FOR THE PUBLIC’S HEALTH
Revitalizing Law and Policy to Meet
Committee on Public Health Strategies to Improve Health
Board on Population Health and Public Health Practice
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
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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 recommendations 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.
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Copyright 2011 by the National Academy of Sciences. All rights reserved.
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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.
“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
Advising the Nation. Improving Health.
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
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 technical 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 engineers. 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 engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president 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 Institute 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 Sciences 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.
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
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
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
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.
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 responsible 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.
In 2009, the Robert Wood Johnson Foundation asked the Institute of Medicine (IOM) to convene a committee to examine three topics in relation 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 prospect 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 respond 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 understand 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.
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 summarizing 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 accountable 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 disease, 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. Recommendations 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 services, 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
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 medical 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 influence policy.
In the three reports, the committee will make a case for increased accountability of all sectors that affect health—including the clinical care delivery system, the business sector, academe, nongovernment organizations, communities, and various government agencies—wherever possible, with coordination by the government public health agency leading or coordinating activities and sectors. The committee’s first report, released in December 2010, focused on measurement of population health and related accountability at all levels of government. The present report reflects the committee’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.