Decisions made in sectors outside of health care—in education, housing and transportation, to name a few—can shape people’s health and well-being. As states continue to recover from the COVID-19 pandemic, some legislatures are using “health notes” to examine the potential health implications of a wide range of proposed legislation.
What Are Health Notes?
Health notes provide brief, objective, nonpartisan summaries of how certain bills could affect health. Developed by the Health Impact Project at The Pew Charitable Trusts, which is an NCSL Foundation sponsor, health notes were introduced in January 2018 as a pilot program to help policymakers identify potential or overlooked links between various sectors and health. The notes provide data to support decision-making but do not include policy recommendations or cost-benefit analyses, nor do they support or oppose legislation.
Where Have Health Notes Been Used?
To date, six states and the District of Columbia have produced a total of 20 health notes. In the District of Columbia, the Metro for D.C. Amendment Act of 2021 would grant a monthly public transportation subsidy to residents 18 and older, prioritizing those earning below 300% of the federal poverty level. The health note revealed that access to safe, affordable and reliable public transportation can support increased physical activity and improved access to jobs and services, which might help people—especially those from low-income households—maintain stable employment and a healthy diet. The note also cited research showing that a reliance on motorized transportation has been linked to numerous negative health outcomes, including higher rates of obesity, air pollution and transportation-related injuries.
In 2020, Pew produced a health note for Colorado SB 20-014, which addressed excused absences in public schools for behavioral health reasons. The note examined the potential health effects of excused school absence policies, the relationship between youth behavioral health and absenteeism, and factors affecting youth behavioral health. Strong evidence shows that behavioral health challenges are associated with an increased risk of students missing school and with a shortage of appropriate behavioral health services and supports for youth, the note concluded.
Pew also partners with nonprofit and nonpartisan policy research centers to provide training and technical assistance with the notes. Policy Matters Ohio, a nonprofit think tank, developed a health note in 2020 for that state’s HB 1 and SB 3, both of which addressed drug sentencing reform. The research suggested the legislation would likely have positive impacts on residents’ health by expanding opportunities for treatment of addiction rather than incarceration.
The North Carolina Budget and Tax Center produced a health note in 2019 for HB 692 to examine the health effects on older adults of proposed changes to their homestead property tax liability. The findings suggested that increasing the share of a fixed income dedicated to housing can affect older people by increasing stress and making it more difficult for them to access and afford medical treatments and stay in their homes.
How Are Health Notes Developed?
Drawing from the best available evidence, the team developing a health note conducts a rigorous, rapid and impartial analysis using peer-reviewed research, scientific data and public health expertise to describe how the legislation could affect issues that influence health. Legislatures can adapt Pew’s multistep process to suit their specific timelines and priorities.
Pew’s health note process includes:
- Inform and educate policymakers and other stakeholders about the notes: Contact and meet with legislators in advance and share example health notes to increase awareness.
- Screening: Identify potential bills that would benefit from an analysis.
- Identify subject-matter experts: Connect with researchers and peer reviewers who can provide guidance during the drafting and finalization of the note.
- Scoping: Examine the potential positive and negative health effects related to the proposed legislation and identify research questions about the bill’s pathways to health.
- Research: Conduct and track the results of a rapid literature search connecting the health pathways and the bill components.
- Drafting: Write the health note and obtain peer review from subject-matter experts, then revise the health note accordingly.
- Dissemination: Share the final health note with legislators and staffers.
- Monitor and evaluate: Determine how many legislators received and read the note to determine if it was helpful in decision-making.
Pew continues to engage with state and local policymakers, as well as state and local agencies and academic institutions, to expand the use of health notes. Pew also provides trainings and technical assistance to organizations and agencies interested in learning how to create health notes.
Sydne Enlund is a senior policy specialist in NCSL’s Health Program.