ASTHO Unveils Top 10 Public Health State Policy Issues to Watch in 2022

December 15, 2021

ARLINGTON, VA—Today, the Association of State and Territorial Health Officials (ASTHO) is unveiling its list of the top 10 state public health policy issues to watch in 2022. Although COVID-19 did not make the “official” list, it is woven into the management plan for nearly every trend. The 10 public health issues to watch in 2022 include public health authority, immunization, mental health, data privacy and modernization, health equity, the public health workforce, human immunodeficiency virus (HIV), Polyfluoroalkyl substances (PFAS), e-cigarettes, and rural health. We summarize key components of each topic below.

Public Health Authority

During the COVID-19 pandemic public health’s legal authority to respond and mitigate infectious disease outbreaks has been challenged and, in many jurisdictions, rolled back. Maintaining the legal authority to prevent and control the spread of infectious disease is key to preparing for and addressing future disease outbreaks. The recent reductions in public health legal authority will make it more difficult to respond to future disease outbreaks.


With the 2021-22 influenza season coinciding with the ongoing COVID-19 pandemic, public health efforts to ensure vaccination for both COVID-19 and flu will be important in 2022 to prevent severe illness from overwhelming the healthcare system. Vaccination is one of public health’s most powerful and cost-effective tools to prevent disease, disability, and death among children and adults.Reducing barriers to access, addressing school requirements (in particular, the variance in requirements across each U.S. state), and employer requirements will be the legislative focus.

Mental Health

The COVID-19 pandemic revealed the barriers and limitations to accessing mental health care at a time when more Americans need support than ever before. Over the past two years there has been a significant increase in mental health challenges experienced by young people, with U.S. Surgeon General Vivek Murthy issuing an Advisory on Youth Mental Health Crisis earlier this month, noting a significant increase in youth suicidal behaviors. Efforts to improve suicide prevention will likely include investments in school-based mental health services and infrastructure for the 988 national suicide prevention hotline. Legislatures will also be focusing on reducing barriers to mental healthcare access.

Data Privacy and Modernization

Data collection and analysis of trends in population health is a core public health function. Years of underinvestment in public health infrastructure prevented many public health agencies from modernizing their data collection and sharing processes, creating information sharing challenges during the COVID-19 pandemic. Modernizing and enhancing public health data collection and sharing, while protecting individual privacy, will likely be a focus of state legislatures in 2022.

Health Equity

To achieve optimal health for all, public health is working with governmental and nongovernmental partners to dismantle structural racism and other forms of structural discrimination. This work, commonly referred to as health equity, focuses on investing additional resources in historically under-invested or disinvested communities. There are many policy opportunities to support health equity across all levels of government. Recent actions by state legislatures include declaring racism as a public health crisis, advancing efforts to improve collecting data on health disparities, and implementing legislative processes to promote health equity.

Public Health Workforce

For nearly two years, state and territorial public health agency staff have mounted an extraordinary effort to stem the COVID-19 pandemic. With near continuous work on COVID-19 as well as the many other public health issues that did not pause during the pandemic the public health workforce is facing detrimental impacts to their physical and mental health. In many places, the opposition to public health measures to address COVID-19 has led to threats and intimidation of public health officials causing several to leave their jobs.


There were approximately 34,800 new HIV infections in the U.S. in 2019, with an estimated 80% of transmissions occurring among people who did not know they had HIV or were not regularly receiving care for their HIV. In 2019, the federal government announced its goal to end the HIV epidemic by 2030. To reach this goal, states are implementing evidence-based policies to prevent future HIV cases. Beyond enhancing HIV testing, states and territories are also implementing policies to improve access to pre-exposure prophylaxis (PrEP); establishing syringe services programs (SSPs) to prevent the spread of infectious diseases; and implementing comprehensive sex education initiatives.


Per- and Polyfluoroalkyl substances (PFAS) are synthetic chemicals used in products such as nonstick cookware, water-repellent clothing, stain-resistant fabrics, cosmetics, and firefighting foam. These chemicals can migrate into soil, water, and air during production and use, with most remaining in the environment without breaking down. PFAS can accumulate in the blood of people and animals over time from exposure to contaminated environmental media (e.g., water, soil) and consumer products (e.g., food packaged in containers made with PFAS). There is evidence that exposure to PFAS may cause harmful health effects, such as decreased vaccine response in children, increased risk of kidney or testicular cancer, and increased cholesterol levels. Public health leaders should monitor trends around assessment and monitoring, water quality standards, firefighting foam restrictions, and consumer product packaging in the year ahead.


Tobacco use in all forms is associated with severe COVID-19 outcomes. During the COVID-19 pandemic, tobacco use increased among smokers. Although some smokers increased their tobacco use due to pandemic-related stress, other smokers were motivated to quit by the increased COVID-19. E-cigarettes, which are inhaled through “vaping” have become exceedingly popular despite the documented health risks. Most e-cigarettes contain nicotine, which is highly addictive, harmful to adolescent brain development, a health danger for pregnant people, and toxic to fetuses. Looking forward, public health officials should monitor legislative trends around flavored products, e-liquid standards, and tobacco price increases.

Rural Health

Rural hospitals are essential to their communities due to their inclusion of a trauma center, service to vulnerable populations, distance from other hospitals, and economic impact. The COVID-19 pandemic highlighted and magnified the factors leading to rural hospital closures across the country, as the suspension of elective procedures with the reduced the use of non-urgent services by apprehensive patients meant a loss of revenue and furloughed healthcare staff. Closure of rural hospitals reduces access to healthcare and economic vitality of the community served by the hospital. Rural health trends with public health impacts to monitor in the coming year include loan repayment and support for medical providers, behavioral health concerns, access to care, and broadband/closing the digital divide.

“Each year ASTHO tracks existing and emerging policy trends that impact state and territorial public health departments,” says Andy Baker-White, ASTHO’s senior director of state health policy. “Many of the trends ASTHO will be following in 2022, such as HIV and e-cigarettes, are quite familiar while others, like the challenges to public health authority and data modernization, are new. Throughout the new year ASTHO will identify and relay policies related to the trends to its members so they can better inform their public health work.”

“We recommend that public health officials monitor these top issues in 2022,” says ASTHO CEO Michael Fraser. “There is no doubt that the ongoing COVID-19 pandemic will continue to play a major role in the lives of public health officials and the American public. But these issues represent areas that we cannot afford to ignore. As we begin to think about emerging from the pandemic, health officials must be prepared to pivot and take action on immunization issues, mental health, data modernization, health equity, and more.”

Each prospectus mentioned in this release will be made available to the public in early January.


ASTHO is the national nonprofit organization representing the public health agencies of the United States, the U.S. territories and freely associated states, and Washington, D.C., as well as the more than 100,000 public health professionals these agencies employ. ASTHO members, the chief health officials of these jurisdictions, are dedicated to formulating and influencing sound public health policy and to ensuring excellence in public health practice.