Introduction
Recent legislative initiatives to establish general privacy laws seek to provide more comprehensive protection for consumer data, but these new laws may also impact access to novel data sources for public health. Separately, the COVID-19 response has exposed weaknesses in data federalism and revealed important lessons on how to improve intergovernmental data exchange. Despite their significance, these challenges are eclipsed by seismic developments in artificial intelligence (AI) capabilities and adoption, which will pose profound regulatory and ethical challenges for public health. Public health perspectives are crucial but underrepresented in AI governance efforts.
Here, we analyze the public health implications of recent data governance developments, with a view toward the future of public health informatics and the potential of diverse data to inform public health actions and drive population health outcomes.
Emerging General Data Privacy Laws
Responding to ever-expanding private sector data collection, federal and state legislators have increasingly introduced and adopted general privacy laws to establish baseline consumer data rights. These laws impose more significant consent requirements for the collection and transfer of sensitive health data. However, they generally exempt data collection by governments and entities already regulated by privacy laws like the Health Insurance Portability and Accountability Act (HIPAA). Such laws should not directly impact traditional public health data collection, such as case reporting. Nonetheless, some new state privacy laws pose potential obstacles to public health’s collection and use of novel data sources that may provide valuable insights on the non-biological determinants of health.
At the federal level, Congress has advanced the American Data Privacy & Protection Act (ADPPA), which proposes comprehensive consumer privacy protections.1 It would establish duties of data minimization for collectors and require affirmative consent for use and transfer of sensitive data. The ADPPA’s definitions of sensitive data are expansive, including health information and data relating to minors, race, and ethnicity. However, the ADPPA exempts from its coverage government authorities and entities already regulated under HIPAA, leaving intact many existing channels of public health data transmission. Although the ADPPA secured House committee approval in 2022, it failed to advance to a full floor vote.Reference Kerry2 Its prospects remain uncertain in the face of continued debate over the scope of state law preemption and individual enforcement rights.
In the absence of Congressional action, states have increasingly passed their own laws. Since 2020, thirteen states have adopted general consumer privacy statutes, and two states have passed health-data specific privacy measures.Reference Folks3 Like the ADPPA, these state laws establish consumer data rights of transparency, access and control, and also broadly define sensitive information to include not just health and children’s data, but also race and ethnicity, biometric and precise geolocation data. However, these laws also exempt government agencies, HIPAA-regulated entities or data, non-profits (in most cases), and most importantly, data used only for public health purposes.Reference Greene4
In states that have adopted very broadly defined privacy laws, businesses and some nonprofits collecting and transferring data with public health relevance — including health-adjacent data and social determinants of health data relating to individuals — could face additional restrictions to share those data with public health partners.
Given these overlapping exemptions, the new wave of state privacy laws should not directly impact established mechanisms for public health data reporting, such as for reportable conditions and laboratory reporting. Nonetheless, subtle exemption variations in each state’s privacy law may still impact the legal basis for public health access to significant data categories collected outside of the clinical care context (e.g., provisions for stringent restrictions on race/ethnicity data or geo-location data). Non-HIPAA individually identifiable data originating from commercial entities — including from mobile apps, wearables or Internet of Things devices — may now require scrutiny to ensure compliance with state law requirements when such data is repurposed for public health use. In states that have adopted very broadly defined privacy laws, businesses and some nonprofits collecting and transferring data with public health relevance — including health-adjacent data and social determinants of health data relating to individuals — could face additional restrictions to share those data with public health partners.Reference Schmit, Larson and Kum5
For instance, Washington’s “My Health My Data Act” broadly applies to data that relates to “individual health conditions or status, diseases, or diagnoses … [and] social, psychological, behavioral and medical interventions” and also “any information that a regulated entity processes to associate [such data] that is derived or extrapolated from non-health information.” This means that businesses and non-profit organizations that are subject to Washington’s law and have data from social interventions (e.g., homelessness or food insecurity) may need to ensure that any transfer of those data to public health partners falls squarely within an existing exemption.6
The Governance of Intergovernmental Data Exchange
Data Federalism
Public health threats transcend jurisdictional boundaries. As such, data sharing between governmental public health partners is vital to inform action and allocate resources effectively. But without a Congressional framework, intergovernmental data use agreements (DUAs) comprise the de facto governance mechanism for intergovernmental data exchange.Reference Fahey7 As the product of intergovernmental negotiations, DUAs add complexity and resist standardization that is needed to effectively manage data across thousands of jurisdictions.
Syndromic Surveillance DUAs and the COVID-19 Response
The DUAs that govern syndromic surveillance data presented a significant barrier to a national real-time view of the initial spread of COVID-19.Reference Schmit8 The DUAs — which restricted federal views of state and local syndromic surveillance data below the HHS region level — were the product of public health professionals carefully balancing individual privacy interests with broader social interests while navigating a complex history of intergovernmental relationships.
These DUA restrictions likely conflicted with WHO ethical guidelines, which impose a broad obligation to share surveillance data with other public health agencies.9 When asked what policy guardrails are needed to permit greater federal access to state and local data, a workgroup of state and local epidemiologists identified many protections that were at least partially addressed in the existing DUAs. While this suggests that greater intergovernmental data sharing is close, the COVID-19 response (and its politicization) strained many interjurisdictional relationships, challenging efforts to align data sharing practices with public health ethical norms.10
Immunization DUAs and the COVID-19 Response
Similar obstacles to exchange arose with DUAs governing the transfer of vaccination information from state immunization information systems (IIS) to the federal government. Prior to COVID-19, IIS were managed through a cooperative federalism in which states operated registries with federal funding assistance and policy guidance, but did not transfer individually identifiable recipient information to federal public health agencies.11 However, the Operation Warp Speed response plan called for centralized federal data collection of such individual information for the purposes of monitoring second dose administration and vaccine safety.12 Several states objected to the provisions of the Centers for Disease Control & Prevention’s proposed DUA, raising concerns that (1) the transfer of individual information might violate state law; (2) the transferred information might be repurposed for federal immigration enforcement efforts; and (3) federal data collection of individual and demographic data might also conflict with state de-identification standards.13 These concerns were eventually addressed pragmatically following the transition between administrations in the early phase of the vaccination campaign, including through amendments by some states to the CDC DUA, issuance of clarifying federal guidance, and public commitments to preclude immigration enforcement use.14 Notably, these commitments to preclude immigration enforcement data uses align with WHO ethical guidelines.15
The lessons of COVID-19 point to opportunities to streamline key terms for data transfers between the federal government and state, territorial or tribal partners, notwithstanding the heterogeneity of public health data sources.Reference Curran16 These could include standardized provisions defining the scope of federal access to identifiable information, both in the ordinary course and during public health emergencies; appropriately defined legal and technical standards for data de-identification; limits on secondary transfer and use, including access for law-enforcement purposes; data rights; controlling cybersecurity standards; and governance mechanisms. Encouragingly, the CDC’s Data Modernization Initiative has now established objectives to adopt such standardized agreements for core data sources by 2024.17
Regulating Data Processing: AI and Public Health
AI presents several opportunities to improve public health operations. There are numerous potential public health AI applications. For instance, AI could be used to enhance existing surveillance systems to help identify timely patterns and trends and could be extremely helpful for systems with complex data, like syndromic surveillance and wastewater surveillance. AI could be used to support precision public health, where complex data on health risk factors enable targeted and individualized personalized interventions. AI will inevitably support Learning Health Systems, which continually and systematically incorporate new discoveries and clinical observations into sophisticated clinical decision support tools. AI also could be immensely valuable for supporting efficient resource allocation decisions, potentially game-changing to chronically underfunded public health agencies.Reference Panch18
However, managing data is a primary concern with introducing AI into public health systems. The accuracy of AI models relies on thorough training and testing, requiring copious data. Yet, the existing public health IT infrastructure is likely insufficient for many jurisdictions that still struggle with interoperability and outdated systems. In many ways, the future of AI in public health depends on the success of the Data Modernization Initiative.
Regulation is another central issue facing public health AI integration. Governance of AI is a technology-wide challenge faced by industry and government alike. Traditional legislative processes are slow and will inevitably be outpaced by AI. Increasingly, governance deliberations are focusing on “soft law,” which describes judicially unenforceable guidelines, standards, and rules intended to guide industry behavior. The most common critique of soft law governance is that it relies excessively on industry self-regulation, which has a mixed history of success. One solution is to bridge soft and hard law through collaborative governance, wherein governments incorporate soft law standards into hard law regulatory frameworks, marrying the enforcement capability of hard laws and the flexibility of soft laws.Reference Schmit, Doerr and Wagner19
Recent international AI governance efforts include the EU AI Act and China’s Global AI Governance Initiative. The EU’s AI Act has a risk-based framework with more stringent requirements for riskier applications.20 In the U.S., the Biden Administration’s recent Executive Order and OMB guidelines provide a blueprint for developing federal AI standards.21 Within these efforts, however, the public health perspective is nonexistent. AI risks often amount to population-level harms, and public health ethics have evolved to address these unique risks. In an analysis of 638 soft law frameworks, not one had a public health focus.Reference Gutierrez and Marchant22 AI governance lacking this perspective could prevent useful applications of AI in public health and impede government regulation of AI as a structural determinant of health.
Conclusion
Since data are essential to public health practice, laws that regulate data are critical dimensions of public health authority. Long ago, the public health paradigm expanded beyond biological determinants of health to include political, environmental, and social determinants of health. Similarly, the scope of public health data governance must expand beyond traditional health privacy laws — like HIPAA — to be inclusive of the data that reflect the political, environmental, and social factors that impact our health. These health-adjacent data are at risk of being locked out of future public health informatics by the current wave of laws regulating data and their processing.
Public health agencies and organizations would be well advised to follow legislative developments, educate policymakers on preserving access to data, and contribute to parallel efforts to standardize DUA terms. The inclusion of legislative exceptions that permit data to be used, transferred, and processed for public health purposes is an effective means to support future public health informatics activities. However, care should be taken to restrict inappropriate data use and ensure established ethical principles serve as a lodestar for public health data governance.
Acknowledgements and Disclaimer
The authors did not receive funding for this work and have no conflicts to disclose. This article discusses general developments and is not intended to provide legal advice.
Open access
