Infrastructure Law Could Advance Health Equity

Legislation signed by President Joe Biden on Nov. 15 broadly addresses U.S. infrastructure in a way not seen in almost 70 years. The bipartisan Infrastructure Investment and Jobs Act presents an opportunity to improve health equity, giving more Americans a chance to be as healthy as possible, through changes to the built environment and related initiatives.

Many provisions address key infrastructure concerns directly tied to health, for example, the availability of clean water, transportation improvements, and more effective land use. Expanded access to broadband internet, another priority in the legislation, also will help improve Americans’ health by connecting them to the care they need.

Ensuring availability of clean water

The availability of clean drinking water and the proper disposal of wastewater are essential for good health. The new law calls for several new or updated policies, bolstered by $55 billion in dedicated funding, regarding these systems. For example:

• Upgrading public water systems to ensure safe drinking water. That includes replacement of lead pipes and service lines, particularly in small, rural, low-income, and disadvantaged communities. In addition, grant funding will support lead testing at school and childcare programs as well as remediation.
• Connecting eligible households to public water systems; providing financial assistance to rural and low-income households; and helping plan, design, or construct municipal sewer or stormwater overflow mitigation. The primary focus will be on distressed communities.
• Connecting, expanding, repairing, and improving water quality, pressure, and services on reservation land serving tribal populations in five geographic regions across the country. Funding is also available for sanitation improvements in rural and native villages in Alaska.
• Providing the Environmental Protection Agency with technical assistance funds to assess how well community water and wastewater systems comply with environmental, health, and safety requirements intended to counter potential public health threats, such as lead exposure.

Today, more than 2 million Americans lack access to running water, indoor plumbing, or wastewater services because their households are not connected to public water systems or their communities, often remote and small, do not have access to appropriately matched solutions.

Almost 9 million lead pipes across the U.S. put people at risk of lead exposure regularly. The Health Impact Project’s 2017 report on childhood lead exposure recommended replacing lead service lines, particularly in low-income communities and communities of color that tend to be disproportionately at higher risk. The study also called for frequent testing of children, for whom exposure can be particularly harmful.

Another growing challenge is drinking water contamination from combined sewer overflows. Pew’s flood-prepared communities project has suggested several mitigation measures, including green infrastructure—the use of plants, soil, and natural systems to manage stormwater. The new law offers potential funding for such improvements.

Health-friendly transportation improvements

Transportation options such as walking, bicycling, and public transportation, and ways in which streets and other community resources are designed, can play a pivotal role in health and equity. The law was drafted to increase investments in improved transportation. The federal money can be used to:

• Prioritize projects that integrate trails and bikeways with public transportation, use public input in developing plans, consider race and income-based disparities in pedestrian and cyclist safety, provide access to jobs and services for low-income communities, connect communities historically severed by highway construction, and advance environmental protection and quality of life.
• Support projects that would change street design and mitigate air pollution, flooding, and urban heat island effect, the reality that some urban areas are significantly warmer than surrounding areas because of development and human activities. The law prioritizes initiatives based on research and assessment of tree canopy gaps, flood-prone locations, and urban heat island hot spots within low-income and disadvantaged communities.
• Replace school buses with those certified to reduce emissions and operate entirely or in part using an alternative fuel. The law prioritizes such replacements for high-need local educational agencies, Bureau of Indian Affairs-funded schools, and schools servicing children who reside on Native American land and in rural or low-income areas.

Built environments designed to promote more walking and bicycling can provide opportunities for increased physical activity, social interaction and cohesion, and lower traffic-related death and injury rates. Policies that promote the use of materials to mitigate high temperatures and reduce stormwater runoff, or reduce emissions by replacing diesel school buses with electric ones, also support positive health outcomes and help to revitalize neighborhoods economically.  

However, transportation infrastructure is not equitably distributed across communities and has historically left some people unable to access the resources than can boost educational or employment prospects for residents. This law directs specific funding to disadvantaged communities of color and low-income communities to create opportunities for all to access a diversity of affordable transportation modes.

Updating land use policies

Land development and zoning policies often dictate the availability and affordability of housing, walkability and transportation in a neighborhood, levels of crime, and other health-related factors. The new law specifically invests in measures to improve land use, particularly for transportation and clean energy infrastructure. For example, the law:

• Allocates funding for metropolitan planning areas that integrate housing, transportation, and economic development strategies. It also encourages coordination between public and private entities, and supports locating housing near employment opportunities to promote economic stability, the consideration of affordable housing needs, and increasing the share of households with sufficient, affordable access to transportation networks.
• Mandates increasing safe and accessible transportation options to accommodate people of all ages and abilities. Funds have been appropriated to remediate brownfields (potentially contaminated previously developed land) to site clean energy projects, and to clean up superfund sites contaminated with hazardous substances, to ensure mitigation. 

Expanding broadband availability

About 30 million Americans currently do not  have broadband connectivity—high speed, reliable internet—while up to 162 million are not using internet at broadband speeds. That impedes their ability to work, learn, and access health care and government services from home. The law funds increased physical infrastructure for broadband and should help ensure equitable distribution of networks. It allocates funding to:

• Help states provide broadband to unserved and underserved locations, defined as places with no access to high speed service or lacking access to reliable internet.
• Connect eligible community anchor institutions such as hospitals and educational institutions to broadband networks.
• Collect data, map, and plan for broadband deployment.
• Install internet and Wi-Fi infrastructure or reduced-cost broadband within multifamily residential buildings, giving priority to service for those living at or below 150% of the federal poverty line.
• Support programs in states that provide affordable internet-capable devices to serve low-income individuals, youth, and seniors in a community.
• Provide competitive digital equity grants for nonstate entities, such as Native American tribal organizations, foundations, and others.

The Brookings Institution has found significant gaps in broadband access, adoption, and use in rural America, communities of color, and in low-income communities. And that too often leads to inequitable outcomes, such as a lack of access to education, social supports, or participation in civic activities for some communities. Expanding physical infrastructure to connect underserved communities, increasing affordability, and improving digital literacy all can help address these gaps.

Pew’s broadband access initiative works withstate and federal lawmakers, researchers, and other partners to accelerate progress toward universal, affordable high-speed internet service. The project provides no-cost support to state broadband programs, including training and peer-to-peer engagement, on topics such as data strategy and program design. A health impact project analysis this year found that community engagement with a broad set of stakeholders can promote equitable infrastructure decision-making in many sectors, including access to broadband.  

Considering the interconnected effects of each of the components of built environment policy and planning can promote better health and equity outcomes.

Research shows that policies that affect development of these infrastructure components have the power to change people’s living conditions, thereby improving their health and advancing health equity. Policymakers and other stakeholders should consider these health implications while making decisions about how to implement the provisions in this law to ensure that the spending helps advance health equity through improvements to built environment infrastructure.

Ruth Lindberg is the director of and Mimi Narayan is an officer with The Pew Charitable Trusts’ Health Impact Project.