Taking Note: Examining Policies' Effects on Public Health

By Sydne Enlund | Vol. 28, No. 14 | April 2020


The health of constituents remains a top priority for state legislators. Evidence shows that decisions made in sectors outside of public health and health care—such as education, housing and employment—can directly affect some of the factors that shape people’s health. Some states are piloting the use of a “health note” as a new strategy to examine the potential health implications of proposed legislation and policies in not only health, but other sectors.

Similar to a fiscal note used to determine the financial effects of state legislation, a health note provides brief, objective and nonpartisan summaries of how certain bills could affect health. Health notes were developed by the Health Impact Project at The Pew Charitable Trusts and introduced in January 2018 as a pilot program. The goal of the health note is to help state policymakers identify any potential or overlooked connections between various sectors and health.

Drawing from available research, health notes can be developed in a short time frame (e.g., two weeks) so they can be used in the legislative process. The Pew Project research team conducts rigorous, rapid and impartial analysis using peer-reviewed research, scientific data and public health expertise to describe how the legislation could affect issues that strongly influence health, including education, employment and housing. Pew also partners with nonprofit and nonpartisan policy research centers to assist in the research process. Health notes are intended to provide policymakers with data to support decision-making. They do not make policy recommendations and are not intended to provide a cost-benefit analysis or to support or oppose legislation.

Moving forward, Pew will engage with interested state and local policymakers to identify an entity—such as a state or local agency, nonprofit organization or academic institution—to create future health notes and support these organizations as they create a sustainable structure and process. Pew also provides trainings and technical assistance to organizations or agencies interested in learning how to conduct research for and create health notes.

State Action

Colorado and Indiana were the first two states to participate in the health note pilot program. In one example, Colorado HB 19-1262 prohibited school districts from charging fees for full-day public kindergarten. Health note findings revealed a number of short-term benefits for students’ academic achievement, health and well-being. These included improved access to school-based physical activity, nutrition education, breakfast and lunch programs, as well as vision and hearing screenings. The health note found that full-day kindergarten is particularly beneficial for lower-income students, children of color and English language learners. It also highlighted that the longer-term effects of full-day kindergarten can fade if students attend lower-quality educational programs after leaving kindergarten. This bill became law in 2019.

In another example, Indiana HB 1006 required a reduction in caseloads for family case managers at the Indiana Department of Child Services. The health note found that lighter caseloads were associated with improved outcomes and positive health implications for children and families served by case managers. The review also found that caseload reduction was one of several factors that can reduce work-related stress and burnout among the case managers. This bill was enacted in 2019.

So far, health notes have been produced for nine bills in Indiana and Colorado, including those described above. Other notes have examined bills that would:

  • Expand the availability of behavioral health care providers in shortage areas (Colorado SB 18-024, enacted in 2018).
  • Expand access to school lunches (Colorado HB 19-1171, enacted in 2019).
  • Create a youth workforce readiness program (Indiana SB 158).
  • Make it easier for homeless youth to obtain state-issued identification such as a birth certificate or driver’s license (Indiana SB 464, enacted in 2019).
  • Create a new high school equivalency pilot program (Indiana SB 234).
  • Allow excused absences for behavioral health concerns (Colorado SB 20-014).
  • Expand behavioral health training for K-12 educators (Colorado SB 20-001).

With the help of independent, nonprofit research and policy organizations in each state, the health note pilot program expanded to California, North Carolina and Ohio in 2019.. These organizations have examined bills ranging from changes to unemployment insurance to workers’ compensation programs to legalizing accessory dwelling units.