Assessing Health Impacts Across Sectors

By Kate Blackman and Douglas Shinkle | Vol . 24, No. 41 / November 2016


Did you know?

  • Health impact assessments follow six steps: screening, scoping, assessment, recommendations, reporting, and monitoring and evaluation.

  • More than 400 health impact assessments of policies and projects have been conducted in the U.S.

  • Depending on scope and length, costs for health impact assessments can range from $10,000 to $150,000.

People’s health is largely dependent on factors outside of the health care system, including the circumstances in which they live, learn, work and play. These social, economic and environmental conditions that influence health are increasingly part of the policy discussion as health care costs relentlessly pressure state budgets and lawmakers look for ways to prevent costly chronic diseases and conditions.

Health impact assessments (HIAs) are tools to help determine the potential effects of policies on people’s health and to inform decision-making. HIAs take health into account in policies across various sectors, including economic development, transportation, agriculture, education, energy and the environment. HIAs use a broad definition of health, incorporating the social, economic and physical conditions that affect overall well-being. These include opportunities for education, employment and physical activity, as well as access to housing, transportation and healthy foods.

Health impact assessments are structured processes that use scientific data, health expertise and stakeholder input to examine the potential health effects of a proposed law, policy, program or project. HIAs evaluate consequences and examine how different populations—such as a rural community or low-income neighborhood—may be affected. HIAs seek to add information to the decision-making process and propose recommendations that minimize health risks or negative effects and capitalize on health benefits. HIAs have been conducted worldwide, and in the United States, they have been used at the federal, state and local levels.

Health in all policies” is a similar, though less structured, approach that involves collaboration and stakeholder input across sectors in an effort to incorporate health considerations in decision-making processes. HIAs are one tool that can be used to support an overall health in all policies approach. Regardless of the specific strategy, policymakers can use tools to understand the larger contexts that affect health.

State Action

States have required analyses of health effects for policies in specific sectors, such as the energy or transportation fields. For example, Colorado and Texas mandate analyses of health impacts related to licensing facilities that handle or transport radioactive material.

State lawmakers in more than 15 states have considered more than 50 bills since 2009 related to studying the health effects of policies or projects. Some states may incorporate elements of health impact assessments, while others explicitly require comprehensive HIAs.

Alaska began using HIAs related to oil, gas and mining projects at the local and tribal levels in 2005. The Legislature considered a bill in 2010 that would have included analyses of health effects in environmental projects. While the bill did not pass, the state’s department of health and social services uses HIAs as part of the permit process for major oil, gas and mining projects.

Washington and Massachusetts were among the first to use HIAs in the transportation sector. The Washington Legislature enacted SB 6099 in 2007, requiring a health impact assessment for a project to replace a 1.5-mile bridge connecting Seattle with a major suburb. The law required the HIA “to calculate the project’s impact on air quality, carbon emissions, and other public health issues.” The final HIA evaluated multiple scenarios and numerous interventions with potential public health benefits. Many of these, such as transit, bicycling and pedestrian improvements, additional green space, a landscaped highway lid, stormwater upgrades and noise reduction were incorporated into the project. In addition, Washington enacted legislation in 2006 authorizing the board of health to conduct health impact reviews at the request of legislators or the governor.

The Massachusetts legislature created the healthy transportation compact in 2009 to increase interagency collaboration between the state’s department of transportation and other agencies as part of an effort to apply a health lens to policies. The compact aims to “achieve positive health outcomes through the coordination of land-use, transportation and public health policy.” The law also requires using HIAs to determine the effects of transportation projects on public health. The first HIA was conducted on an elevated highway corridor in the Somerville area that carries a large volume of traffic, but also limits mobility and connectivity within the city. 

As part of health care reform efforts, Vermont’s 2012 legislation directed the department of health to recommend “a plan to institute a public health impact assessment process” for policy and planning decisions made by state and local agencies. The resulting plan focused on recommendations for HIAs related to the built (man-made) environment. The department has conducted HIAs related to transportation (road corridors) and development (zoning, infrastructure), as well as paid sick leave and marijuana regulation.

Legislation has also been the subject of HIAs conducted by outside groups. For example, researchers at the University of Nevada, Las Vegas conducted an HIA about pending legislative changes in Nevada addressing availability and state funding of full-day kindergarten. The researchers cited the connections between full-day kindergarten, educational attainment and health. The Legislature approved the bill, which expanded full-day kindergarten throughout the state.

Federal Action

Some federal laws require analyses of health effects related to policies or projects. For example, the National Environmental Policy Act (NEPA) requires examining the environmental impact of significant federal agency actions. Though it does not specify an HIA by definition, the required analysis is similar in its approach of requiring a report or recommendations related to health and environmental effects. The stated purpose of the law includes promoting efforts that “prevent or eliminate damage to the environment” and that “stimulate the health and welfare of man.” At least 16 states have NEPA equivalents—state laws that similarly mandate analysis of effects on environmental and human health.

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