Why do an assessment?

Many laws and policies have been “on the books” for a long time.  They may have been enacted during a time when social norms and governmental or organizational practices were vastly different.  They may have been superseded by a later law and never officially repealed.  Whatever the reason, it’s important to routinely assess both existing and proposed laws and policies to ensure that the legal infrastructure for public health supports the practice of public health, and that the drafting, design, implementation and enforcement of laws are equitable.

For state and local public health agencies that are accredited or seeking accreditation through the Public Health Accreditation Board, Domain 6 of the Standards requires documentation of review of public health laws or laws with public health implications.  This review must be conducted regularly and should evaluate laws for consistency with evidence-based or promising practices as well as for the impact on health equity.  Agencies are encouraged to use tools like the Equity Assessment Framework to guide this review, as well as checklists, templates and model laws.  Finally, agencies are encouraged to solicit input from key stakeholders.

When should you do an assessment?

Conducting a regular assessment of laws and policies is a strategy for addressing health equity, especially when that assessment includes and is informed by community perspectives.  The Equity Assessment Framework should be used any time a law or policy is being reviewed for changes, is being newly drafted, has recently been passed (or rescinded or repealed) and the new or updated requirements have to be implemented.  This review can be prompted by changes in state or federal law, court rulings and changes in administration or leadership.

Laws, regulations, ordinances and policies should also be on a regular review schedule.  For policies, this might be annually, while regulations might be reviewed every five years.  One strategy is to conduct reviews in accordance with the timeline for your agency or organization’s strategic planning process (3-5 years).  Agencies and organizations should consider maintaining a comprehensive listing of all polices with last date of review and a mechanism for alerting the appropriate points of contact when a review is due.

Who should use this tool?

This tool should be used by anyone who has a role in the policy development process, and ideally would be used as an exercise for cross-sector teams using collaborative approaches like Health in All Policies to address an identified issue.  Potential users would come from:

• State and Local Government Agencies
• Community Groups and Organizations (like Neighborhood Associations and Community Advisory Councils as well as non-profit organizations and Faith-based Groups)
• Businesses that have a strong role and relationships in their communities
• Individuals and groups in K-12 Education
• Health Care Delivery Organizations

This is not an exhaustive list.  If you are thinking about enacting a new law or policy or making updates to an old one and there are implications for the health and well-being of people and communities, you should use the equity assessment framework to help guide the process and engage a diverse set of voices in the conversation.

What kinds of laws and policies should you look at?

If you are revising, creating or implementing a law or policy (or even rescinding!) you should assess the impact on vulnerable communities.  In the table below are examples of the types of laws and policies that could be assessed by each stakeholder group, but these can be cross cutting. The teams conducting an assessment should have representation from all impacted stakeholders. 

State and Local Government	Community Groups and Organizations	Businesses	K-12 Education	Health Care Delivery Organizations
• Pre-emption • Housing (Zoning, Landlord-Tenant Laws, Affordability and Stability, Nuisance Laws) • Transportation (all types for all ages and abilities) • Public Health Measures (Alcohol Outlet Density, Tobacco Control) • Business Licensure • Code Enforcement • Procurement, Contracting, Grants (include equity language)	• Community Safety (Police, Fire, EMS) • Land Use • Fees and Fines • Safe Streets (traffic, pedestrian) • Community Advisory Boards and Committees • Civil Rights Laws • Food and Nutrition Programs • Child Care • Allocation of Tax Dollars	• Hiring and Retention • Worker Protections • Paid Leave Policies • Training and Professional Development • Performance Evaluation • Disciplinary Process • Workplace Wellness • Organizational Self-Assessment • Community Involvement • Workforce Diversity	• School Health (nurses, peer support, behavioral health) • Quality and Accessible Pre-K Programs • School Discipline • School Nutrition • Funding sources and allocation • Teacher Recruitment and Retention • Course Offerings • Extracurricular Activities	• Workforce Diversity • Hospital Community Benefits • Billing and Collections • Funding programs and initiatives that address the social determinants of health (food insecurity, transportation, housing, etc.) • Data collection • Language, literacy, and accessibility • Research Guidelines • Access to Care

All of these categories may include laws and policies that create accountability, like requiring performance measures or performance evaluation; establishing multi-sector task forces to provide ongoing oversight; or promoting or requiring data-informed decision making.

How do you do it?

This is a flexible process! You should use the tools that you are most comfortable with. You can use tools from multiple sources to create a process that works for your team.

What might an assessment using the Equity Assessment Framework look like in action?

• A public health program manager might seek guidance from a team that includes the agency attorney on whether recommendations in the Community Guide can or should be implemented.
• A neighborhood association might host a town hall on ballot initiatives that will impact the neighborhood, inviting in key speakers and community leaders and asking questions based on the framework.
• A business might conduct and publicly share the results of an assessment of its workforce, management and leadership diversity. It can use the data along with the framework to inform changes in recruitment, hiring and retention.
• Teachers, other school personnel and groups that advocate on their behalf might conduct an assessment of “pandemic clauses” that some school personnel are being asked to sign in order to return to the classroom during the COVID-19 outbreak, especially in light of existing laws regarding outbreaks of communicable disease in the school setting.
• Health care delivery organizations might assess data reporting requirements and penalties, while also considering the impact of requiring the collection of more comprehensive demographic information (like sexual orientation and gender identity, broader race and ethnicity categories, occupation, and education level).

You can also see the application of the Equity Assessment Framework to Marketplace Special Enrollment Periods and an Institutional Racism bill from New Mexico as examples.

For examples of comprehensive review and update of important laws related to health and equity, check out…

…a summary of New Mexico’s efforts to modernize its Public Health Act in 2017.

…a report from the Commission to Study Racial Inequity in Virginia Law from 2019.

You can also find additional resources on the types of laws and policies to review using the Equity Assessment Framework at the links below.

• CityHealth
• ChangeLab Solutions
• Essential Hospitals Institute: Health Equity
• Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health
• Policies to Eliminate Racial Disparities in Education: A Literature Review
• Strategic Practices and Actions to Advance Health Equity in Local Health Departments   

This post was written by Dawn Hunter, Deputy Director, Network for Public Health Law – Southeastern Region Office.

The Network for Public Health Law provides information and technical assistance on issues related to public health. The legal information and assistance provided in this post do not constitute legal advice or legal representation. For legal advice, readers should consult a lawyer in their state.

Support for the Network is provided by the Robert Wood Johnson Foundation (RWJF). The views expressed in this post do not represent the views of (and should not be attributed to) RWJF.