Policy as a Public Health Tool

Sharon McDonnell MD MPH

Dartmouth Medical School MPH Program

ECS 154

Goals

1. In ECS 154 we will learn about and practice specific areas of policy relating to the Attorneys General Office and their campaign to address pharmaceutical financing, health and consumer protection

2. In this podcast I summarize policy approaches to public health problems

3. Provide examples to illustrate the ideas and approaches

Policy Interventions for Health In US constitution there is no specific right or law about health

Federal Government engagement in health was originally through regulation of interstate commerce

Local and States were involved through “protection” and police powers

Successive re-defining of the unacceptable with changes in role of law, government, and methods

Case in point: Protection and the significant changes in the role of the FDA reflecting cross-culture forces

Health and the Law

Health and the law intersect on many levels –Health care policy is shaped through a combination of methods at the local, state and federal level.

Many agencies in Government at National, State and local level

Governmental roles mandated by policy or regulation: Protection, detection and response to Public Health

Major Roles: Define health status of population Prevent and protect - Road safety, car design Disease and health threat investigation

Disease detection, case finding, contact tracing Provide or assure for treatment and case management

(e.g., quarantine, Chemoprophylaxis, Monitor, evaluate (access, outreach)

Surveillance, monitoring, and evaluation

Public Health Intervention Wheel

Public Health Intervention Wheel

Policy

Policy Areas Goal setting (Healthy people, performance standards)

Recommendations and Guidelines (associated with funding or standards)

Legislation- Laws, regulations, and rules (Media exposure, age limits)

Litigation (lead, air quality, tobacco)

Enforcement (product recall, fines, seat belts, BAC, lead levels)

How does policy work? Tension between “freedom” and “protection” Most policy limits choice or freedoms (social contract)

Must wear helmet Folate fortification (19% decrease in neural tube defects and

100% decrease in pellagra) Is it acceptable that government or lawmakers are involved in

the issue? Some say “no, never” Does culture change precede policy change or does policy

change reflect cultural change? Other mechanisms: Psychological forces exerted on people

that want to be law abiding, not fined, embarrassed, or lose rights to drive. Among states that enacted laws defining DUI based on a BAC of 0.08% there as been a 7% median decrease of in fatal alcohol-related MVA crashes.

When is a policy response the “right” thing

The legal system helps define the roles and responsibilities of different players in the health care system or about health issues.

For example, state and federal laws have been used to set the minimum standards that affect the provision of health care, the scope of health coverage, public program policy, consumer protections, as well as the regulation of pharmaceuticals and medical devices.

The judicial system also oversees and enforces malpractice compensation that help protect patients and doctors as well as policies that affect patient privacy and patient rights.

Does a law make sense? Since 1980, the courts have analyzed regulations affecting

advertising for commercial products or professional services under the four-part test set forth by the U.S. Supreme Court in Central Hudson Gas & Electric Corp. v. Public Service Commission of New York. The "Central Hudson" test asks:

(1) whether the issue concerns lawful activity and is not misleading;

(2) whether the asserted government interest is substantial; and, if so,

(3) whether the regulation directly advances the governmental interest asserted; and

(4) whether it is not more extensive than is necessary to serve that interest.

Government bears the burden of identifying a substantial interest and justifying the challenged restriction:

“The government is not required to employ the least restrictive means conceivable, but it must demonstrate narrow tailoring of the challenged regulation to the asserted interest — a fit that is not necessarily perfect but reasonable; that represents not necessarily the single best disposition but one whose scope is in proportion to the interest served.”

The four parts of the Central Hudson test are not entirely discrete. All are important and, to a certain extent, interrelated

More guidance on laws and rules Can you see what you are trying to control?

“Making an example”-- demonstrating the importance of law and that people can get caught

Evidence for the “risk”

Passive vs active

Effort involved to reach end (floridation of water vs flouride tablets or changing the RR crossing or education)

Targeting How laws happen… culture change or changing culture?

First….. Targeted laws towards a specific population that may be at increased risk or vulnerable or to whom we feel protective Age or condition (e.g., child safety seat laws or pregnancy) Behavior or risk (“drug abusers” or persons with HIV/AIDs) As a means to enjoy a “good” ie Educational requirements

(e.g., vaccination requirements for child care and school attendance)

Second…..Broad-based policies Community-wide interventions (e.g., water fluoridation, smoking bans and laws)

Mello NEJM 354;24 www.nejm.org june 15, 2006

Mensah Prev Chronic Dis 2004 Jan [date cited]. URL: http://www.cdc.gov/pcd/issues/2004/jan/03_0033.htm

This exploration of the frontier of laws to fight obesity illustrates the dynamic nature of the relationship between public health law and the broader cultural and public health environment.

There are many historical examples of the law driving social change; however, progressive laws are unlikely to be implemented until the dominant cultural mores are sufficiently favorable