ASTHO Unveils Top 10 Public Health Policy Issues to Watch in 2023

December 14, 2022

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 2023. The issues on the list include the public health workforce and legal authority, immunization, reproductive health, overdose prevention, mental health, data privacy and modernization, health equity, environmental health, tobacco and nicotine products, and HIV.

Each year, ASTHO tracks existing and emerging policy trends that impact state and territorial public health departments. “While there are several familiar topics, like HIV and tobacco, we are seeing a new emphasis on issues like reproductive healthcare and overdose prevention,” says Michael Fraser, chief executive officer of ASTHO. “We have learned a lot over the past three years in responding to the COVID-19 pandemic, monkeypox outbreak, and outbreaks of diseases like measles—each highlighting the need for strong public health policy at the state and territorial level.”

Immunization: Vaccination is one of the most powerful and cost-effective tools to prevent disease, disability, and death among children and adults. During the 2019-2020 season, flu vaccines prevented approximately 7.5 million illnesses, 105,000 hospitalizations, and 6,300 flu-related deaths. In November 2022, CDC issued a Health Alert Network (HAN) Health Advisory warning of sharp increases in respiratory diseases—including influenza and COVID-19—earlier in the year than anticipated. ASTHO anticipates that states will consider legislation to reduce barriers to accessing vaccines, consider changes to childhood vaccination requirements, and continue investing in their immunization information systems.

Reproductive Health: Reproductive healthcare encompasses the physical, mental, and social wellbeing of people in relation to the reproductive system. Public health agencies support reproductive health across all stages of life by coordinating funding sources, promoting education and awareness, and providing data to identify health inequities and work to address them. States and territories will likely consider legislation to improve contraception access, expand comprehensive sex education, and enhance data security and privacy of reproductive health data.

Overdose Prevention: Drug overdoses, both fatal and nonfatal, continue to increase in the United States, with the majority of overdose deaths involving opioids. In 2020, the rate of drug overdose deaths rose 31% over the previous year; preliminary 2021 data indicates that more than 105,000 lives were lost. States and territories will likely consider legislation aimed at reducing fatal overdoses, including decriminalizing fentanyl test strips, increasing naloxone access through co-prescribing requirements, and supporting community distribution of naloxone through schools.

Public Health Agency Workforce and Authority: Governmental public health has a responsibility to protect the public’s health and safety, which can be supported by various legal authorities and a strong public health workforce. For the upcoming 2023 legislative sessions, ASTHO expects jurisdictions to address issues related to public health legal authority and the public health workforce, including sustaining recent investments in public health workers, considering professional licensure requirements for public health workers, and determining the process for and scope of public health orders to control the spread of disease.

Mental Health: An estimated one in five U.S. adults has a mental illness, and in recent years significantly more youth have reported mental health challenges. In 2021, almost half of high school students reported feeling persistently sad or hopeless in the past year. In addition, estimates suggest that half of youth with a mental illness do not receive treatment. To address these alarming trends, state legislatures continue to pursue a wide array of policies to improve mental health access and outcomes. States and territories will likely consider legislation to improve suicide prevention and education, invest in youth mental health, and expand access to mental health professionals through telehealth and licensing flexibilities.

Data Privacy and Modernization: Public health departments continue to improve data collection, working to facilitate timely data sharing between healthcare providers and public health authorities while strengthening data privacy protections. States and territories will likely consider legislation to modernize public health data systems and strengthen privacy, including increasing public health agency access to existing health information exchanges, strengthening legal protections of identifiable health data, and collecting more demographic data.

Health Equity: The COVID-19 pandemic amplified health inequities in historically marginalized populations living in both urban and rural communities. From improving public health data collection, to better understanding health disparities, to incorporating health equity and anti-racism policies across all levels of government, state and territorial legislatures can improve health for all residents. ASTHO expects legislatures to consider bills aimed at improving healthcare access for rural communities, working to collect more robust disaggregated data on race, ethnicity, and economic status, and investing in programs to dismantle structural racism.

HIV: In 2019, the federal government set a goal to reduce new HIV infections by 90% by 2030. Over the past year, rates of new HIV infections have declined, however, it is unclear whether that reflects a true decrease in cases or fewer people being tested for HIV. Aligned with this federal goal, states and territories are considering legislation to reduce HIV stigma and prevent new infections. ASTHO expects state and territorial legislators to consider legislation expanding access to pre-exposure prophylaxis (PrEP), establishing or enhancing syringe service programs, and decriminalizing HIV.

Environmental Health: State and territorial legislatures play an important role in advancing environmental public health, from establishing standards for drinking water to considering which food products are subject to state food safety regulations. ASTHO expects state and territorial legislatures to consider legislation supporting comprehensive climate adaptation planning, defining what qualifies as cottage foods, and establishing maximum contaminant levels for PFAS chemicals.

Tobacco and Nicotine Products: According to CDC, tobacco use is the leading cause of preventable disease, disability, and death in the United States. There are indications that cigarette smoking is declining, while the use of diverse nicotine products is gaining popularity among younger users. Nicotine, a highly addictive chemical compound found in tobacco products—including electronic cigarettes—is harmful to adolescent brain development and pregnant people, as well as generally harmful to all people when exposed to the lungs. ASTHO expects states and territories to consider legislation prohibiting the sale of flavored tobacco products, increasing the price of tobacco products, and expanding which public areas are deemed smoke-free environments.

For more information on each topic, visit ASTHO’s legislative prospectus series webpage.


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.