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Committee on Public Health Strategies to Improve Health
Board on Population Health and Public Health Practice
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board
of the National Research Council, whose members are drawn from the councils of the National
Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The
members of the committee responsible for the report were chosen for their special competences
and with regard for appropriate balance.
This study was supported by Contract No. 65863 between the National Academy of Sciences
and Robert Wood Johnson Foundation. Any opinions, findings, conclusions, or recommenda-
tions expressed in this publication are those of the author(s) and do not necessarily reflect the
view of the organizations or agencies that provided support for this project.
International Standard Book Number-13: 978-0-309-18691-9
International Standard Book Number-10: 0-309-18691-9
Additional copies of this report are available from the National Academies Press, 500 Fifth
Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in
the Washington metropolitan area); Internet, http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at: www.
iom.edu.
Copyright 2011 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures
and religions since the beginning of recorded history. The serpent adopted as a logotype by
the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche
Museen in Berlin.
Suggested citation: IOM (Institute of Medicine). 2011. For the Public’s Health: Revitalizing
Law and Policy to Meet New Challenges. Washington, DC: The National Academies Press.
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“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
— Goethe
Advising the Nation. Improving Health.
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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of
distinguished scholars engaged in scientific and engineering research, dedicated to the
furtherance of science and technology and to their use for the general welfare. Upon
the authority of the charter granted to it by the Congress in 1863, the Academy has
a mandate that requires it to advise the federal government on scientific and techni-
cal matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter
of the National Academy of Sciences, as a parallel organization of outstanding en-
gineers. It is autonomous in its administration and in the selection of its members,
sharing with the National Academy of Sciences the responsibility for advising the
federal government. The National Academy of Engineering also sponsors engineer-
ing programs aimed at meeting national needs, encourages education and research,
and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi-
dent of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of
Sciences to secure the services of eminent members of appropriate professions in
the examination of policy matters pertaining to the health of the public. The Insti-
tute acts under the responsibility given to the National Academy of Sciences by its
congressional charter to be an adviser to the federal government and, upon its own
initiative, to identify issues of medical care, research, and education. Dr. Harvey V.
Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sci-
ences in 1916 to associate the broad community of science and technology with the
Academy’s purposes of furthering knowledge and advising the federal government.
Functioning in accordance with general policies determined by the Academy, the
Council has become the principal operating agency of both the National Academy
of Sciences and the National Academy of Engineering in providing services to the
government, the public, and the scientific and engineering communities. The Council
is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph
J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the
National Research Council.
www.national-academies.org
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COMMITTEE ON PUBLIC HEALTH
STRATEGIES TO IMPROVE HEALTH
MARTHE R. GOLD (Chair), Professor and Chair, Department of
Community Health and Social Medicine, Sophie Davis School of
Biomedical Education, City College, New York, NY
STEVEN M. TEUTSCH (Vice Chair), Chief Science Officer, Los Angeles
County Department of Public Health, Los Angeles, CA
LESLIE BEITSCH, Associate Dean for Health Affairs; Director, Center
on Medicine and Public Health, Florida State University College of
Medicine, Tallahassee, FL
JOYCE D. K. ESSIEN, Director, Center for Public Health Practice, Rollins
School of Public Health, Emory University; Retired Medical Officer,
Captain US Public Health Service, Centers for Disease Control and
Prevention, Atlanta, GA
DAVID W. FLEMING, Director and Health Officer for Public Health,
Seattle & King County, Seattle, WA
THOMAS E. GETZEN, Professor of Risk, Insurance and Health
Management, Fox School of Business, Temple University; Executive
Director, International Health Economics Association (iHEA)
Philadelphia, PA
LAWRENCE O. GOSTIN, Linda and Timothy O’Neill Professor of Global
Health Law and the Director of the O’Neill Institute for National and
Global Health Law at Georgetown University, Washington, DC
GEORGE J. ISHAM, Medical Director and Chief Health Officer,
HealthPartners, Bloomington, MN
ROBERT M. KAPLAN, Director, Office of Behavioral and Social Sciences
Research, National Institutes of Health, Bethesda, MD
WILFREDO LOPEZ, General Counsel Emeritus, New York City
Department of Health and Mental Hygiene, NY
GLEN P. MAYS, Professor and Chairman, Department of Health Policy
and Management, Fay W. Boozman College of Public Health, University
of Arkansas Medical Sciences, Little Rock, AR
PHYLLIS D. MEADOWS, Associate Dean for Practice, Office of Public
Health Practice; Clinical Professor, Health Management and Policy,
University of Michigan, Ann Arbor, MI
MARY MINCER HANSEN, Director of the Masters of Public Health
Program; Adjunct Associate Professor, Department of Global Health,
Des Moines University, IA
POKI STEWART NAMKUNG, Health Officer, Santa Cruz County Health
Services Agency, Santa Cruz, CA
MARGARET E. O’KANE, President, National Committee for Quality
Assurance, Washington, DC
v
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DAVID A. ROSS, Director, Public Health Informatics Institute, The Task
Force for Global Health, Decatur, GA
MARTÍN JOSÉ SEPÚLVEDA, IBM Fellow and Vice President,
International Business Machines Corporation, Somers, NY
STEVEN H. WOOLF, Professor, Departments of Family Medicine,
Epidemiology, and Community Health, Virginia Commonwealth
University, Richmond, VA
Study Staff
ALINA B. BACIU, Study Director
AMY GELLER, Program Officer
ALEJANDRA MARTÍN, Research Assistant
ALLISON BERGER, Senior Program Assistant
ROSE MARIE MARTINEZ, Board Director, Board on Population Health
and Public Health Practice
vi
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Reviewers
This report has been reviewed in draft form by individuals chosen
for their diverse perspectives and technical expertise, in accordance with
procedures approved by the National Research Council’s Report Review
Committee. The purpose of this independent review is to provide candid
and critical comments that will assist the institution in making its published
report as sound as possible and to ensure that the report meets institutional
standards for objectivity, evidence, and responsiveness to the study charge.
The review comments and draft manuscript remain confidential to protect
the integrity of the deliberative process. We wish to thank the following
individuals for their review of this report:
Susan Allan, University of Washington
Bobbie Berkowitz, Columbia University Medical Center
Denise Chrysler, University of Michigan School of Public Health
Susan J. Curry, The University of Iowa
Leah Devlin, University of North Carolina Chapel Hill
Kenneth W. Kizer, University of California Davis Health System
Elizabeth A. McGlynn, Kaiser Permanente Center for Effectiveness &
Safety Research
David Meltzer, University of Chicago
Margaret A. Potter, University of Pittsburgh
Helen Rubenstein, William Mitchell College of Law
Derek Yach, Pepsi Co., Inc.
vii
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viii REVIEWERS
Although the reviewers listed above have provided many constructive
comments and suggestions, they were not asked to endorse the conclusions
or recommendations nor did they see the final draft of the report before its
release. The review of this report was overseen by Mark R. Cullen, Stanford
University, and Hugh Tilson, University of North Carolina. Appointed by
the National Research Council and Institute of Medicine, they were respon-
sible for making certain that an independent examination of this report was
carried out in accordance with institutional procedures and that all review
comments were carefully considered. Responsibility for the final content of
this report rests entirely with the authoring committee and the institution.
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Contents
Preface: Introduction to the Series of Reports xi
Summary 1
1 Introduction: Why Law and Why Now? 13
From the History of the Law and Public Policy in Public Health, 20
Values, Social Norms, and the Public View of Health, 23
References, 25
2 The Law and Public Health Infrastructure 27
The Organization of Government Public Health in the
United States, 27
Modernizing Public Health Statutes, 33
The Locus of Government Responsibility for the Public’s Health, 48
References, 52
3 Law and the Public’s Health: Law as a Tool for Improving
Population Health 57
Models of Legal Intervention, 57
Other Examples of Legal and Policy Tools, 61
Conclusion, 68
References, 68
ix
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x CONTENTS
4 Intersectoral Action on Health 73
Pathways Between Health and Its Determinants, 75
The Role of Policy as a Determinant of Health, 76
The “Health in All Policies” Movement, 79
Structures to Support Collaboration in Promoting Health in
All Policies, 90
The Role of Scientific Evidence in HIAP, 94
References, 104
APPENDIXES
A Acronyms 111
B Meetings Agendas Held by the Committee on Public Health
Strategies to Improve Health (May 2010–December 2010) 113
C Committee Biosketches 117
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Preface:
Introduction to the Series of Reports
In 2009, the Robert Wood Johnson Foundation asked the Institute of
Medicine (IOM) to convene a committee to examine three topics in rela-
tion to public health: measurement, the law, and funding. The committee’s
complete three-part charge is provided in Box P-1. The IOM Committee
on Public Health Strategies to Improve Health explored the topics in the
context of contemporary opportunities and challenges and with the pros-
pect of influencing the work of the health system (broadly defined as in the
report summary) in the second decade of the 21st century and beyond. The
committee was asked to prepare three reports—one on each topic—that
contained actionable recommendations for public health agencies and other
stakeholders that have roles in the health of the U.S. population. This report
is the second in the series.
The committee’s three tasks and the series of reports prepared to re-
spond to them are linked by the recognition that measurement, laws, and
funding are three major drivers of change in the health system. Measurement
(with the data that support it) helps specialists and the public to understand
health status in different ways (for example, by determinant or underlying
cause where national, local, and comparative evidence is available), to un-
derstand the performance of the various stakeholders in the system, and to
understand the health-related results of investment. Measurement also helps
communities to understand their current status, to determine whether they
are making progress in improving health, and to set priorities for their next
actions. Although the causal chains between actions of the health system
and health outcomes are not always clearly elucidated, measurement is a
fundamental requirement for the reasons listed above.
xi
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xii PREFACE
BOX P-1
Charge to the Committee
Task 1 (completed)
The committee will review population health strategies, associated metrics, and
interventions in the context of a reformed health care system. The committee will
review the role of score cards and other measures or assessments in summariz-
ing the impact of the public health system, and how these can be used by policy
makers and the community to hold both government and other stakeholders ac-
countable and to inform advocacy for public health policies and practices.
Task 2 (accomplished in the present report)
The committee will review how statutes and regulations prevent injury and dis-
ease, save lives, and optimize health outcomes. The committee will systematically
discuss legal and regulatory authority; note past efforts to develop model public
health legislation; and describe the implications of the changing social and policy
context for public health laws and regulations.
Task 3 (to be addressed in a forthcoming report)
The committee will develop recommendations for funding state and local health
systems that support the needs of the public after health care reform. Recom-
mendations should be evidence based and implementable. In developing their
recommendations the committee will:
• Review current funding structures for public health,
• Assess opportunities for use of funds to improve health outcomes,
• Review the impact of fluctuations in funding for public health,
• Assess innovative policies and mechanisms for funding public health ser-
vices, and community-based interventions and suggest possible options
for sustainable funding.
Laws transform the underpinnings of the health system and also act
at various points in and on the complex environments that generate the
conditions for health. Those environments include the widely varied policy
context of multiple government agencies, such as education, energy, and
transportation agencies, as well as many statutes, regulations, and court
cases intended to reshape the factors that improve or impede health. The
measures range from national tobacco policy to local smoking bans and
from national agricultural subsidies and school nutrition standards to local
school-board decisions about the types of foods and beverages to be sold in
school vending machines.
Funding that supports the activities of public health agencies is provided
primarily by federal, state, and local governments. However, government
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xiii
PREFACE
budgets must balance a variety of needs, programs, and policies, and the
budgets draw on different sources (including different types of taxes and
fees), depending on jurisdiction. Therefore, the funds allocated to public
health depend heavily on how the executive and legislative branches set
priorities. Other funding sources support public health activities in the
community, including “conversion” foundations formed when nonprofit
hospitals and health insurers became privatized (such as The California
Wellness Foundation). Additionally, funds for population health and medi-
cal care activities may be provided by community-based organizations with
substantial resources, not-for-profit clinical care providers, and stakeholders
in other sectors.
The subjects addressed in the three reports are not independent of each
other and, indeed, should be viewed together. For example, measurement of
health outcomes and of progress in meeting objectives can provide evidence
to guide the development and implementation of public health laws and
the allocation of resources for public health activities. Laws and policies
often require the collection of data and can circumscribe the uses to which
the data are put, for example, prohibiting access to personally identifiable
health information. Similarly, statutes can affect funding for public health
through such mechanisms as program-specific taxes or fees. And laws shape
the structure of public health agencies, grant them their authority, and influ-
ence policy.
In the three reports, the committee will make a case for increased ac-
countability of all sectors that affect health—including the clinical care de-
livery system, the business sector, academe, nongovernment organizations,
communities, and various government agencies—wherever possible, with
coordination by the government public health agency leading or coordinat-
ing activities and sectors. The committee’s first report, released in December
2010, focused on measurement of population health and related account-
ability at all levels of government. The present report reflects the commit-
tee’s thinking about legal and public policy reform on three levels: first,
pertaining to the public health agencies’ powers, duties, and limitations as
defined in enabling statutes (i.e., that establish their structure, organization,
and functioning); second, the use of legal and policy tools to improve the
public’s health; and third, pertaining to other sectors of government at the
national, state, and local levels, and the role of a diverse set of private and
not-for-profit sector actors. The committee’s final report on funding, will
consider resource needs and approaches to addressing them in a predictable
and sustainable manner to ensure a robust population health system.
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