In recent years, much of the public policy conversation about Americans’ health has focused on reforming the health care system. But the public policies that affect Americans’ health—individually and as a nation—go far beyond the realm of medicine and health care. Policy choices related to the environment, agriculture, education, housing, transportation and more can all have a bearing on health and safety.
In an article in the November 2011 Health Affairs, Elizabeth Rigby, PhD, of the 2005-2007 cohort of the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program, notes that Congress recognized this reality in the Patient Protection and Affordable Care Act, the health care reform bill that President Obama signed into law in 2010. One of the law’s provisions created the National Prevention, Health Promotion, and Public Health Council (the Prevention Council), bringing together Cabinet-level officers from departments and agencies across the federal government to map policies for disease prevention, wellness and health promotion.
Rigby writes that the Prevention Council “provides an important opportunity to improve the nation’s health through a cross-sector approach to federal policy making.” But she goes on to note that the initiative “must overcome key challenges that stem from the current polarized political environment and budgetary crisis, inherent challenges to interagency collaboration, and the tendency for agencies to overlook the health impacts of policies designed to address non-health issues.”
“The Prevention Council is an exciting step forward,” Rigby says, “because it acknowledges what RWJF and the Health & Society Scholars program have been advancing for some time: that health is not just a function of health care or genetics, but also of the broader society in which we live, a society that the government and other institutions are involved in structuring.” Moreover, she says, the Prevention Council “really institutionalizes that acknowledgement with respect to the federal government by focusing on disease prevention not just at the Department of Health and Human Services, but at other agencies, too.”
An Ambitious Interagency Effort
Chaired by the U.S. Surgeon General, the Prevention Council is required by statute to include leaders of the Departments of Health and Human Services, Agriculture, Education, Transportation, Labor, Homeland Security, and Interior, as well as the Federal Trade Commission, the Environmental Protection Agency, the Office of National Drug Policy, the Domestic Policy Council, and the Corporation for National and Community Service. The Administration has also included an additional five representatives—one each from the White House Office of Management and Budget and from the Departments of Defense, Housing and Urban Development (HUD), Justice and Veterans Affairs.
An assistant professor at the Trachtenberg School of Public Policy at the George Washington University in Washington, D.C., Rigby points out that each of those departments or agencies operates programs that are specifically aimed at health issues. For example, the Department of Defense operates fitness and obesity programs; Housing and Urban Development runs a Healthy Homes program; and Justice has a youth violence prevention initiative.
Such programs have clear health implications, and Rigby says that the staff who operate them probably see the programs through that lens. “The next step,” she says, is to “broaden understanding of how ‘non-health policies’ affect health, within each of those agencies, so that it’s not just the person at HUD who deals with the lead paint inspection program, or who’s working to put playgrounds in subsidized housing communities, who thinks in terms of health.”
In her Health Affairs article, Rigby offers another example of “non-health programs” that have health effects. She notes that many experts believe the No Child Left Behind Act of 2001 has had a significant impact on children’s health, even though it does not focus on health objectives. The law requires states to administer standardized tests in a handful of academic subjects, as a condition of federal education funding. That requirement has, in turn, prompted schools to spend more time “teaching to the test,” which many believe has accelerated the trend away from physical education in public schools just as the pediatric obesity problem has worsened.
Cooperation and Awareness
Rigby writes that what’s needed is a “cooperation strategy” in which “officials in the health sector partner with colleagues in non-health agencies to help them meet their non-health objectives…. Over time, this strategy can help identify mutually beneficial arrangements. It can also increase the number of agency personnel who are aware of the unrecognized health impacts of their work, thereby broadening participation in future health-focused efforts.”
Rigby also suggests that the population health community conduct “health impact assessments” of proposed policies or regulations, evaluating proposals in terms of how they are likely to affect public health. Similar assessments of proposed policies are required by law where environmental impacts are anticipated, and cost-benefit analyses are commonly conducted to assess the economic impact of regulations expected to impose costs beyond a certain threshold. Assessments of likely health impacts would give policy-makers another lens through which to examine proposals, and they would help educate their counterparts in non-health areas about the far-reaching consequences of policies that might not on first glance have health implications.
Toxic Political Environment a Threat
In the meantime, the Prevention Council faces the challenge of surviving what Rigby describes as the “polarized political dynamic surrounding all aspects of the Affordable Care Act.” Opponents of the health reform law have taken aim at the Prevention Council and at the Prevention and Public Health Fund (the Prevention Fund) intended to support prevention efforts, often using harsh rhetoric. Opponents have dismissed the effort as “social engineering,” and called the Prevention Fund, a “health care slush fund,” Rigby says. She notes that such “criticisms tap long-standing ideological tensions between liberals and conservatives that could undermine support for the Prevention Council.”
Moreover, the ongoing budget fights in Washington could have an impact on funding. In 2011, the House of Representatives voted to eliminate the Prevention Fund, altogether. The White House promised a veto, and the bill eventually died in the Senate. However, as part of ongoing deficit-cutting efforts, the President has since proposed scaling back the Fund. Given budget pressures and Washington’s ongoing political polarization, funding is at best insecure.
Still, the Prevention Council and the Prevention Fund together mark an important turning point, Rigby says. Despite the funding insecurity, she expects the effort will move forward “because it’s so central to the effort to get health care costs under control, and because it funds a lot of programs that are very popular and important in local areas, where the politics are maybe not so intense.”
The Robert Wood Johnson Foundation Health & Society Scholars program is based on the principle that progress in the field of population health depends upon multidisciplinary collaboration and exchange. Its goal is to improve health by training scholars to investigate rigorously the connections among biological, genetic, behavioral, environmental, economic and social determinants of health and develop interventions that integrate and act on these determinants to improve health. The program is intended to produce leaders who will change the questions asked, the methods employed to analyze problems and the range of solutions to reduce population health disparities and improve the health of all Americans.