implement a program, no matter how justified it appears to public health advocates. We must do a much better job of framing our message, as well as listening and responding to legitimate public concerns. Especially in the current antigovernment political environment, public health interventions must be framed so that the public can see that these are good ideas that will benefit individuals and communities. To present them otherwise is to risk a backlash and the further erosion of public health interventions. To be sure, we should not passively accept illegitimate complaints about paternalism. Nor should practitioners forego acting every time someone objects to some inconvenience. But our messaging strategy must focus on convincing the public we seek to serve of why our interventions are necessary and beneficial. Tone is clearly critical, but we should also rethink how we engage the public and use our legal tools. In the past, public health has been strongest at the conceptual level and much weaker at implementation. As the disastrous experience with Obamacare’s health exchanges demonstrates, implementation is as important as policy design. • Peter D. Jacobson University of Michigan School of Public Health • Wendy E. Parmet Northeastern University School of Law DOI: 10.1002/hast.243
uInnovative
Policies under Bloomberg’s ‘New’ Public Health
Professor Gostin describes how the Bloomberg administration’s public health measures represent a “‘new’ public health” of innovative initiatives. I want to suggest a definition for “innovative” in this context: innovative initiatives acknowledge that providing individuals with information is not sufficient to ensure healthy choices and that instead these initiatives must 6 HASTIN G S C E N T E R R E P ORT
target behavioral elements of decisionmaking. The evolution of the Bloomberg administration’s initiatives reflects a change in the way the administration views individual responsibility for health decisions: a move from trusting individuals to make good decisions for themselves to a more proactive—and, some may say, paternalistic—view that individuals need active help making good health decisions. Early policy initiatives focused on regulations limiting third-party harm (through restaurant and bar smoke-free laws) or providing consumers with information (through menu labeling requirements) in the hope that individuals would make better decisions. They targeted products with well-documented health risks (tobacco and trans fats). Bloomberg’s more
Bloomberg’s innovative health initiatives implicitly acknowledge the difficulty of making healthy choices. recent public health initiatives expanded beyond the justifications of third-party harm and included the restriction of products with empirically more tenuous ties to negative health effects (sugary drinks). Newer regulations thus seek to improve public health by actively providing individuals with an environment that fosters healthy choices and discourages unhealthy ones. In making choices about lifestyle and risk, individuals face two significant challenges. First, many health choices are complex. Making the healthy choice requires familiarity with information that has resulted from empirical studies on health outcomes. Second, many healthy choices are difficult to execute because of competing interests, specifically when choices involve trading off short-term pleasures for long-term health benefits. These challenges are evident in Bloomberg’s initiative requiring calorie information on restaurant menus and in the initiative’s shortcomings. Individuals reading this information may not
know how many calories they should consume in a single meal or that they should consider not only total calories but also sodium content and other nutritional factors. In addressing only the first challenge of making a healthy choice, this initiative may not be as effective as policy-makers had expected. Even if individuals overcome the first challenge, they still face the second. Unhealthy food can taste good, be quick and easy to prepare, and may also be cheaper. These forces conspire to complicate the execution of healthy choices, particularly for lower-income individuals who do not have the time or money to purchase or prepare healthier options. The benefits of unhealthy food are immediate, but the costs in terms of bad health may be years away. The evolution of Bloomberg’s public health initiatives seems to recognize the difficulty of executing healthy choices. Implicit in the administration’s decision to implement the sugary drink serving size restriction appears to be an acknowledgement that providing nutritional information alone is insufficient. Instead, Bloomberg’s innovative policies embrace the notion that successful health initiatives must be tailored to the particulars of human decision-making. The regulation about the serving size of sugary drinks, for example, is a multifaceted policy initiative that addresses behavioral patterns behind food and drink consumption. The regulation acts in some ways like a tax by making the consumption of sugary drinks more expensive. Individuals who want to purchase a thirty-two-ounce drink would be, in effect, forced to buy two sixteen-ounce drinks instead. The serving size restriction acts as an information disclosure to the extent that it suggests the appropriate serving size for sugary drinks. The consumer is forced to make separate purchase decisions for additional servings. The regulation allows the human body time to become satisfied between decision points and provides the consumer time to reflect before purchasing another drink. This type of intervention takes into consideration behavioral elements of decision-making to make the regulation as effective as possible while January-February 2014
not banning the product outright. As such, the serving size restriction provides an exemplar for the innovative policies of the “new” public health. • David P. Borden Washington, DC DOI: 10.1002/hast.244
uThe
Affordable Care Act and the Need for Public Health Leadership
Professor Gostin’s description of Mayor Bloomberg’s legacy is exactly on point. Bloomberg has implemented a series of public health interventions that have improved the lives not only of New Yorkers but also of people around the world, who are now able to point to his visionary efforts and say, “New York has done it. Why can’t we?” As mayor, Bloomberg was uniquely willing to maximize the authority of his office to further public health. As the United States moves toward implementation of the Affordable Care Act, there is now more than ever a need for public health leadership of Bloomberg’s caliber. For states like Kentucky, which has fully embraced the ACA, public health measures must become integral to the discussion of the future of health care delivery. As the only Southern state that is both running its own health benefit exchange and expanding Medicaid, Kentucky is poised to be healthier and more economically competitive. But meaningful progress on health outcomes requires that all stakeholders think holistically to build on the ACA, moving beyond the traditional popular viewing of health primarily through the lens of personal responsibility, toward a more inclusive framework acknowledging the myriad socioeconomic and environmental influences on health. A broad-based public health focus is not optional in a post-ACA world—the realities of health care cost control will demand it. Before, cost containment January-February 2014
was achieved primarily through costshifting (in employer-based and individual market coverage), tightened eligibility standards (under Medicaid) and more limited benefits (in all these cases). With the ACA coverage requirements, these strategies will no longer be possible—under the ACA, we are all in this together, and the health of each of us (along with the attendant costs of poor health) influences the cost for everyone. And we will be better for it, because for the first time there is no viable option for long-term cost control but to improve health at a population level. Make no mistake—access to health care is a critical precondition for health, as World Health Organization Director General Margaret Chan emphasized in stating that universal coverage is “the
A broad-based public health focus is mandatory in a postAffordable Care Act world. single most powerful concept that public health has to offer.” Kentucky has led many states in capitalizing on the ACA’s potential. But access to care is insufficient for population health without critical public health measures addressing the socioeconomic determinants that so strongly influence health outcomes, creating the conditions in which people can lead healthy, fulfilling lives. Bloomberg well understands this and continues to show tremendous leadership, most recently by successfully urging the City Council to raise to twenty-one the minimum age for tobacco purchases. New York now has among the lowest rates of youth smoking in the country—a dramatic improvement undoubtedly caused in significant part by the strong tobacco-control measures Bloomberg championed. In contrast, Kentucky’s rate is among the highest, an unsurprising statistic given relevant sociocultural factors: tobacco taxes are low, less than 40 percent of the population is covered by comprehensive smokefree workplace legislation, cigarettes are
sold—and in some cases smoked!—in some government buildings, and tobacco has deep historical cultural significance in much of the state. While the ACA requires coverage of tobacco cessation as a preventive service, the act changes none of the sociocultural factors influencing tobacco use. Without a systemic public health approach, Kentucky is likely to keep seeing lung cancer rates among the country’s highest—only now, under the ACA, millions more will be spent on lung cancer treatments, most of which will be unsuccessful, given the notoriously low lung cancer survival rates. We can and must do better. As public health advocates, we must continue to strengthen popular understanding of the linkages between health care, public health, and healthy lives, building on the momentum created by the ACA. As government, we should lead by example in structuring our workplaces and employee benefit packages. We must reject reflexive antipaternalistic objections of “my health is none of the government’s business.” This is patently false. As Gostin rightly observed, governments should be held accountable for the health of their inhabitants. And popular rhetoric to the contrary, no man is an island—our health, and our lives, are all intertwined. Bloomberg understood and acted upon this better than any elected leader in recent memory. Because of how he shifted the paradigm for the appropriate scope of government’s role in promoting population health, leaders around the country and the world may now stand on his shoulders as they strive to create societies in which all people have the ability to lead healthy, fulfilling lives. The views expressed herein are solely my own and do not necessarily represent the views of the Cabinet for Health & Family Services, Frankfort, KY, for which I am the executive director of the Office of Health Policy. • Emily Whelan Parento Cabinet for Health & Family Services, Frankfort, KY DOI: 10.1002/hast.245
H AS TI N GS C E N TE R RE P O RT
7
uInnovative
Policies under Bloomberg’s ‘New’ Public Health
Professor Gostin describes how the Bloomberg administration’s public health measures represent a “‘new’ public health” of innovative initiatives. I want to suggest a definition for “innovative” in this context: innovative initiatives acknowledge that providing individuals with information is not sufficient to ensure healthy choices and that instead these initiatives must 6 HASTIN G S C E N T E R R E P ORT
target behavioral elements of decisionmaking. The evolution of the Bloomberg administration’s initiatives reflects a change in the way the administration views individual responsibility for health decisions: a move from trusting individuals to make good decisions for themselves to a more proactive—and, some may say, paternalistic—view that individuals need active help making good health decisions. Early policy initiatives focused on regulations limiting third-party harm (through restaurant and bar smoke-free laws) or providing consumers with information (through menu labeling requirements) in the hope that individuals would make better decisions. They targeted products with well-documented health risks (tobacco and trans fats). Bloomberg’s more
Bloomberg’s innovative health initiatives implicitly acknowledge the difficulty of making healthy choices. recent public health initiatives expanded beyond the justifications of third-party harm and included the restriction of products with empirically more tenuous ties to negative health effects (sugary drinks). Newer regulations thus seek to improve public health by actively providing individuals with an environment that fosters healthy choices and discourages unhealthy ones. In making choices about lifestyle and risk, individuals face two significant challenges. First, many health choices are complex. Making the healthy choice requires familiarity with information that has resulted from empirical studies on health outcomes. Second, many healthy choices are difficult to execute because of competing interests, specifically when choices involve trading off short-term pleasures for long-term health benefits. These challenges are evident in Bloomberg’s initiative requiring calorie information on restaurant menus and in the initiative’s shortcomings. Individuals reading this information may not
know how many calories they should consume in a single meal or that they should consider not only total calories but also sodium content and other nutritional factors. In addressing only the first challenge of making a healthy choice, this initiative may not be as effective as policy-makers had expected. Even if individuals overcome the first challenge, they still face the second. Unhealthy food can taste good, be quick and easy to prepare, and may also be cheaper. These forces conspire to complicate the execution of healthy choices, particularly for lower-income individuals who do not have the time or money to purchase or prepare healthier options. The benefits of unhealthy food are immediate, but the costs in terms of bad health may be years away. The evolution of Bloomberg’s public health initiatives seems to recognize the difficulty of executing healthy choices. Implicit in the administration’s decision to implement the sugary drink serving size restriction appears to be an acknowledgement that providing nutritional information alone is insufficient. Instead, Bloomberg’s innovative policies embrace the notion that successful health initiatives must be tailored to the particulars of human decision-making. The regulation about the serving size of sugary drinks, for example, is a multifaceted policy initiative that addresses behavioral patterns behind food and drink consumption. The regulation acts in some ways like a tax by making the consumption of sugary drinks more expensive. Individuals who want to purchase a thirty-two-ounce drink would be, in effect, forced to buy two sixteen-ounce drinks instead. The serving size restriction acts as an information disclosure to the extent that it suggests the appropriate serving size for sugary drinks. The consumer is forced to make separate purchase decisions for additional servings. The regulation allows the human body time to become satisfied between decision points and provides the consumer time to reflect before purchasing another drink. This type of intervention takes into consideration behavioral elements of decision-making to make the regulation as effective as possible while January-February 2014
not banning the product outright. As such, the serving size restriction provides an exemplar for the innovative policies of the “new” public health. • David P. Borden Washington, DC DOI: 10.1002/hast.244
uThe
Affordable Care Act and the Need for Public Health Leadership
Professor Gostin’s description of Mayor Bloomberg’s legacy is exactly on point. Bloomberg has implemented a series of public health interventions that have improved the lives not only of New Yorkers but also of people around the world, who are now able to point to his visionary efforts and say, “New York has done it. Why can’t we?” As mayor, Bloomberg was uniquely willing to maximize the authority of his office to further public health. As the United States moves toward implementation of the Affordable Care Act, there is now more than ever a need for public health leadership of Bloomberg’s caliber. For states like Kentucky, which has fully embraced the ACA, public health measures must become integral to the discussion of the future of health care delivery. As the only Southern state that is both running its own health benefit exchange and expanding Medicaid, Kentucky is poised to be healthier and more economically competitive. But meaningful progress on health outcomes requires that all stakeholders think holistically to build on the ACA, moving beyond the traditional popular viewing of health primarily through the lens of personal responsibility, toward a more inclusive framework acknowledging the myriad socioeconomic and environmental influences on health. A broad-based public health focus is not optional in a post-ACA world—the realities of health care cost control will demand it. Before, cost containment January-February 2014
was achieved primarily through costshifting (in employer-based and individual market coverage), tightened eligibility standards (under Medicaid) and more limited benefits (in all these cases). With the ACA coverage requirements, these strategies will no longer be possible—under the ACA, we are all in this together, and the health of each of us (along with the attendant costs of poor health) influences the cost for everyone. And we will be better for it, because for the first time there is no viable option for long-term cost control but to improve health at a population level. Make no mistake—access to health care is a critical precondition for health, as World Health Organization Director General Margaret Chan emphasized in stating that universal coverage is “the
A broad-based public health focus is mandatory in a postAffordable Care Act world. single most powerful concept that public health has to offer.” Kentucky has led many states in capitalizing on the ACA’s potential. But access to care is insufficient for population health without critical public health measures addressing the socioeconomic determinants that so strongly influence health outcomes, creating the conditions in which people can lead healthy, fulfilling lives. Bloomberg well understands this and continues to show tremendous leadership, most recently by successfully urging the City Council to raise to twenty-one the minimum age for tobacco purchases. New York now has among the lowest rates of youth smoking in the country—a dramatic improvement undoubtedly caused in significant part by the strong tobacco-control measures Bloomberg championed. In contrast, Kentucky’s rate is among the highest, an unsurprising statistic given relevant sociocultural factors: tobacco taxes are low, less than 40 percent of the population is covered by comprehensive smokefree workplace legislation, cigarettes are
sold—and in some cases smoked!—in some government buildings, and tobacco has deep historical cultural significance in much of the state. While the ACA requires coverage of tobacco cessation as a preventive service, the act changes none of the sociocultural factors influencing tobacco use. Without a systemic public health approach, Kentucky is likely to keep seeing lung cancer rates among the country’s highest—only now, under the ACA, millions more will be spent on lung cancer treatments, most of which will be unsuccessful, given the notoriously low lung cancer survival rates. We can and must do better. As public health advocates, we must continue to strengthen popular understanding of the linkages between health care, public health, and healthy lives, building on the momentum created by the ACA. As government, we should lead by example in structuring our workplaces and employee benefit packages. We must reject reflexive antipaternalistic objections of “my health is none of the government’s business.” This is patently false. As Gostin rightly observed, governments should be held accountable for the health of their inhabitants. And popular rhetoric to the contrary, no man is an island—our health, and our lives, are all intertwined. Bloomberg understood and acted upon this better than any elected leader in recent memory. Because of how he shifted the paradigm for the appropriate scope of government’s role in promoting population health, leaders around the country and the world may now stand on his shoulders as they strive to create societies in which all people have the ability to lead healthy, fulfilling lives. The views expressed herein are solely my own and do not necessarily represent the views of the Cabinet for Health & Family Services, Frankfort, KY, for which I am the executive director of the Office of Health Policy. • Emily Whelan Parento Cabinet for Health & Family Services, Frankfort, KY DOI: 10.1002/hast.245
H AS TI N GS C E N TE R RE P O RT
7
