Look Before You Legislate


As a society, we are learning more about how the social and political structures of the past have determined the health of populations today. But what can be done to ensure that new policies in the future improve health and don’t exacerbate existing inequities?

The health impact assessment (HIA), also known as a health impact review, is one strategy to predict how newly proposed legislation would affect population health before a bill is ever enacted. In 1999, the city of San Francisco conducted the first HIA in the US to assess the health effects of a proposal to increase the minimum wage. The review found that increasing the minimum wage would have substantial health benefits. Since then, use of HIAs has continued to increase across the US, from only 27 assessments in 2007 to 225 by 2013. Cities and states vary in their utilization, with most reviews conducted in California, Alaska, Massachusetts, Minnesota, and Washington.

The Washington State Board of Health began conducting HIAs in 2006 as part of the state’s growing interest in equitable health policy. Legislators voluntarily request and apply for an assessment. The Board of Health then conducts an extensive analysis of existing evidence and literature pertaining to the topic. They determine whether a bill will effectively improve health, how effective it will be, and who it will most likely benefit. They do not provide recommendations, only objective analysis. Since 2006, twenty Washington legislators have requested a total of 36 HIAs.

In order for the US to tap in to the full potential of HIAs, states will need to increase awareness of such analyses or consider requiring assessments for certain types of legislation.


Keshia M. Pollack Porter, Ruth Lindberg, and Arielle McInnis-Simoncelli conducted interviews and in-depth analysis of 32 HIAs completed in Washington to better understand how impact reviews are being utilized. Most HIAs were conducted for legislation pertaining to education, healthcare, social services, labor, and employment bills, but a number of HIAs evaluated policies in agriculture, criminal justice, disaster preparedness, and natural resources. Overall, legislators reported that it was useful to have evidence-based support for their proposed bills. They found the HIAs particularly helped their chances of passing legislation that aimed to improve health. The study revealed a lack of awareness of the program to be the most common reason legislators did not request an assessment.

For the majority of bills, the HIA bolstered the credibility of the proposed legislation. For example, an educational budget proposed allocation of funding to attract higher-quality educators to lower-income neighborhoods. The assessment found that the program would be effective and had the potential to reduce health disparities for a large population of minority students. The incentive program is currently ongoing and looking to further expand its funding.

In some instances, proposed legislation was found to be less effective than legislators likely hoped. One bill proposed limiting the use of chemical and mechanical restraint as discipline against students. However, the HIA found the frequency of such use was rare and the benefits of the proposed legislation would therefore be minimal.

In 2009, a HIA flagged a proposed budget cut, revealing it would likely produce detrimental health effects and worsen health disparities. The HIA determined that any cut in funding would greatly reduce support for subsidized healthcare for children in poverty, limiting many families’ access to vaccination. The HIA found that the funding cut would disproportionately affect low-income families, minority communities, and women.

HIAs guide evidence-based decision-making in policy. Internationally, the World Bank requires HIAs for policies regarding oil, gas, and mining. In the US, however, participation remains voluntary for legislators. In order for the US to tap in to the full potential of HIAs, states will need to increase awareness of such analyses or consider requiring assessments for certain types of legislation.

Photo by Markus Spiske on Unsplash