States Work to Factor Health Into Broader Policymaking

State lawmakers in Indiana and Colorado are piloting an approach to broadening the consideration of health when exploring legislation related to housing, education, employment, land-use planning, and other topics critical to residents’ quality of life. 

They are using what are known as health notes, developed by the Health Impact Project. These provide brief, objective, and nonpartisan summaries of how proposed legislation could affect health. The notes draw from the best available peer-reviewed research, scientific data, and public health expertise to help legislators understand the connections between decisions in a variety of sectors and the health of their constituents. These states are the first to take part in the two-year pilot program that began in January 2018.

In Indiana, for example, legislators sought assistance in analyzing the possible health effects of a bill to reduce the workloads of state Department of Child Services’ family case managers. The resulting health note found that lighter caseloads were associated with improved outcomes for children and families served by case managers—with positive health implications. The review also found that caseload reduction was one of several factors that can affect work-related stress and burnout among these managers.

So far, health notes have been produced for six bills in Indiana and Colorado, including one signed into law in Colorado in 2018. The others have examined bills that would expand access to school lunches, create a youth workforce readiness program, prohibit charging fees for all-day public kindergarten, and make it easier for homeless youth to obtain state-issued identification such as a birth certificate or driver’s license.

Evidence shows that decisions made in sectors outside public health or  health care—such as employment, education, housing, transportation, and criminal justice—can have profound and lasting effects on the factors that shape health and health outcomes. The health notes can help policymakers identify the potential and often-overlooked connections among these various sectors and health. Findings can also be used between legislative sessions to inform development of new proposals or to conduct more research on legislative topics. Finally, health notes can help the public to better understand how specific legislation might protect, promote, or harm health.

This year, the pilot program will expand to three additional states—Ohio, California, and North Carolina—with the help of independent, nonprofit research and policy organizations in those states.

Typically, the health notes, which draw from available research, can be developed in a short time frame so that they can be used in the legislative process. They assess both positive and negative potential effects on health. The Health Impact Project research team starts with a preliminary literature review to understand potential connections between the bill and the social and economic factors that affect health. The team then outlines the bill’s potential links to health considerations and develops research questions, contextual background questions, and key search terms that are peer-reviewed by an external subject matter expert. Next, the research team conducts an expedited literature review using a systematic approach to minimize bias and answer the identified research questions. 

Health notes consider the context of the legislation and include available local data to illustrate the potential impact on specific populations, locations, and programs. They are not intended to provide a cost-benefit analysis or to support or oppose policies. Instead, they can provide policymakers with data to support decision-making. 

Ruth Lindberg is a manager with and Stacey Millett directs the Health Impact Project.