Benjamin Mason Meier, JD, LLM, MPhil Columbia University

1. State Public Health Law ReformAssessing the Policy Impact of the Turning Point Model State Public Health Act Benjamin Mason Meier, JD, LLM, MPhil Columbia University March 30, 2009 CENTER FOR HEALTH POLICY COLUMBIA UNIVERSITY

2. Outline • Background • Framework • Methods • Results • Analysis • Implications/Limitations • Future Research

3. Public Health Law Reform • Healthy People 2010 • Law as a Determinant of Health • Future of Public Health • Public Health Law Reform • Assessment of State Public Health Enabling Laws “Public health law in the United States is ripe for reform” “State public health laws are, in many cases, seriously outdated…” “…the Nation’s public health infrastructure would be strengthened if jurisdictions had a model law and could use it regularly for improvements.”

4. Turning Point Statute Modernization Collaborative • Mission “To transform and strengthen the legal framework for the state public health system through a collaborative process to develop a model state public health law.” • The Turning Point Model State Public Health Act • Phase I: State Public Health Law Assessment • Phase II: Development of a Model Law • Turning Point Model State Public Health Act - released September 2003 • Phase III: Dissemination & Education

5. Turning Point Act - Topics Topics addressed within the Act’s 9 substantive Articles include: • Mission and Essential Services • Public Health Infrastructure • Collaboration and Relationships • Public Health Authorities and Powers • Public Health Emergencies • Public Health Information Privacy • Administrative Procedures, Criminal/Civil Enforcement

6. States have used the Act as the basis for state public health law reforms Wisconsin Act 198, “An Act Related to Public Health,” is based on multiple articles /provisions of the Act Turning Point Act - States That HaveIntroduced and PassedBills or Resolutions Legislative Tracking Passed Bills: 26

7. Transforming National Collaboration into State Legislation—Study Design • Natural Experiment • Objectives - Assess the Impact of the Turning Point Act • Compare how the Turning Point Act is used by policy-makers in public health law reforms • Describe the effectiveness of the Turning Point Act as a model for state law • Apply lessons from the Turning Point experience to future reform efforts and empirical research

8. Conceptual Framework • Reasons for Reform (Grad 1990, Gostin 2000) • Antiquated • Unfocused • Inconsistent • Process of Reform (Gebbie 1998, 2000) • Stages • Actors • Forces • Why • How

9. Working Assumption • Policy consideration of the Turning Point Act will differ in form, substance, and process according to: • state political institutions, • individual actors, and • perceived imperatives in public health

10. Methods - Comparative Case Study • Individual Case Studies • Wisconsin • Alaska • Nebraska • South Carolina • Comparative Method • Varied Responses to the Same Model • Case Selection – Congruence with the Turning Point Act • Legal Analysis of Reforms in Comparison with Model Act • Informant Sample • Legislators • Bureaucrats • Advocates • Semi-Structured Interviews • Public health problems addressed by reforms • Obstacles to reform • Subsequent changes in public health programs • Content Analysis

11. SOUTH CAROLINA • Lack of an External Galvanizing Force • Bureaucratic Expansiveness and the Risk of Backsliding Comparative Results – State Political and Policy Efforts Matter NEBRASKA • Stakeholder Collaboration • Lack of Legislative Support • Risk of Backsliding • Selective Incorporation by Regulation WISCONSIN • The Turning Point Experience • Stakeholder Collaboration • Bottom-Up Reform • Strong Legislative Champion • Non-Politicization ALASKA • The Turning Point Experience • Top-Down Reform • Republican Support for a “Democratic Bill” • Politicization of Public Health NEBRASKA • Stakeholder Collaboration • Lack of Legislative Support • Risk of Backsliding • Selective Incorporation by Regulation SOUTH CAROLINA • Lack of an External Galvanizing Force • Bureaucratic Expansiveness and the Risk of Backsliding WISCONSIN • The Turning Point Experience • Stakeholder Collaboration • Bottom-Up Reform • Strong Legislative Champion • Non-Politicization ALASKA • The Turning Point Experience • Top-Down Reform • Republican Support for a “Democratic Bill” • Politicization of Public Health

12. Alaska—A Process Model of Successful State Public Health Law Reform Stage I: Emergence and Utilization of the Act • Dominant Actors • Turning Point Collaborative • Division of Public Health • Key Forces • Agenda Setting • Result • Model Developed for Discussion of Issue Stage II: Development of Draft Law • Dominant Actors • Division of Public Health • Office of the Attorney General • Key Forces • Public Health Imperatives • Result • State Law Developed Pursuant to Turning Point Act Stage III: Legislative Action • Dominant Actors • Legislators • Division of Public Health • Advocacy Groups • Key Forces • Politicization of Public Health • Result • Reform of State Public Health Law

13. South Carolina Department of Health and Environmental Control Analysis – Correlates of Reform Health Commissioner Public Health Ass’n • Inhibitors DOH • Facilitators • Unaltered Model Language • Gap Analysis • Agenda Setting • Lack of Impetus for Reform • Key Partnerships • Legislative Champions Turning Point Act Completed • Fear of Backsliding • Lack of Legal Leadership Assembly Chair Activist Governor Contributing Partner Meetings Begin Assembly Bill 881 Introduced

14. Analysis – Common Correlates Comparative Process Model – Stages of Reform, Principal Actors and Decisive Forces

15. Implications / Limitations Meier, Hodge & Gebbie (2007-2009) • Resources to support future reforms • Little understanding of current state of law • Need for additional research on: • State of Public Health Legislation • Effect of Law on Performance Transitions in State Public Health Law: Comparative Analysis of State Public Health Law Reform Journal of Health Politics, Policy and Law Report from the Field Alaska Public Health Law Reform

16. Future Studies • Competencies for Applying Law • Gap Analyses for Public Health Law Reforms • Relationship between Public Health Law Reform and Health System Performance • Essential Services in Law (Meier, Merrill & Gebbie 2009) • Law & Performance (Merrill, Meier, Keening & Gebbie 2009) • Link between Public Health Law, Individual Health Behaviors, and Public Health Outcomes

17. Conclusions • States selectively codify provisions of the Turning Point Act based upon individual, political, and institutional factors. • Additional research is necessary to determine the effect of these reformed laws. • For more information on legislative tracking and comparative case studies, see: www.publichealthlaw.net/Resources.htm. Benjamin Mason Meier, JD, LLM, MPhil Columbia University bmm2102@columbia.edu

18. Case Selection – Congruence with the Turning Point Act Legislative Tracking SOUTH CAROLINA WISCONSIN NEBRASKA ALASKA Alaska HB 95 – An Act relating to the duties of the Dept of Health & Social Services (June 2005) AB 881 – An Act Related to Public Health (March 2006) No Proposed Legislation or Regulation 173 NAC 6 – Directed Health Measures to Prevent or Limit the Spread of Communicable Disease, Illness, or Poisoning (Feb. 2007) Passed Bills: 26

19. Legislative Tracking • Little understanding of current state of law Passed Bills: 26