Public Health Legislation in Island Areas
June 23, 2025 | Beth Giambrone, Shannon Vance
The U.S. territories and freely associated states, collectively known as the Island Areas, do not fall under the category of a state or federal district. The Federated States of Micronesia, Republic of the Marshall Islands, and Republic of Palau are sovereign nations with a Compact of Free Association with the federal government. American Samoa, Guam, Northern Marina Islands, Puerto Rico, and U.S. Virgin Islands have American sovereignty but do not have voting representation in Congress.
While the Island Areas share many concerns with their state counterparts, they face different challenges. Legislation in the Island Areas includes proposals to improve access to nutritional foods, deter substance use, and promote healthy aging.
Public Health Governance
American Samoa is considering SB 39-02, which seeks to clarify the leadership of the Department of Health. The bill revises the title of Director of Health to Director of Public Health, outlines the requirements for the position, and references current statute to mandate they serve as the Chair of the Health Services Regulatory Board. The bill passed the Senate in February 2025 and is under consideration in the House.
Food and Nutrition
Earlier this year, the Commonwealth of the Northern Mariana Islands (CNMI) legislature introduced SB 24-31, which would permit certain cottage food operations and home-based business — or microenterprise home kitchens — that prepare and sell freshly cooked meals directly to consumers, known as microenterprise home kitchen operations. The bill also outlines regulations needed to obtain a permit for operation and limits annual sales to $50,000.
Puerto Rico is considering PC-88, which seeks to enhance the nutritional status, health, and overall quality of life of the territory’s residents. The bill authorizes the Commission on Food and Nutrition to advise and guide food businesses to offer healthier options at checkout areas, display informational materials about the risks of consuming low-nutrition foods, and create yearly reports to the governor and legislative assembly.
Maternal and Child Health
Guam introduced 24-38, which would require emergency health care facilities to provide care to victims of sexual assault, including information on contraception and sexually transmitted infections and emergency contraception upon request. The bill also requires health care facilities to have written policies ensuring employees are trained to provide medically and factually accurate information about sexually transmitted infections and emergency contraception and provide that information to sexual assault victims.
In the current legislative session Puerto Rico is considering several measures focused on children’s health. Two bills are related to vaccination requirements for preschool and/or school-aged children. PC 59 would require influenza vaccines for preschool and school-aged children, while PS 32 would add Human Papillomavirus (HPV) to the required vaccination schedules for age-appropriate students. In addition, PS 247 would direct the Secretary of Education to incorporate guidance and education on health conditions and developmental disorders that may impact student learning, such as chronic diseases, into the school health curriculum.
Substance Use
In April 2024, the CNMI legislature enacted HB 23-80, establishing an opioid settlement fund and directing expenditures from the fund to substance use disorder abatement through specific entities, including non-profit organizations that engage in substance use prevention. The law also establishes an Opioid Proceeds Council, tasked with ensuring accountability and transparency in fund allocation. In July 2024, the legislature also enacted HB 23-23, establishing an overdose policy for the Commonwealth. Among other things, the law authorizes first responders and emergency service employees to possess, store, and administer opioid overdose reversal medication, authorizes the Chief Medical Officer to issue a standing order for opioid reversal medication, and provides immunity from civil or criminal liability in the case of an adverse outcome, except in cases of gross negligence or willful misconduct.
While limited data suggests the opioid crisis is generally less pronounced in island jurisdictions, officials are considering policy actions to prevent overdoses and other health consequences from substance use. The U.S. Virgin Islands are considering 36-0021, which would require health care practitioners prescribing Schedule II controlled substances or opioid pain relievers as part of a course of treatment for chronic or acute pain to discuss the risks associated with the drugs with their patients the first time the drug is prescribed, and again before issuing a third prescription during the course of treatment.
As the Island Areas grapple with lowering high rates of tobacco use, two island jurisdictions recently introduced or enacted legislation regulating nicotine delivery systems. In 2024, the Federated States of Micronesia passed Public Law 23-72, which prohibits importing and exporting nicotine delivery systems including e-cigarettes. (Federated States of Micronesia is a freely associated state and not subject to the laws of the United States, which would allow import and export of nicotine delivery systems if approved for marketing by FDA.) Guam is currently considering 03-38, which would prohibit possessing, using, and purchasing electronic nicotine delivery systems by people under 21 years of age, as well as establish a licensing procedure for retailers.
Island jurisdictions are also considering legislation on betelnut (i.e., areca nut), which is wrapped in a leaf with afok or bweesch, a powdered limestone mixture, and chewed, often with tobacco. Betelnut has stimulant properties and harmful effects, and is classified as a carcinogen by the World Health Organization. In January, CNMI enacted SB 23-54, which regulates the sale of afok or bweesch under the Pure Food and Drug Control Act. The Republic of the Marshall Islands recently introduced the Betelnut Regulations Act of 2025, which would allow importing, distributing, and selling betelnut, but would prohibit sale and distribution to minors. It would also establish an import tax, with a portion of the revenues distributed to local governments for public health programs addressing the impact of betelnut use, community development projects, and enforcement regulations pertaining to betelnut use. The bill also allows local governments to enact additional ordinances but does not prohibit importation.
Healthy Aging
Guam is considering 31-38, which would establish a legal and regulatory framework for developing and overseeing assisted living facilities, including nursing homes and residential care facilities. Puerto Rico, where one in four people is 65 years of age or older, also introduced a resolution (RC-84) that would direct the Committee on Older Adults and Social Welfare to investigate and report on the current state of public policy regarding individuals diagnosed with dementia, including assessing how they are identified, accessible services, and compliance with relevant laws and regulations.
ASTHO is committed to supporting the work of the U.S territories and freely associated states to improve population health and will continue to track and share legislative proposals that may yield positive health outcomes for their residents.