Health Policy and Public Health

1
Health Policy and Public Health

• E. Richard Brown, Ph.D.
• Professor, UCLA School of Public Health
  Director, UCLA Center for Health Policy Research
• October 2004

2
My lecture

• Importance of public policy for public health
• What is public policy?
• Examples of public policy applied to public
  health
• Example of successful public policy campaign
  against cigarette smoking in U.S.

3
What health issues can public policy address?

• The Institute of Medicine of National Academy of
  Sciences, in a report on The Future of Public
  Health, argued that one of public healths most
  critical missions is to assure the conditions
  in which people can be healthy
• What are the conditions that affect health?

4
Leading causes of death in U.S., 2000

• The 10 leading causes of death in the U.S. in
  2000
• Heart Disease 710,760
• Cancer 553,091
• Cerebrovascular Disease 167,661
• Chronic Lung Disease 122,009
• Unintentional Injuries 97,900
• Diabetes 69,301
• Pneumonia and Influenza 65,313
• Alzheimer Disease 49,558
• Kidney Disease 37,251
• Septicemia 31,224
• Other 499,283
• Total 2,403,351
• Mokdad AH, et al. Actual Causes of Death in the
  United States, 2000.JAMA. 2004 291 1238 - 1245

5
Actual causes of death in U.S., 2000

• The factors that directly led to the 10 leading
  causes of death, determined by epidemiological
  studies
• Tobacco 435,000
• Diet/inactivity patterns 400,000
• Alcohol 85,000
• Certain infections 75,000
• Toxic agents 55,000
• Motor vehicles 43,000
• Firearms 29,000
• Sexual behavior 20,000
• Drug use 17,000
• Total 1,159,000
• Mokdad AH, et al. Actual Causes of Death in the
  United States, 2000.JAMA. 2004 291 1238 - 1245

6
Contributing causes of death that public policy
can address

• Many factors contribute to the 10 leading causes
  of death in U.S.
• Many of these are factors that public policy can
  address

• Can definitely be addressed by public policy
• Personal health-related behaviors
• Education and personal attitudes
• Employment, poverty, income distribution,
  housing, and adequate nutrition
• Lack of community and family cohesion
• Easy availability of guns and norms promoting
  violence
• Industries that profit from tobacco, alcohol, or
  toxic substances
• Race, gender, ethnic and religious discrimination

• Difficult to address by public policy
• Heredity
• Social, economic and political values

7
What is public policy?

• Rules that have been adopted through a process
  authorized by constitution or law
• Guides government agencies and societal authority
• If implemented, affects private action
• Types of public policy
• Legislative
• Funding (budgets and appropriations)
• Regulatory (e.g., standards and regulations) by
  public agencies
• Rulings by courts (case law)

8
Public policy includes funding for health programs

• Amount of funding provided by government for
• Health care services and programs
• Public health, including health education
• Includes agency budgets and grants to others
• Adding to or reducing funding may affect health
• Example
• Funding for anti-smoking campaign
• Funding of community health workers to educate
  residents about chronic illness and reduce
  community risks
• Funding for expansion of Medi-Cal (Medicaid) and
  the Healthy Families Program (SCHIP) to cover the
  uninsured

9
Public policy affects behavior through education

• Influences health-related behaviors through
  education
• Informing and educating public about
• risks of certain behaviors
• value of changing behaviors
• Affects personal and organizational behaviors
• Examples
• Public education campaign to discourage teenagers
  from smoking
• Educating parents and children to encourage
  healthful food choices

10
Public policy affects behavior and health by
shaping incentives and environment

• Affects behaviors or actions by shaping
  incentives and/or other forces that influence
  behaviors
• Financial incentives reduce demand with taxes
• Example Tobacco taxes reduce smoking initiation
• Example Make more healthful food the less
  expensive choice in school cafeterias and at
  super markets
• Financial incentives increase demand with
  subsidies or tax credits
• Example Tax credits to encourage people to
  purchase health insurance (Bush proposal)

11
Public policy affects behavior through regulation

• Influences health-related behaviors through
  regulation and police powers
• Prescribing or prohibiting behaviors and
  providing penalties for violation
• Affects personal and organizational behaviors
• Examples
• Restricting childrens access to tobacco
• Requiring schools to offer more healthful food in
  school cafeterias
• Proposition 72 will require medium and large
  employers to pay-or-play

12
Examples of public health policy in U.S.

• Examples of public health policy
• Anti-smoking policies
• Restrict sale and use of tobacco products (very
  successful)
• Food and Drug Act
• Assure safe and effective prescription drugs
  (moderately successful)
• Assure safe and nutrition foods (moderately
  successful)
• Clean Air Act
• Reduce particulate matter and other air pollution
  (moderately successful)
• Clean Water Act
• Reduce contamination of water supply (moderately
  successful)
• Adoption and implementation of all these policies
  were fought by industries they regulate

13
Example of successful campaign against cigarette
smoking in U.S.

• Major campaign against smoking began with
  official government report
• In 1964, Surgeon General of U.S., released
  Smoking and Health, Americas first widely
  publicized official recognition that cigarette
  smoking is cause of cancer and other serious
  diseases
• Surgeon General understood that it would be
  controversial and attacked by tobacco industry
• Based on review of more than 7,000 articles
  relating to smoking and disease published
  peer-reviewed journals
• Research supported development of official report
  that confronted tobacco industry
• Required courageous action by Surgeon General and
  other public health leaders

14
Example of successful campaign against cigarette
smoking in U.S.

• Gradually increasing support for anti-smoking
  campaign
• Organizations
• American Cancer Society and American Lung
  Association
• Public health organizations
• Medical associations
• Public education about dangers of smoking
• Increasing support for anti-smoking policies
• Policies to restrict sale of tobacco products,
  restrict or ban smoking in public places, and tax
  cigarettes gained increasing support even when
  fought by powerful tobacco industry
• As smoking prevalence declined, smaller
  proportion of population opposed regulating
  tobacco products and smoking
• Even smokers now support such policies

15
Example of successful campaign against cigarette
smoking in U.S.

• Anti-smoking policies
• Public policies that prohibit sale of cigarettes
  and other tobacco products to children
• Requiring picture identification to verify that
  person is over minimum age
• Making it a misdemeanor to buy cigarettes for a
  minor
• Public policies that increase the cost of smoking
  for children by increasing tax on cigarettes and
  other tobacco products
• Young peoples purchase of cigarettes is
  especially price sensitive because they have low
  incomes
• Works best if target population is not already
  addicted to cigarettes
• If tax is excessive, may encourage black market
• Tax revenues used to fund anti-smoking campaigns
  and other purposes

16
Example of successful campaign against cigarette
smoking in U.S.

• Anti-smoking policies
• Public policies that restricted advertising of
  cigarettes and other tobacco products on TV
• Public policies that restrict smoking in wide
  variety of public places
• Started with local (city and county) laws banning
  smoking in government buildings and requiring
  non-smoking sections of restaurants
• Then bans on smoking in public places (government
  and non-government buildings, transportation,
  etc.)
• In California, smoking is banned in all buildings
  used by public, including restaurants and bars
  spreading to other states

17
Example of successful campaign against cigarette
smoking in U.S.

• Cigarette Smoking Prevalence
• 1965
• Total adult population 41.9
• Adult males 51.2
• Adult females 33.7
• 2002
• Total adult population 22.4
• Adult males 24.7
• Adult females 20.1
• U.S. smoking prevalence is much lower than nearly
  all European countries

18
Proposition 72 Referendum on The Health
Insurance Act of 2003

• What is it?
• Pay-or-play employer mandate, enacted in
  October 2003
• Employers with 200 or more workers, beginning in
  2006, must provide or pay for health insurance
  for their eligible workers and workers dependent
  children and spouses
• Employer pays 80 and employee up to 20 of cost
• Eligible worker must work at least 100 hours a
  month and be employed by the firm for at least 3
  months
• Employer can provide health plan OR pay into
  State health insurance fund that will provide
  health plan to eligible workers/dependents
• Employers with 50-199 workers, beginning in 2007,
  must provide or pay for health insurance for
  their eligible workers
• Employers with 20-49 workers must provide or pay
  for health insurance for their eligible workers
  only IF State enacts tax credit to subsidize cost

19
Proposition 72 Referendum on The Health
Insurance Act of 2003

• Arguments for it
• 6.3 million Californians experience a lack of
  coverage during the year
• Over 80 of uninsured are workers and family
  members
• 61.6 of uninsured employees work for employer
  who does not offer health benefits
• 679,000 uninsured workers and dependents would be
  covered in first year and 1.1 million at full
  implementation
• Levels the playing field among all employers
• Ending the free ride that many employers now get
  when they do not pay for their employees health
  benefits
• Eliminating the competitive disadvantage that
  responsible employers experience when their
  competitors do not pay for health benefits
• Will reduce uncompensated care provided by
  hospitals and clinics
• Will reduce burden on taxpayers

20
Proposition 72 Referendum on The Health
Insurance Act of 2003

• Arguments against it
• Prop 72 does not control health care costs
• Prop 72 would cost employers a lot of money
• Learn more about Prop 72 (and other health
  propositions) at HealthVote2004.org
  http//www.healthvote2004.org/72/healthinsurance.p
  hp?pid72

21
The policy process

• Setting the policy agenda issues that
  policy-makers and leaders are paying serious
  attention to
• Personal problem that is a social issue is
  amenable to public policy
• Make it a priority for policy makers
• Develop alternatives to address the issue
• Link problem to options that can address it
• Adoption of a policy option among the
  alternatives
• Implementation of the policy

22
What shapes the policy process?

• Public opinion
• What factors shape public opinion?
• Mass media
• Policy influentials and leaders
• Research findings if communicated to policy
  makers, advocates, media
• Organized political pressure

• Interest groups

• Social movements
• Grassroots organizing
• Mobilization
• Media advocacy

• Elections
• Election outcomes affect the policy process and
  policy!

23
Summing up

• Public policy is a critically important tool for
  public health
• Can help establish conditions that are essential
  to improving the health of the whole population
  and specific population groups
• Public policy includes many aspects of public
  health programs and interventions
• From funding of programs and services to health
  education to regulations and their enforcement
• Public policy has been key element of successful
  public health campaign to reduce smoking
  prevalence
• Public policy is a tool to enhance public health

24
www.chis.ucla.edu