State Public Health Law Reform Assessing the Policy Impact of the Turning Point Model State Public Health Act Benjamin Mason Meier, JD, LLM, MPhil Columbia University COLUMBIA UNIVERSITY CENTER FOR HEALTH POLICY March 30, 2009

Outline Background Framework Methods Results Analysis Implications/Limitatio ns 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 Healthy People 2010 “State public health laws are, in many cases, seriously outdated…” “Public health law in the United States is ripe for reform”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 Have Introduced 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 Force Bureaucratic 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 Health Key Forces Agenda Setting Result 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 General Key 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 Commissioner DOH Assembly Chair Activist Governor 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 ActorsPublic Health Partners Legal CounselLegislative Champions ForcesAgenda SettingGap Analysis Leadership 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 ( ) Transitions in State Public Health Law: Comparative Analysis of State Public Health Law Reform Journal of Health Politics, Policy and Law Report from the Field Alaska Public Health Law Reform

Future Studies Competencies for Applying Law Gap Analyses for Public Health Law Reforms Relationship 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: Benjamin Mason Meier, JD, LLM, MPhil Columbia University

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