Moderated Mediation Analysis of Structural Stigma and Suicidal Ideation and Behaviors Among Sexual and Gender Minority Adults.

Purpose: This study aimed to conduct a moderated mediation analysis to understand further the complex pathways through which structural stigma in the form of transgender sports bans was associated with suicidal ideation and behaviors among sexual and gender minority (SGM) adults. Methods: A cross-sectional survey of 1033 adults who identified as SGM from across the 50 U.S. states and Washington, DC was conducted between January 28 and February 7, 2022. Distal discrimination distress was the mediation variable; individual resilience and social resources were the moderation variables. Familiarity with transgender sports bans represented structural stigma. The conditional process analysis was applied to build a moderated mediation model. Both conditional direct and indirect effects were computed by estimated coefficients. All models were based on linear regression. Results: Our final model explained nearly half (46%) of the variation in suicidal ideation and behaviors between those SGM adults familiar and those not familiar with transgender sports bans. Social resources significantly moderated the conditional indirect effect of distal discrimination distress (adjusted estimate = -0.23; 95% confidence interval = -0.37 to -0.08). Conclusion: Both discrimination distress and social resources influenced the association between structural stigma as measured by familiarity with transgender sports bans and suicidal ideation and behaviors among SGM adults. Findings support the need for future research examining the pathway between structural stigma and suicidal ideation and behaviors among SGM adults and how minority stress, social safety, and other constructs shape this pathway.

Food and Housing Insecurity in Nevada During the COVID-19 Pandemic.

The COVID-19 pandemic intensified concerns regarding food and housing insecurity in the United States, particularly among vulnerable populations. After the pandemic prompted a shutdown of nonessential businesses in Nevada, unemployment rose dramatically as the gaming, tourism, and hospitality industries struggled. This study analyzed the results of two telephone surveys of Nevada adults' experiences in 2020 (n = 1000) and 2021 (n = 1002). The results demonstrate between 2020 and 2021 an 8.24 percentage point decline in food insecurity (FI) from 30.2% to 21.96% and a 12.58 percentage point increase in housing insecurity (HI) from 12.27% to 24.85%. Age, disability status, and certain categories of race/ethnicity and income were associated with both HI and FI in 2020, but disability was no longer significant in 2021. Instead, spouse/partner-status, living with children ≤ 18-years-old and receipt of SNAP benefits were significantly associated with FI in 2021. In particular, health status became a significant factor of both HI and FI. People of color experienced FI disparities compared to Whites. Asians/Hawaiians/Pacific Islanders were 3.22 times (95% CI 1.51, 6.86) more likely to experience FI in 2021 than Whites. A matched, longitudinal analysis also revealed that Whites experienced a significant 9.1 percentage point estimated decline in the probability of FI between 2020 and 2021. However, the reduction among non-White participants was statistically insignificant at 2.5 percentage points. Results indicate the importance of supporting the food and housing needs of people of color and individuals with disabilities. Further research should especially investigate the comparative FI rate among Asians/Hawaiians/Pacific Islanders in 2021 and offer solutions to the soaring prevalence of housing insecurity.

An assessment of the move your way program among hispanic adults in Las Vegas, Nevada.

BACKGROUND: Physical activity (PA) is important because of its associated health benefits. However, many Americans remain inactive. The 2018 guidelines recognize that PA bouts of less than 10 min are beneficial. The U.S. Department of Health and Human Services' Office of Disease Prevention and Health Promotion created the Move Your Way® (MYW) campaign to provide PA resources for communities and healthcare providers. This study aims to describe the reach of the MYW campaign, and assess whether having seen, heard, or read (SHR) about MYW, or having seen the MYW logo, was associated with PA knowledge, self-efficacy, and behavior among Hispanics residing in the Las Vegas, Nevada area. METHODS: Hispanics, aged 18-74, were surveyed at community events (n = 481) or via an online survey (n = 123). Respondents were asked if they had SHR of MYW, were aware of 2018 PA recommendations, and to report their personal PA behavior, PA knowledge, PA intentions, and demographics. RESULTS: Respondents (71% female) completed a 38-42-item survey. Approximately (12.4%) had SHR of the MYW campaign and 16.1% had seen the MYW logo. Only 3.4% and 15% identified, "150 minutes per week" and "75 minutes per week" as the 2018 guidelines for moderate physical activity (MPA) and vigorous physical activity (VPA), respectively. Those who had SHR of the MYW campaign were more likely to correctly identify 150 min per week as the MPA guideline and had greater confidence in overcoming selected PA barriers. Regression analysis showed that those who had seen the MYW logo were more likely to meet strength guidelines, and that those who had SHR of MYW or saw the logo were more likely to know the recommended minutes of MPA. CONCLUSIONS: Knowledge of the MYW program positively associates with some PA behaviors and PA correlates.

Moderating Effect of Community and Individual Resilience on Structural Stigma and Suicidal Ideation among Sexual and Gender Minority Adults in the United States.

BACKGROUND: Structural stigma in the form of discriminatory laws and policies impacts the mental health of sexual and gender minorities, especially with regard to suicidality. However, this relationship could be moderated by resilience. The past two years has brought anti-SGM legislation, particularly transgender sports bans, at the state level in the United States into focus. This study aims to understand if the relationship between familiarity with transgender sports bans (proposed or enacted) and suicidality was moderated by individual or community resilience. METHODS: This was a cross-sectional study of survey data collected from a national sample of 1033 SGM adults in the United States between 28 January and 7 February 2022. Univariate and multivariate moderation analyses were used. RESULTS: In the univariate analyses and the final model, community resilience moderated the relationship between structural stigma and suicidality (p = 0.0002); however, individual resilience did not (p = 0.0664). CONCLUSION: Interventions to bolster community resilience may attenuate the negative mental health impacts of structural stigma and are warranted, along with concerted efforts to minimize structural stigma in the form of discriminatory laws and policies targeting people who are SGM.

The Association Between State-Issued Mask Mandates and County COVID-19 Hospitalization Rates.

CONTEXT: Mask mandates are one form of nonpharmaceutical intervention that has been utilized to combat the spread of SARS-CoV2, the virus that causes COVID-19. OBJECTIVE: This study examines the association between state-issued mask mandates and changes in county-level and hospital referral region (HRR)-level COVID-19 hospitalizations across the United States. DESIGN: Difference-in-difference and event study models were estimated to examine the association between state-issued mask mandates and COVID-19 hospitalization outcomes. PARTICIPANTS: All analyses were conducted with US county-level data. INTERVENTIONS: State-issued mask mandates. County-level data on the mandates were collected from executive orders identified on state government Web sites from April 1, 2020, to December 31, 2020. MAIN OUTCOME MEASURES: Daily county-level (and HRR-level) estimates of inpatient beds occupied by patients with confirmed or suspected COVID-19 were collected by the US Department of Health and Human Services. RESULTS: The state issuing of mask mandates was associated with an average of 3.6 fewer daily COVID-19 hospitalizations per 100 000 people (P < .05) and a 1.2-percentage-point decrease in the percentage of county beds occupied with COVID-19 patients (P < .05) within 70 days of taking effect. Event study results suggest that this association increased the longer mask mandates were in effect. In addition, the results were robust to analyses conducted at the HRR level. CONCLUSIONS: This study demonstrated that state-issued mask mandates were associated with reduction in COVID-19 hospitalizations across the United States during the earlier portion of the pandemic. As new variants of the virus cause spikes in COVID-19 cases, reimposing mask mandates in indoor and congested public areas, as part of a layered approach to community mitigation, may reduce the spread of COVID-19 and lessen the burden on our health care system.

Serial Mediation Analysis of the Association of Familiarity with Transgender Sports Bans and Suicidality among Sexual and Gender Minority Adults in the United States.

BACKGROUND: Discriminatory laws and policies are a form of structural stigma that is associated with increased suicidality among sexual and gender minority (SGM) people. Unfortunately, in the United States, there has been an increase in state-level discriminatory laws and policies targeting SGM people in 2021 and 2022, particularly, transgender sports bans. The purpose of this study was to (1) determine if familiarity with transgender sports bans was associated with suicidality among SGM adults; and (2) determine if interpersonal stigma and/or individual stigma mediated this association. METHODS: This was a cross-sectional study of data collected from a national sample of 1033 SGM adults in the United States between 28 January and 7 February 2022. Univariate and serial mediator models were used in this analysis. RESULTS: The increased suicidality was associated with familiarity with state-level transgender sports bans among SGM adults (p-value = 0.0150). Even after interpersonal and individual stigma mediated this relationship, the association between suicidality and familiarity with state-level transgender sports bans remained (p-value = 0.0106). CONCLUSION: State-level transgender sports bans appear to exacerbate existing disparities in mental health, especially for individuals who are familiar with the bans. They directly discriminate against people who are transgender and indirectly stigmatize the broader SGM community.

A Mixed-Methods Assessment of Residential Housing Tenants' Concerns about Property Habitability and the Implementation of Habitability Laws in Southern Nevada.

Housing is a key health determinant. Habitability laws set minimum standards for adequate housing. However, accessing them to ensure adequate housing may be a challenge for many tenants. This paper explores the need for rental housing policy that would better support adequate and safe housing, particularly for low-income renters. A mixed-methods approach assessed residential tenant habitability concerns in Clark County, Nevada, through calls relayed to the Clark County Landlord-Tenant Hotline (CCLTH). Of the 2865 calls, 74.3% were from ZIP codes that were 80% of the median income and below. There was a significant relationship between the ZIP code-level income and the reporting of at least one essential habitability concern. Of the 266 participants that responded to a follow-up call, 34.6% reported that their complaint was resolved and there was no association between resolution and income. Qualitative data analysis from phone interviews revealed two central themes: (1) resources to navigate landlord-tenant laws are limiting and (2) housing policies need to be strengthened to help tenants and keep people housed. Understanding tenant concerns regarding substandard housing and related inequities can help inform rental housing policy and its implementation to promote healthy homes and improve health outcomes for communities burdened by poor rental housing conditions.

Assessing Determinants of COVID-19 Vaccine Hesitancy in Nevada.

In December 2020, we conducted a telephone survey to determine what factors are connected to COVID-19 vaccine hesitancy among adults in Nevada. The survey was based on factors identified in other studies, such as demographic variables (age, race, ethnicity, gender, household income, urbanicity, educational attainment), health status, previous COVID-19 infections, social media engagement, adherence to social distancing guidelines, beliefs about COVID-19, and political ideology identifications. Using a proportional odds model, we compared vaccine hesitancy levels to determine the odds of being more likely versus unlikely to get the COVID-19 vaccine. Of 1,000 people surveyed, 30.4% exhibited vaccine hesitancy. Findings showed that adults with significantly lower odds of vaccine hesitancy included those who were male, older, worried about COVID-19 infection or its community effects, adhered to social distancing, and reported higher incomes. Adults who identified as African American or Black or as multiple or "other" races exhibited significantly higher odds of vaccine hesitancy than White adults. Adults self-identifying as conservative had significantly higher odds of vaccine hesitancy than others. Vaccine hesitancy levels suggest possible hurdles to addressing the COVID-19 pandemic in a state with high visitor volumes and demographics that resemble the country's future as minority White, highlighting possible lessons for future pandemics. Most measures of COVID-19 worry were not significantly associated with vaccine hesitancy, suggesting that vaccination efforts should focus on other motivators. COVID-19 vaccination efforts should also directly encourage uptake by younger and middle-aged adults who are female, African American, have lower incomes, and identify as conservative.

Association of State-Issued Mask Mandates and Allowing On-Premises Restaurant Dining with County-Level COVID-19 Case and Death Growth Rates - United States, March 1-December 31, 2020.

CDC recommends a combination of evidence-based strategies to reduce transmission of SARS-CoV-2, the virus that causes COVID-19 (1). Because the virus is transmitted predominantly by inhaling respiratory droplets from infected persons, universal mask use can help reduce transmission (1). Starting in April, 39 states and the District of Columbia (DC) issued mask mandates in 2020. Reducing person-to-person interactions by avoiding nonessential shared spaces, such as restaurants, where interactions are typically unmasked and physical distancing (≥6 ft) is difficult to maintain, can also decrease transmission (2). In March and April 2020, 49 states and DC prohibited any on-premises dining at restaurants, but by mid-June, all states and DC had lifted these restrictions. To examine the association of state-issued mask mandates and allowing on-premises restaurant dining with COVID-19 cases and deaths during March 1-December 31, 2020, county-level data on mask mandates and restaurant reopenings were compared with county-level changes in COVID-19 case and death growth rates relative to the mandate implementation and reopening dates. Mask mandates were associated with decreases in daily COVID-19 case and death growth rates 1-20, 21-40, 41-60, 61-80, and 81-100 days after implementation. Allowing any on-premises dining at restaurants was associated with increases in daily COVID-19 case growth rates 41-60, 61-80, and 81-100 days after reopening, and increases in daily COVID-19 death growth rates 61-80 and 81-100 days after reopening. Implementing mask mandates was associated with reduced SARS-CoV-2 transmission, whereas reopening restaurants for on-premises dining was associated with increased transmission. Policies that require universal mask use and restrict any on-premises restaurant dining are important components of a comprehensive strategy to reduce exposure to and transmission of SARS-CoV-2 (1). Such efforts are increasingly important given the emergence of highly transmissible SARS-CoV-2 variants in the United States (3,4).

School absenteeism is linked to household food insecurity in school catchment areas in Southern Nevada.

OBJECTIVES: Food security and school attendance are both important for health, well-being and academic performance of children and adolescents. However, their intersection remains underexamined, especially in the USA. The current study considered the association between elementary school-level absenteeism and household food insecurity. DESIGN: The current study linked school-level absenteeism and household food insecurity rates using geographic information system mapping and applied the tobit regression model to examine their association. SETTING: The Clark County, Nevada, public school district - the fifth largest in the USA and in a state with disproportionate food insecurity and chronic school absenteeism rates. PARTICIPANTS: Data consisted of school-level absenteeism rates from 185 elementary schools and census tract-level household food insecurity rates. RESULTS: Average daily attendance rates were lower for schools with catchment areas that had higher average household food insecurity (FI), decreasing by -0·0232 % per 1 % increase in FI rate (P-value = 0·022). They were also significantly associated with most absenteeism risk factors. Average daily attendance rate was negatively associated with Free and Reduced Lunch eligibility percentage (-0·010 per 1 % increase in FI, P-value < 0·001) and Individualized Education Program participation percentage (-0·039 % per 1 % increase in FI, P-value = 0·033), but positively associated with parent-teacher conference participation rate (0·006 % per 1 % increase in FI, P-value = 0·025) and white student percentage (0·011 % per 1 % increase in FI, P-value = 0·022). CONCLUSIONS: The current study suggests a link between household food insecurity and elementary school-level absenteeism. Understanding this link is important for policy and practice because schools are frequent settings for food insecurity mitigation interventions.

Differences in rapid increases in county-level COVID-19 incidence by implementation of statewide closures and mask mandates - United States, June 1-September 30, 2020.

BACKGROUND AND OBJECTIVE: Community mitigation strategies could help reduce COVID-19 incidence, but there are few studies that explore associations nationally and by urbanicity. In a national county-level analysis, we examined the probability of being identified as a county with rapidly increasing COVID-19 incidence (rapid riser identification) during the summer of 2020 by implementation of mitigation policies prior to the summer, overall and by urbanicity. METHODS: We analyzed county-level data on rapid riser identification during June 1-September 30, 2020 and statewide closures and statewide mask mandates starting March 19 (obtained from state government websites). Poisson regression models with robust standard error estimation were used to examine differences in the probability of rapid riser identification by implementation of mitigation policies (P-value< .05); associations were adjusted for county population size. RESULTS: Counties in states that closed for 0-59 days were more likely to become a rapid riser county than those that closed for >59 days, particularly in nonmetropolitan areas. The probability of becoming a rapid riser county was 43% lower among counties that had statewide mask mandates at reopening (adjusted prevalence ratio = 0.57; 95% confidence intervals = 0.51-0.63); when stratified by urbanicity, associations were more pronounced in nonmetropolitan areas. CONCLUSIONS: These results underscore the potential value of community mitigation strategies in limiting the COVID-19 spread, especially in nonmetropolitan areas.

Decline in COVID-19 Hospitalization Growth Rates Associated with Statewide Mask Mandates - 10 States, March-October 2020.

SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), is transmitted predominantly by respiratory droplets generated when infected persons cough, sneeze, spit, sing, talk, or breathe. CDC recommends community use of face masks to prevent transmission of SARS-CoV-2 (1). As of October 22, 2020, statewide mask mandates were in effect in 33 states and the District of Columbia (2). This study examined whether implementation of statewide mask mandates was associated with COVID-19-associated hospitalization growth rates among different age groups in 10 sites participating in the COVID-19-Associated Hospitalization Surveillance Network (COVID-NET) in states that issued statewide mask mandates during March 1-October 17, 2020. Regression analysis demonstrated that weekly hospitalization growth rates declined by 2.9 percentage points (95% confidence interval [CI] = 0.3-5.5) among adults aged 40-64 years during the first 2 weeks after implementing statewide mask mandates. After mask mandates had been implemented for ≥3 weeks, hospitalization growth rates declined by 5.5 percentage points among persons aged 18-39 years (95% CI = 0.6-10.4) and those aged 40-64 years (95% CI = 0.8-10.2). Statewide mask mandates might be associated with reductions in SARS-CoV-2 transmission and might contribute to reductions in COVID-19 hospitalization growth rates, compared with growth rates during <4 weeks before implementation of the mandate and the implementation week. Mask-wearing is a component of a multipronged strategy to decrease exposure to and transmission of SARS-CoV-2 and reduce strain on the health care system, with likely direct effects on COVID-19 morbidity and associated mortality.

Changes in Depression and Physical Activity Among College Students on a Diverse Campus After a COVID-19 Stay-at-Home Order.

The numerous negative health impacts of COVID-19, which include expected changes to psychiatric illness and physical activity (PA), are disproportionately distributed in the United States. Mental illnesses and physical inactivity are prevalent among U.S. college students. This study examined whether there was a change in minutes of PA and depression scores after a stay-at-home order and examined predictors of these changes. An online survey was sent to all undergraduate and graduate students attending a large, diverse university via an electronic newsletter. The survey requested information about demographic and academic data, cardiorespiratory fitness, and depression symptoms. Paired t-tests and logistic regression were employed. Our sample (n = 194) was predominantly female (73%), young (mean age of 25), not a sexual minority (82%), and had a mean 3.4 GPA. Students reported worse depression scores (p < 0.01) and fewer minutes of PA (p = 0.01) after the stay-at-home order. There was a small but significant (p = 0.04) correlation between changes in total minutes of PA and depression scores. Senior (p = 0.05) and Hispanic (p = 0.03) students were less likely to report worsening depression scores than freshmen and white students, respectively. Asian students were significantly more likely than white students to report decreased PA. This study suggests that COVID-19 and its consequences may be contributing to reduced PA and greater depression symptoms in college students and that sub-groups have been affected differently. Targeted interventions to promote PA and support mental health may bolster the ability for resilience of college students.

Governors' Use of Executive Orders and Proclamations in Hurricane Response, 2006-2018.

Hurricanes can destroy or overwhelm communities and cause or exacerbate health conditions. Legal mechanisms and practices may aid or impede hurricane response. In the United States, where states have primary public health responsibility, state governors possess legal powers to address hurricanes. They often exercise these powers using executive orders and proclamations-legal mechanisms that direct public and private parties. Although executive orders and proclamations are critical for hurricane preparedness and response, how governors use them to respond to hurricanes is not fully understood. Using legal epidemiology, we systematically identified and analyzed hurricane-related executive orders and proclamations issued in the United States from January 1, 2006, through December 31, 2018. We found 468 relevant executive orders and proclamations, 14% of which were issued, at least in part, to benefit a jurisdiction other than the issuer's state. We observed variations in when and where such orders and proclamations were issued. Executive orders and proclamations were most commonly used to direct government response or recovery (32%), handle and administer government resources (31%), and suspend legal requirements perceived to inhibit response (27%). Fewer orders and proclamations regulated private parties (10%). Understanding how governors use executive orders and proclamations to respond to hurricanes can bolster future preparedness and response efforts.

Correction to: Temporal trend of research related to gun violence from 1981 to 2018 in the United States: a bibliometric analysis.

An amendment to this paper has been published and can be accessed via the original article.

Temporal trend of research related to gun violence from 1981 to 2018 in the United States: a bibliometric analysis.

BACKGROUND: We aimed to evaluate the variation in gun violence-related research in the US over time to determine if there are meaningful changes in frequency of research at certain time points. Related publications were searched from the Web of Science. METHODS: We searched articles from Web of Science to collect publication data of gun violence research in three disciplines (clinical sciences, life sciences, and social behavior sciences) from 1981 to 2018. The joinpoint regression approach was applied to evaluate the trend of publication ratio. We also adopted the generalized additive mixed model to compare the publication ratio among the three research disciplines. RESULTS: During the study period, each research discipline had a significant decrease in publication ratios, especially social behavioral sciences from 2001 to 2011, with an annual percentage change = - 9.77% (95% CI = - 13.45, - 5.93; p-value < .0001). After combining the three research disciplines, the average change of the publication ratio was significantly increased 9.18% (95% CI = 6.42, 12.01; p-value < .0001) per year from 1981 to 2018. Compared to social behavioral sciences, both clinical sciences and life sciences had a significantly smaller publication ratio. CONCLUSIONS: Gun violence research exhibited a significant downward trend in publications in the early 2000s, which may be attributed at least in part to limited federal funding, but the publication ratio increased since the 2010s. To enhance the amount of peer-reviewed gun violence research so that research-informed gun violence interventions are more likely to succeed, decision-makers should keep supporting quality research.

The Relationship between School Absenteeism and Substance Use: An Integrative Literature Review.

Background: Chronic school absenteeism is prevalent among high school students in the United States. Its impacts on academic success and health are cause for concern. One specific area of concern is its relationship to youth substance use; chronic absenteeism is associated with using alcohol, marijuana, tobacco, and other drugs. Despite important findings, absent from the literature is a recent and systematic synthesis of related research. Objective: We aimed to examine the literature to provide a better understanding of the relationship between chronic school absenteeism and the use of alcohol, tobacco, marijuana and other drugs among U.S. high school students. Methods: We conducted an integrative review of existing peer-reviewed literature using key terms in five databases from the education and health sectors. We included English-language, quantitative and qualitative studies published between 1992 and October 2017 and focused on U.S. students in grades 9 through 12 and between ages 13 and 21. We extracted data and study quality measures for included studies. Results: After screening 3,130 articles using titles and abstracts and reviewing 99 full-text articles, 37 met inclusion criteria. Most were cross-sectional, used local-level data, widely varied in sampling, were of limited generalizability, and simultaneously considered school absenteeism and the use of multiple substances. Due to methodological issues, the relationship between chronic absenteeism and substance use is difficult to fully understand. Conclusions: We confirm the connection between school absenteeism and substance use among U.S. youth, highlight a limited understanding of how and why this relationship manifests, and call for absenteeism research that uses longitudinal methods, national data, and clearly articulated methodologies and self-appraised limitations.

Health-Information Seeking and Intention to Quit Smoking: Do Health Beliefs Have a Mediating Role?

BACKGROUND: Smoking is a leading cause of preventable deaths. Smoking cessation can reduce the risk of smoking-associated disease and death. But smoking cessation involves behaviour change. Existing research indicates that health-information seeking and health-promoting behaviours can be positively associated. However, in the context of smoking, the relationship between seeking health information and intending to quit smoking remains only partially understood. AIM: This study aimed to examine the relationship between seeking health information and intending to quit smoking and to determine whether this relationship is mediated by health beliefs. METHODS: We used data from the fourth cycle of the US National Cancer Institute's Health Information National Trends Survey (HINTS). Logistic regression was used to assess the independent variable (ie, health-information seeking) and dependent variable (ie, intention to quit smoking) as mediated by health belief. RESULTS: Our findings suggest that smokers who seek health information have a 2.67 times higher odds of intending to quit smoking than smokers who do not seek health information. However, health beliefs do not have an intervening effect between seeking health information and intending to quit smoking. DISCUSSION: Seeking health information is important in predicting attempts to quit smoking, regardless of the smokers' pre-existing health beliefs. Our findings support cessation efforts that encourage smokers to seek health information. Determining optimal ways to encourage smokers to seek smoking-related information could support achieving and maintaining smoking cessation. CONCLUSION: Cessation programmes and policies should encourage smokers to seek health information. Additional research should further examine smokers' motivators and cues for health-information seeking and should further probe smokers' beliefs about the risks of smoking.

A State of Uncertainty: An Analysis of Recent State Legislative Proposals to Regulate Preventive Services in the United States.

This policy brief examines preventive services state legislation trends in the United States during uncertainty regarding the Affordable Care Act (ACA), which requires certain coverage of 4 evidence-based preventive services categories without additional patient costs under §2713. We used a legal mapping approach to search for and analyze state legislation related to preventive services proposed or enacted over a 25-month period of ACA uncertainty. We screened 1231 bills and coded the 76 screened-in bills. Next, we determined their characteristics and examined trends. Bills originated in 28 states, and 69.7% were not enacted. Only 3.9% contained requirements contingent on ACA modifications. About 56.6% referenced services covered by §2713, but usually not entire §2713 categories. Bills also mentioned preventive services in general (53.9%) and services outside §2713's scope (21.1%). About 55.3% applied to private insurance, and 75.0% only to one patient group. Bills generally promoted access, and 51.3% specifically prohibited cost-sharing. But 26.3% of the bills limited access to preventive services. State-level legislation targets preventive services, usually expanding, but sometimes limiting, access. Most bills single out specific services without fully incorporating evidence-based recommendations. State legislation may therefore promote access to preventive services but can favor certain services, deviate from experts' recommendations, and increase nationwide variability. State legislation can function as an important lever for access to preventive services across patient groups. This may be especially important during uncertainty about federal policy. However, the design of state-level proposals is critical for maximizing access to preventive services.