State Public Health Law Reform

Assessing the Policy Impact of the Turning Point Model State Public

Health Act

Benjamin Mason Meier, JD, LLM, MPhilColumbia University

COLUMBIA UNIVERSITY

CENTER FOR HEALTH POLICY

March 30, 2009

Outline

Background Framework Methods Results Analysis Implications/

Limitations Future Research

Public Health Law Reform

Law as a Determinant of Health

Future of Public Health Public Health Law

Reform Assessment of State

Public Health Enabling Laws

“…the Nation’s public health infrastructure would be strengthened if jurisdictions had a model law and could use it regularly for improvements.”

Healthy People 2010

“State public health laws are, in many cases, seriously outdated…”

“Public health law in the United States is ripe for reform”

Turning Point Statute Modernization Collaborative

Mission “To transform and

strengthen the legal framework for the state public health system through a collaborative process to develop a model state public health law.”

The Turning Point Model State Public Health Act Phase I: State Public

Health Law Assessment Phase II: Development of

a Model Law Turning Point Model State

Public Health Act - released September 2003

Phase III: Dissemination & Education

Turning Point Act - Topics

Topics addressed within the Act’s 9 substantive Articles include: Mission and Essential Services Public Health Infrastructure Collaboration and Relationships Public Health Authorities and Powers Public Health Emergencies Public Health Information Privacy Administrative Procedures, Criminal/Civil

Enforcement

Turning Point Act - States That HaveIntroduced and Passed Bills or Resolutions

Legislative Tracking

States have used the Act as the basis for state public health law reforms

Wisconsin Act 198, “An

Act Related to Public Health,” is based on multiple articles /provisions of the Act

Passed Bills: 26

Transforming National Collaboration into State Legislation—Study Design

Natural Experiment Objectives - Assess the Impact of the

Turning Point Act Compare how the Turning Point Act is used by policy-

makers in public health law reforms Describe the effectiveness of the Turning Point Act as a

model for state law Apply lessons from the Turning Point experience to

future reform efforts and empirical research

Conceptual Framework

Why How Reasons for Reform

(Grad 1990, Gostin 2000) Antiquated Unfocused Inconsistent

Process of Reform

(Gebbie 1998, 2000) Stages Actors Forces

Working Assumption

Policy consideration of the Turning Point Act will differ in form, substance, and process according to: state political institutions, individual actors, and perceived imperatives in public health

Methods - Comparative Case Study

Comparative Method Varied Responses to

the Same Model

Case Selection – Congruence with the Turning Point Act Legal Analysis of

Reforms in Comparison with Model Act

Informant Sample Legislators Bureaucrats Advocates

Semi-Structured Interviews Public health problems

addressed by reforms Obstacles to reform Subsequent changes in public

health programs

Content Analysis

Individual Case Studies

Wisconsin Alaska Nebraska South Carolina

Comparative Results – State Political and Policy Efforts Matter

ALASKA

The Turning Point Experience

Top-Down Reform

Republican Support for a “Democratic Bill”

Politicization of Public Health

WISCONSIN

The Turning Point Experience

Stakeholder Collaboration

Bottom-Up Reform

Strong Legislative Champion

Non-Politicization

SOUTH CAROLINA

Lack of an External Galvanizing ForceBureaucratic Expansiveness and the Risk of Backsliding

NEBRASKA

Stakeholder Collaboration

Lack of Legislative Support

Risk of Backsliding

Selective Incorporation by Regulation

ALASKA

The Turning Point Experience

Top-Down Reform

Republican Support for a “Democratic Bill”

Politicization of Public Health

WISCONSIN

The Turning Point Experience

Stakeholder Collaboration

Bottom-Up Reform

Strong Legislative Champion

Non-Politicization

NEBRASKA

Stakeholder Collaboration

Lack of Legislative Support

Risk of Backsliding

Selective Incorporation by Regulation

SOUTH CAROLINA

Lack of an External Galvanizing Force

Bureaucratic Expansiveness and the Risk of Backsliding

Alaska—A Process Model of Successful State Public Health Law Reform

Stage I: Stage I: Emergence and Utilization of the Act

Dominant Actors Turning Point

Collaborative Division of Public

HealthKey Forces

Agenda SettingResult

Model Developed for Discussion of Issue

Stage III:Stage III: Legislative Action

Dominant Actors Legislators Division of Public

Health Advocacy Groups

Key Forces Politicization of

Public Health Result

Reform of State Public Health Law

Stage II:Stage II: Development of Draft Law

Dominant Actors Division of Public

Health Office of the

Attorney GeneralKey Forces

Public Health Imperatives

Result State Law

Developed Pursuant to Turning Point Act

Analysis – Correlates of Reform

Facilitators Inhibitors

Contributing Partner

Meetings Begin

Turning Point Act Completed

Assembly Bill 881 Introduced

South Carolina Department of Health

and Environmental Control

Public

Health

Ass’n

Health Commissione

r DOH

Assembly Chair Activi

stGovernor

Agenda Setting Key Partnerships

Gap Analysis

Legislative Champions

Fear of Backsliding Lack of Legal

Leadership

Lack of Impetus for Reform

Unaltered Model Language

Analysis – Common Correlates

Comparative Process Model – Stages of Reform, Principal Actors and Decisive Forces

I. Utilization of the Turning Point Act

II. Development of Draft Law

III. Regulatory Action

Actors Public Health Partners

Legal Counsel Legislative Champions

Forces Agenda Setting Gap AnalysisLeadership

Advocacy

Implications / Limitations

Resources to support future reforms

Little understanding of current state of law

Need for additional research on: State of Public Health

Legislation Effect of Law on

Performance

Meier, Hodge & Gebbie(2007-2009)

Transitions in State Public Health Law: Comparative Analysis of State Public Health Law Reform

Journal of Health

Politics, Policy

and Law

Report from the FieldAlaska Public Health Law Reform

Future Studies

Competencies for Applying LawGap Analyses for Public Health Law ReformsRelationship between Public Health Law Reform and Health System Performance

Essential Services in Law (Meier, Merrill & Gebbie 2009) Law & Performance (Merrill, Meier, Keening & Gebbie 2009)

Link between Public Health Law, Individual Health Behaviors, and Public Health Outcomes

Conclusions

States selectively codify provisions of the Turning Point Act based upon individual, political, and institutional factors.

Additional research is necessary to determine the effect of these reformed laws.

For more information on legislative tracking and comparative case studies, see: www.publichealthlaw.net/Resources.htm.

Benjamin Mason Meier, JD, LLM, MPhilColumbia Universitybmm2102@columbia.edu

Legislative Tracking

Passed Bills: 26

Alaska HB 95 – An Act relating to the

duties of the Dept of Health & Social

Services (June 2005)

AB 881 – An Act Related to Public Health

(March 2006)

No Proposed Legislation or Regulation

173 NAC 6 – Directed Health Measures to

Prevent or Limit the Spread of Communicable Disease, Illness, or

Poisoning (Feb. 2007)

WISCONSINALASKANEBRASKASOUTH CAROLINA

Case Selection – Congruence with the Turning Point Act

Legislative Tracking

Passed Bills: 26

Little understanding of current state of law