Using Legal Epidemiology to Advance Health Equity

Story at a Glance

• Legal epidemiology is the study of law as a factor in the cause, distribution, and prevention of disease and injury across populations. In plain language, legal epidemiology is about learning how laws and policies affect health.
• ChangeLab Solutions currently partners with the Centers for Disease Control and Prevention’s (CDC’s) Public Health Law Program (PHLP) to deliver legal epidemiology trainings to staff from health departments and organizations who participate in 10-month learning cohorts.
• Health departments and organizations that are interested in building their confidence in finding, reading, and analyzing laws and policies to learn about their impacts on health should consider joining the 2023-2024 Legal Epidemiology Learning Cohort.

Legal Epi Know-How for Health Departments & Organizations

We all know that laws — including laws on the books as well as policies and legal practices related to implementation and enforcement — can affect health in both positive and negative ways. Health-promoting laws like smoke-free air ordinances and paid leave create measurable gains in community health. At the same time, harmful laws like discriminatory housing policies and legislation that preempts public health authority can drive health inequities between different population groups. Thus, the law is a tool that can be used to either improve or harm health, depending on how it is used.

How, then, can public health professionals systematically identify and track laws of public health importance? And how can they compare the impact of these laws on health over time and across jurisdictions? One way to answer these questions is a practice known as legal epidemiology, or legal epi for short. Pioneered by experts at Temple University’s Center for Public Health Law Research (CPHLR) and the CDC’s Public Health Law Program (PHLP), legal epidemiology has grown substantially as a field over the past decade.

Unlike traditional legal research, legal epidemiology transforms the text of a law into measurable data, using approaches that are scientific, systematic, and transparent. Two primary types of legal epidemiology studies are legal mapping and legal evaluation. Legal mapping is a process for capturing important features of laws and policies and for identifying how they vary across jurisdictions or institutions and over time. This process can help public health practitioners identify gaps in the laws of their home jurisdictions and can inform how they create, champion, and implement laws and policies. Legal evaluation, on the other hand, involves overlaying legal mapping data with data about health outcomes or the social determinants of health to identify trends and potential correlations between laws, health, and equity. Ultimately, legal epidemiology can help to identify and evaluate evidence-based legal solutions to public health problems and inform effective legal strategies that combat health inequities.

ChangeLab Solutions currently partners with PHLP to deliver legal epidemiology trainings to staff from health departments and organizations who participate in 10-month learning cohorts. Health departments and organizations that participate in these learning cohorts follow a practice-based curriculum to develop foundational legal research and evaluation skills. The experience can build participants’ confidence in finding, reading, and analyzing laws and policies that address fundamental drivers of health inequity — such as structural discrimination and racism, income inequality and poverty, disparities in opportunity, disparities in political power, and governance that limits meaningful participation. Participants receive feedback and technical support from PHLP about legal epidemiology best practices as well as support from ChangeLab Solutions on issues related to health equity, law, and policy. At the end, participants have the opportunity to publish a legal epidemiology data set or otherwise share their work with other practitioners and community partners.

The learning cohort is designed to meet participants where they are. To that end, individual projects can be tailored and scaled depending on participants’ goals, capacity, and resources. Further, carrying out a legal epi project benefits from participation by people with varying skill sets, including those without prior legal training. Project teams can include lawyers, epidemiologists, data scientists, evaluators, and other public health practitioners. In short, with the right training, any health department or organization can leverage the tools of legal epi to promote health equity, no matter their existing skills or experience.

Louisville, KY, Advances Healthy Food Access

In 2018, the Louisville Metro Department of Public Health and Wellness (LMPHW) joined an earlier iteration of the legal epi learning cohort, which involved a partnership between PHLP, ChangeLab Solutions, and CPHLR’s Policy Surveillance Program (PSP), which served as the lead training and technical assistance provider for participating teams. LMPHW had the express goal of broadening the skill sets of staff in the its Center for Health Equity so that they could better support their community partners in reaching their policy goals. Several Louisville neighborhoods faced the very real possibility of becoming food deserts after the closure of five nearby grocery stores in the years preceding the project. The Louisville legal epi team — which consisted of a project manager, two researchers with food access and epidemiology expertise, respectively, and a hunger innovation fellow from a local community organization — decided to focus their project on local policy options for expanding healthy food access and reducing food insecurity in those Louisville neighborhoods.

“After the market closures, community members communicated very clearly with us about their need for healthy food access,” says Taylor Ingram, the project manager for the team. “As public health practitioners, we could have talked all day about the social determinants of health, but what we really needed was a solution.”

In their search for possible solutions, the Louisville team focused their legal mapping research on city- and county-level laws related to small food retailers, such as food financing laws or healthy food financing incentives. The team reviewed laws and policies from a total of 14 jurisdictions across the country that were geographically and demographically similar to Louisville. Seven local jurisdictions met the research qualifications to be included in the team’s final cross-sectional dataset: Baltimore, Kansas City, Miami, Prince George County, San Francisco, Seattle, and Washington, DC.

“Thanks to the learning cohort, our public health staff are now much more sophisticated at researching and analyzing the impact of laws and policies on health.” - Taylor Ingram, project manager at LMPHW

According to Ingram, the legal epi trainings the Louisville team received through the learning cohort greatly expanded the LMPHW Center for Health Equity’s ability to translate their public health research and analysis skills into policy change. The trainings and curriculum prepared the Louisville team and their colleagues for presenting to local decision makers about how similar localities across the US created policy innovations to address healthy food access. Ingram explains, “Local governments don’t want to be the first, but they also don’t want to be the last. Being able to share data and examples from other jurisdictions increases decision makers’ comfort level with policy options.” She said that before the learning cohort, staff in her department couldn’t have researched municipal codes to find examples in the way that they do now, and that they have used these skills “time and time again.”

The team also collaborated with the Louisville Department of Economic Development to gain insight into the feasibility of different healthy food policy options in their jurisdiction. Efforts from community members and government officials alike have led to increased interest in Louisville’s food systems and the allocation of $3.5 million for creation of a community-owned grocery store in 2020.

“It took a lot of time and work, but thanks to the learning cohort, our public health staff are now much more sophisticated at researching and analyzing the impact of laws and policies on health,” says Ingram. “It felt amazing to publish our data set and contribute to the field of health policy work at the national level.”

Certificate of Need Laws in Washington State

In 2019, a team from the Washington State Department of Health joined the learning cohort to receive training and technical assistance on policy surveillance and legal epidemiology methods from PSP, who continued as the lead training and technical assistance provider working in partnership with PHLP and ChangeLab Solutions. The team’s aim was to evaluate state-level certificate of need laws around the US so that they could understand how to improve certificate of need within their home state — a topic that decisionmakers, from the state health officer to state legislators, had a demonstrated interest in. Certificate of need is the regulatory process that many states use to determine whether a new healthcare facility should be permitted. The federal government required states to adopt certificate of need laws in the 1970s to stop financially unviable health care facility project proposals from moving forward — a requirement that was rolled-back in the 1980s, and which 34 US states have subsequently chosen to reinstate and regulate for themselves.  

“Not that long ago, the Washington state legislature conducted economic impact studies of certificate of need laws,” explains Michael Ellsworth, federal relations director at the Washington State Department of Health. “Our hope was that by learning more about public health law through a legal epidemiology lens, we could contribute to everyone’s understanding of how these laws do and don’t work, as the case may be.”

With guidance from subject matter experts at PSP and PHLP, the Washington State team — including two attorneys and several non-attorneys who worked on administering certificate of need — developed a framework for categorizing data to learn how certificate of need laws differ in requirements and approaches across US states. The substantial amount of data collected by the team revealed significant variations in how the states evaluated certificate of need applications. In total, the team recorded answers to 45 questions as part of their data collection efforts, covering topics such as type of facility, exemptions, decision-making authority, financial criteria, service measurements, and application processing procedures. Their findings revealed that:

• Half of all states — primarily those along the East Coast and Pacific Northwest, and Alaska and Hawaii — have certificate of need laws that specifically include health equity criteria.
• 25 states do not require public hearings on the certificate of need process and its findings.
• The timing for a regular review process can range between 45 days in Oklahoma and Mississippi, to up to a full year in New York. In Illinois, for example, the regular process can take up to 120 days and then be extended for an additional 120 days.
• Less than half of all states have criteria in their laws for specific facility types, such as nursing homes, psychiatric hospitals, or kidney dialysis centers.

According to Ellsworth, using legal epi methods allowed the team to identify regulatory innovations that they would not have otherwise discovered and better understand how variations in certificate of need criteria can either promote or inhibit the construction of healthcare facilities that serve priority populations, with divergent implications for health equity. The experience also gave team members an opportunity to work with colleagues from across their agency and see the “big picture” impacts of their day-to-day programmatic work.

“Legal epidemiology is something that public health staff everywhere can learn to do whether or not they have law degrees,” says Ellsworth. “We certainly learned a tremendous amount from being part of the learning cohort and we’ve got several new legal epi projects planned for the future.”

Telehealth Access in Alameda County, CA

During the most recent legal epi learning cohort, which wrapped up in spring 2022, ChangeLab Solutions and PHLP piloted a new curriculum that emphasizes how health departments and organizations can leverage legal epi methods to promote health equity, and PHLP took on the role of lead technical assistance provider. One of the participating teams was comprised of staff from the Quality Improvement and Accreditation Unit within the Alameda County Department of Public Health located in Alameda County, California. The Alameda County team’s project focused on how the intersection between Medicaid and telehealth policies affects the lives of people living with HIV/AIDS. Medicaid, which is a federal program administered with considerable discretion by individual US states, covers 42% of the adult population living with HIV. (Medicaid provides health insurance coverage to 13% of the US adult population overall).

One of the team’s primary research queries was: how do telehealth policies affect access to high-quality health care for underserved, disproportionately impacted populations? To begin answering this question, the team conducted background research analyzing the types of telehealth services covered by Medicaid and related reimbursement rates in three US states — California, Georgia, and Minnesota. The team plans to develop coding questions about telehealth modalities from this initial scan for use in a legal mapping study.

"How do telehealth policies affect access to high-quality health care for underserved, disproportionately impacted populations?" - a research question posed by the Alameda County team.

Beyond the team’s substantive interest in this topic and its importance to populations they serve, the legal epi learning cohort presented an opportunity to increase staff capacity related to legal research and analysis. “Our long-term goal is to teach legal epi techniques to all of our health department program managers based on what our team has learned from the learning cohort,” says Evette Brandon, quality improvement and accreditation director at the Alameda County Public Health Department. She observes that policy work within the Department can trend toward being reactive rather than proactive. She says that legal epi methods feel like a way to bring law and policy to the forefront while also bolstering programmatic work, improving service provision, and advancing community health.

Action Steps

• Learn more about the 2023-2024 Legal Epidemiology Learning Cohort
• Access the online, on-demand legal epi trainings and resources available from the Public Health Law Academy, developed by the Centers for Disease Control and Prevention (CDC) in cooperation with ChangeLab Solutions
• Explore policy surveillance and legal mapping studies on the Law Atlas website

By Katie Hannon Michel & Patrick Glass

Hero image: Healthy food access laws across the US mapped by the Louisville legal epi team. 

Hero image credit: Creative Commons license from the Center for Public Health Research and Law Atlas.

10/01/2022; updated 11/8/2022 and 8/16/2024