For the Public's Health Revitalizing Law and Policy to Meet New Challenges (2011) / Chapter Skim
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2 The Law and Public Health Infrastructure
2 The Law and Public Health Infrastructure
Pages 27-56
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From page 27... ...
The committee then reviews the recent history of public health law reform, and discusses the changes needed to equip the governmental public health sector to lead and support efforts to improve population health. Finally, the committee discusses the critical question of public health federalism -- that is, the optimal locus of responsibility and authority among the levels of government with regard to health-relevant public policy.
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From page 28... ...
. These include a decentralized or home rule arrangement, under which local public health agencies operate independently of the state and report to local government; a centralized model in which there are no local public health agencies,
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that provide the agencies with authority to conduct public health activities and 2A similar typology, but one that describes five types of local public health agencies, may be found in NACCHO's Local Public Health Agency Infrastructure: A Chart Book (2001)
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. State public health statutes have been reviewed and well-characterized by model Act efforts such as the Turning Point Model State Public Health Act and the Model State Emergency Health Powers Act, both of which provide templates for updating the statutory foundations of public health practice.
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.3 The 10 EPHS have been used as a tool for planning, implementation, and evaluation in public health. Given their purpose to illustrate the range of public health practice, 3 The American Public Health Association, the Association of Schools of Public Health, the Association of State and Territorial Health Officials, the Environmental Council of the States, the National Association of County and City Health Officials, the National Association of State Alcohol and Drug Abuse Directors, the National Association of State Mental Health Program Directors, and the Public Health Foundation.
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However, the 10 EPHS do necessarily spell out the roles of non-health or non-governmental public health actors, or provide a map for implementing health in all policies approaches (intersectoral efforts to consider the health implications of non-health policies)
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. Public health laws need to be sufficiently broad to deal with unforeseen threats, while still giving public officials clearly specified powers and limits.
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In addition to the factors described above, other major shifts have occurred in the backdrop to public health laws, including demographics, health challenges, and in aspects of public health practice. For example, the population lives much longer and the age distribution of the population ranges across a much wider lifespan than was the case when some early public health laws were framed.
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From page 35... ...
jurisdiction -- state, local, tribal, or federal -- is yet fully legally prepared to respond to a major public health threat." Key issues they identified include vaccine allocation, distribution, and dispensing issues; coordination among levels of government about the use of stockpiled material; and the need for sustainable public health response funding. The authors noted that the laws and policies related to the vaccine campaign "presented significant challenges, especially for state and local public health responders," including decisions on vaccine availability, formulation, allocation, prioritization, and guidance as well as tracking, recalls, and adverse event reporting.
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From page 36... ...
When considering the need for change in contemporary public health law, there are several contextual factors and fundamental transformations that must be considered, including • n ational health legislation that holds the promise of expanding ac cess to medical care, thus partially releasing public health agencies from the need to provide safety net clinical services; • a renewed emphasis on and commitment to quality performance and accountability of public health agencies (e.g., the national Public Health Accreditation effort, the 2008 HHS Consensus State ment on Quality in the Public Health System 2009) , and the 2007 Pandemic and All Hazards Preparedness Act provision requiring development of performance standards and measures by (Nelson et al., 2007)
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From page 37... ...
Prior Efforts to Update Public Health Law Two major efforts to review and update public health law took place around the turn of the 21st century: the Turning Point Model State Public Health Act (1997–2003) and Model State Emergency Health Powers Act (MSEHPA, 2001–2002)
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From page 38... ...
The first, advanced by the state public health association, failed because it did not find "the support of those with the political capital necessary to advance these ideas into law" given the majority in power in the Alaskan legislature, but the second emerged from the Republican governor's administration, developed by highly competent leadership of the state public health agency, and was successfully enacted. In the South Carolina case study, a beleaguered public health leadership did not want to risk existing authority by trying to get greater specificity in their enabling statutes, and ultimately did not seek to enact public health reform.
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From page 39... ...
Although this can be accomplished at the state level, it may be less immediately realistic at the local level given the existence of 18,000 local jurisdictions. Recommendation 1: The committee recommends that state and lo cal governments, in collaboration with their public health agencies, review existing public health laws and modernize these as needed to assure that appropriate powers are in place to enable public health agencies to address contemporary challenges to population health.
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. Public Health Accreditation The national public health accreditation effort has intensified discussions about the challenges and opportunities of restructuring local public health in order to enhance capacity and quality of service delivery.
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The rationale for the public health accreditation effort includes addressing the gaps and variations and inadequacies in public health infrastructure. The literature on clinical care system accreditation appears to indicate that the success of accreditation in improving or raising the bar on quality is dependent on factors such as institutional commitment and the collection of quality and better data collection (Greenfield and Braithwaite, 2008; Lewis, 2007)
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From page 42... ...
. The committee believes that governmental public health agencies need to adopt an accreditation process to demonstrate minimum structural and TABLE 2-1 The Relationship Between Existing State-Based Accreditation or Performance Assessment Systems and State Statutes State Type of Program Relationship to Statute Illinois Certification program required for Not addressed in statute, but counties wanting responsibility for supported under authorities of the delegated public health programs state department of public health Michigan Accreditation program based on No specific references in statute, but minimum program requirements and agency draws general authority from required to receive state funding statute Missouri Voluntary accreditation program for Not specifically called for in local public health agencies legislation; independent accreditation body for resource reasons North Accreditation Required by state legislation that Carolina even specifies three categories of accreditation status Washington An assessment program for each Required by legislation local health department or state public health program (Public Health Improvement Plan)
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From page 43... ...
Second, one crucial element that is lacking in many smaller health departments is legal, policy development, and policy analysis capability. Addressing Capacity Challenges of Multiple Small Public Health Agencies The local level of the public health infrastructure described above is highly fragmented among 2,794 local public health agencies (Fielding et al., 2010; Salinsky, 2010)
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From page 44... ...
Proposals have been made on different ways to reorganize local public health structure toward greater effectiveness. Understandably, given the difficulty and lack of resources invested in studying and interpreting findings on this subject, there is a dearth of research and evidence on optimal public health agency structures and related statutory and governance issues.
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From page 45... ...
Disasters and major public health threats cast a bright light on public health agency capabilities and limitations. The National Association of City and County Health Officials has identified four structural and operational approaches to achieving optimal emergency preparedness functioning, but these may be more broadly useful in describing what is currently available in the field.
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From page 46... ...
may be influenced by potentially conflicting agendas, political influences, timelines, and various priorities. This may also mean that counsel has expertise in public policy, but not necessarily specific public health knowledge or any appreciable understanding of public health law.
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From page 47... ...
Hiring attorneys with grant funds and embedding them within particular grant-funded programs to work in an isolated manner may also not be optimal.9 Moreover, the increasing availability of legal assistance from several existing national academic or not-for profit sources such as the Public Health Law Network, while beneficial, cannot take the place of an official legal advisor that is recognized by, and part of the same team as the health officer and the jurisdiction's chief executive. Public health agency legal counsel would require training in public health and in public health law, and should have knowledge and experience in the following areas: • L aws that establish the public health agency and set forth its juris diction and authorities • P rogrammatic aspects of the agency's work • P rocedures and processes consistent with applicable laws and policies Such experience can be obtained through adequate career ladders within a health department, through education or, ideally, a combination of both.
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From page 48... ...
. Following logically from this is that national-level crises such as pandemics and bioterrorism threats require the substantial resources of the federal government, while a localized environmental threat may only require the involvement of the local public health agency.
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From page 49... ...
preemption of state and local authority can often be harmful from a public health standpoint because it can compromise the ability of public health practitioners to implement more stringent standards that may be important and well accepted in a local setting. Ceiling preemption also interferes with local control over local needs and with local-level accountability, and it could limit the ability of jurisdictions to meet the needs of constituents.
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From page 50... ...
Preemption in the field of public health may also lead to non-enforcement of a preemptive federal standard. As discussed below, when a federal agency is given preemptive authority to regulate in an area that local public health agencies have a greater capacity and infrastructure to regulate, the result will likely be that the public health measure will not be enforced.
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From page 51... ...
Food service establishments such as restaurants have historically been regulated and inspected by state and local health departments, and these agencies have well-established, albeit strained, inspection workforces in place. There is also an adjudicatory infrastructure, such as state courts or administrative tribunals, to enforce the sanitary laws and regulations under the auspices of public health agencies.
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From page 52... ...
2007. Public health laws and implications for a national accreditation program: Parallel roadways without intersection?
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2001. Informational privacy and the public's health: The Model State Public Health Privacy Act.
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2009. Major components and themes of local public health laws in select U.S.
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2007. Contrasting experiences of state public health law reform pursuant to The Turning Point Model State Public Health Act.
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2003. Model State Public Health Act: A Tool for Assessing Public Health Laws.
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