Equitable Implementation of Public Health Laws Helps Ensure that Everyone Benefits

Public health laws affect health not only through their substance and design but also through implementation and enforcement. Equitable policymaking requires implementation that respects and works for everyone, with careful attention to the steps of the policy process that follow policy enactment, including enforcement, evaluation, and revision — all of which are necessary to ensure that public health laws have their intended effect. State and local officials working in a range of agencies — from public health to fair employment, housing, consumer protection, government law offices, and more — play a significant role in the implementation and enforcement of public health laws. 

Inequitable enforcement harms health, particularly for people facing discrimination based on disability, race and ethnicity, low incomes, gender, geography, immigration status, or other dimensions of identity. By contrast, equitable enforcement ensures compliance with the law while considering and minimizing harms to marginalized communities. This approach prioritizes enforcement of protective laws in underserved communities and redirects efforts from punitive policies that disproportionately harm these same communities.  

For example, an equitable enforcement approach might encourage proactive enforcement of tobacco retailer licensing laws particularly in low-income neighborhoods while moving away from laws that criminalize youth possession and purchase of tobacco products, which are disproportionately enforced against youth of color and youth from families with low income. Tobacco retailer licensing laws that target businesses selling to youth are more effective and have fewer unintended consequences than laws that punish young people who use tobacco products, which are addictive and deadly by design. 

Rethinking Implementation and Enforcement 

Traditional implementation and enforcement models often include design flaws that result in uneven implementation, increased health disparities, and limited efficacy. One example is reactive enforcement, meaning that enforcement is triggered only after a complaint is filed. Reactive enforcement contributes to inequities given widespread underreporting, particularly for people who may be reluctant to complain because of power imbalances, fear of retaliation, limited English proficiency, mistrust of government agencies, and incomplete knowledge of the law, regulations, or their rights. For example, a family that lives below the poverty line may be hesitant to report housing code violations out of fear that a landlord may retaliate by raising the rent or initiating an eviction. Immigrant families may experience unsafe and harmful living conditions due to their reluctance to engage with law enforcement or government agencies to report crimes or civil violations (e.g., workplace conditions, housing conditions, discrimination in education, housing, or employment) because of language barriers, reporting savvy, or the fear of immigration-related consequences,.  

Reimagining traditional implementation and enforcement processes can help to address such structural challenges. For example, in the housing context, proactive rental inspections in over 25 cities from Boston to Tulsa can improve housing conditions and tenant safety. Including incentives for landlords who maintain safe and habitable housing promotes compliance with the policy.  

Including Partners in Policy 

Another deficiency is failing to include a wide range of partners — especially those closest to the issues a policy addresses — throughout the process of designing and implementing enforcement provisions. Partners include community members, advocacy groups, academics, elected officials, administrators, and enforcing officials. These groups are critical participants in the iterative process of policy development and implementation. While community-based advocacy groups often take the lead in organizing stakeholders, government processes should strive to include a community engagement phase that brings these partners to the table. 

Incorporating community input in a collaborative policy process, in particular, builds community power and facilitates more equitable and effective policy development and implementation. For example, community health workers (CHWs) have direct, firsthand knowledge of community conditions and health needs. In Illinois, the 2014 Community Health Worker Advisory Board Act established a 15-member advisory body, including 8 CHWs serving in counties across the state. This advisory board produced a comprehensive report including recommendations to improve CHW certification, reimbursement, and workforce development programming. The report led to the passage of the CHW Certification and Reimbursement Act in 2021, outlining requirements for a new board including CHWs from across the state to oversee development of the CHW certification program. Empowering CHWs to provide direct input on legislation affecting their profession helped to illuminate the need for improved certification and reimbursement processes, which will ultimately allow CHWs to better serve the public by providing access to high-quality, culturally-competent public health services. 

Designing Policies to Strengthen Rights Rather Than Penalize 

Equitable implementation and enforcement prioritize policies that increase people’s capacity to exercise their legal rights over punitive, health-harming enforcement approaches. Several examples of these policies in action can be found in the housing context.  

Given that the safety, stability, and affordability of housing affects health, the lack of such housing across United States exacerbates existing health disparities. People with disabilities disproportionately experience underenforcement of housing rights and overenforcement of punitive laws that harm their health, safety, stability, and ability to thrive. This harm is often compounded for those who belong to multiple marginalized groups that experience health disparities (e.g. people of color, people with disabilities, people who identify as LGBTQ+, and people with low income). For example, the underenforcement of habitability laws and accessibility requirements can leave people with disabilities and low incomes susceptible to eviction or unable to access adequate housing, making them more likely to experience homelessness. Once unhoused, people with disabilities may be subjected to misapplication and overenforcement of laws that criminalize activities like loitering, panhandling, or camping, sitting, or lying down in public places. 

Policy solutions (Stopping the Vicious Cycle: Equitable Enforcement Strategies to Achieve Safe, Stable, and Accessible Housing for People with Disabilities) should address both underenforcement and overenforcement of housing-related laws. These solutions may include shifting away from measures like chronic nuisance ordinances and laws that effectively criminalize homelessness toward more proactive and preventative measures to ensure people with disabilities have safe, stable, and affordable housing. It is also important to acknowledge that there is no single intervention that can address all the challenges identified here. Local and state governments must consider how policies, systems, and processes interact to identify the most meaningful set of reforms for their circumstances. 

For example, states and localities can establish tenants’ right to counsel. However, right to counsel is only as impactful as the underlying framework of legal rights and protections provided to tenants. To strengthen those protections, public health nonprofits and government departments should also support tenant organizing and tenant-led campaigns in support of policies that would expand their rights and access to safe, stable, and affordable homes (e.g. policies prohibiting evictions without a just cause and policies reforming procedural rules that affect the speed and consequences of eviction cases, among others) with attention to equitable implementation and enforcement of those policies. Additionally, states and localities can fund case management for individuals facing eviction and people who are unhoused to improve housing stability. 

Recommendations 

Potential barriers to equitable implementation include political feasibility, bias among enforcing officials, insufficient capacity at enforcing agencies, and a still-nascent evidence base.  

State and local officials committed to equitable enforcement and implementation of public health laws should: 

• Assess current enforcement and implementation approaches through an equity lens to consider adverse health effects for marginalized populations 
• Prioritize enforcement of laws that proactively protect health (such as housing safety laws) 
• Invest agency resources in enforcement and implementation of protective laws in the most underserved communities 
• Support community-based programs that empower individuals and communities to exercise their legal rights 
• Engage community partners to reimagine policy implementation to move away from punitive approaches toward supportive, preventive approaches