Non-Medical Measures to Improve Public Health: What Works?

Lilo H. Stainton | February 21, 2019 | Health Care
New Jersey has many programs in place, but which are worth spending the most state money — and time — on?

Health report
From pre-kindergarten programs to tobacco taxes to paid family leave, certain state-based initiatives outside the traditional medical system have proven to have a positive impact on public health — and a good return on public investment.

While many of these programs have been established in New Jersey, and in some other states, there has been limited guidance for policymakers on which are the worthiest of the public’s time and money.

To fill that gap, the nonpartisan Trust for America’s Health released a national report today that identifies a half dozen key policy goals and lists tested nonclinical programs that states have used successfully to improve health outcomes and reduce healthcare disparities. Researchers reviewed some 1,500 evidence-based strategies in the process and provide examples of existing state programs with evidence of their economic benefits.

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Among other things, the report — Promoting Health and Cost Control in States — calls for expanding school nutrition programs, promoting healthier behaviors through higher taxes on alcohol and tobacco, as well as needle-exchange programs; it also urges increasing safe and affordable housing options, and supporting economic wellbeing through things like paid family leave and an earned-income tax credit, which can benefit working-class taxpayers.

Of the 15 specific recommendations, New Jersey is credited with having successfully implemented all but two: universal pre-kindergarten, a goal Gov. Phil Murphy has pledged to meet, and rapid re-housing, a program designed to reduce homelessness. Only three other jurisdictions met as many of the policy criteria — Massachusetts, Rhode Island and Washington, D.C., according to the findings.

Highlighting best practices

“New Jersey has enacted and implemented a number of the policies we recommend in this report,” said Adam Lustig, one of the report’s authors. But the goal was not to rank states or assess their performance, he noted, rather to highlight practices that have shown to have a positive impact in multiple states.

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As a menu of options, Lustig said the report is designed to be flexible, so officials can mix and match and build on initiatives already underway. And many of the recommendations can be done by states alone, independent of federal funding or regulation. “There are incremental ways that states can consider some of these policies and move on the continuum to more robust programs,” he said.

In fact, while the Trust report credits New Jersey for its paid family-leave policy, Murphy signed a bill on Tuesday that expands that program significantly — doubling the time family members can take off and increasing the weekly benefit, among other changes.

“Quite simply, paid family leave improves health,” state Department of Health Commissioner Dr. Shereef Elnahal Tweeted Tuesday. “It is no surprise that ensuring a stable livelihood during a time of immense change in families — illness, the birth of a child, and other circumstances — leads to better health outcomes,” he later told NJ Spotlight.

The national report was welcome news to Brandon McKoy, who made similar arguments in a white paper he published last month with two colleagues at New Jersey Policy Perspective, a progressive think tank. “I’m happy to see the conversations around … the true determinants of health continue to grow,” he said.

Medical care alone won’t do

The NJPP paper stressed that only 20 percent of health outcomes are attributed to medical care alone. Behavior, the environment, and social and economic factors account for the remaining 80 percent, it noted — the same factors targeted in the Trust report. “Obviously going to your doctor and having your apple every day is important,” McKoy explained, “but being healthy in a holistic manner requires a lot more than that.”

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McKoy and his fellow authors urged the state to invest more in key social services and supports (including expanding pre-K, the earned-income tax credit and other existing state programs) that they said can help build healthy communities, especially in underserved areas, and better control medical costs over time. They also flagged investment needs in grade schools and higher education, public transit, and health insurance for children who lack coverage.

In creating the report for the Trust for America’s Health — which involved funding from Kaiser Permanente and the Robert Wood Johnson Foundation (full disclosure: RWJF is an NJ Spotlight donor) — researchers reviewed multiple national databases to identify evidence-based policies that met certain criteria. They then looked at how each would impact disease prevention, behavior, or other health criteria, and assessed the economic effect on public finances. They also identified legal and advocacy strategies to help put these policies into play.

A menu of initiatives

The recommendations come in several broad areas and include specific policy initiatives:

  • To take advantage of the connections between good health and early learning, the report calls for expanding high-quality universal pre-school and ensuring that low-income children have access to multiple healthy meals at school. (Only pre-school programs with at least 50 percent participation rates were awarded credit for this program; New Jersey fell in the 21 percent to 40 percent range, according to the Trust.)
  • To reduce the impact of HIV, Hepatitis-C and other potential side effects of intravenous drug use, the researchers recommended establishing syringe-access programs, which they said can have a return of $7.50 for every $1 invested. New Jersey is now beefing up a pilot program established over a decade ago.
  • Promoting healthy behaviors is an obvious way to reduce healthcare costs, and the report notes that states with higher taxes on tobacco and alcohol and strict smoke-free policies have seen a decline in smoking and drinking-related healthcare costs. New Jersey has some of the highest taxes nationwide on cigarettes and booze and some of the most restrictive smoking rules.
  • To encourage exercise and community cohesion, the report urges states to adopt land-use policies and planning goals that encourage safe, walkable neighborhoods. Doing so can reduce obesity and stress, studies show.
  • Safe, stable and affordable housing is now seen as a critical component of health and wellness, and the report underscores the same point. It also notes that the impact of unhealthy homes adds billions of dollars to the cost of healthcare, through asthma, lead poisoning, lung cancer and accidents. To address this, the report calls for policies like “housing first,” an initiative that prioritizes shelter over sobriety and other health issues, which has seen growing support in New Jersey.
  • In the category of economic opportunity and well-being, the report recommends several programs designed to counter poverty from different angles — earned-income tax credits, paid sick and family leave, and fair hiring protections for former inmates, also known as “ban the box” policies. New Jersey has been a leader on several of these fronts, Lustig, the report author, noted.