key: cord-0954140-mf5b224s
authors: Teitelbaum, Joel; McGowan, Angela K.; Richmond, Therese S.; Kleinman, Dushanka V.; Pronk, Nico; Ochiai, Emmeline; Blakey, Carter; Brewer, Karen H.
title: Law and Policy as Tools in Healthy People 2030
date: 2021-03-13
journal: J Public Health Manag Pract
DOI: 10.1097/phh.0000000000001358
sha: e5681f03a6f8ef4c9b73a825e196b4fdeb53d4b1
doc_id: 954140
cord_uid: mf5b224s

Laws and policies are critical determinants of health and well-being. They can encourage positive behaviors and discourage harmful behaviors, and they can enhance or worsen health, health equity, health disparities, and health literacy. Recognizing their contribution to conditions in the environments in which people are born, live, learn, work, play, worship, and age, and people's experiences of these conditions, the US Department of Health and Human Services considered the roles of law and policy throughout its development of Healthy People 2030. Laws and policies often interrelate, but they have different purposes. A law is an established procedure, standard, or system of rules that members of a society must follow. A policy is a decision or set of decisions meant to address a long-term purpose or problem. Healthy People 2030 offers an opportunity for users in diverse sectors and at all levels to use laws and policies to support or inform the initiative's implementation, address health disparities and health inequities, and improve health and well-being in this decade. Introducing new laws and policies or rescinding existing ones to achieve Healthy People 2030 goals offers a chance to rigorously assess outcomes and weigh the balance of good outcomes against unintended consequences.

• A law is an established procedure, standard, or system of rules that members of a society must follow. Laws take many forms, such as constitutional law, statutes, regulations, and case law (ie, court decisions). • A policy is a decision or set of decisions meant to address a long-term purpose or problem.

Laws and policies shape everyday life circumstances, societal institutions, and systems. A policy is not in itself a law, but the policy-making process can identify laws that are needed to accomplish the policy's goals. Policies set out goals and planned activities; laws establish institutional and legal frameworks to achieve them. This article discusses law and policy as levers to improve the health and well-being of populations. It highlights selected examples of objectives specifying a law or policy in Healthy People 2030 and earlier decades. By defining the parameters of individuals' and communities' environments, laws and policies can support health by encouraging beneficial behaviors and healthful circumstances; they can also impede good health or have unequal or unintended effects on health outcomes. When a law or policy negatively affects population health (eg, by preempting healthprotective local laws), programs designed to foster healthful individual behaviors may be inadequate to produce beneficial outcomes for health. 3 Law and policy include statutes, regulations, case law, subregulatory guidance, and institutional policies. Laws and policies can be adopted and influenced at multiple levels-federal, state, tribal, local, and even organizational/institutional. As shown in Figure 1 , each branch of government-executive, legislative, or judicial-plays a unique role in shaping laws and policies, and the process of developing them is continuous (see https://www.usa.gov/branches-of-government). Figure 2 illustrates that the development of law and policy is a continuous, cyclical process that proceeds from development to enactment, implementation, enforcement, evaluation, and back to development. Resources are needed to ensure that we can move from implementation to enforcement. Important steps in creating and influencing laws and policies include the following:

• Leaders and communities identify problems and advance ideas to try to solve them. • Some of those ideas can be enacted or adopted as legal or policy actions. • Law and policy interventions must be funded, implemented, and enforced.

• Laws and policies must be evaluated, like other public health interventions. Evaluation findings can show whether a law or policy is having its desired impact, should be amended, or is causing unintended consequences.

When considering how to address a public health challenge, leaders or communities can examine diverse legal or policy interventions as tools to achieve a public health goal. Different communities might choose distinct legal or policy approaches to achieve similar goals.

Law and policy have been part of Healthy People since its inception, but their roles have varied. Some Healthy People objectives have focused on 

existing laws and policies; others have corresponded to law-and policy-related interventions that have been evaluated and tested and therefore have data demonstrating success toward achieving the desired goal. When law-and policy-relevant data and surveillance information are available, it is possible to project and evaluate the potential and actual impacts of such interventions on specific health targets.

The 1979 Surgeon General's report that launched Healthy People 4 addressed laws, legislation, and regulations in the following areas: reducing the risk of injuries from not wearing seat belts; following speed and helmet laws; labeling foods to give consumer information; ensuring access to optimal levels of community water fluoridation; providing health and safety standards to citizens at all levels; and offering legal aid services to protect older adults. 5, 6 For the 1990 health objectives, each topic was required to address relevant "legislative and regulatory issues," if appropriate. The introduction to this initial set of objectives emphasized the need for legal and public policy research to explore trade-offs between economic returns and health outcomes, as well as short-term versus long-term goals. 7 Over the next 3 decades, objectives in Healthy People 2000, Healthy People 2010, and Healthy People 2020 addressed law and policy to varying degrees (Table 1) . Healthy People 2010 referred to 2 public health law models on public health infrastructure: the Turning Point Model State Public Health Act 8 and the Model State Emergency Powers Act. 9 Healthy People 2020 mentioned policy in its mission to "engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge." 10 Achieving its goal to create "social and physical environments that promote good health for all" would require laws and policies that produce healthy environments. Many Healthy People objectives that do not focus directly on law and policy would benefit from legal and policy approaches to reach their targets.

Healthy People 2030 has fewer objectives dealing directly with law and policy than previous decades, in part, because the initiative has fewer objectives overall 11 and since criteria 12 for selecting objectives this decade adhere strictly to standards for data sources. 13 Nonetheless, the Healthy People 2030 framework, including its foundational principles and plan of action, emphasizes laws and policies and encourages users to examine their effects at the national, state, tribal, and community levels. Table 2 provides selected examples of how laws and policies 

influence life circumstances, systems, and societal institutions, thereby affecting health and well-being. Healthy People 2030 offers an opportunity for individuals and entities in diverse sectors and at all levels (ie, national, tribal, state, or community) to use laws and policies as tools to address health disparities and health inequities and improve health and well-being in this decade. Health and well-being are defined as how people think, feel, and function-at a personal and social level-and how they evaluate their lives as a whole. 26 To change the culture of health and well-being in America, Healthy People 2030 reaches across all sectors of the economy-public, private, and nonprofit. This broad outreach strategy reflects the view that health and well-being are shaped by the social, economic, and physical circumstances of people's lives-not solely by health care services. Laws and policies can play important roles in supporting or informing implementation of health and well-being initiatives.

After a law is passed, a regulatory process occurs, offering users one of many potential opportunities to provide input. Investments and monitoring are needed to ensure that laws are applied as intended. A law that passes with adequate funding and with promulgated regulations that provide guidance on how to administer it is more likely to be effective. Variation occurs in ways that laws and policies affect health initiatives' implementation throughout the United States-over time, by geography and by location-from states to neighborhoods or microneighborhoods.

Health-harming structural and social determinants of health are neither natural nor immutable. They are human-made-often through the creation, revision, repeal, or lack of law and policy-and they can be dismantled through human efforts. Healthy People 2030 users should consider using laws and policies as tools to eliminate health disparities, achieve health equity, and attain health literacy. Table 3 shows examples of legal or policy levers that can be used to advance Healthy People 2030 objectives and support health and well-being.

Additional areas where there are opportunities to advance health and well-being through legal and policy interventions include the following:

• Housing: Lead-based paint was regularly used in housing built prior to 1950, and it remains the most common source of lead poisoning. Low-income children who live in older or substandard housing are at particular risk, since they are more likely to ingest peeling paint or lead-contaminated dust. 29 Lead poisoning irreversibly damages the developing brain and nervous system. 30 Substandard housing conditions such as mold and dust mites can also cause or exacerbate asthma symptoms. 31 • The COVID-19 pandemic: COVID-19 has exacerbated the existing crisis of inadequate access to affordable housing, and only a patchwork of eviction prevention measures is available to protect families from becoming homeless. 32 • Efforts to promote access to healthy foods in low-income communities: In Minneapolis, 33 in 2015, the Staple Food Ordinance required licensed businesses to stock minimum quantities and varieties of 10 types of healthy foods and beverages, including fruits, vegetables, whole grains, and other staples. 34 Separately, Philadelphia instituted a sweetened beverage tax as a measure to reduce soda intake and childhood obesity; the taxes were used to support early childhood education. 35 Relevant frameworks and models can guide individuals and entities in working toward the Healthy People 2030 goal to "engage leadership, key constituents, and the public across multiple sectors to take action and design policies that improve the health and well-being of all." Three examples are as follows:

An HIAP approach relies on collaboration 36 and reflects the understanding that many pressing population health challenges, such as inequities, chronic disease, and the need for insurance reform, are complex, multidimensional, interconnected, and linked to social, economic, and physical environments.

There are a number of models that discuss the role of law and policy to improve health. 37 One such framework explores the use of policies and laws to promote public health and safety. 38 Five featured legal and policy tools are as follows: (a) direct regulation (penalties for risky behavior); (b) deregulation (dismantling legal barriers to desired health behaviors); (c) economic incentives and/or use of subsidies; (d) economic disincentives (ie, taxation and spending); and (e) redress through the court system (civil litigation). These tools can be used to modify environments (eg, built, or physical, socioeconomic, or informational). 3. Multisectoral collaboration: Multisectoral law and policy efforts can shape the economic, physical, and social environments. Improving Require through statute or regulation that children must be vaccinated before starting kindergarten or have an approved waiver.

(1) "Command approach"-Develop laws and policies that require children to be vaccinated before entering school.

(2) "Nudge" approach increases compliance by making vaccinations more difficult to avoid (eg, requiring waivers for school vaccination policies so that students must "opt-out" rather than "opt-in").

Reduce the proportion of persons who are unable to obtain or delayed in obtaining necessary medical care.

(AHS-04)

Remove regulations that create barriers to care when doing so supports health; make it easier to use telehealth for appointments and to access services.

During COVID-19, HHS removed some Medicare payment requirements for in-person care to allow for increased telehealth opportunities, thereby improving safety and reducing potential exposures. 27 Economic incentives

Increase the proportion of students participating in the School Breakfast Program.

(AH-04)

Ensure that breakfast is available to students and that they participate. In schools with a majority of students who are low income, provide increased funding for the School Breakfast Program or adopt a Universal School Breakfast program so that little to no additional effort is needed to participate.

Reduce consumption of added sugars by people who are 2 y and older.

(NWS-10)

Add a tax or fee to sugary products to discourage purchases. A tax on sugar-sweetened beverages could be imposed by a city (eg, by the ounce).

Redress through the court system

Reduce blood lead levels in children aged 1-5 y.

(EH-04)

Ensure lead is removed from housing stock (paint) and water sources (pipes). Enforce ordinances prohibiting lead paint in rental housing. Philadelphia established a specialty Lead Court in conjunction with the health department to work with landlords and tenants to ensure remediation of properties in violation. 28

November/December 2021 • Volume 27, Number 6 Supp www.JPHMP.com

individual and population health and well-being requires partnerships and intersectoral initiatives (eg, among users in education, justice, and employment) to create healthier environments. 3 These efforts can leverage the growing interest in clinical-community-business relationships to create community-wide collaborations.

All people can take part in informing and developing laws and policies. By engaging in the formulation of laws and policies at the national, tribal, state, or community levels, users can work to improve health and well-being in the United States and drive progress on the Healthy People 2030 objectives. The Healthy People 2020 Law and Health Policy Project examined ways that law and policy can be used as tools to achieve Healthy People objectives, offering models and examples for this decade. 39 A collaboration among the Robert Wood Johnson Foundation (RWJF), Centers for Disease Control and Prevention (CDC), CDC Foundation, and the HHS Office of Disease Prevention and Health Promotion, the project developed products communicating the importance of evidence-based legal and policy interventions for reaching Healthy People targets and highlighted examples of how law and policy have been implemented in states, on tribal lands, and in communities around the country. 39, 40 Questions arise as to which laws should supersede (eg, those at the federal or state level, or those at the local level). In the summer of 2020, an example of preemption-the dilemma created when a higher level of government supersedes a lower level of government 41 -occurred in Georgia, where the governor sued the mayor of Atlanta to block a local ordinance that mandated mask wearing in public to slow the spread of COVID-19. 42 Variations in local-level policy come into play in measuring and aggregating state-level health outcomes. As local-level variations in the implementation and enforcement of laws and policies increase, measurement becomes increasingly important and complex.

Healthy People 2030 provides a chance for individuals and entities to show the impacts of law and policy and offers a landscape for stimulating new methods and identifying new data sources to achieve national goals. The field can better understand how variations in laws and policies across the federal, state, tribal, or community levels produce different health outcomes in targeted populations by using highquality surveillance data to measure their effects.

There are opportunities for natural experiments that can be evaluated in a rigorous manner. The rescinding of laws or policies offers one such opportunity since laws and policies can be amended over time, are sometimes rescinded altogether, and can vary from one state to another (or among even more precise geographic locations). For example, the Assault Weapon Ban was enacted federally in 1994 and then allowed to sunset in 2004. An assessment found use of highcapacity semiautomatics as a share of guns used in crime grew by more than 3-fold in the years following expiration of the federal ban. 43 Existing resources can support such work. For example, CDC's Community Guide to Preventive Services and RWJF's County Health Rankings and Roadmaps "What Works for Health?" initiatives provide evidence-based recommendations for public health interventions. The work of organizations that collect, synthesize, and report on the effectiveness of certain types of health-related laws and policies can inform and shape laws and policies for this decade. Such organizations include, but are not limited to, those conducting rigorous evaluation work (eg, the Center for Public Health Law Research, CDC's Public Health Law Program), those that educate about the role of law and policy and share examples of state laws (eg, the Public Health Law Center, the National Conference of State Legislatures), and those that help groups to implement evidence-based practices (eg, the Network for Public Health Law, ChangeLab Solutions). The field is evolving and has a range of rigor; Healthy People offers opportunities to strive for increased rigor.

The new area of legal epidemiology, the "scientific study and deployment of law as a factor in the cause, distribution, and prevention of disease and injury in a population," 44 offers insights into how such measurement could be conducted. It focuses on legal prevention and control (ie, laws and legal practices as interventions to prevent disease and injury), legal etiology (ie, laws and legal practices as causes of disease and injury), and policy surveillance (ie, collecting, analyzing, and disseminating information about laws and other policies that are important to health and well-being). Such tools can be used to assess the impact of public health interventions on Healthy People objectives and on achieving health equity. Proponents of legal epidemiology seek to remove barriers, such as limited availability of timely and rigorous evaluation of the effects of law and legal practices on health, to the effective use of legal action to benefit public health. 45

Introducing new laws and policies or rescinding existing ones offers a chance to rigorously assess outcomes and to weigh the balance of good outcomes against unintended consequences. For example, when federal regulations first began requiring the installation of airbags in cars, lives were saved in frontal collisions. Yet, in the mid-1990s, airbags were found to kill children whose car seats were positioned in front passenger seats. Both good outcomes and unintended consequences occurred. 46 The balance of saved lives was significant. However, evaluation quickly identified that other actions and regulations were needed to ensure that no child seats would be placed in the front seats of cars. Another example of why it is important to evaluate the effects of policies is allowing the exemption of children from vaccination. All 50 states have laws requiring specific vaccines for children, but 45 states and District of Columbia grant exemptions for children whose families have religious objections, and 15 states allow exemptions for people with philosophical objections to vaccinations (https://www.cdc. gov/phlp/docs/school-vaccinations.pdf). Rising rates of nonmedical exemptions could increase vulnerability to disease outbreaks. Rigorous assessment of outcomes related to laws and policies makes explicit the linkages between law, policy, and health and wellbeing.

The COVID-19 pandemic has exposed gaps that need to be addressed for society to return to a new normal that is better than before. For example, during approximately 2 months following the declaration of the coronavirus-related US national emergency on March 13, 2020, vaccination rates for routine pediatric vaccines had dropped by 71%. 47 Children who are not protected by vaccines are more vulnerable to diseases, such as measles. Continued and coordinated efforts among health care providers and public health officials at the national, tribal, state, and local levels will be necessary to achieve catch-up vaccination. Policy approaches may be a highly effective tool for preventing exposures to other communicable disease outbreaks and protect the health of the public.

Researchers and public health leaders can examine the bidirectional effects of laws and policies at the national, tribal, state, and local levels on health and well-being. The local level is often a place of innovation where leaders can act in response to local conditions, and their successes can bubble up. Similarly, local levels can examine the effects on health and well-being over time of changes in federal, state, and tribal policies.

■ Laws and policies are important levers to improve health and well-being.

■ It is crucial to measure and monitor the effect on the health status of populations of legal and policy interventions. Assessments should examine the degree to which such interventions achieve equity, contribute to the effectiveness of health promotion programs, and shape the behaviors of various sectors that influence population health.

■ The impact of laws and policies on health and well-being should be studied in the same manner as other public health interventions. This may be challenging, however, because laws and policies can take years to demonstrate impact. This delayed effect adds to the difficulty of generating short-term scientific evidence within a limited time frame on whether the law or policy contributes to progress toward an objective. As Healthy People enters its fifth decade, longer-term evaluations and interim outcomes for process assessments are needed.

Health law as social justice

Health justice: a framework (and call to action) for the elimination of health inequity and social injustice

Committee on Public Health Strategies to Improve Health, Institute of Medicine. For the Public's Health: Investing in a Healthier Future

Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention

US Department of Health and Human Services. The 1990 Health Objectives for the Nation: A Midcourse Review

Health progress in the United States: results of the 1990 objectives for the nation

Public Health Service, Office of the Assistant Secretary for Health. Promoting Health/Preventing Disease: Objectives for the Nation

The Turning Point Model State Public Health Act: emergency public health law versus civil liberties

Objectives 23-15 (a) and (b), public health infrastructure

Office of Disease Prevention and Health Promotion. Healthy People 2020 Web site

Assistant Secretary of Health and Human Services for Planning and Evaluation Web site

Medicaid's impact on health care access, outcomes and state economies

FDR Presidential Library & Museum Web site

Historic redlining and asthma exacerbations across eight cities of California: a foray into how historic maps are associated with asthma risk

Report: Washington's Three Strikes Law. Columbia Legal Services Web site

Stanford Law School Web site

Health care dollars and regulatory sense: the role of advanced practice nursing

American Association of Nurse Practitioners Web site

Status of state Medicaid expansion decisions: interactive map. Kaiser Family Foundation Web site

Bus. v. Sebelius, 567 US 519. Casetext Web site

The coverage gap: uninsured poor adults in states that do not expand Medicaid. Kaiser Family Foundation Web site

For states that opt out of Medicaid expansion: 3.6 million fewer insured and $8.4 billion less in federal payments

US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Data sources and methods. Healthy People

Health, and well-being, in issue briefs to inform development and implementation of Healthy People 2030. Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2030

Committee-Combined-Issue%20Briefs_2019-508c.pdf. Accessed

Removing regulatory barriers to telehealth before and after COVID-19. Brookings Web site

Public health and law collaboration: the Philadelphia Lead Court Study

Center for Healthy Housing Web site

Wood Johnson Foundation Web site

Homes of low-income minority families with asthmatic children have increased condition issues

COVID-19 Housing Policy Scorecard. Eviction Lab Web site

Counting carrots in corner stores: the Minneapolis Staple Foods Ordinance. Healthy People 2020 Web site

Evaluation of the first U.S. staple foods ordinance: impact on nutritional quality of food store offerings, customer purchases and home food environments

Supreme Court upholds Philly's soda tax. WHYY Web site

Well-Being in All Policies": promoting cross-sectoral collaboration to improve people's lives

Better health faster: the 5 essential public health law services

Public Health Law: Power

Office of Disease Prevention and Health Promotion. Law and health policy. Healthy People 2020 Web site

Law and Health Policy Project. Healthy People 2020 resources. Public Health Law Program Web site

While virus surges, Georgia Governor sues Atlanta Mayor to block mask rules. The New York Times

Criminal use of assault weapons and high-capacity semiautomatic firearms: an updated examination of local and national sources

A transdisciplinary approach to public health law: the emerging practice of legal epidemiology

Perspectives from the field: using legal epidemiology to advance public health practice

Predictors of hazardous child seating behavior in fatal motor vehicle crashes: 1990 to 1998

Effects of the COVID-19 pandemic on routine pediatric vaccine ordering and administration-United States