1. Modernizing Public Health Laws in the 21 st Century: The Impact of the Turning Point Model State Public Health Act on State Legislative Reforms James G. Hodge, Jr. J.D., LL.M. Center for Law and the Public’s Health, Georgetown & Johns Hopkins Universities Benjamin Mason Meier, J.D., LL.M., M.Phil. & Kristine M. Gebbie, Dr.PH, R.N. Center for Health Policy, Columbia University School of Nursing

2. A Brief Overview  Public Health Law Reform in the 21 st Century  The Turning Point Statute Modernization Project  The Turning Point Model State Public Health Act Scope Parameters State Legislative Update  Assessing the Turning Point Act – Analyses from Key Jurisdictions

3. Public Health Law Reform in the 21 st Century The Institute of Medicine, The Department of Health and Human Services, The Trust for America’s Health, Dozens of State Legislators and Health Departments, The Turning Point Statute Collaborative, and others agree...

4. Public Health Law Reform in the 21 st Century Public health law in the United States is ripe for reform

5. Assessment of State Public Health Law  Antiquated. Public health statutes are outdated and may fail to reflect modern constitutional norms, public health and biological sciences, individual and population ethics, and public health practices, policies, and relationships  Unfocused. Public health law does not always articulate a clear mission for public health, nor reflect core or essential public health services.  Inconsistent and Complicated. Public health law is varied and complicated, difficult for the public to comprehend, and challenging at times for health officials to implement

6. Benefits of Public Health Law Reform  Modernize and amend antiquated laws to keep pace with scientific developments  Reflect modern constitutional, legal, and ethical norms  Clarify public health legal powers and duties  Stimulate public health dialogue with policy makers and communities  Improve communication and working relationships within the public health system  Improve public health programs/outcomes

7. Risks of Public Health Law Reform  Statutory editions may change the landscape of public health practice  Changes in public health laws may add costs without matching resources  Statutory reform in state legislatures is fraught with potential complications and compromises  Modernizing public health laws does not assure improved public health practices

8. State Public Health Law Reform Despite the risks, the essential question concerning public health law reform among state law- and policy-makers is not why, but how?

9. “…the Nation’s public health infrastructure would be strengthened if jurisdictions had a model law and could use it regularly for improvements.” DHHS, Healthy People 2010 (similarly stated in IOM, Future of Public Health..., 2003) State Public Health Law Reform

10. Turning Point 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.

11. Turning Point Timeframe Phase I: State Public Health Law Assessment - completed May 31, 2001 Phase II: Development of a Model Law - completed August 31, 2003 Turning Point Model State Public Health Act - released September 16, 2003 Phase III: Dissemination & Education - ongoing

12. Core Collaborative Partners  Alaska  Wisconsin  Colorado  Nebraska  Oregon  CDC  HRSA  APHA  ASTHO  NACCHO  National Governors’ Association  National Conference of State Legislatures  National Indian Health Board  National Association of Local Boards of Health  Institute of Medicine

13. The Turning Point Model State Public Health Act  Scope  Parameters  State Legislative Update  Case Studies in Specific States

14. The Turning Point Act - Scope The Turning Point Act is the most comprehensive model state public health act ever produced in the United States.

15. The Turning Point Act - Topics Topics addressed within the Act’s 9 substantive Articles include: Mission and Functions Public Health Infrastructure Collaboration and Relationships Public Health Authorities and Powers Public Health Emergencies (re: MSEHPA) Public Health Information Privacy (re: the MSPHPA) Administrative Procedures, Criminal/Civil Enforcement

16. The Turning Point Act – What It Is  Legislative provisions for states to use as a tool to compare to their existing public health laws  Balance of community and individual interests to protect the public’s health while respecting civil liberties  Incorporation of an intersectoral public health infrastructure  Essential public health services and functions that can be used in a wide array of public health responses.  Attempt to incorporate modern scientific methods of public health practice consistent with key policy choices.

17. The Turning Point Act – What It Is Not  A mandate to states to improve their public health laws.  Design for a model state and local public health system.  An attempt to cover all areas of public health relevance (e.g., mental health, substance abuse, environmental health).  Specification of public health powers based on certain diseases (e.g., HIV/AIDS, tuberculosis) or conditions (e.g., obesity, injuries).  The only acceptable policy choices for public health practice.

18. The Turning Point Act – Legislative Update  The subject matter of the Act has been featured in over 110 different state legislative bills or resolutions introduced in 33 states since January 1, 2003. Of these bills, 44 have passed in 25 different states.  Many states have used or are using the Act (in whole or part) to assess their existing state public health laws (e.g., AK, AZ, CO, DE, MT, NE, MI, NM, OR, TN, WI)  Alaska HB 95, “An Act relating to the duties of the Dept of Health & Social Services,” passed in June 2005, is directly based on multiple provisions of the Act.

19. CA OR WA ID MT TX SD WY NV OK KS NE CO NM AZ UT ND SC MN WI IA MO AR LA VA NC GA FL AL MS IL WV KY TN NY PA IN OH MI DE NJ CT ME DC MD NHVT PR - (Puerto Rico) HI AK The Turning Point Act - States that have Introduced Bills or Resolutions RI MA MSEHPA Introduced Bills Total: 33 States Data Current as of October 24, 2006

20. CA OR WA ID MT TX SD WY NV OK KS NE CO NM AZ UT ND SC MN WI IA MO AR LA VA NC GA FL AL MS IL WV KY TN NY PA IN OH MI DE NJ CT ME DC MD NHVT PR - (Puerto Rico) HI AK The Turning Point Act - States that have Passed Bills or Resolutions RI MA MSEHPA Passed Bills Total: 25 States Data Current as of October 24, 2006

21. Transforming National Collaboration into State Legislation—A Comparative Case Study  Justification  Justification – Assess how the Turning Point Act is currently being used by state and local law- and policy- makers in legislative and regulatory reform initiatives  Scope  Scope – Describe the effectiveness of the Turning Point Act as a means to promote public health through legal reforms at the state and local levels  Implications  Implications – Apply lessons learned from the Turning Point Act experience to future state legislative reform efforts

22. Public Health Law Reform Pursuant to the Turning Point Act METHODS  Case Study Method  Case Study Method – Successes and Failures  Legislators, Bureaucrats, Advocates  Semi-Structured Interviews  Role of the informant in the legal/regulatory changes  Public health problems addressed by the changes  Obstacles to changes in state law and the strategies used to overcome these obstacles  Subsequent changes in public health regulation, organization or programs based on legal reforms  Expected changes in public health outcomes

23. Preliminary Conclusions—State Political and Policy Efforts Matter ALASKA  The Turning Point Experience  Politicization of Public Health  Top-Down Reform WISCONSIN  The Turning Point Experience  Stakeholder Collaboration  Bottom-Up Reform  Strong Legislative Champion * Preliminary Results SOUTH CAROLINA  Lack of an External Galvanizing Force  Bureaucratic Expansiveness and the Risk of Backsliding

24. Example—A Process Model of Successful State Public Health Law Reform: Alaska Stage I: Stage I: The Emergence and Utilization of the Turning Point Act  Dominant Actors Turning Point Collaboration 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 Executive Branch Advocacy Groups  Key Forces The Turning Point Experience Politicization of Public Health Executive Prerogative  Result Reform of State Public Health Law Stage II: Stage II: The Development of Draft Law  Dominant Actors Division of Public Health Office of the Attorney General  Key Forces Public Health Necessities Political Efforts  Result State Law Developed to Pursuant to Turning Point Act

25. Conclusions  The Turning Point Act is a comprehensive model for state public health authorities to assess their existing laws.  The objective is to use law as a tool for targeted reform initiatives that collectively seek to improve public health infrastructure and outcomes.  Different states have incorporated various parts of the Turning Point Act into their law based upon individual, political, and institutional factors.  For more information, please see the Center for Law and the Public’s Health website at: www.publichealthlaw.net/ Resources/Modellaws.htm or the Center for Health Policy website at: http://www.nursing.hs.columbia.edu/research/ResCenters/chphsr/law_pubHealth.html. www.publichealthlaw.net/ Resources/Modellaws.htm http://www.nursing.hs.columbia.edu/research/ResCenters/chphsr/law_pubHealth.html  Thank you!