Linda Rudolph, MD, MPHPublic Health Institute

September 24, 2013

Policy as a Tool for Improving the Public’s Health:The role of government in promoting and protecting health

Common themes in arguments against public policy for public health

• Freedom vs. the “nanny state”• Government should not limit individual choice

• Individual responsibility is the key to health• People need to take responsibility for their own health• Self-restraint avoids self-inflicted harm

• Let the free market work• Government should not interfere with the market

• We shouldn’t act until the science is settled.• The costs of action outweigh the benefits

• Public health regulations are bad for business & the economy

Why public policy for public health?• Health is important• Public wants and expects government to protect health

• Costs of poor health impact economy• Environments impact health • Environments shape health opportunities and

behaviors• Market failures adversely impact health• Evidence supports public policy for health

Health is important• “The first wealth is health.” (Emerson)

• Healthier population: economic and social benefits

• Healthier population: foundation for more sustainable health care system

• People across political spectrum agree that investments to improve the health of communities makes sense

Shorter Lives, Poorer Health• U.S. among wealthiest nations, but far from healthiest• U.S. spends far more per person on health care than

any other nation• Americans dying at younger ages than people in

almost all other high- income countries• Americans have pattern of poorer health that is

strikingly consistent and pervasive over the life course• Even advantaged Americans—white, insured, college-

educated, upper income—in worse health than similar individuals in other countries

IOM. U.S. Health in International Perspective. 2013

Environments impact health

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Environments shape opportunities and behaviors

Market failures can harm health• Positive or negative externalities• Inadequate or incorrect information • Market and economic actors influence

people’s preferences

Frieden Pyramid

Back to the Future

Rudolph 2013

What can public policy do?

• Increase healthy options• Protect from unhealthy environments or

conduct• Influence preferences• Labelling, warnings, social marketing, incentives

• Price controls, subsidies, consumption taxes• Restrictions or bans• Population wide action

Sassi F, Hurst J. The prevention of lifestyle related disease: an economic framework. OECD working paper 32. Paris: OECD 2008.Frieden T.2013. http://www.nejm.org/doi/full/10.1056/NEJMp1303819

Active Transportation and Health

Maizlish, AJPH, 2013

Shift in active transport from <5 to 22 minutes/day (2% to 15% mode share) in Bay Area:

14% reduction heart disease, stroke, diabetes 6-7% reduction depression, dementia 5% reduction breast and colon cancer Added 9.5 months life expectancy 19% increase bike/ped injuries $1.4 to $22 billion annual Bay Area health

cost savings >14% reduction in GHG emissions

Health in All Policies collaborative approach to improving health

of all people by incorporating health considerations into decision-making across sectors and policy areas

decision-makers are informed about the health, equity, and sustainability consequences of policy options during policy development process

policy outcomes reflect those consequencesFrom: Rudolph L, Caplan J, Dillon L, Ben-Moshe K. (2013) Health in All Policies: A Guide for State and Local Governments. APHA and PHI

We need a California Health and Wellness Trust

• Nearly all federal and state health dollars go to medical care and research• Paltry levels of public spending on population-wide

health programs

• Social determinants of health contribute more to population health than medical care.

• Effective health promotion and disease prevention programs requires adequate and sustainable funding

• Everyone has a role to play; government role is key

Public health is a common good• “[T]he liberty secured by the Constitution...does

not import an absolute right in each person to be...wholly freed from restraint... ‘persons and property are subjected to all kinds of restraints and burdens in order to secure the general comfort, health, and prosperity of the state.’” (Supreme Court,1905, Jacobson v. Massachusetts)

• “The reason we have government in the first place is to solve problems collectively that we can’t solve individually.” (Thomas Farley, NYC Health Commissioner)

Wiley, L., 2012, Jl Law Med Ethics

Thank you.Linda Rudolph, MD, MPHPublic Health Institutelinda.rudolph@phi.org