Advancing health equity in the U.S. requires action from more than just public health and health care leaders. The research is clear that policies that shape the environments in which people live have a greater impact on health outcomes than the care provided in doctors’ offices. These structural and social determinants of health (SDOH)—factors including education, transportation, housing, language, safety, racism and discrimination, environment, and others—are influenced by policy decisions at the local, state, national, and Tribal levels that have historically failed to consider their potential downstream impacts on health outcomes.
Marginalized communities are more likely to be harmed by such policies. The COVID-19 pandemic was a prime demonstration of the disproportionate impacts of factors such as housing conditions, access to preventive care, religion, and workplace regulations on people’s ability to protect themselves and their families.
Health in All Policies Supports Cross-Sector Collaboration to Address SSDOH
Health in All Policies (HiAP) is an interdisciplinary approach that is growing in influence and application in jurisdictions across the U.S.. For decision-makers interested in effecting change upstream to drive improvements in population health, HiAP tools that analyze the potential health and equity impacts of proposed policies (akin to environmental impact assessments) can help inform better and more equitable policy choices.
Several factors can facilitate the success of cross-sector collaboration to address complex health equity challenges by maximizing policies’ health benefits and mitigating potential harms. A May 10 convening organized by the Institute for Health and Social Policy at The Johns Hopkins Bloomberg School of Public Health's Department of Health Policy and Management, hosted in collaboration with the Society of Practitioners of Health Impact Assessment (SOPHIA) and AcademyHealth, explored the HiAP framework and shared tools used in various jurisdictions to advance health outcomes and achieve health equity in diverse communities.
States, Local Governments, and Supporting Organizations Have Designed Context-Specific Tools and Approaches to HiAP
In order to further HiAP and equity broadly, states and localities have developed and refined a number of approaches to analyzing the potential health impacts of proposed policies and integrating these findings into policymaking discussions. The convening brought together representatives of several of these interdisciplinary, cross-sector initiatives:
- Washington, D.C., launched the Council Office of Racial Equity (CORE) in January 2021 with the goal of embedding racial equity in all of the D.C. Council's work. The CORE team conducts Racial Equity Impact Assessments (REIAs) to examine how proposed bills might affect different racial and ethnic populations in the District. CORE has conducted more than 250 REIAs to date, and the REIA has become a mandated part of the legislative process. A REIA’s focus is broader than health, assessing how outcomes may be affected by racial identity—and how decisions may need to adjust to mitigate these differences in outcomes.
- The Colorado General Assembly’s nonpartisan staff have prepared “Demographic Notes” since 2020 estimating the potential impact of a bill on outcomes for various populations—including impacts on health, education, employment, economics, and safety—for populations identified by race, ethnicity, gender identity, sexual orientation, disability, geography, socioeconomic status, or other relevant characteristics for which data are available. As opposed to fiscal notes, which are mandated for each proposed bill, staff prepare Demographic Notes for up to 20 bills each year upon request, and a bill’s progress is not dependent on the analysis.
- Maryland passed legislation in 2017, championed by Senator Shirley Nathan-Pulliam, that led to establishing a HiAP Council and the recommendation that state and local agencies include a HiAP assessment in grantmaking. Just a few years later, the Health Equity Resource Act passed, setting the stage for a new statewide grant program to fund local initiatives centering health equity and addressing SSDOH. To date, 59 Health Equity Resource Communities (HERC) grants have been awarded to organizations to implement and test health equity initiatives in the state.
- Another widely used and adapted HiAP approach is the Health Impact Assessment (HIA). The Health Impact Project, formerly a collaboration between the Robert Wood Johnson Foundation and The Pew Charitable Trusts, created a toolkit of HIAs and related resources to promote cross-sector collaboration and decision-making to improve population health.
- Legislative health notes apply HiAP principles during fast-paced legislative sessions in order to help policymakers identify the health impacts of proposed policies across sectors. The HIA methods were adapted to support expedited decision-making (e.g., by limiting Notes to around ten pages) while advancing equity by highlighting disproportionate anticipated impacts for specific subgroups. Unlike HIAs, the Health Notes do not make recommendations. Preliminary learnings from a Health Notes pilot were published in May. The Health in All Policies Initiative, housed in the Institute for Health and Social Policy at The Johns Hopkins Bloomberg School of Public Health, is now working to create Judicial Health Notes, which will adapt the health note process to analyze court cases.
- A Health Action Plan centers a community’s health needs in designing or rehabilitating affordable housing development. Engagement of housing developers with both public health professionals and community members was a key facilitator for success documented in a pilot evaluation.
- The Environmental Protection Agency (EPA) uses cumulative impact research as part of its environmental justice work, combining assessments of how policies affect people, communities, and places.
Community Engagement, Systems Thinking, and Cross-Sector Collaboration Are Key to Advancing HiAP
The path to HiAP is not without its roadblocks. Data availability and utility are challenges that can stymie efforts, especially when the speed of legislation means conducting analysis with outdated or incomplete information. At the meeting, speakers noted an absence of demographic data collected on income tax forms, limiting the analysis possible for proposed tax bills. Similarly, an overall lack of Washington, D.C.-specific data when conducting REIAs meant many initial analyses by the CORE team utilized national data instead. However, recent increases in policies that require data to be disaggregated by race could strengthen future analysis.
To achieve the intended impact of centering health outcomes in proposed policies, HiAP practitioners take care to monitor the evolving political climate affecting work on health equity and related issues. While some jurisdictions, like Washington, D.C., have centered the term “racial equity” in their work, others use different terminology to recognize how messages about population health and equity are received. Speakers noted the importance of inclusive language in working with communities and policymakers in order to achieve intended public health outcomes. Shifting the narrative means focusing on the end goal of positive health and equity impacts—considering how decisions affect communities’ health, well-being, and vibrancy.
Speakers also emphasized the importance of community engagement in advancing HiAP. Keshia Pollack Porter, Bloomberg Centennial Chair of the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, highlighted that elevating community voices starts at the beginning of the HiAP process, to maximize the impact of policymaking with health outcomes in mind. This means meeting with leaders in community gathering places, conducting meetings at appropriate times, and letting go of preconceived goals in favor of priorities set by the community.
Sandra Whitehead, president of SOPHIA, the international community of HiAP practitioners and champions, shared seven strategies for those interested in advancing HiAP:
- Develop and structure cross-sector relationships;
- Enhance workforce capacity;
- Incorporate health in decision-making processes;
- Coordinate funding and investments;
- Integrate research, evaluation, and data systems;
- Implement accountability structures; and
- Synchronize communications and messaging.
Ultimately, HiAP seeks to institutionalize the consideration of health when making policy and resource decisions. A collaborative approach that centers community voices, educates policymakers, and fosters continuous improvement can lay the foundation across sectors to improve population health and well-being.