New Hampshire's State Budget: A Health Impact Assessment
Date: June 18th, 2012
At any level of government, the budget is the primary policy setting tool. Within this single document, hundreds of policy decisions are made. Any number of these decisions will directly or indirectly impact population health outcomes, particularly among low-income, vulnerable people who are more likely to receive services from public programs.
The impact of these funding decisions on health is only rarely considered, except perhaps in the provision of direct medical care. Thus, while many state budget line items have the potential to impact the health and well-being of our population, they are seldom presented in this light. Such a connection may provide a means of slowing increases in health-related expenditures by identifying more effective allocations for funding and providing an alternative means of evaluation to the standard fiscal note.
The current application of health considerations only in the case of direct medical service provision fails to acknowledge that medical care accounts for a small share of a population’s health and well-being. Grossman and Wolff have noted that the direct provision of health care services has a relatively limited impact when compared with other, population-based interventions. They also identified the relatively higher importance of social determinants – such as education, housing and economic opportunity – on a population’s overall health.
Over the 2010-2011 state budget period the New Hampshire Center for Public Policy Studies (the Center) engaged partners in the identification of budget issues that might significantly impact social determinants of health during the 2012-2013 budget process. The Center’s goals were twofold: First, we wanted to use the Health Impact Assessment (HIA) process to analyze the health impacts of budgetary changes. Second, the project was designed to evaluate the process of applying HIA to a budget. Could the HIA process and toolset be used in real time to identify, describe and highlight the potential impact that fiscal policy decisions may have on health outcomes?
In the end, the HIA assessed the potential health impacts of down-shifting the financial burden of providing services to needy New Hampshire residents resulting from reductions in aid or programs without also reducing local communities’ obligations to pay for those services. Three programmatic changes which could effectively shift financial responsibility for services to local communities were reviewed: elimination of state aid to local communities, reductions in hospital Medicaid reimbursement rates, and changes to the state’s grants to low income families through its Temporary Assistance to Needy Families program.
While there were many pathways through which these changes could impact health in communities, this analysis focused on the impact of downshifting on local decisions regarding housing assistance and the potential for impacting housing instability and associated health issues.
In addition, this analysis evaluates the potential strengths and weaknesses of implementing an HIA in a budgetary process.