October 2019 Volume 4 Issue 1 MADE TO ORDER: USING GUBERNATORIAL EXECUTIVE ORDERS TO PROMOTE HEALTH IN ALL POLICIES Maxim Gakh, JD, MPH Abstract: The Health in All Policies (HiAP) approach presents different and often complementary avenues to address the social determinants of health. But at its core, HiAP relies on collaborations to make health a governmental priority across sectors. In the United States, HiAP efforts can involve multiple levels of government and strategies that may vary in formality. In some states, state-level HiAP efforts may be advanced by gubernatorial executive orders (GEOs). GEOs are often used to promote health. GEOs may be powerful in the HiAP context because of their potential to manage the different sectors that comprise state government and thereby address the social determinants of health. By synthesizing the relevant literature and providing illustrative examples of HiAP- promoting GEOs, this review explores how, why, and whether to use GEOs for HiAP. It demonstrates that GEOs may advance HiAP with or without using a HiAP label, along different steps in the policymaking cycle, and by addressing common HiAP challenges. Champions of HiAP should therefore examine the possible utility of GEOs to promote state-level HiAP efforts. 1 Made to Order : Using Gubernatorial Executive Orders to Promote Health in All Policies Gakh 2 A HiAP strategy aims to promote health through collaboration across sectors Health Impact Assessments (HIAs) can help address the social determinants of health across sectors that make decisions with health consequences (NRC, 2011). These sectors include the built environment, housing, education, agriculture, and energy (NRC, 2011; Rudolph, Caplan, Ben-Moshe, & Dillon, 2013; Wernham & Teutsch, 2015; Towe et al., 2016). HIAs have the ability to engage communities in decision- making, educate policymakers, create partnerships, and link data and scientific evidence to real-time decisions (NRC, 2011; Dannenberg, 2016; Wernham & Teutsch, 2015). In fact, HIAs are one of the few existing, systematic tools available to target decisions that impact these social determinants (NRC, 2011). Addressing the social determinants of health can simultaneously impact populations across multiple health outcomes (Frieden, 2010). Yet HIA work also faces challenges (NRC, 2011; Dannenberg, 2016; Rudolph et al., 2013). An important challenge of using HIAs to target the social determinants is that most HIAs analyze a limited number of issues rather than creating consistent and sustainable change in how decisions with indirect health impacts are approached (NRC, 2011; Wismar et al., 2006). Thus, it is important that HIAs are part of a larger movement aiming for comprehensive integration of health into all sectors’ decisions (IOM, 2011; Kemm, 2006; Rudolph et al., 2013; Wernham & Teutsch, 2015). This movement, sometimes called “Health in All Policies” (HiAP), is rooted in the “healthy public policy” concept (Gottlieb, Fielding, & Braveman, 2012; IOM, 2011; Rudolph et al., 2013; Sihto, Ollila, & Koivusalo, 2006; Gase, Pennotti, & Smith, 2013; Wernham & Teutsch, 2015). HiAP has gained acceptance in the public health field both in the U.S. and globally (Rudolph et al., 2013; Ollila, 2011; Sihto et al., 2006; Wimar et al., 2006; Wernham & Teutsch, 2015) along with the recognition that the social determinants of health are critical in shaping health outcomes (Sihto et al., 2006; Frieden, 2010; Wernham & Teutsch, 2015; WHO, 2008; CDC, 2018; IOM, 2011; APHA, 2012; HHS, 2019). Like HIAs, at its core, HiAP focuses on integrating health concerns into non-health sectors (IOM, 2011; Rudolph et al., 2013; Sihto et al., 2006; Gase et al., 2013; Wernham & Teutsch, 2015; Gakh & Rutkow, 2017). It involves addressing the health implications of policy decisions in non-health sectors, because “other sectors are often key in terms of health determinants” (Ollila, 2011, p.13). But this is easier said than done: “The central issue facing HiAP is how to enhance the feasibility of placing health criteria on the agendas of policy-makers who have not previously considered health” (Sihto et al., 2006, p.11). Operationally, HiAP-related efforts can take many forms (Sihto et al., 2006; Rudolph et al, 2013; Ollila, 2011; Wernham & Teutsch, 2015; Gase et al., 2013). They can focus on specific social determinants or health-related issues (Sihto, et al., 2006; Rudolph et al., 2013; Ollila, 2011; Wernham & Teutsch, 2015). Alternatively, HiAP efforts can directly focus on decision-making processes and systems change to encourage consideration of health across decisions (Sihto et al., 2006; Rudolph et al., 2013; Ollila, 2011; Gase et al., 2013; Wernham & Teutsch, 2015). Cross-sector partnerships are also central to HiAP endeavors (Sihto et al., 2006; Rudolph et al., 2013; Ollila, 2011; Gase et al., 2013; Wernham & Teutsch, 2015). In the broadest sense, these partnerships involve collaboration among governmental, for- profit, and non-profit organizations formed around health-related goals and comprised of context- specific activities and enabled by different structures (Johnston & Finegood, 2015). HiAP efforts are not exclusively government-centric (Rudolph et al., 2013; Ollila, 2011; Wernham & Teutsch, 2015). However, governmental HiAP efforts usually involve collaboration by government agencies that are organized around sometimes seemingly inconsistent missions (Rudolph et al., 2013; Sihto et al., 2006). In the HiAP context, Greer & Lillvis define “intersectoral governance” as “the set of political, Made to Order : Using Gubernatorial Executive Orders to Promote Health in All Policies Gakh 3 legal, and organizational structures that enables the coordination of multiple sectors to address causes of ill health, and is therefore the mechanism permitting HiAP” (2014, p.13). Implementing this type of cross-sector governmental collaboration can encounter barriers, such as variable organizational cultures; limited understandings across organizations; inconsistent definitions of success; and limited resources, tools, and expertise (Johnston & Finegood, 2015; Sihto et al., 2006; Rudolph et al., 2013; Gase et al., 2013; Wernham & Teutsch, 2015). HiAP implementation can pursue formal strategies, informal strategies, or both (Rudolph et al., 2013; Gase et al., 2013; Wernham & Teutsch, 2015). Formal HiAP endeavors, including implementation that relies on law, can catalyze or set out cross-sector HiAP work (Rudolph et al., 2013; Gakh, 2015; Wernham & Teutsch, 2015). In fact, as Hall & Jacobson found in interviews with policy actors, legal mandates can sometimes “encourage buy-in for cross-sector collaboration” (2018, p.6). Different formal, law- based mechanisms are available to issue HiAP-related mandates – including legislation, regulation, and memoranda of understanding – and choosing among them can involve balancing structural factors like legal authority and political realities (Rudolph et al., 2013; Gakh, 2015). Gubernatorial executive orders (GEOs) may be the right mechanisms for state-level HiAP efforts, depending on legal structures and de facto realities (Rudolph et al., 2013; Gakh, 2015). GEOs allow governors to mandate action from multiple state- level sectors simultaneously and may present fewer procedural obstacles and require less political capital to adopt than other legal mechanisms that formalize HiAP (Gakh, 2015). A closer look at GEO documents and how they can be crafted to encourage HiAP is therefore in order. Examining these documents in detail is also an important first step to inform studies on how GEOs impact HiAP implementation. GEOs are an important public health policy mechanism that is well suited for HiAP GEOs are an essential and sometimes overlooked policy mechanism that can advance public health (Gakh, Vernick, & Rutkow, 2013; Gakh, Callahan, Goodie, & Rutkow, 2019). A GEO may allow a state governor to set or operationalize formal changes to programs and policies without the need for official legislative support (Gakh et al., 2013). State laws vary in what a governor can legitimately direct by executive order (CSG, 2010; Ferguson & Bowling, 2008; Gakh et al., 2013). GEOs may be used for symbolic gestures, such as flying flags on state property (Ferguson & Bowling, 2008). But they may also undertake various substantive public health goals by targeting public health emergencies, establishing or modifying government agencies or programs, directing public health agencies, prioritizing health issues, and controlling state operations (Gakh et al., 2013). GEOs can promote the cross-sector governmental work that constitutes HiAP. The literature contains examples of GEOs as law-based, state-level mechanisms to promote HiAP (Pepin, Winig, Carr, & Jacobson, 2017; Weisman, Helmy, Moua, & Aoki, 2018; Gakh, 2015; Polsky, Stagg, Gakh, & Bozlack, 2015; Rudolph et al., 2013; Gase et al., 2013; Wernham & Teutsch, 2015). But a closer look at the mechanism itself in the context of HiAP is warranted because most public health-related GEOs tend to include directives salient to HiAP. These directives include managing government agencies, establishing new government entities, mandating cross-sector collaboration, or requiring the investigation and development of recommendations to address particular health problems (Gakh et al., 2019). This review uses frameworks focused on public health policy and cross-sector collaboration to demonstrate that, like other formal mechanisms, GEOs (1) can promote HiAP with or without using a HiAP label; (2) help prioritize, formulate, adopt, implement, and evaluate HiAP efforts; and (3) address some common Made to Order : Using Gubernatorial Executive Orders to Promote Health in All Policies Gakh 4 barriers to state-level governmental HiAP efforts. To illustrate these points, this review relies on GEOs identified through key terms searches in relevant databases (e.g., Westlaw’s Netscan Executive Orders database and the Lexis Advance databases containing state statutes and legislation and administrative codes and regulations) and from a priori knowledge. GEOs may promote HiAP with or without an articulated commitment to HiAP HiAP implementation can involve sweeping efforts that focus on modifying decisions that impact the social determinants of health or on more discrete health-related priorities (Rudolph et al., 2013). GEOs can support both types of efforts and can do so with or without labeling the effort as “HiAP.” This is important because it demonstrates that GEOs that support HiAP can take many forms. At the broad and explicit end of the range of GEO types, for example, in 2015, Vermont Governor Shumlin issued an order to establish a HiAP Task Force (Vt. Exec. Order No-07-15 (Oct. 6, 2015)). This order recognizes the role that non-health sectors play in health behaviors and outcomes and therefore that health necessitates a “shared responsibility and an integrated and sustained policy response across government” (Vt. Exec. Order No-07-15 (Oct. 6, 2015, p.1)). The Vermont HiAP Task Force, chaired by the state health commissioner and with representatives from different state agencies (e.g., agriculture, commerce, transportation, public service, education, human services, natural resources), is responsible for determining how “to more fully integrate health considerations into all state programs and policies, and promote better health outcomes through interagency collaboration and partnership” (Vt. Exec. Order No-07-15 (Oct. 6, 2015)). California’s HiAP efforts similarly include a 2010 GEO, issued by Governor Schwarzenegger, that also directly establishes an intergovernmental HiAP Task Force rooted in the state’s efforts to manage growth (Cal. Exec. Order No. S-04-10 (Feb. 23, 2010)). A recent New York GEO requires state government entities to integrate the state’s Prevention Agenda priorities and World Health Organizations Domains of Livability, which focuses on healthy aging, into their plans, “guidance, policies, procedures, and procurements” to promote “Health Across All Policies” (N.Y. Exec. Order No. 190 (Nov. 14, 2018, p.1)). However, considering only GEOs that institute broad HiAP initiatives and include HiAP labels overlooks HiAP-promoting GEOs that contain substantive directives that can facilitate cross-sector HiAP work but are not cast in “health in all policies” language. At its core, HiAP is defined as integrating health concerns into other sectors (IOM, 2011; Rudolph et al., 2013; Sihto et al., 2006); HiAP implementation strategies are therefore not limited to HiAP-oriented government organizations (Rudolph et al., 2013; Wernham & Teutsch, 2015; Gase et al., 2013). Understanding how HiAP-like orders can integrate health into other sectors is critical because it reveals a more subtle use of GEOs to advance the HiAP approach. GEOs focused on education and children from several states illustrate how GEOs with no mention of HiAP can encourage more nuanced HiAP-like practice. For example, on its face, a Kansas GEO makes no mention of HiAP, the social determinants of health, or the connection between education and health (Kan. Exec. Order No. 10-05 (Jun. 17, 2010)). However, the order creates a statewide advisory group, with a state health agency representative, focused on early childhood education to examine opportunities for collaboration among state government agencies and to improve existing data systems (Kan. Exec. Order No. 10-05 (Jun. 17, 2010)). A Connecticut order uses a similar approach; it requires the state Office of Early Childhood to establish an interagency effort around early childhood education that includes the health department (Conn. Exec. Order No. 35 (Jun. 24, 2013)). It also requires the state executive branch to “collaborate and cooperate with the Office” (Conn. Exec. Order No. 35 (Jun. 24, 2013, p.2)). Similarly, recognizing that many state government Made to Order : Using Gubernatorial Executive Orders to Promote Health in All Policies Gakh 5 agencies “lead programs that are important to the success and well-being” of children, a Tennessee GEO establishes a Children’s Cabinet focused on “shared policy, planning, coordination, cooperation, and collaboration” (Tenn. Exec. Order No. 10 (Jan. 30, 2012, p.1)). This Cabinet includes state-level government entities, including agencies responsible for education, human services, and health, and requires executive agencies to support the Cabinet’s efforts (Tenn. Exec. Order No. 10 (Jan. 30, 2012)). The Kansas, Connecticut, and Tennessee orders illustrate that, even when GEOs do not contain HiAP language, they can include HiAP-like content requiring cross- sector collaboration around health and integrating health into government work in areas that are important to the social determinants. GEOs may prioritize, formulate, adopt, implement, and evaluate intergovernmental HiAP work Policymaking is a complex and dynamic process with the ability to change health (Brownson, Chriqui, & Stamatakis, 2009; Golden & Moreland-Russell, 2016). Multiple models and frameworks are useful to understand policy in the context of health (Oliver, 2006). Although policy-making is difficult to categorize meaningfully, one way to visualize policymaking is as a five-step cycle comprised of policy prioritization, formulation, adoption, implementation, and evaluation – and back to the start (Golden & Moreland-Russell, 2016). GEOs can support HiAP efforts throughout each step of this policymaking cycle. GEOs can prioritize integrating health into other sectors through cross-sector collaboration. Prioritization involves identifying, selecting, or framing a health-related issue for policy intervention (Golden & Moreland-Russell, 2016). Both HiAP-based and HiAP-like GEOs can do this. For example, the Vermont, New York, and California GEOs clearly establish health as a cross-cutting issue for state government agencies, elevating the importance the importance of considering health across government decisions and the pursuit of HiAP as a goal (Vt. Exec. Order No-07- 15 (Oct. 6, 2015); N.Y. Exec. Order No. 190 (Nov. 14, 2018); Cal. Exec. Order No. S-04-10 (Feb. 23, 2010)). HiAP-like GEOs can also prioritize health issues and approaches across sectors. For instance, a Louisiana GEO names an existing commission as an interagency council to establish, review, update, and implement the state’s plan to address homelessness (La. Exec. Order No. BJ 2013-5 (Mar. 19, 2013)). Similarly, a North Dakota order establishes a statewide, cross- sector coalition to improve “collaboration and coordination on behavioral health services for service members, veterans, and their families and survivors” (N.D. Exec. Order No. 15-01 (Jan. 8, 2015, p.1)). In these examples, GEOs emphasize the importance of health issues and frame health-related problems as cross-sector problems. GEOs can also formulate policy to incorporate health into other sectors. Policy formulation involves developing, articulating, and considering policy solutions to health problems (Golden & Moreland- Russell, 2016). Vermont’s executive order, for instance, requires the interagency HiAP Task Force to report to the governor “potential opportunities to include health criteria in regulatory, programmatic, and budgetary decisions” and strategies from other jurisdictions to integrate health across government decisions (Vt. Exec. Order No-07-15 (Oct. 6, 2015, p.2)). Although not explicitly focused on HiAP, Nevada’s GEO establishing a cross-sector food security council in the health department calls for annual reports with recommendations (Nev. Exec. Order No. 2014-03 (Feb. 12, 2014)). Both GEOs require cooperation around identifying and articulating cross- sector policy solutions focused on health. In addition, GEOs can be vehicles to adopt HiAP or HiAP-like policy. Adoption involves processes that result in choosing a particular policy (Golden & Moreland-Russell, 2016). The issuance of the Vermont, New York, and California HiAP GEOs embodies the adoption of a HiAP approach through Made to Order : Using Gubernatorial Executive Orders to Promote Health in All Policies Gakh 6 formal policymaking channels (Vt. Exec. Order No- 07-15 (Oct. 6, 2015); N.Y. Exec. Order No. 190 (Nov. 14, 2018); Cal. Exec. Order No. S-04-10 (Feb. 23, 2010)). Similarly, while not explicitly HiAP-focused, a Massachusetts GEO that formally adopts for multiple state executive agencies a policy of “procuring Environmentally Preferable Products and Services” to conserve natural resources, limit generation of toxic substances, and reduce negative impacts on health and the environment also operates as formal adoption of state policy integrating health concerns across sectors (Mass. Exec. Order No. 515 (Oct. 27, 2009, p.2)). Executive orders issued by governors can help implement polices that embed health into non-health sectors through collaboration. The implementation phase involves operationalizing adopted policy through specific strategies, tasks, and responsibilities (Golden & Moreland-Russell, 2016). The California, New York, and Vermont HiAP GEOs lay out specific implementation strategies to operationalize HiAP. The Vermont and California GEOs both create HiAP Task Forces (Vt. Exec. Order No-07-15 (Oct. 6, 2015); Cal. Exec. Order No. S-04-10 (Feb. 23, 2010)). In addition, the California order requires the state health department to staff and facilitate the work of the HiAP Task Force (Cal. Exec. Order No. S-04-10 (Feb. 23, 2010)), while the Vermont order requires its HiAP Task Force to develop tools to help state agencies consider health impacts of policy decisions (Vt. Exec. Order No-07-15 (Oct. 6, 2015)). The New York order requires each agency to appoint and deputize a coordinator responsible for HiAP implementation (N.Y. Exec. Order No. 190 (Nov. 14, 2018)). HiAP-like GEOs can also help implement policies that embed health across sectors. For example, Maryland’s Governor Hogan used a GEO to create an executive council committee centered on paid sick leave with representatives from multiple agencies and duties that include collecting data, surveying employees and employers, developing policy recommendations, providing regular updates, and submitting a final report (Md. Exec. Order No. 01.01.2017.08 (May 25, 2017)). While varying in HiAP scope and, with or without using HiAP labels, the Vermont, California, New York, and Maryland GEOs illustrate how GEOs can be used to operationalize the HiAP approach and HiAP principles. Finally, GEOs can also be helpful mechanisms to launch evaluation of efforts that bring health into other sectors. Evaluation is the last stage of the policy cycle and involves examining the impacts of an implemented policy on its target and on other indicators so necessary adjustments can be made (Golden & Moreland-Russell, 2016). The Vermont GEO encourages evaluation of HiAP efforts by requiring Task Force members to describe how they are integrating health concerns into their respective decisions (Vt. Exec. Order No-07-15 (Oct. 6, 2015)). While not mentioning HiAP, a Michigan GEO that forms a state Interagency Council on Homelessness, with representatives from many government agencies including health, orders the Council to craft a plan to end homelessness and then “monitor and oversee the implementation” of the plan through measurable goals, coordinated data and reporting systems, and progress reports (Mich. Exec. Order No. 2015-2, Jan. 16, 2015, p.1)). GEOs can therefore include evaluation components to state-level efforts that bring the health lens into other sectors. GEOs may address some of the problems of cross-sector collaboration around health GEOs can also tackle some common challenges faced by cross-sector collaborative efforts to bring health into governmental decision-making. Greer & Lillvis identify two major barriers to HiAP’s intersectoral governance – (1) “coordination” (i.e., how to get the non-health sector to focus on health) and (2) “durability” (i.e., how to maintain HiAP efforts across time) – by synthesizing relevant literature from the public health, political science, and public administration fields (2014, p.14). They identify three categories of possible ways to overcome these barriers: (1) “political leadership” (i.e., actualizing commitment from leaders), (2) “bureaucratic change” Made to Order : Using Gubernatorial Executive Orders to Promote Health in All Policies Gakh 7 (i.e., modifying existing processes, procedures, and modes of interaction) and (3) “indirect strategies” (i.e., pursuing longer-term changes to policy- making) (Greer & Lillvis, 2014, p.14-15). Related to these solutions, Kania and Kramer articulate five common conditions of “successful collective impact”: (1) shared agendas, (2) consistent metrics, (3) collaborative work that reinforces each other, (4) constant communication, and (5) an organization that can take on coordination (2011, p.23). They argue that “collective impact” – or “the commitment of a group of important actors from different sectors to a common agenda for solving a specific social problem” – provides a way to solve complex problems like health (Kania & Kramer, 2011). Both frameworks provide guidance for HiAP efforts. They are also consistent with other discussions in the HiAP literature (Rudolph et al., 2013; Gase et al., 2013, Wernham & Teutsch, 2015). GEOs are important tools that can be part of the solution to overcome barriers to HiAP. Leadership by policymakers and shared agendas can promote HiAP (Kania & Kramer, 2011; Greer & Lillvis, 2014). GEOs can foster both. Issuing a HiAP- promoting GEO formally establishes HiAP as a cross- sector priority at the highest level of state executive leadership. By using GEOs to create HiAP task forces, the Vermont, New York, and California governors formally signaled to state government agencies from different sectors and to others that they recognize the value of and are committed to HiAP (Vt. Exec. Order No-07-15, (Oct. 6, 2015); N.Y. Exec. Order No. 190 (Nov. 14, 2018); Cal. Exec. Order No. S-04-10 (Feb. 23, 2010)). The language of all three orders acknowledges that health policy is made across sectors and the importance of incorporating health into decision- making (Vt. Exec. Order No-07-15, (Oct. 6, 2015); Cal. Exec. Order No. S-04-10 (Feb. 23, 2010); N.Y. Exec. Order No. 190 (Nov. 14, 2018)). All three orders establish HiAP as a shared priority for state agencies and health as a cross-sector responsibility through formal policy mechanisms issued by the state’s chief executives (Vt. Exec. Order No-07-15, (Oct. 6, 2015); Cal. Exec. Order No. S-04-10 (Feb. 23, 2010); N.Y. Exec. Order No. 190 (Nov. 14, 2018)). The Vermont, California, and New York GEOs also enshrine at least some robustness into their HiAP efforts. California requires delivering one report with recommendations to state government (Cal. Exec. Order No. S-04-10 (Feb. 23, 2010)); Vermont requires an annual report with recommendations to the governor and periodic reporting of progress (Vt. Exec. Order No-07-15, (Oct. 6, 2015)). And New York requires establishing responsible parties (N.Y. Exec. Order No. 190 (Nov. 14, 2018)). HiAP efforts would likely be sustained at least until completion. Furthermore, as long as these GEOs remain in effect, they can serve as a formal commitment to HiAP articulated for all state agencies by the state’s chief executives. HiAP-like GEOs, too, can be a vehicle for leadership to support coordination and durability and to set cross-sector agendas on issues with health impacts. A Colorado GEO, for example, adopts a shared agenda of supporting “zero emissions vehicles” (Colo. Exec. Order No. B-2019-002 (Jan. 17, 2019, p.2)). It creates a cross-sector workgroup of state agencies, including health, and encourages agencies to coordinate efforts while requiring workgroup members to modify their rules, programs, and plans to support this health- promoting goal (Colo. Exec. Order No. B-2019-002 (Jan. 17, 2019)). By requiring the implementation of specific policies and clarifying that the GEO stands “until modified or rescinded” (Colo. Exec. Order No. B-2019-002 (Jan. 17, 2019, p.1)), this GEO also supports the robustness of HiAP-related work. HiAP can involve modifying bureaucratic processes and entities to support coordination and durability, establish coordinating organizations, require reinforcing work, and encourage continuous communication (Kania & Kramer, 2011; Greer & Lillvis, 2014). GEOs can support these types of changes. The California and Vermont GEOs design new state government entities – HiAP task forces – as organizations to coordinate HiAP and assign the responsibility of leading the HiAP efforts to health Made to Order : Using Gubernatorial Executive Orders to Promote Health in All Policies Gakh 8 departments (Vt. Exec. Order No-07-15 (Oct. 6, 2015); Cal. Exec. Order No. S-04-10 (Feb. 23, 2010)). Both orders also require agencies to collaborate in ways that augment each other’s work and encourage communication. California’s GEO calls upon all agencies that report to the governor to cooperate with the HiAP Task Force (Cal. Exec. Order No. S-04-10 (Feb. 23, 2010)). Vermont’s order requires agencies constantly to interact through the new task force as they identify health-promoting strategies; integrate health into their “rulemaking, policies, and programs;” and regularly report progress (Vt. Exec. Order No-07-15, Oct. 6, 2015, p.2). While New York’s order requires establishing HiAP-responsible staff across agencies who also must liaise with a central HiAP committee (N.Y. Exec. Order No. 190 (Nov. 14, 2018). These changes attempt to modify normal bureaucratic structures and processes to enable HiAP. A HiAP-like GEO from Washington focused on carbon pollution (Wash. Exec. Order 14-04 (Apr. 29, 2014)) also changes bureaucracy, establishes coordinating entities, requires reinforcing work, and encourages continuous communication. Among its mandates are requirements to non-health agencies like the departments of transportation, commerce, ecology, and administration, to take on specific tasks related to clean energy (Wash. Exec. Order 14-04 (Apr. 29, 2014)). It contains requirements for mutually- supportive work, such as including reviewing statutory limits on greenhouse gas emissions, reducing state government contributions to emissions, and stimulating renewable energy (Wash. Exec. Order 14-04 (Apr. 29, 2014, p.8)). These tasks contribute to a more comprehensive state policy. This Washington order also shifts existing government structures. It creates an “Energy, Transportation, and Climate subcabinet […] to organize, coordinate, and implement state agency work” related to carbon pollution, comprised of senior leaders from various state departments (Wash. Exec. Order 14-04 (Apr. 29, 2014)). Furthermore, this GEO encourages communication through collaboration on recommendations and by including federal, tribal, regional, and local partners in implementation (Wash. Exec. Order 14-04 (Apr. 29, 2014)). Finally, stressing transparency and inclusiveness as well as creating and using shared data and metrics can support sustaining HiAP indirectly (Kania & Kramer, 2011; Greer & Lillvis, 2014). Here too GEOs may be a helpful mechanism. For example, the California GEO requires its HiAP Task Force to “convene regular public workshops to present its work plan” and also to “solicit input from stakeholders” to inform its HiAP report (Cal. Exec. Order No. S-04-10 (Feb. 23, 2010, p.2)). The California and Vermont GEOs may also indirectly encourage transparency and inclusiveness through HiAP reports and recommendations that are made publicly available. Similarly, a Pennsylvania HiAP-like GEO, which focuses on cross-sector management, policy, and problem-solving, attempts to “engage internal and external stakeholders” to improve state government operations through “continuous process improvement methods” and by tracking key data indicators and publishing online the goals and progress of the governor’s administration (Pa. Exec. Order 2018-01 (Feb. 1, 2018, p.1)). By improving data systems, integrating stakeholders into government decision-making, and promoting transparency, these GEOs may indirectly contribute to HiAP efforts. Order with Caution GEOs serve as a legal mechanism with the potential to support state-level HiAP efforts. They can do this by focusing directly on HiAP or by championing HiAP-like principles. They can help prioritize, formulate, adopt, implement, and evaluate HiAP efforts. They can also target some of the common obstacles that HiAP cross- sector efforts face. However, GEOs may not always be the most appropriate vehicle to establish formal HiAP endeavors, and cautious optimism is in order. The GEOs presented here demonstrate the potential of GEOs to promote HiAP. But GEOs are just mechanisms Made to Order : Using Gubernatorial Executive Orders to Promote Health in All Policies Gakh 9 – means to ends. Like all mechanisms, GEOs as mechanisms are outcome-neutral. The extent to which they promote or hinder HiAP is a function of what they actually say and how they are actually implemented. Even though, on their face some GEOs look like they could support HiAP, they miss opportunities; they do not contain language to integrate health into other sectors even when they recognize the role other sectors play in health. Florida’s order on transportation in one of the state’s economic hubs serves as an example. While this GEO articulates the importance of health and the connections between health, transportation, community development, economic activity, and the environment, and also includes cross-sector collaboration and community engagement directives, the order alludes to health without saying that some of the cross-sector partners must bring a health perspective to the collaboration (Fla. Exec. Order No. 13-319 (Nov. 1, 2013)). Therefore, the precise language of the GEO plays a vital part in the GEO’s ability to promote cross-sector collaboration with health in mind. GEOs also have structural limitations that are consequential in the HiAP context. For example, as previously discussed, there is state-by-state variation about what governors can do with GEOs (CSG, 2010; Ferguson & Bowling, 2008; Gakh et al., 2013). In some states there is no express legal authority to issue GEOs in areas especially relevant to HiAP – such as reorganizing the executive branch, creating governmental entities, or targeting administration – though there nevertheless may be implied authority to do so (CSG, 2010). Similarly, in some states, certain GEOs may need to undergo legislative review or the same procedural processes as administrative regulations (CSG, 2010; Ferguson & Bowling, 2008). Such requirements may lessen the appeal of GEOs for HiAP by negating some of the speed and simplicity that makes GEOs appealing in the first place. Like other policy mechanisms, GEO requirements can change over time, lapsing in many ways; they can sunset by their own provisions, expire by operation of law, or be over-ridden through political processes – by the same or a subsequent governor or through legislative action (Gakh et al., 2013). Recognizing these limitations is important in deciding whether to pursue a HiAP-promoting GEO. While state governments are critical for HiAP implementation in the United States, federal and local governments should not be overlooked. There are many important HiAP efforts at the local level, some that also use executive orders. For example, the sustainability effort in Washington D.C. includes a mayoral order creating a cross-sector HiAP task force to plan for and recommend HiAP operationalization (D.C. Exec. Order No. 2013-209 (Nov. 5, 2013)). Local-level orders should be examined in further detail. Beyond executive orders, municipal, county, and regional government entities are important HiAP partners (Rudolph et al., 2013; Wernham & Teutsch, 2015), especially because many of the social determinants of health (e.g. education, housing, transportation) are particularly affected by local policy (Dean, Williams, & Fenton, 2013). Relatedly, in evaluating the potential use of a GEO for HiAP, interactions between federal, state, and local government entities should be considered. As Washington State’s Partnership Council on Juvenile Justice GEO demonstrates, sometimes HiAP-like GEOs may be in direct reaction to federal policy. This order makes clear that the Council it establishes is a direct response to federal legislation that “requires each state to establish a state juvenile justice advisory group to receive [federal] funds” (Wash. Exec. Order No. 10-03 (Sept. 13, 2010, p.1)). While orders like these can simultaneously respond to federal policy and promote HiAP, the extent to which they evidence a genuine commitment to state-level, HiAP-promoting policy merits asking. It may be difficult to distinguish policy from politics; the intent of a GEO that looks like it promotes HiAP may actually be to achieve an alternative goal. This is important because the intent of a HiAP-promoting GEO may affect the robustness of the resulting HiAP effort. Made to Order : Using Gubernatorial Executive Orders to Promote Health in All Policies Gakh 10 Notably, whether HiAP-promoting GEOs actually result in HiAP implementation is an important question. Just because a health sector representative is involved in cross-sector collaboration around health does not mean the health perspective will prevail or even receive adequate attention. Limited authority, resources, commitment, bureaucratic changes, or know-how that accompany a GEO that appears HiAP-promoting may result in unsuccessful State Citation with Date Issued Online Availability Order Topic Additional information on implementation (where available) California Ca. Exec. Order No. S-04-10 (Feb. 23, 2010) https://wayback.archive-it. org/5763/20101008184544/http:// gov.ca.gov/executive-order/14537/ Health in All Policies https://www.cdph. ca.gov/Programs/OHE/ Pages/HIAP.aspx Colorado Colo. Exec. Order No. B-2019-002 (Jan. 17, 2019) https://www.colorado.gov/ governor/sites/default/files/ inline-files/b_2019-002_support- ing_a_transition_to_zero_emis- sions_vehicles.pdf Zero Emissions Vehicles https://www.colorado. gov/pacific/cdphe/ zero-emission-vehi- cle-mandate-proposal Connecticut Conn. Exec. Order No. 35 (Jun. 24, 2013) https://portal.ct.gov/-/media/ Office-of-the-Governor/Execu- tive-Orders/Others/Governor-Dan- nel-P-Malloy--Executive-Or- der-No-35.pdf Office of Early Childhood https://www.ct.gov/ oec/site/default.asp Washington, D.C. D.C. Exec. Order No. 2013-209 (Nov. 5, 2013) https://www.dcregs.dc.gov/ Common/NoticeDetail.aspx?noti- ceId=N0045216 Sustainable DC https://www.sustain- abledc.org/ Florida Fla. Exec. Order No. 13-319 (Nov. 1, 2013) https://www.flgov.com/wp-con- tent/uploads/orders/2013/13-319- plan.pdf East Central Florida Corridor Task Force https://spacecoasttpo. com/plan/east-cen- tral-florida-corri- dor-task-force/ Kansas Kan. Exec. Order No. 10-05 (Jun. 17, 2010) https://kslib.info/DocumentCenter/ View/578/EO-10-05?bidId= Early Childhood Advisory Council --- Louisiana La. Exec. Order No. BJ 2013-5 (Mar. 19, 2013) https://www.doa.la.gov/Pages/osr/ other/2013BJexo.aspx Interagency Council on Homelessness --- Massachusetts Mass. Exec. Order No. 515 (Oct. 27, 2009) https://www.mass.gov/execu- tive-orders/no-515-establish- ing-an-environmental-purchas- ing-policy Environmental Purchasing Policy https://www.mass. gov/environmental- ly-preferable-prod- ucts-epp-procure- ment-programs HiAP efforts or even further undermine public health. Even more crucial but difficult to evaluate is whether HiAP-promoting GEOs actually improve the social determinants of health. Of course, these evaluation questions are equally important to ask of all public health efforts, including efforts that use other legal mechanisms to formalize policy. Despite these cautions, GEOs should not be overlooked by HiAP practitioners and advocates as vehicles to promote cross-sector HiAP efforts in state government. https://wayback.archive-it.org/5763/20101008184544/http://gov.ca.gov/executive-order/14537/ https://wayback.archive-it.org/5763/20101008184544/http://gov.ca.gov/executive-order/14537/ https://wayback.archive-it.org/5763/20101008184544/http://gov.ca.gov/executive-order/14537/ https://www.cdph.ca.gov/Programs/OHE/Pages/HIAP.aspx https://www.cdph.ca.gov/Programs/OHE/Pages/HIAP.aspx https://www.cdph.ca.gov/Programs/OHE/Pages/HIAP.aspx https://www.colorado.gov/governor/sites/default/files/inline-files/b_2019-002_supporting_a_transition_to_zero_emissions_vehicles.pdf https://www.colorado.gov/governor/sites/default/files/inline-files/b_2019-002_supporting_a_transition_to_zero_emissions_vehicles.pdf https://www.colorado.gov/governor/sites/default/files/inline-files/b_2019-002_supporting_a_transition_to_zero_emissions_vehicles.pdf https://www.colorado.gov/governor/sites/default/files/inline-files/b_2019-002_supporting_a_transition_to_zero_emissions_vehicles.pdf https://www.colorado.gov/governor/sites/default/files/inline-files/b_2019-002_supporting_a_transition_to_zero_emissions_vehicles.pdf https://www.colorado.gov/pacific/cdphe/zero-emission-vehicle-mandate-proposal https://www.colorado.gov/pacific/cdphe/zero-emission-vehicle-mandate-proposal https://www.colorado.gov/pacific/cdphe/zero-emission-vehicle-mandate-proposal https://www.colorado.gov/pacific/cdphe/zero-emission-vehicle-mandate-proposal https://portal.ct.gov/-/media/Office-of-the-Governor/Executive-Orders/Others/Governor-Dannel-P-Malloy--Executive-Order-No-35.pdf https://portal.ct.gov/-/media/Office-of-the-Governor/Executive-Orders/Others/Governor-Dannel-P-Malloy--Executive-Order-No-35.pdf https://portal.ct.gov/-/media/Office-of-the-Governor/Executive-Orders/Others/Governor-Dannel-P-Malloy--Executive-Order-No-35.pdf https://portal.ct.gov/-/media/Office-of-the-Governor/Executive-Orders/Others/Governor-Dannel-P-Malloy--Executive-Order-No-35.pdf https://portal.ct.gov/-/media/Office-of-the-Governor/Executive-Orders/Others/Governor-Dannel-P-Malloy--Executive-Order-No-35.pdf https://www.ct.gov/oec/site/default.asp https://www.ct.gov/oec/site/default.asp https://www.dcregs.dc.gov/Common/NoticeDetail.aspx?noticeId=N0045216 https://www.dcregs.dc.gov/Common/NoticeDetail.aspx?noticeId=N0045216 https://www.dcregs.dc.gov/Common/NoticeDetail.aspx?noticeId=N0045216 https://www.sustainabledc.org/ https://www.sustainabledc.org/ https://www.flgov.com/wp-content/uploads/orders/2013/13-319-plan.pdf https://www.flgov.com/wp-content/uploads/orders/2013/13-319-plan.pdf https://www.flgov.com/wp-content/uploads/orders/2013/13-319-plan.pdf https://spacecoasttpo.com/plan/east-central-florida-corridor-task-force/ https://spacecoasttpo.com/plan/east-central-florida-corridor-task-force/ https://spacecoasttpo.com/plan/east-central-florida-corridor-task-force/ https://spacecoasttpo.com/plan/east-central-florida-corridor-task-force/ https://kslib.info/DocumentCenter/View/578/EO-10-05?bidId= https://kslib.info/DocumentCenter/View/578/EO-10-05?bidId= https://www.doa.la.gov/Pages/osr/other/2013BJexo.aspx https://www.doa.la.gov/Pages/osr/other/2013BJexo.aspx https://www.mass.gov/executive-orders/no-515-establishing-an-environmental-purchasing-policy https://www.mass.gov/executive-orders/no-515-establishing-an-environmental-purchasing-policy https://www.mass.gov/executive-orders/no-515-establishing-an-environmental-purchasing-policy https://www.mass.gov/executive-orders/no-515-establishing-an-environmental-purchasing-policy https://www.mass.gov/environmentally-preferable-products-epp-procurement-programs https://www.mass.gov/environmentally-preferable-products-epp-procurement-programs https://www.mass.gov/environmentally-preferable-products-epp-procurement-programs https://www.mass.gov/environmentally-preferable-products-epp-procurement-programs https://www.mass.gov/environmentally-preferable-products-epp-procurement-programs Made to Order : Using Gubernatorial Executive Orders to Promote Health in All Policies Gakh 11 Maryland Md. Exec. Order No. 01.01.2017.08 (May 25, 2017) https://content.govdelivery.com/ attachments/MDGOV/2017/05/25/ file_attachments/822423/Executi- veOrder%2B01.01.2017.08.pdf Committee on Paid Sick Leave Policy https://www.dllr.state. md.us/paidleave/paid- leavereport.pdf Michigan Mich. Exec. Order No. 2015-2 (Jan. 16, 2015) https://www.michigan.gov/ documents/snyder/EO_2015- 2_479496_7.pdf Interagency Council on Homelessness https://www. michigan.gov/whit- North Dakota N.D. Exec. Order No. 15-01 (Jan. 8, 2015) http://www.nd.gov/veterans/ files/resource/2015.1.8%20Execu- tive%20Order%202015-01.pdf Cares Coalition https://www.ndcares. nd.gov/ Nevada Nev. Exec. Order No. 2014-03 (Feb. 12, 2014) http://gov.nv.gov/uploadedfiles/ govnvgov/Content/News_and_Me- dia/Executive_Orders/2014_Imag- es/EO_2014-03_GovernorsCoun- cil_FoodSafety.pdf Governor’s Council on Food Security http://dpbh.nv.gov/ Programs/OFS/GCFS_ Meetings/OFS_-_Gov- ernor_s_Food_Securi- ty_Council/ New York N.Y. Exec. Order No. 190 (Nov. 14, 2018) https://www.governor.ny.gov/ news/no-190-incorporat- ing-health-across-all-poli- cies-state-agency-activities Health Across All Policies https://health.ny.gov/ prevention/preven- tion_agenda/health_ across_all_policies/ Pennsylvania Pa. Exec. Order 2018- 01 (Feb. 1, 2018) https://www.oa.pa.gov/Policies/ eo/Documents/2018-01.pdf Governor’s Office of Performance Through Excellence https://www.gover- nor.pa.gov/about/ office-performance-ex- cellence/#about Tennessee Tenn. Exec. Order No. 10 (Jan. 30, 2012) https://publications.tnsosfiles. com/pub/execorders/exec-or- ders-haslam10.pdf Governor’s Children’s Cabinet --- Vermont Vt. Exec. Order No- 07-15 (Oct. 6, 2015) https://legislature.vermont. gov/statutes/section/03APPEN- DIX/003/00069 Health in All Policies https://www.health- vermont.gov/about- us/our-vision-mission/ building-culture-health Washington Wash. Exec. Order No. 10-03 (Sept. 13, 2010) https://www.governor.wa.gov/ sites/default/files/exe_order/ eo_10-03.pdf Partnership Council on Juvenile Justice https://www.dshs. wa.gov/ra/office-ju- venile-justice/wash- ington-state-part- nership-council-juve- nile-justice Washington Wash. Exec. 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https://www.michigan.gov/documents/snyder/EO_2015-2_479496_7.pdf https://www.michigan.gov/documents/snyder/EO_2015-2_479496_7.pdf https://www.michigan.gov/whitmer/0,9309,7-387-90501_90626-346529--,00.html https://www.michigan.gov/whitmer/0,9309,7-387-90501_90626-346529--,00.html http://www.nd.gov/veterans/files/resource/2015.1.8%20Executive%20Order%202015-01.pdf http://www.nd.gov/veterans/files/resource/2015.1.8%20Executive%20Order%202015-01.pdf http://www.nd.gov/veterans/files/resource/2015.1.8%20Executive%20Order%202015-01.pdf https://www.ndcares.nd.gov/ https://www.ndcares.nd.gov/ http://gov.nv.gov/uploadedfiles/govnvgov/Content/News_and_Media/Executive_Orders/2014_Images/EO_2014-03_GovernorsCouncil_FoodSafety.pdf http://gov.nv.gov/uploadedfiles/govnvgov/Content/News_and_Media/Executive_Orders/2014_Images/EO_2014-03_GovernorsCouncil_FoodSafety.pdf http://gov.nv.gov/uploadedfiles/govnvgov/Content/News_and_Media/Executive_Orders/2014_Images/EO_2014-03_GovernorsCouncil_FoodSafety.pdf 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Lahtinen, & K. Leppo (Eds.). Health in All Policies: Prospects and potentials. (p. 231-252). Finland: Ministry of Social Affairs & Health. Retrieved from http://hiaconnect. edu.au/old/files/Health_in_All_Policies.pdf Made to Order : Using Gubernatorial Executive Orders to Promote Health in All Policies Gakh 15 World Health Organization (WHO). (2008). Closing the gap in a generation: Health equity through action on the social determinants of health, Geneva, Switzerland: WHO Press. Retrieved from http://apps.who.int/iris/ bitstream/10665/69832/1/WHO_IER_CSDH_08.1_eng.pdf. CORRESPONDING AUTHOR Maxim Gakh, JD, MPH School of Public Health, University of Nevada, Las Vegas Box 453063, 4505 S. Maryland Parkway Las Vegas, NV 89154-3063 maxim.gakh@unlv.edu CHIA Staff: Editor-in-Chief Cynthia Stone, DrPH, RN, Professor, Richard M. Fairbanks School of Public Health, Indiana University-Purdue University Indianapolis Journal Manager Angela Evertsen, BA, Richard M. Fairbanks School of Public Health, Indiana University-Purdue University Indianapolis Chronicles of Health Impact Assessment Vol. 4 Issue 1 (2019) DOI: 10.18060/23268 © 2019 Author(s): Gakh, M. This work is licensed under a Creative Commons Attribution 4.0 International License ACKNOWLEDGEMENTS The author would like to thank his university for supporting this work and also to thank and acknowledge contributions of researchers and practitioners in the area of Health in All Policies. The publication fees for this article were supported by the UNLV University Libraries Open Article Fund