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Compared with urban residents, rural Americans have seen slower declines in cancer deaths, have lower incidence but higher death rates from cancers that can be prevented through screening, have lower screening rates, are more likely to present with later-stage cancers, and have poorer cancer outcomes and lower survival. Rural health provider shortages and lack of cancer services may explain some disparities. The literature was reviewed to identify factors contributing to rural health care capacity shortages and propose policy recommendations for improving rural cancer care. Uncompensated care, unfavorable payer mix, and low patient volume impede rural physician recruitment and retainment. Students from rural areas are more likely to practice there but are less likely to attend medical school because of lower graduation rates, grades, and Medical College Admission Test (MCAT) scores versus urban students. The cancer care infrastructure is costly and financially challenging in rural areas with high proportions of uninsured and publicly insured patients. A lack of data on oncology providers and equipment impedes coordinated efforts to address rural shortages. Graduate Medical Education funding greatly favors large, urban, tertiary care teaching hospitals over residency training in rural, critical access and community-based hospitals and clinics. Policies have the potential to transform rural health care. This includes increasing advanced practice provider postgraduate oncology training opportunities and expanding the scope of practice; improving health workforce and services data collection and aggregation; transforming graduate medical education subsidies to support rural student recruitment and rural training opportunities; and expanding federal and state financial incentives and payments to support the rural cancer infrastructure.

Among the morass of critical issues impacting the results of the midterm elections in 2022 were core public health issues related to health care access, justice, and reforms. Collectively, voters’ communal health and safety concerns dominated outcomes in key races which may shape national, state, and local legal approaches to protecting the public’s health in the modern era.

As the United States emerges from the worst public health threat it has ever experienced, the Supreme Court is poised to reconsider constitutional principles from bygone eras. Judicial proposals to roll back rights under a federalism infrastructure grounded in states’ interests threaten the nation’s legal fabric at a precarious time. This column explores judicial shifts in 3 key public health contexts — reproductive rights, vaccinations, and national security — and their repercussions.

Immunizing hundreds of millions against COVID-19 through the most extensive national vaccine roll-out ever undertaken in the United States has generated significant law and policy challenges. Beyond initial controversies in the development and FDA authorization of the vaccines, multiple issues pervade their real-time allocation and administration. This commentary briefly examines premier law and policy issues shaping the COVID-19 national vaccination campaign.

IntroductionThe long-term impact of COVID-19 is unknown. We developed a 5-year prospective cohort study designed to generate actionable community-informed research about the consequences of COVID-19 on adolescents ages 12–17 years in Arizona.MethodsThe study has two primary outcomes: 1) acute and long-term outcomes of COVID-19 illness and 2) symptoms of depression and anxiety. Data is collected using an online survey with plans to integrate qualitative data collection methods. The survey is administered at baseline, 4, and 8 months in year one, and annually in years two through five. This study is informed by Intersectionality Theory, which considers the diverse identities adolescents have that are self and socially defined and the influence they have collectively and simultaneously. To this end, a sample of variables collected is race/ethnicity, language usage, generational status, co-occurring health conditions, and gender. Additional measures capture experiences in social contexts such as home (parent employment, food, and housing security), school (remote learning, type of school), and society (racism).ResultsFindings are not presented because the manuscript is a protocol designed to describe the procedure instead of report results.DiscussionThe unique contributions of the study is its focus on COVID-19 the illness and COVID-19 the socially experienced pandemic and the impact of both on adolescents.

Objective To compare health care expenditures between older US adults (≥50 years) with pain who were prescribed opioid medications and those who were not. Design Cross-sectional. Setting Community-based adults in the 2015 Medical Expenditure Panel Survey (MEPS). Subjects Nationally representative sample of US adults alive for the calendar year, aged 50 years or older, who reported having pain in the past four weeks. Methods Older US adults (≥50 years) with pain in the 2015 MEPS data were identified. The key independent variable was opioid prescription status (prescribed opioid vs not prescribed opioid). Hierarchical linear regression models assessed health care expenditures (inpatient, outpatient, office-based, emergency room, prescription medications, other, and total) in US dollars for opioid prescription status from a community-dwelling US population perspective, adjusting for covariates. Results The 2015 study cohort provided a national estimate of 50,898,592 noninstitutionalized US adults aged ≥50 years with pain in the past four weeks (prescribed opioid N = 16,757,516 [32.9%], not prescribed opioid N = 34,141,076 [67.1%]). After adjusting for covariates, individuals prescribed an opioid had 61% greater outpatient (β = 0.477, P 0.05). Conclusions This study raises awareness of the economic impact associated with opioid use among US older adults with pain. Future research should investigate these variables in greater depth, over longer time periods, and in additional populations.

A series of denialist state laws thwart efficacious public health emergency response efforts despite escalating impacts of the spread of the Delta variant during the COVID-19 pandemic. However, public and private actors are fighting back to obstruct or reverse anti-public health maneuvers through legal challenges focused on (1) constitutional structural- and rights-based challenges; (2) use of conditional spending requirements; (3) federal preemption; (4) disability and other anti-discrimination laws; (5) waivers or routine uses of public health powers; and (6) civil liability claims.

Introduction: While cancer deaths have decreased nationally, declines have been much slower in rural areas than in urban areas. Previous studies on rural cancer service capacity are limited to specific points along the cancer care continuum (eg screening, diagnosis or treatment) and require updating to capture the current rural health landscape since implementation of the 2010 Affordable Care Act in the USA. The association between current rural cancer service capacity across the cancer care continuum and cancer incidence and death is unclear. This cross-sectional study explored the association between breast cancer service capacity and incidence and mortality in Arizona's low populous counties. Methods: To measure county-level cancer capacity, clinical organizations operating within low populous areas of Arizona were surveyed to assess on-site breast cancer services provided (screening, diagnosis and treatment) and number of healthcare providers were pulled from Centers for Medicare and Medicaid Services National Provider Identifier database. The number of clinical sites and healthcare providers were converted to county-level per capita rates. Rural-Urban Continuum codes were used to designate rural or urban county status. Age-adjusted county-level breast cancer incidence and death rates from 2010 to 2016 were obtained from the Arizona Department of Health Services, Arizona Cancer Registry. Descriptive statistics were used to summarize the results. Multivariate regression was used to evaluate the association between cancer service capacity and incidence and mortality in 13 out of Arizona's 15 counties. Results: Rural counties had more per capita clinical sites (20.4) than urban counties (8.9) (p=0.02). Urban counties had more per capita pathologists (1.0) than rural counties (0) (p≤0.01). In addition to zero pathologists, rural counties had zero medical oncologists. Rural county status was associated with a decrease in breast cancer incidence (β=-20.1, 95% confidence interval: -37.2-3.1). Conclusion: While Arizona's sparsely populated rural counties may have more physical infrastructure per capita, these services are dispersed over vast geographic areas. They lack specialists providing cancer services. Non-physician clinical providers may be more prevalent in rural areas and represent opportunities for improving access to cancer preventive services and care. Compared to urban counties, rural county status was associated with lower detected breast cancer incidence rates although there were no statistically significant differences in breast cancer mortality. Other factors may contribute to rural-urban differences in breast cancer incidence. Future research should explore these factors and the association between cancer capacity and local resources because the use of county-level data represents a challenge in Arizona, where counties average over 19 425 km2 (7500 square miles).

Laws and policies are vital tools in preventing outbreaks and limiting the further spread of disease, but they can vary in content and implementation. This manuscript provides insight into challenges in responding to recent vaccine-preventable disease outbreaks by examining legislative changes in California, policy changes on certain university campuses, and the laws implicated in a measles outbreak in Minnesota.

Recent outbreaks of vaccine-preventable diseases (e.g., mumps and meningitis) among young adults at higher education institutions (e.g., university, college, and junior college campuses) have proliferated nationally. Collectively, they illustrate a pressing public health concern regarding low vaccination rates among higher education populations contributing to outbreaks of communicable diseases. A primary cause of these outbreaks are lax requirements for student vaccinations among higher education institutions as a requirement for matriculation. A series of inconsistences and failures concerning vaccination law or policy requirements among select higher education institutions lends to profound public health and ethical repercussions for students and community members. Against the backdrop of rising rates or outbreaks of vaccine-preventable conditions among institutional populations, addressing these findings is vital to alleviate future outbreaks on campuses and surrounding locales.

This study is a prospective, population-based cohort of individuals with a history of SARS-CoV-2 infection and those without past infection through multiple recruitment sources. The main study goal is to track health status over time, within the diverse populations of Arizona and to identify the long-term consequences of COVID-19 on health and well-being. A total of 2,881 study participants (16.2% with a confirmed SARS-CoV-2 infection) have been enrolled as of December 22, 2020, with a target enrollment of 10,000 participants and a planned follow-up of at least 2 years. This manuscript describes a scalable study design that utilizes a wide range of recruitment sources, leveraging electronic data collection to capture and link longitudinal participant data on the current and emerging issues associated with the COVID-19 pandemic. The cohort is built within a collaborative infrastructure that includes new and established partnerships with multiple stakeholders, including the state's public universities, local health departments, tribes, and tribal organizations. Challenges remain for ensuring recruitment of diverse participants and participant retention, although the electronic data management system and timing of participant contact can help to mitigate these problems.

In the second year of the COVID-19 pandemic, widespread distribution and administration of vaccines are raising hopes of achieving herd immunity—and returning to some sense of normalcy—in the U.S. Health care providers, long-term care facilities, airlines, restaurants, universities, and other entities are currently considering, or have already implemented, COVID-19 vaccine mandates, leaving Americans wondering whether these entities can require them to get vaccinated. Complex questions underlie the legality of vaccine mandates. Public misperceptions blur the line between voluntary, mandated, and compelled vaccinations, highlighting controversial gray area cases. Though often used interchangeably, public health law distinguishes between these three approaches to vaccination requirements.

Since its emergence from Wuhan, China in late 2019, novel coronavirus, 2019-nCoV, is spreading rapidly, escalating domestic and international concerns, and lead

Electronic cigarettes (e-cigarettes) are a growing public health concern because of a dramatic increase in use by adolescents and the uncertainty of potential health impacts. These health concerns and lack of an established federal regulatory scheme have led many local and state governments to address the regulatory void for e-cigarettes by incorporating them into the statutory definition of tobacco or by passing laws specific to the use of e-cigarettes. In August 2016, the US Food and Drug Administration issued a final rule deeming e-cigarettes within their authority; providing uniform requirements like premarket approval applications, Harmful and Potentially Harmful Constituents reporting, and warning labels; and establishing 18 years as a minimum age of purchase. Although the impact on the public's health remains uncertain, regulations and laws governing e-cigarettes continue to develop. This review highlights the available data regarding safety and public health impacts of e-cigarettes and details the status of US regulations and policies affecting their sale and use. Cancer 2017;123:3007-14. © 2017 American Cancer Society.

Assuring the nation’s health promises to be among the premier political objectives underlying the 2020 U.S. Presidential election. A diverse field of 23 leading Democratic-declared Presidential candidates (ages 37-77 years) are prioritizing health issues. Assessing candidates’ positions since the inception of their campaigns, we have identified 10 primary health law and policy platforms as of June 1, 2019 (see Table 1 and research methodology). Candidates’ dominant themes center on universal health care, climate change, and reproductive rights. Many also address policies on mental health coverage, gun violence prevention, and Affordable Care Act (ACA) reforms. Just over half of candidates are opining on regulated substances (e.g., opioids, cannabis), health interests and rights of lesbian, gay, bisexual, transgender, and queer (LGBTQ) persons, and lowering of prescription drug prices. The candidates’ varying ideas on these issues deviate significantly from the current administration and, at times, from each other.

To examine how combinations of state policies, rather than single policies, are related to uptake of human papillomavirus (HPV) vaccine.Using publicly available records and the literature, we characterized policies for each US state and Washington, DC, in 2015 (n = 51), including (1) Medicaid expansion, (2) policies permitting HPV vaccination in pharmacies, (3) school-entry requirements, (4) classroom sex education mandates, and (5) parental education mandates. Using qualitative comparative analysis, we identified which existing combinations of these policies were necessary and sufficient for high HPV vaccine initiation among adolescents, with National Immunization Survey-Teen data.No single policy was necessary or sufficient for high HPV vaccine uptake; however, 1 set of policies had consistently high HPV vaccine uptake: adoption of all policies except parental education mandates (girls: consistency = 1.00, coverage = 0.07; boys: consistency = 0.99, coverage = 0.08).We identified a set of polices related to high HPV vaccine uptake. Future studies should examine how these policies and others, individually and in combination, are associated with HPV vaccine uptake. Public Health Implications. This study provides insight into what sets of policies are consistently related to high HPV vaccine uptake.

On October 26, 2017, the Department of Health and Human Services (HHS) formally declared a national state of public health emergency (PHE) in response to the opioid epidemic. Since renewed multiple times, HHS' PHE assimilates emergency declarations among a handful of state, tribal, and local governments. Countless public and private sector entities have engaged in additional opioid emergency response efforts across the United States. These emergency declarations and measures collectively respond to the worst PHE confronting the country since the origination of this specific emergency classification in 2001. Americans across all socioeconomic groups are at risk of, or already addicted to, opioids in one form or another. Several hundred thousand Americans have lost their lives to prescription or illicit opioid misuse over the course of the epidemic. Nearly 130 more Americans die each day from opioid misuse. Millions are directly impacted by excess morbidity arising from opioid use disorders (OUDs). Most people know someone who is at risk of, or has succumbed to, opioid abuse. This epidemic is truly the juggernaut of PHEs. While emergency responses to date are purposeful and often well-intended, for manifold reasons they have also proven inadequate in authorizing and funding sufficient, efficacious responses. More significant approaches and greater investments are needed to prevent excess mortality and morbidity. Commencing with an assessment of the impacts of the opioid crisis, existing legal and policy responses, and failures to control the epidemic, a series of interventions are proposed to (1) stymie opioid-related overdoses and deaths in real time and (2) obviate deleterious impacts for future generations.

Inmates in cramped living quarters, a situation common to correctional facilities, are especially vulnerable to disease. Cramped living conditions, coupled with above-average rates of HIV, tuberculosis, and other communicable diseases, increase inmates' risk of problematic health outcomes. Thus, high-quality health care and sustained efforts to prevent disease are especially important to improve inmate health within correctional facilities. Compliance with federal privacy restrictions pursuant to the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule and state disease reporting requirements will foster inmate health and assist efforts to prevent the spread of disease. This article examines the interplay between HIPAA rules and state reporting laws to preserve health information privacy and to control the spread of disease.

Since its inception in 2010, the Network for Public Health Law (Network) has aligned with federal, state, tribal, and local public health practitioners to assess how law can promote and protect the public’s health. In 2013, Network authors illustrated major trends in public health laws and policies emanating from an internal assessment of thousands of requests for technical assistance nationally. More recently, the Robert Wood Johnson Foundation (RWJF) has invited the Network and other partners to consider new ideas and strategies toward building a “culture of health.” Per Figure 1, RWJF’s conception of a culture of health emphasizes key action areas essential to the promotion of health across all sectors and diverse populations.

In an increasingly interconnected global community, severe disasters or disease outbreaks in one country or region may rapidly impact global health security. As seen during the responses to the earthquakes in Haiti and Japan, Typhoon Haiyan in the Philippines, and the current Ebola outbreak in West Africa, local response capacities can be rapidly overwhelmed and international assistance may be necessary to support the affected region to respond and recover and to protect other countries from the spread of disease. For example, President Obama stated on September 16, 2014, that “if the [Ebola] outbreak is not stopped now, we could be looking at hundreds of thousands of people infected, with profound political and economic and security implications for all of us…. [T]his…is not just a threat to regional security — it’s a potential threat to global security if these countries break down…. And that’s why…I directed my team to make this a national security priority.”

This paper discusses recent changes to state legal frameworks for mandatory vaccination in the context of school and healthcare worker vaccination. It then discusses state laws that allow pharmacists the authority to vaccinate.

Background: Community Paramedicine (CP) is a rapidly evolving field within prehospital care where paramedics step outside of their traditional roles of treating acute conditions to provide elements of primary and preventive care. It is unclear if current state oversight regarding the scope of practice (SOP) for paramedics provides clear guidance on the novel functions provided and skills performed by CP programs. Objective: To determine the process and authority, as currently defined by state laws and regulations in the United States, to expand paramedic SOP in order to perform CP roles and to assess state EMS agencies' interpretation of paramedic SOP as it applies to CP. Methods: We conducted a systematic review of laws, regulations, and policies from the 50 U.S. states in effect between February and June 2016 that define or apply to paramedic SOP. We determined whether each state's SOP included 21 potential skills applicable to CP within the following categories: assessment, treatment & intervention, referrals, and prevention & public health. Laws were also queried for mechanisms for expanding SOP, alternate destinations, and community paramedicine for each state. Additionally, we surveyed representatives from U.S. State Emergency Medical Services (EMS) agencies and asked which of these skills were a part of their current SOP. All data was coded into Excel™ and analyzed using descriptive statistics. Results: All 50 U.S. states have laws relating to EMS. Forty-one states have a statewide SOP (82%), and 3 states have statewide protocols from which the SOP has been inferred for purposed of this study, but may not legally constitute SOP in this jurisdiction (6%). 20 states (40%) had a clearly defined mechanism for expanding SOP. Sixteen states (32%) had laws specific to CP. Seven states (14%) allowed for patients to be transported to alternate destinations. Of the 21 skills surveyed, on average there were 8.63 (6.41–10.85) fewer skills for paramedics found in state SOP laws and regulations than were reported as being a part of a state's paramedic SOP. All skills demonstrated variability between the legal review and survey results with 13.04–96.15% concordance. Conclusion: There is a lack of guidance and consistency regarding CP programs and scope of practice. Further studies are needed to understand best practices around regulation and oversight of CP.

James G. Hodge, Jr., Leila Barraza, Susan Russo, Kellie Nelson, and Greg Measer Introduction Obesity is the definitive epidemic of the modern era in the United States. Its well-documented public health impacts, especially related to children and adolescents, are horrific. Nearly one-third of American minors are overweight; over 50% of them are obese.1 Already, these kids suffer from multiple adverse physical and mental health conditions. Sadly, absent serious communal and individual interventions, their lives may be cut short compared to their own parents’ life expectancy. While recent surveillance suggests childhood obesity may be trending down slightly in some populations, public health experts remain concerned about the threat obesity poses to the health of America’s youth. The concurrent travesty underlying childhood obesity is the relative societal failure to slow and reverse its spread. If obesity were a highly infectious disease, then government would have declared states of public health emergency decades ago and used nearly every legally supported intervention possible to stymie its impacts. Of course, obesity is not a fast-moving epidemic. Rather, it creeps slowly like a vine across the population, smothering generations of kids in its path. Public health interventions addressing it seem to plod along as well. Long-standing public health studies, discussed below, have pointed to the links between minors’ weight gains and their consumption of caloric sweetened beverages (CSBs) like soft drinks, flavored juices, and energy drinks. As a major source of “empty calories,” CSBs contribute extensively to childhood obesity, but kids’ access to and consumption of these beverages remain largely unregulated. Parents and policymakers are waking up to these findings, working to rid CSBs from select elementary and secondary schools,2 enacting citywide bans on larger portion sizes,3 and controlling the sale and promotion of CSBs on city property.4 Not only have some of these reforms stalled due to public opinion and legal wrangling, they collectively fall short of (or outright miss) the intended target. We propose a more definitive intervention. In the sections below, we take apart and analyze the legal and policy issues underlying a proposed ban on the sale to and possession of CSBs by minors in all public places. To the extent our proposed ban is legally viable, buttressed by available scientific evidence on the harms related to minors’ consumption of CSBs, closely tied to reducing gains in childhood obesity, and already in place in select school districts, it reflects the future of public health policy within and across states.

Public health law research reveals significant complexities underlying the use of law as an effective tool to improve health outcomes across populations. The challenges of applying public health law in practice are no easier. Attorneys, public health officials, and diverse partners in the public and private sectors collaborate on the front lines to forge pathways to advance population health through law. Meeting this objective amidst competing interests requires strong practice skills to shift through sensitive and sometimes urgent calls for action to address known threats to the health of individuals and the community. It also necessitates objective, timely information and national and regional legal support.

In the United States, tens of thousands of Americans die each year of heart disease, stroke, or other chronic conditions tied to hypertension from long-term overconsumption of sodium compounds. Major strides to lower dietary sodium have been made over decades, but the goal of reducing Americans' daily consumption is elusive. The Food and Drug Administration (FDA) has been urged to consider stronger regulatory limits on sodium, especially in processed and prepared foods. Still, FDA categorizes salt (and many other sodium compounds) as "generally recognized as safe," meaning they can be added to foods when ingested in reasonable amounts. Legal reforms or actions at each level of government offer traditional and new routes to improving chronic disease outcomes. However, using law as a public health tool must be assessed carefully, given potential trade-offs and unproven efficacy.

As conceptualized by the Robert Wood Johnson Foundation and its partners, a culture of health centers on a society in which health flourishes across all populations and sectors. Law, among other tools, is critical to advancing a culture of health across multiple arenas. In this manuscript, Network for Public Health Law colleagues illustrate how legal innovations at all levels of government contribute to societal health. Examples include modern laws that promote healthy and safe low-income housing, telemedicine reimbursement, paid sick and safe time, healthy food and beverages, reduced smoking rates, child vaccinations, universal pre-k, adolescents' healthy sleep, overdose prevention, and medical-legal partnerships.

From their relative obscurity over the past three decades, varied strains of Ebola disease have emerged as a substantial global biothreat. The current outbreak of Ebola, beginning in March 2014 in Guinea, is projected to infect tens of thousands of people before being brought under control. Some estimate the outbreak could exceed 100,000 cases and extend another 12-18 months. Ebola’s spread has the potential to extend across the globe, but is concentrated in several African countries (e.g., Democratic Republic of Congo, Sierra Leone, Liberia, Guinea, Nigeria, and Senegal). Collectively, these countries are home to nearly 290 million people. Among Liberia’s population of 4.1 million, over 1,100 people have already died from Ebola in less than 6 months; by comparison, if this same outbreak and death rate occurred in the United States, over 88,000 Americans would perish.

Since its inception in September 2010, the Network for Public Health Law has responded to hundreds of public health legal technical assistance claims from around the country. Based on a review of these data, a series of major trends in public health practice and the law are analyzed, including issues concerning: the Affordable Care Act, tobacco control, emergency legal preparedness, health information privacy, food policy, vaccination, drug overdose prevention, sports injury law, public health accreditation, and maternal breastfeeding. These and other emerging themes in public health law demonstrate the essential role of law and practice in advancing the public's health.

BPA Production and Associated Health Risks Bisphenol A (BPA) is a chemical agent found in many everyday products, including canned goods and plastic food containers. BPA exposure is linked to a variety of adverse health effects, such as obesity and diabetes. To protect the public's health — especially the health of vulnerable fetuses, infants, children, and pregnant women — BPA regulations should encompass products intended specifically for these populations. Even with tremendous public outcry against the use of BPA, current federal restrictions do not reach far enough. The U.S. Food and Drug Administration (FDA) recently banned the use of BPA in children's sippy cups and baby bottles, but failed to address its inclusion in canned infant formula or plastic tableware.BPA production began in the 1950s to make epoxy resins and was later employed to create polycarbonate plastic products.