Health Impact Assessments Inform State Policymaking

by Katherine Barrett and Richard Greene
The phrase “evidence-based” has become ubiquitous in state government circles. The concept is simple: Decisions, in an evidence-based system, are made based on validated prior experiences and research, rather than just on opinions, anecdotes and ideologies.
But, “often that work hasn’t included health,” said Rebecca Morley, director of the Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and the Pew Charitable Trusts. Morley’s efforts, along with others, have been to encourage and assist states and localities in developing so-called health impact assessments, or HIAs, which are “a very specific tool for bringing health issues to decision making,” she explained.
HIAs use a variety of procedures, methods and tools to evaluate the potential health effects of a policy, program or project, according to the World Health Organization.
HIAs have been around, to some extent, for decades, though using that particular name for them is a more recent phenomenon. Suzanne Condon, former associate commissioner of public health in Massachusetts, recalled an instance in 1990 when the mayor of Leominster, Massachusetts, was concerned about the health hazards in building a play area for children in an abandoned lot that contained metal contaminants. Condon helped him do a careful toxicology study, which led to laying 4 to 5 inches of gravel over the ground to protect the children’s health.
Since then, the use of health impact assessments has gathered steam, acquiring that moniker along the way. The movement really started to gain traction in the United States in 2009, when there were 62 HIAs completed, many in California. More recently, there have been closer to 400 a year, almost all in states and localities, as opposed to the federal government. 
HIAs can uncover potential hazards that may not be obvious to either decision makers or the general public. For example, around 10 years ago, “there was a proposal to build a new low-income housing complex for seniors near a very busy freeway in the San Francisco area,” said Aaron Wernham, chief executive officer of the Montana Healthcare Foundation.
The idea was favorably received in most circles. But when developers began to work with health officials to create a health impact assessment, people realized the influx of moving vehicles into the neighborhood could create problems for older residents. “So, they worked with the developers to use windows that wouldn’t let the pollution in,” said Wernham, so residents wouldn’t suffer from respiratory issues. “They also made changes so there wouldn’t be as much noise. And we know that noise has impact on health in terms of sleep.”
Unlike their cousins, environmental impact statements, these HIAs aren’t generally used to stop a project but “to inform a project,” explained Morley. 
“Some people have said that HIAs are like birthing a baby,” said Emily Bourcier, operations and development manager at the Center for Community Health and Evaluation of the Group Health Research Institute. “Once it’s done, you’re not done.” 
Bourcier’s point is that HIAs—like any kind of evaluation—haven’t delivered on their promise until actions have been taken to help alleviate any of the potential health hazards uncovered in the process. This can be complicated by the fact that, in many instances, the team that put together the HIA is disbanded after the report is disseminated, but before efforts are made to ensure the recommendations have a chance to be incorporated in decisions.
Of course, like other management tools, HIAs are not a silver bullet. There are, however, a number of ways in which they can be used to optimize the likelihood they will improve health outcomes for a state and potentially save health dollars down the line (if Medicaid costs drop, for example).
A handful of keys to success are laid out in an article titled “An Evaluation of Health Impact Assessments in the United States” that was published in 2015. It was written for the Centers for Disease Control and Prevention by Bourcier and others. They point out the importance of putting together the right team for an HIA, including “experts in the content related to the decision under consideration [and] knowledge of the decision-making process.” The article also encouraged bringing decision makers on board early on and throughout the process in addition to delivering early findings of the HIA to stakeholders even before recommendations are made.
Of course, properly done HIAs aren’t cheap. Pew and other foundations have helped subsidize many health impact assessments. But one of the major sources of funding, the CDC, has recently had its budget for underwriting HIAs cut by Congress. 
This move took place in the end-of-the-year appropriations process in December 2015, said Margo Pedroso, deputy director of the Safe Routes to School National Partnership. The House of Representatives chose to cut the funding, with the rationale that the change would allow the CDC to focus on more direct public health activities. The subject may not be entirely closed, however, as a number of national, state and local organizations have written to Congress asking for a restoration of funding in fiscal year 2017. 
This congressional decision is an exemplar of a phenomenon that we’ve long seen at all levels of government. Efforts that have long-term payoffs often are given second class status, while direct services are favored. In the short run, this may be a politically expedient philosophy. But in the long run, it doesn’t necessarily serve the citizens well. Without appropriate planning and a real understanding of all the costs associated with a governmental effort, additional expenses and problems will likely crop up down the line.

About Barrett and Greene

CSG Senior Fellows Katherine Barrett and Richard Greene are experts on state government who work with Governing magazine, the Pew Charitable Trusts, the Volcker Alliance, the National Academy of Public Administration and others. As CSG senior fellows, Barrett and Greene serve as advisers on state government policy and programming and assist in identifying emerging trends affecting states.