Publication Date: 
Wednesday, February 18, 2015

This report explores the relationship between major health law recommendations from the federal government and the actual output of state legislative policy-makers. Providing evidence-informed policy recommendations to state, local and tribal policy-makers is part of the job description of federal health agencies. The Department of Health and Human Services publishes a compendium of recommendations, Healthy People 2020, the latest in a decennial series that began in 1980. The United States Preventive Services Task Force maintains the Community Guide for Preventive Services, which commissions systematic reviews of well-studied interventions. The Centers for Disease Control and Prevention produces evidence-based recommendations across the full range of health topics the agency addresses, from active living to vaccination. By definition, evidence-based recommendations require an evidence base, which in practical terms means that federal recommendations are biased towards policies that have already been deployed and studied. Recommendations are meant to speed the wide adoption of policies that seem to be working. Federal recommendations miss their target when state and local policymakers are not aware of the recommendations, or do not regard them as credible and actionable.

State and local policymakers can also be understood as producers of health policy “recommendations.” They may be enacting legal interventions that are well-supported by evidence, but have not been addressed in federal recommendations, or they may be addressing new problems for which policy responses have not yet been developed or evaluated. In the tradition of states as laboratories for democracy, state and local policymaking can contribute to the store of evidence based intervention options – but only if state and local legal interventions are expeditiously evaluated and the results effectively diffused.

A healthy health-policy cycle requires a dialogue among federal experts and state and local policy-makers. It is plain that federal recommendations can only make a difference if they influence the policies adopted at the state and local level. It should be equally plain, however, that state and local innovation spreads by peer adoption, and requires a federal response to achieve its full value: federal agencies like NIH and CDC take the lead in conducting and funding the research that bridges the gap between innovation and evidence-based policy; federal recommendations (and all the technical and funding assistance associated with them) are a primary means of disseminating and translating evidence into widely adopted policy.

Using a database of proposed and enacted health legislation created by the Association of State and Territorial Health Officers (ASTHO), and classified by Public Health Law Research (PHLR) staff, we identified 799 bills from the most recent two-year state legislative cycle (2012-14) containing 1,227 specific legal interventions. We compare these “state policymaker recommendations” with 104 specific recommendations for legislative or regulatory action identified in a 2014 scan of four major federal policy resources: Winnable Battles, Prevention Status Reports, the Community Guide for Preventive Services, and Healthy People 2020.

Emphasizing that causal explanations are beyond the scope of this project, we find an intriguing pattern of coherence and variation between federal recommendations and the bills introduced or enacted in the states. In some topic areas, like tobacco control, limiting use of antimicrobials on farms, and policy support for breast-feeding, there is substantial alignment: states are enacting the policies the federal government is recommending. In others, like opioid overdose, states are taking actions recommended by the federal government, and adding additional interventions of their own. There are also topics on which the federal recommendations have little to say, but states are vocal: state policy makers, for example, have been concerned with establishing safety standards or licensure programs for cottage or homemade foods, a topic not addressed in federal recommendations. Finally, there are topics, like alcohol policy, where numerous and specific federal recommendations are met with complete silence at the state level.

A substantial literature suggests the need for agencies in the “knowledge transfer” business to take a comprehensive, strategic approach in communicating evidence to policy-makers, and that one important element of that approach is supporting research that addresses questions that are important to policymakers. An expert recommendation from a federal agency is one item in the evidence-translation tool kit.  Given the effort and care that goes into crafting federal policy recommendations, and some evidence that such guidance can help spread evidence-based policies, we conclude with two recommendations for further action: that federal health agencies undertake to better understand 1) whether their recommendations are being used by state and local policy makers, and 2) how federal efforts in policy evaluation and evidence translation can improve the pace and outcomes of state and local innovation.