Public Health Policy and Legislation as Tools to Drive Population Health

1. Public Health Policy and Legislation as Tools to Drive Population Health Edward P. Richards Director, Program in Law, Science, and Public Health Louisiana State University Law Center richards@lsu.edu White Paper - Legal Strategies to Manage Obesity and Increase Physical Activity: http://biotech.law.lsu.edu/cphl/slides/pennington-2012.htm

2. Levels of Action • Federal • Can implement a policy globally • May be necessary for reimbursement changes • Hard to change if you get it wrong • State • Allows experimentation • Local • Powerful in big cities, less effective in small cities

3. Legal Theories of Action • (Increasing power order) • Parens Patria (state as parent) • Protecting the individual • Police Power • Protecting the general public • National Security Power • Protecting the state itself • Can we save the constitution and lose the union?

4. Modes of Direct Legislative Action • Modify the environment through direct regulation • Sanitation • Modify the environment through tax or other financial incentives • Cap and trade for power plant emissions • Directly mandate changes in individual behavior • War on drugs • Financial incentives to change individual behavior • Soda taxes • Tobacco taxes

5. CDC Ten Great Public Health Achievements • Vaccination • Motor-vehicle safety • Safer workplaces • Control of infectious diseases • Decline in deaths from coronary heart disease and stroke • Safer and healthier foods • Healthier mothers and babies • Family planning • Fluoridation of drinking water • Recognition of tobacco use as a health hazard

6. Public Health Failures • Drug Policy • Prescription pain killers kill more people than illegal drugs • The war on drugs has filled prisons and destroyed the lives of millions • Sexually transmitted disease control • Broke down in the 1970s with the bathhouses • Enabled HIV and limited the effectiveness of HIV control for 20 years

7. Is Obesity an Unintended Consequence of Other Laws and Policies? Can we successfully manage obesity without addressing these underlying drivers?

8. Agricultural Policy in the 1950s • Make food staples more affordable • Make meat affordable for everyone • Unintended consequences • Emphasis on processed grain based foods and meat • Supersizing as marketing edge • Larger portions at home • The snack culture

9. Land Use Law and Zoning • Separate commercial and residential development to make neighborhoods more healthful • Single use zoning • Encourage green field development to reduce the cost of housing • Low density housing requires automobiles, so there is no need to walk • Single use zoning means to place to walk to

10. Building Regulations • Fire regulations keep stairs closed and at the edge of the building • Security regulations often limit routine access to stairs • ADA and other regulations require easy access for handicapped persons, but non-discrimination regs also prevent this access from being limited to disabled persons

11. Vending Machines in Schools • Driven by budget cuts • Generate important income for many schools • Lead to the breakdown of rules against eating in schools, otherwise no income

12. School Lunches – Why Fast Food? • Many schools are overcrowded • Lunches are served to many more students than the kitchens and cafeterias are designed for • Fast food, especially when it is supplied by third parties, is the only way to serve the crowd

13. Physical Activity of Students • Many schools do not require students to have organized physical activity each day • PE was cut as budgets were cut • PE was cut to make more room for substantive courses • Schools increased homework so students do not have time to play after school

14. Failed Social Infrastructure • Crime in poor neighborhoods • Children cannot play outside • Food insecurity • Contributes to obesity • Limited availability of grocery stores and produce • Failed k-12 education • Probably the most important determinant of obesity.

15. The Risk of Medicalization • There are powerful forces that push the medicalization of problems • This allows the problem to monetized • Medical procedures • Drug sales • Legislatures like these “fixes” and the dollars that flow from them to their campaign funds • They can consume precious dollars and divert attention from structural changes

16. Legislative Priorities • Legislatures have limited in health issues • It is critical that this not be squandered with ineffective legislation or legislation that has little impact on health • Legislatures like “easy” legislation, such as banning sodas, to avoid more critical issues • “We passed a law, why isn’t the problem solved?”

17. The Problem of the Long Term • Legislatures do not like to deal with problems that have no quick fix or whose fix is very expensive • K-12 education • Social infrastructural issues • If we find effective strategies for obesity control, they will take a very long time for results • How do we keep legislative focus to keep programmatic and research dollars flowing for problems that do not have short-term fixes?