Law and Policy as Tools in Healthy People 2030

Abstract

Laws and policies are critical determinants of health and well-being. They can encourage positive behaviors and discourage harmful behaviors, and they can enhance or worsen health, health equity, health disparities, and health literacy. Recognizing their contribution to conditions in the environments in which people are born, live, learn, work, play, worship, and age, and people's experiences of these conditions, the US Department of Health and Human Services considered the roles of law and policy throughout its development of Healthy People 2030. Laws and policies often interrelate, but they have different purposes. A law is an established procedure, standard, or system of rules that members of a society must follow. A policy is a decision or set of decisions meant to address a long-term purpose or problem. Healthy People 2030 offers an opportunity for users in diverse sectors and at all levels to use laws and policies to support or inform the initiative's implementation, address health disparities and health inequities, and improve health and well-being in this decade. Introducing new laws and policies or rescinding existing ones to achieve Healthy People 2030 goals offers a chance to rigorously assess outcomes and weigh the balance of good outcomes against unintended consequences.

Context

Together, laws and policies form the foundation for US society, guiding its behaviors and norms and determining its resiliency. Laws and policies are critical determinants of health and well-being. They can encourage positive behaviors and discourage harmful behaviors, and they can enhance or worsen health, health equity, health disparities, and health literacy. Central to the entire range of economic sectors, they contribute to conditions in the environments in which people are born, live, learn, work, play, worship, and age, and people's experiences of these conditions.1,2 Recognizing this critical influence on improving health, the US Department of Health and Human Services (HHS) considered the role of laws and policies throughout the development of Healthy People 2030.

Law and policy often interrelate, but they have different purposes.

• A law is an established procedure, standard, or system of rules that members of a society must follow. Laws take many forms, such as constitutional law, statutes, regulations, and case law (ie, court decisions).

• A policy is a decision or set of decisions meant to address a long-term purpose or problem.

Laws and policies shape everyday life circumstances, societal institutions, and systems. A policy is not in itself a law, but the policy-making process can identify laws that are needed to accomplish the policy's goals. Policies set out goals and planned activities; laws establish institutional and legal frameworks to achieve them. This article discusses law and policy as levers to improve the health and well-being of populations. It highlights selected examples of objectives specifying a law or policy in Healthy People 2030 and earlier decades.

By defining the parameters of individuals' and communities' environments, laws and policies can support health by encouraging beneficial behaviors and healthful circumstances; they can also impede good health or have unequal or unintended effects on health outcomes. When a law or policy negatively affects population health (eg, by preempting health-protective local laws), programs designed to foster healthful individual behaviors may be inadequate to produce beneficial outcomes for health.3

Law and policy include statutes, regulations, case law, subregulatory guidance, and institutional policies. Laws and policies can be adopted and influenced at multiple levels—federal, state, tribal, local, and ev-en organizational/institutional. As shown in Figure 1, each branch of government—executive, legislative, or judicial—plays a unique role in shaping laws and policies, and the process of developing them is continuous (see https://www.usa.gov/branches-of-government).

FIGURE 1.

Devising Laws and Policies at All Levels of Government to Meet Healthy People Goals^a

^aDetailed information on branches of the US government can be found at https://www.usa.gov/branches-of-government.

Figure 2 illustrates that the development of law and policy is a continuous, cyclical process that proceeds from development to enactment, implementation, enforcement, evaluation, and back to development. Resources are needed to ensure that we can move from implementation to enforcement.

FIGURE 2.

Law and Policy Development—A Continuous Process.

Important steps in creating and influencing laws and policies include the following:

• Leaders and communities identify problems and advance ideas to try to solve them.

• Some of those ideas can be enacted or adopted as legal or policy actions.

• Law and policy interventions must be funded, implemented, and enforced.

• Laws and policies must be evaluated, like other public health interventions. Evaluation findings can show whether a law or policy is having its desired impact, should be amended, or is causing unintended consequences.

When considering how to address a public health challenge, leaders or communities can examine diverse legal or policy interventions as tools to achieve a public health goal. Different communities might choose distinct legal or policy approaches to achieve similar goals.

Historical uses of law and policy within Healthy People

Law and policy have been part of Healthy People since its inception, but their roles have varied. Some Healthy People objectives have focused on existing laws and policies; others have corresponded to law- and policy-related interventions that have been evaluated and tested and therefore have data demonstrating success toward achieving the desired goal. When law- and policy-relevant data and surveillance information are available, it is possible to project and evaluate the potential and actual impacts of such interventions on specific health targets.

The 1979 Surgeon General's report that launched Healthy People4 addressed laws, legislation, and regulations in the following areas: reducing the risk of injuries from not wearing seat belts; following speed and helmet laws; labeling foods to give consumer information; ensuring access to optimal levels of community water fluoridation; providing health and safety standards to citizens at all levels; and offering legal aid services to protect older adults.5,6 For the 1990 health objectives, each topic was required to address relevant “legislative and regulatory issues,” if appropriate. The introduction to this initial set of objectives emphasized the need for legal and public policy research to explore trade-offs between economic returns and health outcomes, as well as short-term versus long-term goals.7

Over the next 3 decades, objectives in Healthy People 2000, Healthy People 2010, and Healthy People 2020 addressed law and policy to varying degrees (Table 1). Healthy People 2010 referred to 2 public health law models on public health infrastructure: the Turning Point Model State Public Health Act8 and the Model State Emergency Powers Act.9 Healthy People 2020 mentioned policy in its mission to “engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge.”10 Achieving its goal to create “social and physical environments that promote good health for all” would require laws and policies that produce healthy environments. Many Healthy People objectives that do not focus directly on law and policy would benefit from legal and policy approaches to reach their targets.

TABLE 1. Healthy People Across the Decades: Objectives and Topic Areas Addressing a Law or Policy.

Decade	Objectives That Specify a Law and Policy	Topic Areas With Law and Policy Objectives	Topic Areas
Healthy People 1990	4 of 226 objectives	3 of 15 topic areas	Toxic Agent and Radiation Control; Smoking and Health; Nutrition
Healthy People 2000	27 of 319 objectivesa	10 of 22 topic areas	Tobacco; Substance Abuse: Alcohol and Other Drugs; Violent and Abusive Behavior; Unintentional Injuries; Occupational Safety and Health; Environmental Health; Food and Drug Safety; Cancer, Diabetes and Chronic Disabling Conditions; Immunization and Infectious Diseases
Healthy People 2010	23 of ∼1000 objectivesb	6 of 28 topic areas	Environmental Health; Injury and Violence Prevention; Physical Activity and Fitness; Public Health Infrastructure; Substance Abuse; Tobacco Use
Healthy People 2020	59 of >1200 objectivesb	10 of 42 topic areas	Adolescent Health; Early and Middle Childhood; Environmental Health; Injury and Violence Prevention; Maternal, Infant, and Child Health; Nutrition and Weight Status; Physical Activity; Preparedness; Substance Abuse; Tobacco Use
Healthy People 2030	7 of 355 objectives	3 of 42 topic areas/work groups	Environmental Health; Oral Health; Tobacco Use

^aIn Health People 2000, some objectives were included under more than 1 topic area. Duplicate objectives were given more than 1 objective number (eg, 3.11 and 10.18) to indicate that they fell under each of those topic areas. For this exercise, these objectives are counted twice to reflect they are in both topic areas.

^bIn Healthy People 2010 and Healthy People 2020, some objectives are grouped under a main objective “header.” The subobjectives are the measurable objectives. The number of relevant objectives reflects all measurable objectives that are related to law and policy.

Law and policy in Healthy People 2030

Healthy People 2030 has fewer objectives dealing directly with law and policy than previous decades, in part, because the initiative has fewer objectives overall11 and since criteria12 for selecting objectives this decade adhere strictly to standards for data sources.13 Nonetheless, the Healthy People 2030 framework, including its foundational principles and plan of action, emphasizes laws and policies and encourages users to examine their effects at the national, state, tribal, and community levels. Table 2 provides selected examples of how laws and policies influence life circumstances, systems, and societal institutions, thereby affecting health and well-being.

TABLE 2. Selected Examples of How Laws and Policies Affect Health and Well-being.

How Laws and Policies Behave	How Laws and Policies Influence Life Circumstances, Societal Institutions, Systems	Selected Examples: Intended Consequences of Laws and Policies	Selected Examples: Effects of Laws and Policies on Health
Shape social conditions and structures that affect inequities.	Mitigate or exacerbate poverty, racism, illness, market failure, racism, or individual behavior that harms others.	Medicaid—Expand access to “mainstream” health care for low-income individuals and families.14	Even before Medicaid expansion under the Patient Protection and Affordable Care Act of 2010 (ACA), Medicaid coverage was associated with a range of positive health behaviors and outcomes for vulnerable populations.15
Maintain social conditions at the federal, tribal, and state levels.	Maintain current effects (eg, physical, mental, and emotional impacts) of laws and policies on the health and well-being of individuals and populations.	In 1933, the Home Owners Loan Corporation (HOLC) began a program, institutionalized as the Wagner-Steagall Housing Act in 1937,16 to reduce home foreclosures during the Depression. Redlining was the unintended consequence.	Residents of 8, historically redlined California cities shows neighborhoods are more than twice as likely as their peers to visit emergency departments for asthma. Redlined neighborhoods show higher levels of diesel particulate matter in the air.17
Distribute health and well-being across populations.	Apply the law selectively based on characteristics of the individual or population.	“Three Strikes, You're Out” laws—In 1993, Washington State was first to pass a policy mandating that anyone convicted of a third serious felony was sentenced to life in prison without possibility of parole.18 The policy's intent was to serve justice for crime victims; prevent crimes; and encourage criminals to leave the state, retire, or stop criminal behavior.	The Three Strikes law disproportionately affected African Americans and the mentally ill.19
Require sufficient regulatory attention, funding, and enforcement.	Negative influences on health and well-being can occur due to lack of regulatory attention, underfunding, or underenforcement of laws.	A definitive 1992 study showed that primary care nurse practitioners are capable of providing cost-effective, safe, high-quality care, but their role has been severely limited by restrictions on their scope of practice, prescriptive authority, and eligibility for reimbursement. Eliminating these restrictions would enable advanced practice nurses to increase access to care while preserving quality and reducing costs.20	In Pennsylvania, by state statute, nurse practitioners gained prescriptive authority in the 1970s. However, because nurses were overseen by the state board of medicine and nursing, regulations were never released. Thus, no prescriptive authority could take place.21,22 This example shows that the evidence is not driving law, policy, and regulation. If evidence were to drive changes in law and policy, a more equitable society with reduced health disparities could result.
Take on new meaning through their interpretation.	In 2012, the US Supreme Court decided that the Affordable Care Act's Medicaid expansion could only be implemented by states on a voluntary basis, not a mandatory one.23	Congress intended the Medicaid expansion to apply nationwide, since states risked Medicaid funding by not expanding.24	As of January 2020, several million people across 14 states lacked access to Medicaid's benefits.25

Healthy People 2030 offers an opportunity for individuals and entities in diverse sectors and at all levels (ie, national, tribal, state, or community) to use laws and policies as tools to address health disparities and health inequities and improve health and well-being in this decade. Health and well-being are defined as how people think, feel, and function—at a personal and social level—and how they evaluate their lives as a whole.26 To change the culture of health and well-being in America, Healthy People 2030 reaches across all sectors of the economy—public, private, and nonprofit. This broad outreach strategy reflects the view that health and well-being are shaped by the social, economic, and physical circumstances of people's lives—not solely by health care services. Laws and policies can play important roles in supporting or informing implementation of health and well-being initiatives.

Program or Policy

After a law is passed, a regulatory process occurs, offering users one of many potential opportunities to provide input. Investments and monitoring are needed to ensure that laws are applied as intended. A law that passes with adequate funding and with promulgated regulations that provide guidance on how to administer it is more likely to be effective. Variation occurs in ways that laws and policies affect health initiatives' implementation throughout the United States—over time, by geography and by location—from states to neighborhoods or micro-neighborhoods.

Health-harming structural and social determinants of health are neither natural nor immutable. They are human-made—often through the creation, revision, repeal, or lack of law and policy—and they can be dismantled through human efforts. Healthy People 2030 users should consider using laws and policies as tools to eliminate health disparities, achieve health equity, and attain health literacy. Table 3 shows examples of legal or policy levers that can be used to advance Healthy People 2030 objectives and support health and well-being.

TABLE 3. Legal or Policy Levers to Advance Healthy People 2030 Objectives.

Legal Tool or Lever	Healthy People Objectives	Relevant Legal/Policy Intervention	How the Laws/Policies Are Implemented
Direct regulation	Maintain the vaccination coverage level of 2 doses of the MMR vaccine for children in kindergarten. (IID-04)	Require through statute or regulation that children must be vaccinated before starting kindergarten or have an approved waiver.	(1) “Command approach”—Develop laws and policies that require children to be vaccinated before entering school. (2) “Nudge” approach increases compliance by making vaccinations more difficult to avoid (eg, requiring waivers for school vaccination policies so that students must “opt-out” rather than “opt-in”).
Deregulation	Reduce the proportion of persons who are unable to obtain or delayed in obtaining necessary medical care. (AHS-04)	Remove regulations that create barriers to care when doing so supports health; make it easier to use telehealth for appointments and to access services.	During COVID-19, HHS removed some Medicare payment requirements for in-person care to allow for increased telehealth opportunities, thereby improving safety and reducing potential exposures.27
Economic incentives	Increase the proportion of students participating in the School Breakfast Program. (AH-04)	Ensure that breakfast is available to students and that they participate.	In schools with a majority of students who are low income, provide increased funding for the School Breakfast Program or adopt a Universal School Breakfast program so that little to no additional effort is needed to participate.
Economic disincentives taxation and spending	Reduce consumption of added sugars by people who are 2 y and older. (NWS-10)	Add a tax or fee to sugary products to discourage purchases.	A tax on sugar-sweetened beverages could be imposed by a city (eg, by the ounce).
Redress through the court system	Reduce blood lead levels in children aged 1-5 y. (EH-04)	Ensure lead is removed from housing stock (paint) and water sources (pipes).	Enforce ordinances prohibiting lead paint in rental housing. Philadelphia established a specialty Lead Court in conjunction with the health department to work with landlords and tenants to ensure remediation of properties in violation.28

Abbreviations: HHS, US Department of Health and Human Services; MMR, measles-mumps-rubella.

Additional areas where there are opportunities to advance health and well-being through legal and policy interventions include the following:

• Housing: Lead-based paint was regularly used in housing built prior to 1950, and it remains the most common source of lead poisoning. Low-income children who live in older or substandard housing are at particular risk, since they are more likely to ingest peeling paint or lead-contaminated dust.29 Lead poisoning irreversibly damages the developing brain and nervous system.30 Substandard housing conditions such as mold and dust mites can also cause or exacerbate asthma symptoms.31

• The COVID-19 pandemic: COVID-19 has exacerbated the existing crisis of inadequate access to affordable housing, and only a patchwork of eviction prevention measures is available to protect families from becoming homeless.32

• Efforts to promote access to healthy foods in low-income communities: In Minneapolis,33 in 2015, the Staple Food Ordinance required licensed businesses to stock minimum quantities and varieties of 10 types of healthy foods and beverages, including fruits, vegetables, whole grains, and other staples.34 Separately, Philadelphia instituted a sweetened beverage tax as a measure to reduce soda intake and childhood obesity; the taxes were used to support early childhood education.35

Relevant frameworks and models can guide individuals and entities in working toward the Healthy People 2030 goal to “engage leadership, key constituents, and the public across multiple sectors to take action and design policies that improve the health and well-being of all.” Three examples are as follows:

1. Health and well-being in all policies and laws (HIAP): An HIAP approach relies on collaboration36 and reflects the understanding that many pressing population health challenges, such as inequities, chronic disease, and the need for insurance reform, are complex, multidimensional, interconnected, and linked to social, economic, and physical environments.

2. Policy and law as tools to promote population health: There are a number of models that discuss the role of law and policy to improve health.37 One such framework explores the use of policies and laws to promote public health and safety.38 Five featured legal and policy tools are as follows: (a) direct regulation (penalties for risky behavior); (b) deregulation (dismantling legal barriers to desired health behaviors); (c) economic incentives and/or use of subsidies; (d) economic disincentives (ie, taxation and spending); and (e) redress through the court system (civil litigation). These tools can be used to modify environments (eg, built, or physical, socioeconomic, or informational).

3. Multisectoral collaboration: Multisectoral law and policy efforts can shape the economic, physical, and social environments. Improving individual and population health and well-being requires partnerships and intersectoral initiatives (eg, among users in education, justice, and employment) to create healthier enviro-nments.3 These efforts can leverage the growing interest in clinical-community-business relationships to create community-wide collaborations.

Implementation and/or Dissemination

All people can take part in informing and developing laws and policies. By engaging in the formulation of laws and policies at the national, tribal, state, or community levels, users can work to improve health and well-being in the United States and drive progress on the Healthy People 2030 objectives.

The Healthy People 2020 Law and Health Policy Project examined ways that law and policy can be used as tools to achieve Healthy People objectives, offering models and examples for this decade.39 A collaboration among the Robert Wood Johnson Foundation (RWJF), Centers for Disease Control and Prevention (CDC), CDC Foundation, and the HHS Office of Disease Prevention and Health Promotion, the project developed products communicating the importance of evidence-based legal and policy interventions for reaching Healthy People targets and highlighted examples of how law and policy have been implemented in states, on tribal lands, and in communities around the country.39,40

Questions arise as to which laws should supersede (eg, those at the federal or state level, or those at the local level). In the summer of 2020, an example of preemption—the dilemma created when a higher level of government supersedes a lower level of government41—occurred in Georgia, where the governor sued the mayor of Atlanta to block a local ordinance that mandated mask wearing in public to slow the spread of COVID-19.42 Variations in local-level policy come into play in measuring and aggregating state-level health outcomes. As local-level variations in the implementation and enforcement of laws and policies increase, measurement becomes increasingly important and complex.

Evaluation

Healthy People 2030 provides a chance for individuals and entities to show the impacts of law and policy and offers a landscape for stimulating new methods and identifying new data sources to achieve national goals. The field can better understand how variations in laws and policies across the federal, state, tribal, or community levels produce different health outcomes in targeted populations by using high-quality surveillance data to measure their effects.

There are opportunities for natural experiments that can be evaluated in a rigorous manner. The rescinding of laws or policies offers one such opportunity since laws and policies can be amended over time, are sometimes rescinded altogether, and can vary from one state to another (or among even more precise geographic locations). For example, the Assault Weapon Ban was enacted federally in 1994 and then allowed to sunset in 2004. An assessment found use of high-capacity semiautomatics as a share of guns used in crime grew by more than 3-fold in the years following expiration of the federal ban.43

Existing resources can support such work. For example, CDC's Community Guide to Preventive Services and RWJF's County Health Rankings and Roadmaps “What Works for Health?” initiatives provide evidence-based recommendations for public health interventions. The work of organizations that collect, synthesize, and report on the effectiveness of certain types of health-related laws and policies can inform and shape laws and policies for this decade. Such organizations include, but are not limited to, those conducting rigorous evaluation work (eg, the Center for Public Health Law Research, CDC's Public Health Law Program), those that educate about the role of law and policy and share examples of state laws (eg, the Public Health Law Center, the National Conference of State Legislatures), and those that help groups to implement evidence-based practices (eg, the Network for Public Health Law, ChangeLab Solutions). The field is evolving and has a range of rigor; Healthy People offers opportunities to strive for increased rigor.

The new area of legal epidemiology, the “scientific study and deployment of law as a factor in the cause, distribution, and prevention of disease and injury in a population,”44 offers insights into how such measurement could be conducted. It focuses on legal prevention and control (ie, laws and legal practices as interventions to prevent disease and injury), legal etiology (ie, laws and legal practices as causes of disease and injury), and policy surveillance (ie, collecting, analyzing, and disseminating information about laws and other policies that are important to health and well-being). Such tools can be used to assess the impact of public health interventions on Healthy People objectives and on achieving health equity. Proponents of legal epidemiology seek to remove barriers, such as limited availability of timely and rigorous evaluation of the effects of law and legal practices on health, to the effective use of legal action to benefit public health.45

Discussion

Introducing new laws and policies or rescinding existing ones offers a chance to rigorously assess outcomes and to weigh the balance of good outcomes against unintended consequences. For example, when federal regulations first began requiring the installation of airbags in cars, lives were saved in frontal collisions. Yet, in the mid-1990s, airbags were found to kill children whose car seats were positioned in front passenger seats. Both good outcomes and unintended consequences occurred.46 The balance of saved lives was significant. However, evaluation quickly identified that other actions and regulations were needed to ensure that no child seats would be placed in the front seats of cars. Another example of why it is important to evaluate the effects of policies is allowing the exemption of children from vaccination. All 50 states have laws requiring specific vaccines for children, but 45 states and District of Columbia grant exemptions for children whose families have religious objections, and 15 states allow exemptions for people with philosophical objections to vaccinations (https://www.cdc.gov/phlp/docs/school-vaccinations.pdf). Rising rates of nonmedical exemptions could increase vulnerability to disease outbreaks. Rigorous assessment of outcomes related to laws and policies makes explicit the linkages between law, policy, and health and well-being.

The COVID-19 pandemic has exposed gaps that need to be addressed for society to return to a new normal that is better than before. For example, during approximately 2 months following the declaration of the coronavirus-related US national emergency on March 13, 2020, vaccination rates for routine pediatric vaccines had dropped by 71%.47 Children who are not protected by vaccines are more vulnerable to diseases, such as measles. Continued and coordinated efforts among health care providers and public health officials at the national, tribal, state, and local levels will be necessary to achieve catch-up vaccination. Policy approaches may be a highly effective tool for preventing exposures to other communicable disease outbreaks and protect the health of the public.

Researchers and public health leaders can examine the bidirectional effects of laws and policies at the national, tribal, state, and local levels on health and well-being. The local level is often a place of innovation where leaders can act in response to local conditions, and their successes can bubble up. Similarly, local levels can examine the effects on health and well-being over time of changes in federal, state, and tribal policies.

Implications for Policy & Practice

• Laws and policies are important levers to improve health and well-being.

• It is crucial to measure and monitor the effect on the health status of populations of legal and policy interventions. Assessments should examine the degree to which such interventions achieve equity, contribute to the effectiveness of health promotion programs, and shape the behaviors of various sectors that influence population health.

• The impact of laws and policies on health and well-being should be studied in the same manner as other public health interventions. This may be challenging, however, because laws and policies can take years to demonstrate impact. This delayed effect adds to the difficulty of generating short-term scientific evidence within a limited time frame on whether the law or policy contributes to progress toward an objective. As Healthy People enters its fifth decade, longer-term evaluations and interim outcomes for process assessments are needed.