Policy Points This is a pivotal time for state leaders and policymakers to lean into opportunities to enhance infectious disease control in the United States. There are extensive opportunities for state-led initiatives to be influential in the areas of public health infectious disease detection, public health funding, and public health infrastructure. It is imperative to remember that "all responses are local" and that the ultimate authority to detect, investigate, control, and prevent the spread of infectious diseases in the United States falls to states. CONTEXT:Over the last decade, the United States has encountered numerous infectious disease-related public health threats, observed declines in life expectancy and childhood vaccination rates, and experienced rapid changes and reorganizations to the domestic public health system. There is a window of opportunity for state leaders and policymakers to strengthen state, tribal, local, and territorial public health infrastructure amidst a changing federal landscape in order to ensure optimized infectious disease control in the United States. METHODS:This perspective synthesizes evidence from the public health literature and draws on the collective experience of the authors working in the applied public health field. We offer considerations for state leaders and policymakers to ensure optimized infectious disease control in the United States though state-led initiatives and direction. FINDINGS:Although many public health activities related to infectious disease detection, investigation, control, and prevention are funded and directed by federal public health authorities, state, tribal, local, and territorial health departments have held the legal authority for this work since the early 19th century. Recent changes and relative instability at the federal level are noteworthy; however, "all responses are local" and the ultimate authority to detect, investigate, control, and prevent the spread of infectious diseases in the United States falls to states. CONCLUSIONS:State leaders have a duty and responsibility to protect the health of their population and ensure a posture of readiness to effectively respond to infectious disease health threats. States can step forward and embrace innovation in this space to ensure optimized infectious disease control in the United States prior to the next emerging infectious disease public health threat.
Policy Points Over the past year, the nation's highest-ranking public health officials have pursued a concerted strategy of degrading access to childhood vaccines and undermining public confidence in vaccine safety and efficacy. As primary regulators of medical care, states have the power to maintain strong public health protections. A strong childhood vaccination policy has three components: maintaining a robust routine childhood vaccination schedule; focusing on broad vaccine access; and restoring public confidence in the safety and efficacy of childhood immunization. CONTEXT:Beginning in 2025, longstanding opponents of vaccines have held the highest positions of federal public health policy powers. METHODS:Using these powers, high ranking officials have sought to disrupt vaccine coverage and delivery and sow public mistrust in vaccine safety and efficacy. FINDINGS:The results of their efforts have been confusion and declining levels of childhood immunization. As of summer 2026, a federal court has enjoined efforts to degrade the childhood vaccine schedule and the public health expertise of the Advisory Committee on Immunization Practices, whose recommendations lie at the heart of US vaccine policy. CONCLUSION:As the nation's most important regulators of public health practice, states play a critical role in countering these efforts and protecting vaccine accessibility and acceptance.
Policy Points Telehealth increases access to health care services for patients, including rural and underserved communities, and a 50-state survey of telehealth policies can further the study of the impact of telehealth on patient outcomes. This legal mapping study tracked telehealth policies by state Medicaid programs and found widespread adoption, especially in reimbursement for audio-only telehealth (adopted by 0 to 43 states from 2018 to 2023). State adoption of telehealth policies appeared to be independent of rurality, health professional shortage, Medicaid expansion, broadband internet availability, and any tested state factor (e.g., demographics, unemployment, COVID-19 cases). CONTEXT:Telehealth can improve access to medical and mental health care for rural and under-resourced communities. US states rapidly expanded policies enabling telehealth care delivery during the COVID-19 pandemic, possibly driven by certain state factors, such as rurality. Variation in state policies regarding Medicaid, the largest US health insurance program by enrollment, enables the naturalistic study of telehealth care expansion and health outcomes for underserved individuals. This study aimed to identify state policies addressing Medicaid telehealth care delivery and to examine explanatory state factors associated with telehealth adoption. METHODS:Legal mapping (50-state survey) methods were used to identify US state laws and policies addressing telehealth for Medicaid populations in effect up to December 31, 2023. Two researchers independently abstracted relevant information and analyzed data, guided by a supervising public health attorney and physician. The main outcome was the count of (equally weighted) policies in effect during each month by state. Multivariable regressions were used to examine the data for associations between policy counts and several potential explanatory state factors from 2018 to 2023. FINDINGS:A mean of 2.7 telehealth policies (standard deviation, 1.4; range, 0-6) were in effect across state Medicaid programs during the study period. Most adoption occurred during 2020 and 2021, with an audio-only reimbursement policy being the most rapidly adopted, increasing from 0 to 43 states over the course of 5 years. State adoption of telehealth policies appeared to be independent of rurality, health professional shortage, Medicaid expansion, broadband internet availability, and any tested state factor (e.g., demographics, income, unemployment, COVID-19 cases and deaths). CONCLUSIONS:States rapidly enacted many Medicaid policies to facilitate telehealth care delivery, which was not driven by any singular state factor. Policy plays an important role in the implementation of evidence-based health care tools, such as telehealth. This 50-state survey can be used to understand policy effects on patient care access and quality for rural and underserved populations.
Policy Points Position Universal, High-Quality Education as a Foundational Public Health Strategy. Long-term health and life expectancy in the United States are shaped more by educational attainment than by any other single factor. Disparities in access to early childhood, K-12, and higher education perpetuate cycles of chronic disease, economic hardship, and shortened lifespan, particularly in marginalized communities. Policymakers must recognize education as a critical public health intervention and commit to providing universal access to high-quality education at every stage of life. This transformation requires shifting the focus from mere per-pupil spending toward the national scaling of high-impact instructional models, such as intensive, high-dosage tutoring and adaptive learning. Leveraging generative AI to provide personalized, real-time instruction tailored to individual student needs is essential to bridge the achievement gap at scale. Furthermore, achieving true educational equity requires decoupling school quality from local property taxes, integrating health literacy and nutrition into curricula, and ensuring higher education remains affordable and accessible for all. Transform the Food and Built Environment to Advance National Metabolic Resilience. The structure of America's food system and built environment directly fuels the escalating burden of obesity, diabetes, and related chronic diseases. Federal and state policies must fundamentally shift agricultural subsidies away from calorie-dense, nutrient-poor commodities toward specialty crops and fresh produce. To ensure these healthy choices are the default for every household, the federal government must finalize and enforce mandatory, interpretive front-of-package warning labels for ultra-processed foods. This shift, designed to move beyond the passive Nutrition Facts panel, will provide at-a-glance transparency and incentivize industrywide reformulation. Furthermore, metabolic health must be integrated into the K-12 experience through mandatory daily high-intensity physical activity to improve cardiorespiratory fitness and cognitive performance and minimally processed school meals. Finally, investments in active transportation infrastructure, including pedestrian greenways and safe routes to school, are essential to encourage movement as a default, closing the "convenience gap" that disproportionately burdens low-income and rural Americans. Normalize Chronic Obesity Management. Acknowledging that no nation has successfully reversed the obesity epidemic through behavioral advice alone, the United States must treat obesity as a chronic biological condition rather than a temporary lifestyle lapse. It is imperative that public and private payers guarantee universal, affordable access to evidence-based treatments, including next-generation pharmacotherapies (such as GLP-1 receptor agonists). These clinical strategies must be coupled with a modernized, real-time health data infrastructure to monitor outcomes and ensure equitable access at the neighborhood level. CONTEXT:Over the past three decades, mortality from leading causes such as cardiovascular disease and cancer has declined in the United States, but the burden of chronic, disabling conditions, including musculoskeletal disorders, mental and substance use disorders, and obesity, has grown or stagnated, widening the gap between total years lived and years lived in good health. These shifts are accompanied by persistent and widening inequities in longevity by geography, race/ethnicity, and socioeconomic status. METHODS:This analysis draws on the 2023 Global Burden of Disease Study, which estimates mortality, disability, and risk factor burden for 375 diseases and 88 risk factors nationally and at the state level, combined with findings from the US Health Disparities project. The latter uses small-area estimation to evaluate county-level life expectancy and mortality across five racial/ethnic groups and four educational strata, and the "Ten Americas" framework, which stratifies the population by race/ethnicity, geography, and socioeconomic context. FINDINGS:In 2023, US life expectancy reached 78.5 years and healthy life expectancy 64.5 years, both still below prepandemic 2019 levels, with a persistent 13-14-year gap between life expectancy and healthy life expectancy. Ischemic heart disease remained the leading cause of death, but drug use disorders rose from the 26th to the leading cause of disability, a 562% increase since 1990, while Alzheimer disease and musculoskeletal disorders also climbed in rank. High systolic blood pressure remained the top mortality risk factor despite a large decline, while high body mass index and high fasting plasma glucose burdens grew substantially. State-level disparities widened, with West Virginia and Mississippi trailing Hawaii by wide and increasing margins. Life expectancy gaps by race/ethnicity, education, and place were large and growing, reaching 20.4 years across the "Ten Americas" by 2021, with county-level life expectancy spanning more than 27 years nationally. CONCLUSIONS:US health trends reflect a shift from fatal to disabling disease, driven substantially by the obesity/metabolic and substance use epidemics, layered onto deep and widening structural inequities by race/ethnicity, place, and education. Reversing these trends requires a multidimensional policy agenda spanning universal, high-quality education; reform of the food and built environment; normalized clinical management of obesity; expanded, integrated substance use and mental health treatment; and modernized, real-time public health data infrastructure.
Policy Points Improving population health while reducing inequality is possible, but it depends on broad institutional investments whose benefits extend across the socioeconomic distribution rather than accruing primarily to the advantaged. The education-health gradient is sensitive to the race between technology and education. Recent advances have disproportionately benefitted college-educated persons, and differential automation risk and unequal access to therapeutics, such as GLP-1 agonists, may widen these gaps further and further entrench this inequalities without policy intervention to improve the health of the whole population. To the extent that technological displacement accelerates job loss and compounds the economic and social precarity already driving the stagnation in life expectancy among less-educated persons, the educational divide in health is poised to widen further unless policies decouple access to health insurance from employment status or otherwise shore up the labor market position of the most vulnerable workers. CONTEXT:In this perspective, we have reviewed the historical evidence on the association between education and health in the United States, arguing that attention to public policies related to both education and technology are fundamentally important in understanding historical changes in the educational divide in life expectancy. METHODS:Our assessment of the literature suggests that the relatively narrow educational gap in life expectancy throughout much of the 20th century until 1970 reflected a rapid expansion of education in the population combined with the deployment of technologies that benefitted the majority of Americans. In the latter part of the 20th century and into the 21st century, however, life expectancy for Americans with less than a college degree stalled, whereas the life spans of college-educated Americans grew at a rapid pace. FINDINGS:We argue that the faster pace of technological change compared to educational changes in the population fueled the rise in life expectancy of college-educated persons, with life expectancy among less-educated persons being increasingly contingent on state policies focused on employment and health opportunities. CONCLUSIONS:The implications of these findings suggest that the educational divide in adult health is likely to grow even greater in the decades ahead with continued rapid technological advances.
Policy Points Public health has lost political influence because of a mismatch between the forms of power primarily deployed in this field—knowledge and moral authority—and the forms of power that currently shape societal rules and health outcomes—economic, political, ideological, and physical. Rebuilding the influence of public health requires a strategy shift that returns the field to its roots: building people power through partnerships with labor and community organizing groups; strengthening ideological power through the development of narrative infrastructure; and in moments of institutional breakdown, deploying nonviolent disruptive power to protect population health. Context Public health is inherently political, yet it has struggled in recent decades to influence the societal decisions that shape population health. Despite strong evidence supporting policies across domains such as environmental protection, infectious disease control, labor conditions, and reproductive health, the field has faced growing political backlash and policy retrenchment. This Perspective argues that these challenges reflect a mismatch between the forms of power public health primarily deploys and the forms of power that currently shape societal rules and health outcomes. Analytic Approach This Perspective draws on an established typology of power to conceptually analyze the forms of power available to public health practitioners and to actors advancing policies and institutional arrangements detrimental to public health. Findings Public health has relied primarily on knowledge and moral power, whereas actors advancing policies detrimental to health increasingly wield economic, political, ideological, and physical power within a neoliberal political economy. Under conditions of polarization, disinformation, and institutional capture, knowledge and moral power alone are structurally insufficient to shape the societal rules that determine health. The analysis identifies additional forms of power available to public health—including people, ideological, and nonviolent disruptive power—that could strengthen the field's political influence while remaining consistent with health equity values. Conclusions The analysis suggests a strategic shift for public health: rebuilding people power through partnerships with labor and community organizing groups, strengthening ideological power through sustained investment in narrative infrastructure, and, when democratic institutions fail to protect health, joining with others in the strategic use of nonviolent disruptive power. More broadly, advancing population health will require public health to engage more deliberately with power and politics rather than relying on evidence alone.
Policy Points Acute dietary switching from ultra-processed food to minimally processed food elicits no physiological withdrawal, a key indicator that people rely on ultra-processed foods for reasons other than food addiction. France and Japan are countries with low adult obesity prevalence attributable to agricultural and school nutrition policies that encourage greater consumer reliance on a diversity of fiber-rich, polyphenol-rich, minimally processed foods. Traditional, high-fiber dietary patterns optimize gut-microbiota function, elevating the biological precursors required for the natural expression of the satiety hormone glucagon-like peptide-1 (GLP-1). Public health progress in reducing US obesity prevalence will be more effectively achieved by subsidizing and expanding consumer access to whole foods than from efforts to prevent the food industry from making their ultra-processed food products hyperpalatable. CONTEXT:In this commentary, we applaud Gearhardt and colleagues' focus on the negative health effects of consuming ultra-processed foods but suggest that the bigger dietary contributor to obesity risk is American consumers' lack of access to a diverse range of gut microbiota-accessible foods. METHODS:We cite scientific literature supportive of the health benefits of consuming fiber-rich, polyphenol-rich, minimally processed plant foods, which are more likely to provide substrate to one's commensal gut microbes than would consuming ultra-processed foods. We also cite results from randomized, controlled feeding studies showing that study participants who were switched from an ultra-processed food condition to a minimally processed food condition did not report withdrawal symptoms or evidence of tolerance, thereby undermining Gearhardt and colleagues' thesis that consumers' overconsumption of calories could be attributed to the addictiveness of ultra-processed foods. FINDINGS:We cite scientific literature illustrating the health benefits of consuming traditional dietary patterns, such as the Mediterranean dietary pattern, which feature a diversity of fiber-rich, polyphenol-rich, minimally processed foods. CONCLUSIONS:We conclude that government agricultural and educational policies that increase consumer access to gut microbiota-accessible foods may be a more effective long-term approach to reducing nutrition-related chronic diseases than policies that limit the ability of the food industry to increase the hyper-palatability of ultra-processed foods.
Policy Points Chronic absence should be recognized as a public health indicator and early warning sign that systems are failing to meet the developmental, social, and health needs of students. Improving student attendance requires cross-sector policy action across education, health, and public health to address the structural and social determinants of chronic absence. A prevention-oriented public health approach is essential, focusing on root causes that schools cannot address alone such as poor health, housing instability, and unreliable transportation. CONTEXT:Chronic absence, defined as missing more than 10% of time in school, has risen sharply in the United States following the COVID-19 pandemic and now affects more than one in four students. It reflects unmet health and social needs and is patterned by deep structural inequalities. Both short- and long-term consequences include adverse impacts on educational attainment, health, and social outcomes. Despite this, chronic absence remains largely framed and addressed as an education-sector problem, limiting the scope and effectiveness of current responses. METHODS:This perspective synthesizes interdisciplinary evidence from education, public health, and child development literature, drawing on ecological and life course frameworks to reconceptualize chronic absence as a public health issue. We develop a conceptual model integrating multilevel determinants of attendance across individual, family, school, community, and structural domains, and identify implications for policy and cross-sector action. FINDINGS:Viewing chronic absence through a public health lens reframes it from a purely educational outcome to a signal of unmet need and a multidimensional indicator of system performance. Attendance patterns reflect the interaction of health, social, and structural factors that lie largely outside of the control of schools. Current approaches often emphasize individual responsibility, while overlooking the broader conditions that shape attendance. Reframing chronic absence in this way underscores the need for coordinated cross-sector interventions that address underlying determinants. CONCLUSIONS:Positioning chronic absence as a public health priority enables a more coherent response. We propose three principles to guide action: (1) use school attendance data as a vital sign of student and system well-being; (2) develop strategic partnerships to align goals and drive progress; and (3) develop strengths-based policies and programs to prevent chronic absence. Without this shift, efforts to reduce chronic absence are likely to remain fragmented and insufficient to achieve equitable improvements in child health and educational outcomes.
Policy Points Disruptions to federal health data infrastructure threaten states' ability to identify health disparities, target interventions, and evaluate programs, making state-level investment in data infrastructure and systems especially urgent. States can build resilient, equity-centered data systems by enacting data disaggregation legislation, investing in data systems with bridging methodologies for data continuity, and establishing governance frameworks that protect privacy while facilitating data access. CONTEXT:Health equity depends on data equity: the representation of communities in the data used to identify disparities, target interventions, and hold systems accountable. Recent shifts in federal health data infrastructure, including changes to datasets and reductions in agency capacity, have introduced uncertainty for state officials who bear primary responsibility for population health outcomes. Even apart from these shifts, robust state capacity matters in its own right, making investment in resilient data infrastructure a timely priority. METHODS:We examine how changes in federal health data infrastructure affect states' capacity to advance data equity and how policymakers can respond. We review across state data disaggregation legislation, draw on the California Health Interview Survey (CHIS) as a model case, and synthesize evidence on data interoperability, governance, and dissemination. FINDINGS:Some states are already moving beyond federal minimums on race and ethnicity data collection. For example, Connecticut, Oregon, and Massachusetts have enacted expansive laws collecting detailed subgroups; Illinois, New York, and New Jersey have added Middle Eastern and North African and other categories across all state agencies. Colorado and Oregon extend collection to sexual orientation, gender identity, and disability status. We offer examples from California's recent legislation and show how CHIS operationalizes such mandates. We also identify persistent constraints, including incomplete demographic fields in administrative data, workforce and interoperability gaps, and the need for governance frameworks and data firewalls that safeguard privacy. CONCLUSIONS:State-led data infrastructure will help build effective public health practice. The aim is not 50 incompatible systems but an ecosystem of comprehensive and inclusive systems that are more granular, responsive, and community-accountable. For such an ecosystem to function, the systems must still communicate, which depends on shared standards and definitions that keep data comparable across states and over time. Realizing this vision requires diversified funding, cross-agency coordination, strong governance, and active roles for researchers, philanthropy, and communities, so that progress in measuring disparities endures across changing policy environments.
Policy Points Reimposing work requirements for the Supplemental Nutrition Assistance Program-by removing temporary, location-based waivers-causes a decline in food assistance participation among childless women. This loss of nutritional support prior to pregnancy is linked to tangible, negative health outcomes for their infants. Analyses show that, when work requirements are reimposed, there are statistically significant increases in very low birth weight and very preterm births. These adverse effects are found among first-time mothers, the group most likely to have been subject to these work requirements as "able-bodied adults without dependents" just prior to their pregnancy. CONTEXT:Able-bodied adults without dependents (ABAWDs) are eligible for Supplemental Nutrition Assistance Program benefits for only 3 months in any 36-month period, after which they are subject to a work requirement to continue receiving benefits. Because ABAWDs may later have children, this work requirement for childless adults may affect the health of pregnant women and their infants through the mother's nutritional well-being prior to pregnancy. The objective of this study was to examine whether temporary county-level waivers of these work requirements improved health outcomes for mothers and their infants. METHODS:This study used restricted National Vital Statistics System natality data from 2004 to 2018, with virtually every birth in the United States in that period, linked at the county-month level to a dataset of ABAWD work-requirement waivers in the year prior to pregnancy. Several binary maternal and infant health outcomes were examined in intent-to-treat analyses using two-way fixed-effects regressions and event studies with application of an estimator robust to heterogeneous treatment effects. The analysis also controlled for economic conditions upon which waiver eligibility is determined. FINDINGS:Statistically significant increases in adverse birth outcomes were found for first-time mothers exposed to (re-introduced) work requirements just before pregnancy, including a 14% increase in very low birth weight infants and a 10% increase in very preterm births relative to baseline rates. In contrast, the introduction of a waiver was associated with little change in birth outcomes. For maternal outcomes, the removal of a waiver was unexpectedly associated with a significant reduction in eclampsia and a decline in labor inductions. The study found little to no effect of waiver status on other maternal outcomes, such as diabetes or cesarean section rates. CONCLUSIONS:This study found evidence that work requirements for food benefits may harm infant health, particularly when waivers are terminated. These results provide evidence that may inform policymakers weighing the costs and benefits of modifications to ABAWD work requirements.
Policy Points For half a century, firearm-related deaths and injuries have been endemic in the United States, with COVID-19 contributing to a record high of 48,830 deaths in 2021, an epidemic rate increase. By 2023, national trends masked a significant 10-fold difference in firearm-related death rates among states. Over decades, some states have experienced large, sustained reductions in firearm-related death rates, while others have experienced increases. Firearms are a consumer product that fit the definition of a market-driven epidemic (MDE), with the firearms industry having successfully marketed gun ownership through strategies that include fear, predatory tactics, and emphasis on lethality; stalling public health research for decades; and employing strategies used in other industries to promote potentially harmful products. Evidence from classic MDEs, such as tobacco and prescription opioids, demonstrates that large-scale, long-term reductions in harmful use can be achieved through a combination of focused, effective interventions and engaged governments, nongovernmental organizations, academia, media outlets, and, at times, companies themselves. The United States has developed a robust array of evidence-based mitigation strategies to reduce firearm-related harm, including gun safety laws, focused hospital and mental health programs, community and environmental programs, and social and economic policies. Applying insights from classic MDEs, building on what has worked, and increased active engagement among stakeholders are needed to reduce preventable firearm harm. CONTEXT:The United States has among the highest firearm-related deaths in the world. In 2023, suicides accounted for 58% of firearm-related deaths and 38% of homicides. Firearms have become the leading cause of death among those under age 19. Nonfatal injuries, outnumbering deaths over two-to-one, often lead to lifelong physical and mental health sequelae. The firearms market, valued at around $40 billion per year, is one-tenth the estimated $500 billion cost of the epidemic due to medical costs, work loss, and quality-adjusted life years lost. METHODS:Peer-reviewed literature, government documents, and media reports were used to analyze the firearms epidemic according to the market-driven epidemics (MDE) definition and framework of five often overlapping phases: (1) market development; (2) evidence of harm; (3) corporate resistance; (4) mitigation; and (5) market adaptation. The MDE framework emerged from the analysis of efforts that reduced cigarette, sugar, and prescription opioid use. The central question for mitigating the firearm MDE is: What combination of interventions and actors will achieve large-scale, long-term reductions in firearm-related deaths and other harm? FINDINGS:The epidemic of firearm harm fits the MDE definition and is progressing through the five stages of an MDE. Phase 1. Firearms marketing accelerated rapidly when the focus shifted from marksmanship, sportsmanship, and hunting to themes of self-defense, home protection, patriotism, and masculinity. Phase 2. Evidence of harm at the population level has linked firearm ownership or possession to significant increases in suicide deaths, homicide, femicide, and gun-related injuries. Phase 3. Firearms industry resistance has used "corporate playbook" strategies to downplay the evidence of preventable harm, discredit public health, and influence the passage of favorable legislation. Phase 4. Decades of action by government, academia, and civil society have produced an array of mitigation interventions shown to reduce firearm-related suicides, homicides, and other harm. Jurisdictions that have implemented these measures have been able to achieve significant, sustained decreases in firearm-related deaths, while some high-burden areas that have declined to implement such measures and have enacted permission policies have experienced notable increases in firearm-related deaths. Phase 5. The firearms market has evolved through consumer demand for "non-lethal" alternatives (i.e., TASERs, rubber bullets) and through company expansion of overseas sales and pursuit of new technologies (i.e., "smart guns," magazine safeties). CONCLUSIONS:High rates of firearm-related deaths and injuries are not inevitable. By treating the firearm harm epidemic as the market-driven problem it is, drawing on insights from other MDEs strategies, substantial reductions in violence may be achievable across the United States. States and cities have significantly reduced gun violence without infringing Second Amendment rights. The greatest unmet challenge now is generating increased engagement in gun safety among states and communities still experiencing high levels of preventable firearm deaths and related harms.
Policy Points Rural communities have more limited access to medical care and worse health outcomes. Existing federal and state policies largely fall short in addressing rural access disparities. Rural health woes require increased government funding for providers and the embrace of alternative health delivery mechanisms, as well as expanded public-private/nonprofit partnerships to overcome access barriers. CONTEXT:Rural and urban areas have diverged significantly in health care access and health outcomes over the last four decades. Federal and state policies have played important roles in shaping these trends. METHODS:I qualitatively review previous and existing federal and state policies that have shaped contemporary rural-urban health disparities. I review academic literature on recent policy enactments that have shown promise for alleviating some rural health struggles as well as scholarship on how the politics of rural health have stymied better policymaking. FINDINGS:Large scale federal investments (e.g., the Hill-Burton Act) were required to bring modern health care to rural communities in the first place, but inadequate and nonuniversal policies enacted since the 1970s and the increasing corporatization of health care over the last decades have led to withering rural health care access. The recent "One Big Beautiful Bill Act" will likely make these matters worse. Policies that have expanded telehealth and mobile health access, as well as subsidized rural transportation services and changes to public payer reimbursement policies, have provided some optimism. However, the broader politics of rural health limit policy opportunities. CONCLUSION:Rural health has suffered, in part, due to state and federal policy failures. While some incremental changes have certainly shown evidence of potential improvements, a more radical policy agenda may be needed to maintain or improve health care access in rural communities. There is mixed-to-negative evidence regarding whether the political environment will allow for sufficient policy improvements.
Policy Points State policies and programs play an outsized role in shaping availability and access to sexual and reproductive health services across the nation. This has a major impact on women's access to contraception, abortion, and maternity services. In particular, state decisions about health care Medicaid coverage and payment, professional credentialing, reproductive rights, and regulatory policy all affect whether access to sexual and reproductive health services is broadened or constrained and ultimately whether low-income women will be able to access the broad range of services they need. Beyond coverage and payment, examples of recent state policies impacting reproductive health care include telehealth provision of abortion, pharmacists' prescribing authority, and efforts related to maternal health care quality improvement and oversight. CONTEXT:Access to sexual and reproductive health care varies widely by geography, and state-level policies play a major role in establishing the contours that govern the coverage, provision, availability, and costs of services. The role of state-level policies has been amplified in the wake of the 2022 Supreme Court ruling in Dobbs v. Jackson Women's Health Organization, which eliminated the federal right to abortion care allowing states to set their own policies to ban or protect abortion. Additionally, states play a major role in shaping Medicaid policies that affect access to contraception and maternity care. This Perspective examines the many ways that state policy choices affects access to three interrelated areas of reproductive health care: contraception, abortion, and maternity care. METHODS:State policy actions and decisions are at the core of reproductive health coverage and access. They are shaped by funding decisions, eligibility, and coverage polices established by the legislative and administrative bodies. This includes state policies related to contraceptive coverage and rights, Medicaid eligibility, telehealth and pharmacy access, scope of Medicaid and private insurance coverage, and efforts related to quality improvement and oversight. FINDINGS:Affordability, availability, and coverage are still barriers to sexual and reproductive health services in many parts of the nation. Several states have intentionally erected barriers to abortion care, but structural challenges also affect contraception and maternity care access. Financing and regulatory policies treat contraception, abortion, and maternity care as distinct domains, but they are inextricably linked and many women often seek these services from the same clinicians. State level policies related to health coverage, reimbursement levels, workforce supply, and quality of care all overlap and affect the care that women receive and their experiences with the health care system. CONCLUSIONS:State policymakers play an outsize role in developing and implementing approaches to address their resident's reproductive health needs. The implementation of Medicaid work requirements and other federal cuts to health spending in the next several years is expected to lead to a major increase in people becoming uninsured at the same time that the reproductive health care safety-net faces financial uncertainty. States that take a coordinated, systems-level approach to health care can strengthen access, improve care delivery, and better meet patients' reproductive health care needs.
Policy Points The pressing need for alignment across the US health system has the potential to amplify the reach and impact of the public health system by stretching available dollars and facilitating broader access to services. States should explicitly position themselves as system integrators of shared infrastructure, aligning public health with other systems through shared governance, service delivery, financing, and technology solutions. Particularly in rural communities that lack reliable access to essential health care and social services, states should prioritize regional and shared service models as scalable opportunities to address workforce shortages, achieve economies of scale, expand access, and sustain services. CONTEXT:The US public health system is facing an inflection point characterized by chronic underinvestment, workforce and service delivery challenges, outdated data infrastructure, growing health inequities, and increasing instability within the broader health care safety net including projected Medicaid coverage changes and continued rural hospital closures. Fragmentation across public health, health care, social services, and financing systems limits the nation's ability to address complex population health challenges and invest in prevention. METHODS:This paper examines opportunities for state-led alignment of the public health system through a systems-oriented framework. Drawing on current policy developments, emerging evidence, national frameworks, and state-based examples, we identify and analyze five strategies through which states can strengthen population health: (1) aligning Medicaid and public health around shared population health goals; (2) developing more sustainable and flexible financing mechanisms; (3) expanding regional service delivery and shared-service models; (4) strengthening public-private partnerships; and (5) aligning technology and data modernization efforts with critical infrastructure needs. FINDINGS:The analysis highlights how state governments can serve as system integrators and stewards of shared infrastructure by aligning governance, financing, service delivery, partnerships, and technology across traditionally siloed sectors. Examples from multiple states demonstrate the potential for Medicaid-public health integration, blended and braided financing approaches, regional service delivery models, public-private collaborations, and interoperable data systems to improve efficiency, expand access to services, strengthen workforce capacity, support population health outcomes, and increase system sustainability. These approaches are particularly important in rural and underserved communities, where workforce shortages, hospital closures, and limited resources threaten access to essential services. CONCLUSIONS:Addressing today's public health challenges requires moving beyond fragmented, program-specific approaches toward a more integrated, prevention-focused health system. States are uniquely positioned to lead this transformation by aligning public health with innovations in Medicaid, financing, service delivery, private-sector partnerships, and technology infrastructure. Strategic state leadership can improve efficiency, sustainability, and responsiveness while strengthening foundational public health capacity. In an era of resource constraints and rising health threats, state-led systems alignment positions states as integrators of shared infrastructure and represents a critical opportunity to improve population health and build a more resilient public health system.
Policy Points Community organizers addressing health issues use narrative strategy to shift public attitudes, build support for health-affirming policies, and motivate collective action. Through a mixed methods research partnership with a power-building organization, we evaluate how narrative power is leveraged to disrupt dominant ideas about the health care system-testing the impact of counter-narratives grounded in the lived experiences of people most harmed by structural failures. Findings demonstrate that strategic messaging from community organizers about health policy issues has the potential to shift policy-relevant beliefs, particularly those related to attributions of blame and intent to take collective action. CONTEXT:Building narrative power, a foundational strategy used in community organizing, involves dismantling dominant narratives that uphold inequity and constructing counternarratives that advance health equity and racial justice by reshaping how people make sense of the world. Yet, the mechanisms through which narrative power can influence public opinion and subsequent policy are seldom evaluated with research. METHODS:In partnership with a power-building organization, we developed and tested two counternarratives that challenge dominant framings of the US health care system. In this three-phase study, we (1) conducted interviews with community organizers to explore their motivations and health care experiences, (2) iteratively developed two counternarratives reflecting the system's complexity and unaffordability, and (3) tested the counternarratives in a randomized experiment (N = 1,587), against a constructed dominant narrative and a no-message control. Following exposure to an assigned narrative, participants completed a posttest questionnaire measuring the primary (policy perceptions and intentions to participate in civic actions to improve health care) and secondary (perceptions of causal attributions and blame) outcomes. FINDINGS:Our results indicate the dominant narrative effectively individualizes blame for poor health and dampens motivation for civic engagement. Meanwhile, counternarratives rooted in the lived experiences and language of those most harmed by the system have potential to shift public beliefs, increase attribution for poor health to external factors vs. internal factors, and motivate some types of collective action. CONCLUSIONS:Our findings show the dominant narrative about health care does what health justice organizers argue it is designed to do: perpetuate harmful myths of individual blame for structural problems, shifting blame for health challenges away from powerful institutions. However, there is potential for counternarratives to reframe public perception and motivate collective action. Our study underscores the value of research partnerships between grassroots organizers and academic researchers in developing narrative power strategies.
Policy Points Housing is a fundamental social determinant of health and is particularly amenable to policy intervention. Policies that seek to improve health should improve housing quality, affordability, and stability. The public housing program has improved health across the life course, but the structure of the program currently limits its applicability. Public housing can be adapted to foster policy innovation at the state level. A renewed public housing program should (1) serve a broader income spectrum; (2) integrate across levels of government; (3) capitalize on the social support benefits of project-based housing; (4) emphasize effective administration; and (5) develop funding sources less vulnerable to political shifts. CONTEXT:Housing is a fundamental social determinant of health and is particularly amenable to policy intervention. However, the nationwide housing affordability crisis presents significant challenges for leveraging housing policy to improve population health in the United States. The US public housing program began during the New Deal, but has changed considerably since the mid-20th century. The program provides affordable and stable housing to nearly 1 million low-income families, and may offer lessons for a way forward in improving health through better and more stable housing. METHODS:Comparing the health impacts of US housing programs, public housing stands out as an unexpected success. Children in public housing experience better mental health, fewer emergency room visits, and greater housing stability. Adults report better physical and mental health, reduced risk of diabetes, and improved food security. However, recent federal housing policy has emphasized the tenant-centered housing voucher program at the expense of public housing. FINDINGS:While the contemporary public housing program improves health and well-being across the life course, the early public housing program may offer lessons to improve outcomes in the 21st century. Specifically, a renewed public housing could focus on high-quality construction, emphasize effective management, and serve a broader spectrum of income levels. I also outline how public housing could benefit from an increasing role for state policy and enable integration across levels of government. CONCLUSIONS:Housing is particularly responsive to public housing, but current housing policies have proven insufficient to guarantee stable housing for all. The public housing program offers a promising way forward to leverage housing to address the US population health crisis.
Policy Points Medicaid Section 1115 demonstration projects have been used to test innovative strategies to modify Medicaid programs but must demonstrate "budget neutrality" with respect to federal Medicaid expenditures. But this limitation ignores the intertwined nature of Medicaid and Medicare. Extending Section 1115 budget neutrality policies to include Medicare expenditure savings could create incentives to develop novel Medicaid policies that could improve the health of Medicare beneficiaries and lower Medicare expenditures as well. CONTEXT:Medicaid Section 1115 demonstration projects are widely used to test innovative policies but are subject to "budget neutrality" limits so that federal expenditures do not exceed what the federal government would have spent if the project was not adopted. Potential savings to Medicare are not considered, despite the fact that millions of beneficiaries are enrolled in both programs and virtually all middle-aged Medicaid beneficiaries will eventually enroll in Medicare. METHODS:Relevant federal policies are analyzed to examine the potential impact of expanding Section 1115 budget neutrality policies to include potential Medicare savings. FINDINGS:Historically, budget neutrality policies were not set by statute but were administratively established. Allowing Medicare savings to be counted is a more holistic approach to budgeting that would allow states to develop innovations like Medicaid long-term care or diabetes prevention policies that have repercussions for Medicare. However, in 2025 Congress approved an amendment (Section 71118) that limits budget neutrality calculations to Medicaid savings alone. CONCLUSIONS:While there is a reasonable policy basis to include Medicare savings in Section 1115 budget neutrality calculations to improve health for millions of Medicare beneficiaries and to increase federal savings, this would require modifying the limitations imposed by Section 71118.
Policy Points Racial equity impact assessments (REIAs) provide policymakers with systematic evidence on how proposed legislation may affect racial equity and subsequently shape structural determinants of health. Across 409 bill-level equity impact ratings derived from 296 final REIAs from 2021 to 2024, nearly half of REIAs (46%) indicated that proposed legislation would likely advance racial equity, 9% signaled potential adverse effects, 10% were neutral, and one-third were inconclusive or negligible. REIAs provide an opportunity to assess potential equity impacts prior to enactment, informing policy design by helping policymakers anticipate harms and consider revisions that may support more equitable policy processes. The effectiveness of REIAs depends on a supportive political context and accountability structures, as adverse findings alone do not guarantee legislative action to mitigate inequities. CONTEXT:Racial equity impact assessments (REIAs) are used by local governments to integrate equity considerations into policymaking and decision-making processes by evaluating potential impacts of proposed legislation before enactment. Despite their growing adoption, limited empirical evidence exists on how REIA findings are characterized or how equity-focused evidence is taken up within legislative processes. METHODS:A descriptive analysis of all racial equity impact assessments (REIAs) conducted in the District of Columbia between 2021 and 2024 (n = 296 REIAs; 409 bill-level equity impact ratings). REIA ratings were categorized as positive, adverse, neutral, or inconclusive/negligible and analyzed across eight policy domains (e.g., health and human services, criminal justice and public safety, budget and fiscal policy). Legislative outcomes for bills with adverse ratings were classified as enacted with modification, enacted without modification, or not enacted. FINDINGS:Nearly half (46.4%) of REIA ratings indicated positive equity impacts, while 9.0% identified potential adverse effects; 34% were inconclusive/negligible. Equity impacts varied substantially by policy domain, with positive findings concentrated in health and human services and economic policy and adverse findings more common in criminal justice, environmental, and infrastructure domains. Among bills with adverse ratings, 62.2% were enacted with modifications, 24.3% without modification, and 13.5% were not enacted. CONCLUSIONS:REIAs provide a mechanism for identifying potential policy equity impacts prior to enactment, but adverse findings alone do not guarantee legislative action. Strengthening institutional accountability structures and the integration of equity evidence into decision-making processes is critical to ensuring that identified harms lead to meaningful policy change and to maximizing the effectiveness of REIAs as a tool to advance population health equity.
