Improving State Health Policy Assessment: An Agenda for Measurement and Analysis

We examine the scope of inquiry into the measurement and assessment of the state public health policy environment. We argue that there are gains to be made by looking systematically at policies both within and across health domains. We draw from the public health and public policy literature to develop the concepts of interdomain and intradomain policy comprehensiveness and illustrate how these concepts can be used to enhance surveillance of the current public health policy environment, improve understanding of the adoption of new policies, and enhance evaluations of the impact of such policies on health outcomes.The 2011 Institute of Medicine report For the Public’s Health: Revitalizing Law and Policy to Meet New Challenges called public policy “among the most powerful tools to improve population health.”1^(p18) However, the institute’s recommendation that legislators and government agencies “familiarize themselves with the array of legal and policy tools available”1^(p68) poses substantial challenges in the absence of conceptual and methodological clarity on how these tools should be measured, classified, adopted, and used, especially at the state level.2–4 Categorizing and assessing different provisions of state policies is a complex task, made even more difficult by the absence of standardized methods.5,6 Different approaches to operationalizing policy measures have also led, in some cases, to conflicting evidence of their effectiveness.7–9 Furthermore, these assessments have largely treated public health issues as independent silos, with little reference to how policies may work in concert or at odds with one another either within or across public health domains.10Several authors have highlighted the important limitations of existing studies that fail to account for the full range of policies that may have contributed to the outcome in question.10,11 To date, however, there is still relatively little systematic surveillance of the complete set of public health policies adopted by states across multiple public health arenas, and there has been even less of a focus on the evolution and impact of these different combinations of policies on health outcomes.We argue here that an integrated and systematic assessment of public health policies within and across health domains is necessary for measuring the effectiveness of any individual health policy or law. Such an assessment is also necessary to understand how and why US states and localities have constructed vastly different health policy landscapes over time. Note that by “policy” we refer to the enactment or modification of laws, the development or modification of regulatory measures, and the setting of funding priorities, including the development of specific public sphere programs. By “health policy landscape,” we refer to the total number of health policies in place in a given jurisdiction at any given time.Our objective is to respond to growing interest among policymakers and advocates in understanding the ways policy tools can be used to improve population health both within and across health areas.3 Indeed, findings from a 2007 Association of State and Territorial Health Officials (ASTHO) survey indicated that state health agencies ranked “developing effective health policy” among their top 5 priorities.12 Our argument is thus meant to engage researchers and advocates in considering how to apply a more thorough approach to their work in policy development and analysis and to assist them in communicating these ideas to policymakers.In developing a framework for conceptualizing the broader state health policy landscape, we begin by introducing 2 new constructs: intradomain policy comprehensiveness and interdomain policy comprehensiveness. We discuss the ways in which these constructs aid in illuminating the composition of different state policy landscapes and discuss how they may influence the study, measurement, and effects of public health policies. To illustrate our arguments, we construct a data set of 27 public health policies in all 50 states between 1980 and 2000 and discuss observed patterns in public health policy adoption. We then review the literature on internal and external determinants of policy adoption and diffusion and consider the ways these determinants may be associated with the comprehensiveness of states’ health policy landscapes. We end with a series of research questions that stem from our approach.