1. Linda Rudolph, MD, MPH Public Health Institute September 24, 2013 Policy as a Tool for Improving the Public’s Health: The role of government in promoting and protecting health

2. 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

3. 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

4. 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

5. 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

7. Environments impact health

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9. Environments shape opportunities and behaviors

10. Market failures can harm health Positive or negative externalities Inadequate or incorrect information Market and economic actors influence people’s preferences

11. Frieden Pyramid

12. Back to the Future Rudolph 2013

14. 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

15. 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

16. 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 consequences From: Rudolph L, Caplan J, Dillon L, Ben-Moshe K. (2013) Health in All Policies: A Guide for State and Local Governments. APHA and PHI

17. 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

18. 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

19. Thank you. Linda Rudolph, MD, MPH Public Health Institute linda.rudolph@phi.org linda.rudolph@phi.org