What Is A Health Equity Impact Assessment (HEIA)?

In June 2023, New York became the first state to require specific types of healthcare facilities to conduct a Health Equity Impact Assessment (HEIA) when building or remodeling facilities or changing services materially.

The HEIA process has wide-ranging benefits to many healthcare organizations and stakeholders that want to identify the unintended potential health impacts of a policy, program, or initiative on vulnerable or marginalized populations.

New York State sets the bar for health equity-driven decisions

New York State Public Health Law § 2802-b Health Equity Impact Assessments (HEIA) took effect on June 22, 2023. Various “Article 28" healthcare organizations that submit a Certificate of Need application must also include the Health Equity Impact Assessment documents.

Those organizations include general hospitals, nursing homes, midwifery birth centers, ambulatory surgery centers, and certain diagnostic and treatment centers. The types of changes that trigger the HEIA requirement include establishment, ownership, construction, renovation, and change in service of healthcare facilities.

The goal of requiring an HEIA is to ensure that there is awareness, prevention, or plans to help mitigate adverse effects on vulnerable populations, including facility closure or changes that substantially reduce or move services. The HEIA should also highlight how a project could enhance health equity and improve health disparities.

The HEIA must consider and report on the potential impact of a project on at least 12 medically underserved groups based on income, race, gender, sexual orientation, age, disability status, as well as other factors.

What is a Health Equity Impact Assessment?

Broadly, an HEIA identifies the possible and unintended health impacts that any policy, program, or initiative could have historically underserved people. A health equity impact assessment outlines if and how a project will affect access to healthcare services, health equity, and health disparities with particular attention to medically underserved populations in a specific service area.

An HEIA should include 4 features:

• Qualitative and quantitative methods and best available data sources
• Input from stakeholders, such as leaders from healthcare organizations, local government, and community-based organizations, as well as representatives from the community that may be impacted
• Focus on the potential effects of a proposed policy, program, or project across other sectors of health
• Recommendations to monitor and manage potential effects

Born out of the increased use of health impact assessments (HIA) over the past 15 years, the HEIA provides a more focused consideration of issues that affect health equity—social determinants of health and health disparities.

How can an HEIA benefit healthcare organizations?

HEIAs are increasingly used by policy decision-makers to grasp how policies, projects, and programs affect health equity. Not only can carrying out an HEIA raise possible unintended dependencies and impacts that affect historically underserved groups, but the process also supports the inclusion of internal and external stakeholders.

Conducting an HEIA can build awareness of equity-related issues while demonstrating how the organization considers and addresses equity needs. This can be a powerful tool for engaging the community and gaining support for change.

How are other states using HEIAs?

Other states have also committed to using HEIAs in their policy decision-making activities.

North Carolina's Department of Health and Human Services created a Health Equity Impact Assessment Tool for their HEIA process. They developed a validated tool used in 13 counties to implement evidence-based strategies through their Improving Community Outcomes for Maternal and Child Health Initiative. Their goal is to take care that changes to policies, systems, and practices address health inequities and reduce longstanding disparities.

In North Carolina, HEIAs are also used to examine the implications of legislative proposals, proactively design more equitable policies, evaluate the equitability of current programs, policies, or agency practices, and develop new initiatives or programs with equitable outcomes as the objective.

For example, their Family Forward program wanted to support more childcare flexibility for working parents. They created a certification program through which employers can proactively assure employees and potential employees of their commitment to various family-friendly policies.

These state and county programs also used their annual HEIA process to create programs like a collaborative community-centered health movement focused on eliminating inequities in infant mortality.

Additionally, their work has created a repository of stakeholder-driven input to help them prioritize resources and effort. Their HEIAs have uncovered needs, including:

• Treating Black women's pain
• Lack of labor and delivery services in rural areas
• Need for more women of color in OB/GYN, midwife, and doula roles

Washington State's Department of Health has used HEIAs to inform its funding process, evaluate its public health accreditation proposal, and determine the agency's position on proposed legislation. The City of Seattle developed its assessment using the Department of Performance Expectations and the Mayor's Office through its Race and Social Justice Initiatives.

In Washington, the Health Impact Review (HIR) is an objective, non-partisan, evidence-based tool that provides the Governor and state Legislators with information about how proposed legislation may impact health and health equity. In 2023, for example, the state is reviewing HIR reports that affect policy for a wide-ranging set of health issues, including:

• Alcohol concentration
• Reducing the risks of lethality and other harm associated with gun violence, gender-based violence, and other types of violence
• Testing individuals who provide language access to state services

• Preventing the use of vapor and tobacco products by minors

Health Equity Impact Assessment steps

While HEIA tools vary, the main steps of the HEIA process include:

Screening: Determine the need and purpose of conducting the HEIA.

Scoping: Delineate what health impacts will be evaluated, what populations will be considered, and what analysis methods will be used.

Assessment: Profile the current programs or policies that will be evaluated and collect evaluation input and data on potential positive and negative impacts on health.

Recommendations: Identify suggested changes that could avoid or mitigate negative consequences and maximize positive ones.

Mitigation: Create a plan for implementing the recommendations.

Monitoring: Outline how the possible impacts will be tracked and data collected.

Reporting: Provide regular updates as the changes are implemented, along with mitigation steps that have successfully realized positive and avoided negative impacts.

When creating an HEIA final report, many authors indicate a rating for each impact monitored, including:

• Positive impacts are those that have or will improve health disparities
• Neutral impacts show no positive or negative effect
• Negative impacts hold potential or have demonstrated negative unintended changes to health equity

And some assessment areas may show both positive and negative effects.

As mitigation plans are implemented, the HEIA report can document how the impact rating changed over time. This can be a powerful visual tool to show how the stakeholders and partners used the HEIA process to avoid undesirable outcomes and optimize positive changes.

HEIA as a catalyst for change that improves health equity

The use of HEIAs can catalyze change to ensure that changes in healthcare facilities, services, and policies lead to equity-enhancing impacts for historically marginalized patient populations. As states consider following New York's lead, more healthcare, government, and community organizations will consider conducting health equity impact assessments as a standard part of strategic planning.

Contact us to see how we can help you conduct a Health Equity Impact Assessment.