement of research to better understand the health effects of PFAS contamination, and calls for federal guidance to standardize assessments and set environmental limits.

Rural Health: Hospital Closures Threaten Community Access to Healthcare
In the last decade, 134 rural hospitals closed, and more are at risk of closing despite being an essential service to their communities. States are adopting legislation to stem this tide, including laws to create tax incentives for rural hospital systems, establishing and providing technical assistance to rural hospitals, and increasing rural hospital Medicaid reimbursement rates. In 2021, ASTHO expects states to continue their efforts to protect rural health services by allowing tax credits for donations to rural hospitals, encouraging rural healthcare providers through loan repayment programs, and expanding healthcare provider scope of practice.


Andy Baker-White, JD, MPH, is the senior director of state health policy at ASTHO
Margaret Davis, JD, is the director of state health policy at ASTHO
Beth Giambrone, MPP, is the senior analyst of state health policy at ASTHO