Promoting Health and ISSUE REPORT Cost Control in States: How States Can Improve Community Health & Well-being Through Policy Change OPEN Organic FEBRUARY 2019 Acknowledgements Trust for America’s Health (TFAH) is a nonprofit, nonpartisan Trust for America’s Health gratefully acknowledges generous public health policy, research, and advocacy organization that financial support from the Robert Wood Johnson Foundation promotes optimal health for every person and community and and Kaiser Permanente. Any opinions, findings, conclusions, or makes the prevention of illness and injury a national priority. recommendations expressed in this material are those of the authors and do not necessarily reflect the views of the funders. TFAH BOARD OF DIRECTORS ADVISORY GROUP Gail Christopher, DN Octavio Martinez, Jr. MD, DrPH, This report benefited from the insights and expertise of the following Chair of the TFAH Board MBA, FAPA Advisory Group members. Although they have reviewed the report, neither President and Founder, Ntianu Executive Director they nor their organizations necessarily endorse its findings or conclusions. Center for Healing and Nature Hogg Foundation for Mental Health Chris Aldridge, MSW Anand Parekh, MD, MPH Former Senior Advisor and Vice The University of Texas at Austin Senior Advisor Chief Medical Advisor President, W.K. Kellogg Foundation Karen Remley, MD, MBA, National Association of County & Bipartisan Policy Center David Fleming, MD MPH, FAAP City Health Officials Catherine D. Patterson, MPP Vice Chair of the TFAH Board Former CEO and Executive Vice Jeremie Greer, MPP Managing Director, Urban Health Vice President of Global Health President Vice President, Policy & Research and Policy Programs American Academy of Pediatrics Prosperity Now de Beaumont Foundation PATH John Rich, MD, MPH Robin Hacke, MBA Marcus Plescia, MD, MPH Robert T. Harris, MD Co-Director Executive Director Chief Medical Officer Treasurer of the TFAH Board Center for Nonviolence and Social Center for Community Investment Association of State and Senior Medical Director Justice Territorial Health Officials General Dynamics Information Drexel University Shelley Hearne, DrPH Technology President Elizabeth Skillen, PhD, MS Eduardo Sanchez, MD, MPH CityHealth Senior Advisor Theodore Spencer Chief Medical Officer for Policy Research, Analysis and Secretary of the TFAH Board Prevention and Chief of the Center Sandra Henriquez Development Office New York, NY for Health Metrics and Evaluation Former Chief Operating Officer Office of the Associate Director American Heart Association Rebuilding Together Stephanie Mayfield Gibson, MD for Policy and Strategy Senior Physician Advisor and Umair A. Shah, MD, MPH Chrissie Juliano, MPP Centers for Disease Control and Population Health Consultant Executive Director Director Prevention Harris County, Texas Public Health Big Cities Health Coalition Cynthia M. Harris, PhD, DABT Brian Smedley, PhD Director and Professor Vince Ventimiglia, JD John B. King, JD, EdD Co-founder and Executive Director Institute of Public Health Chairman, Board of Managers President and Chief Executive National Collaborative for Florida A&M University Leavitt Partners Officer Health Equity The Education Trust David Lakey, MD Kendall Stagg, JD, MPP Chief Medical Officer and Vice Howard Koh, MD, MPH Director of Community Health Chancellor for Health Affairs Harvey V. Fineberg Professor Kaiser Permanente The University of Texas System of the Practice of Public Health Jennifer Sullivan, MHS Leadership, Department of Health Senior Policy Analyst Policy and Management Center on Budget and Policy REPORT AUTHORS CONTRIBUTORS Harvard T. H. Chan School of Priorities Public Health Adam Lustig, MS John Auerbach, MBA Fred Zimmerman, PhD Manager, Promoting Health & Cost President and Chief Executive Officer Donna Levin, JD Professor, Department of Health Control in States (PHACCS) National Director J. Nadine Gracia, MD, MSCE Policy and Management & Center The Network for Public Health Law Marilyn Cabrera, MPH Executive Vice President and Chief for Health Advancement Policy Associate, Promoting Health Operating Officer Giridhar Mallya, MD, MSHP UCLA Fielding School of Public & Cost Control in States (PHACCS) Senior Policy Advisor Health Julia Sabrick Robert Wood Johnson Foundation TFAH Intern Shauneequa Owusu, MS Senior Vice President of Innovation TFAH wishes to recognize and thank Lindsay Cloud and Scott Burris and Impact of Temple University’s Center for Public Health Law Research for ChangeLab Solutions their collaboration and contributions to this report. 2 TFAH • tfah.org Table of Contents contents TABLE OF CONTENTS Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Report Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 GOAL 1: Support the Connections Between Health and Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Policy Recommendation 1a: Universal Pre-Kindergarten Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Policy Recommendation 1b: Enhancing School Nutrition Programs and Standards . . . . . . . . . . . . . . . . . 19 GOAL 2: Employ Harm-Reduction Strategies to Prevent Substance Misuse Deaths and Related Diseases . . 22 Policy Recommendation 2a: Syringe Access Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 GOAL 3: Promote Healthy Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Policy Recommendation 3a: Smoke-Free Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Policy Recommendation 3b: Tobacco Pricing Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Policy Recommendation 3c: Alcohol Pricing Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 GOAL 4: Promote Active Living and Connectedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Policy Recommendation 4a: Complete Streets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 GOAL 5: Ensure Safe, Healthy, and Affordable Housing for All . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Policy Recommendation 5a: Housing Rehabilitation Loan and Grant Programs . . . . . . . . . . . . . . . . . . . . 43 Policy Recommendation 5b: Rapid Re-Housing Programs/Housing First . . . . . . . . . . . . . . . . . . . . . . . . 45 GOAL 6: Create Opportunities for Economic Well-Being . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Policy Recommendation 6a: Earned Income Tax Credit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Policy Recommendation 6b: Earned Sick Leave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Policy Recommendation 6c: Paid Family Leave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Policy Recommendation 6d: Fair Hiring Protections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Related Policies and Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Current State Policies Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 FEBRUARY 2019 3 Executive Summary EXECUTIVE SUMMARY GOAL 1: Support the Connections Between Health and Learning Despite advances in healthcare, too many Americans will continue to needlessly fall ill unless we change the conditions that contribute to poor health. Adopting policies that improve access to quality education, safe housing, jobs, and more can have lasting effects on individual health. The circumstances we all encounter in our everyday lives shape our health. Whether it’s where we live, how we eat, GOAL 1: Support the Connections where we go to school, our workplaces, who we care for, or Between Health and Learning what opportunities we have (or don’t have) to succeed, it all 1a. Universal Pre-Kindergarten Programs has a profound effect on long-term health—regardless of what type of medical care we receive. 1b. nhancing School Nutrition Programs and E Standards The United States spends trillions of dollars a year on health, but currently more of that money goes toward treating disease than it does to preventing it. Prevention starts with GOAL 2: Employ Harm-Reduction people leading a healthy lifestyle, yet for too many Americans, Strategies to Prevent Substance Misuse poverty, discrimination, access to education, the immediate Deaths and Related Diseases environment, and other systemic barriers make it difficult to 2a. Syringe Access Programs prioritize a healthy lifestyle and even more difficult to lead one. Fortunately, state-level decision makers are in a strong position GOAL 3: Promote Healthy Behavior to change the conditions in which people live, work, learn, and play. They can prevent the onset of disease, help residents lead 3a. Smoke-Free Policies healthier lives, lower healthcare costs, and increase productivity 3b. Tobacco Pricing Strategies by removing obstacles and expanding opportunities. 3c. Alcohol Pricing Strategies But in an age of endless information, identifying the most effective and efficient strategies for improved health and GOAL 4: Promote Active Living and reduced healthcare costs can seem like an impossible and Connectedness overwhelming task. Trust for America’s Health (TFAH) 4a. Complete Streets created Promoting Health and Cost Control in States: How States Can Improve Community Health & Well-being Through Policy Change, to pinpoint evidence-based policies and provide state GOAL 5: Ensure Safe, Healthy, and leaders with information on how to best promote healthy Affordable Housing for All lifestyles and control costs. 5a. ousing Rehabilitation Loan and Grant H This report is the first product of the PHACCS initiative, it Programs identifies policies for good health that look beyond healthcare, 5b. Rapid Re-Housing Programs/Housing First part of a larger effort to foster cross-sector collaboration; because, changes to any given policy area can impact the GOAL 6: Create Opportunities for population’s well-being and states’ ability to control costs. Economic Well-Being Additionally, PHACCS recognizes the value of state- and local- level collaboration and includes considerations for those 6a. Earned Income Tax Credit FEBRUARY 2019 relationships so that policy can be implemented successfully. 6b. Earned Sick Leave FEBRUARY 2019 PHACCS acknowledges that the needs of every state are unique 6c. Paid Family Leave and therefore provides a range of options for each state to 6d. Fair Hiring Protections consider. Specifically, this report supports the following goals and policies for states: 4 TFAH • tfah.org Introduction several evidence-based policies that MARY JOHNSON’S STORY can be implemented to address these hurdles and reduce health disparities.1 Mary Johnson sat in her doctor’s doctor recommended. What’s more, office at the end of her physical exam. she didn’t feel safe exercising in her The United States is spending more and She listened patiently as her doctor neighborhood. The YWCA was a few more on healthcare services to treat carefully reviewed her current health miles away, but there wasn’t an easy disease. Yet spending on the drivers of status, which included the fact that she way to get there by mass transit. And good health—quality housing, healthy was 20 pounds overweight, prediabetic, she already knew the main trigger for foods, and education—is stagnant. and asthmatic. The doctor reviewed her asthma: her apartment building had Residents of other countries that have the importance of a healthful diet and a leaky roof, which resulted in mold and higher ratios of spending on social physical activity as well as avoiding mildew. The landlord, however, wasn’t services to spending on healthcare the environmental triggers for her inclined to fix the problem, and Mary services have better health and live longer asthma. Mary liked her doctor and couldn’t afford to move. despite the U.S. spending more money appreciated the doctor’s concerns. per capita on medical services than any She ended the appointment with her other country.2,3 Healthcare spending But she knew it would be difficult to doctor by smiling and saying she’d is the second largest component of make the necessary changes to her try to adopt all the recommended states’ general fund spending, tends to behavior. There were few local stores behaviors. She did want to be grow at rates greater than inflation, and that sold fresh fruits or vegetables healthier. But she also knew those focuses on treating illness rather than in her community. And besides, she changes were not realistic. There were prevention. In 2018, Medicaid made up was on a tight budget and the most just too many obstacles in her way. an estimated 20.2 percent of all states’ affordable foods weren’t the ones her general fund spending and grew at a rate of 7.3 percent.4 Increasing investments in This story will sound familiar to many policies that improve education, housing, prevention to complement the significant Americans. No matter how good their transportation, and more. investments already being made in medical care or how motivated they are disease treatment can promote health, As illustrated by Mary Johnson’s case, the to get healthier, the conditions present lower healthcare costs, and increase social and economic factors related to in many Americans’ lives prevent them productivity. Changing conditions to where people live, learn, play, and work from reaching optimal health. ensure that everyone has the opportunity are interconnected and significantly to make healthy choices requires The ability to promote the health and impact health. Unfortunately, for collaboration across fields and specialties. well-being of the Mary Johnsons of the too many Americans, a lack of basic That’s how the nation will weave together world rests more and more with local resources like nutritious foods or a culture of health. and state policymakers than it does quality housing have resulted in poor with the medical community. While the health. Certain populations, including Though state policymakers are in the healthcare sector plays an important role racial and ethnic minorities, sexual best position to drive meaningful policy in providing necessary health services to and gender minorities, people living in change, it is difficult to sift through individuals, most of the factors that keep poverty and in rural communities, and reams of studies and ascertain which people healthy are outside of healthcare formerly incarcerated individuals often policies work and which don’t. To providers’ areas of expertise and control. have worse health outcomes than other provide state leaders with timely and But state policymakers are in a position groups. These inequities in health can relevant information, TFAH identified to ensure that everyone living in their often be attributed to differences in the strongest evidence-based policies state has the opportunity to remain living conditions, exposure to traumatic from around the country. We scoured healthy, to prosper, and to reach their full events, and access to needed resources several nationally recognized databases potential. To make these opportunities in their community, which in many cases and reviewed hundreds of initiatives to a reality, state leaders must change how are a result of discriminatory policies develop an easy-to-use single report and they think about health and advocate for and practices. Fortunately, there are resource hub for state policymakers. TFAH • tfah.org 5 What’s in This Report? How to Use This Report Promoting Health and Cost Control in The policies highlighted in this report important national trends related to States: How States Can Improve Community provide a menu of options for state demographic shifts, health challenges, Health & Well-being Through Policy leaders to explore as they consider and the wide range of factors that Change strengthens officials’ capabilities how to best use their state’s resources influence an individual’s health. by highlighting evidence-based and to improve the health and well-being This can help decision makers better -informed policies that can improve of their population. The PHACCS understand why the recommended health and well-being in their states. initiative recognizes that each state has policies in this report are so valuable. PHACCS also focuses on state-level its own priorities and political dynamics policies that can control healthcare to consider. This report was crafted National Trends costs. We look beyond the healthcare specifically to cater to the needs of all Life Expectancy system, since policies in other sectors state policymakers and it is our hope can also improve health and states’ that all states can consider at least one of Overall, Americans are growing older budgets over time. This report looks the policies included in this report. This and becoming more diverse. In the beyond medical procedures and report is intended to guide state officials last decade, the life expectancy at birth clinical services and focuses instead on toward the best evidence-based policies in the United States rose from 77.8 opportunities to improve how people that promote health and well-being. to 78.6 years.5 However, disparities in live, learn, work, and play. The report life expectancy by race and ethnicity Case examples in this report highlight still exist. In 2016, the life expectancy identifies policies that: how some states have adopted a of Black Americans was 74.8 years, l l everage the connection between recommended policy; this provides significantly lower than the expectancy health and learning, decision makers with added insight for Latinos (81.8 years) and Whites into how a policy was designed and (78.5 years). While this gap closed l p romote healthy living and implemented. Each recommended over the past few decades, Black life connectedness through the built policy is also accompanied by a list of expectancy continues to significantly lag environment, considerations for effective design and behind all other races and ethnicities.6 l f oster healthy behaviors, implementation to provide additional guidance and suggestions for officials. Disparities in life expectancy are also l s upport healthy and affordable widening between high- and low-income Together, the policy recommendations, housing, and earners. Men in the top 1 percent of case examples, and considerations in l c reate economic opportunities. this report can be used to inform policy household income live 14.6 years longer proposals that can be enacted and than men in the bottom 1 percent. This report provides detailed information While the gap for these two income implemented by individual states to on its recommended policies, including groups is smaller for women (10.1 promote health. descriptions of the policies, summaries years), this persistent disparity shows of the health and economic evidence, This report is just the start. TFAH that significant barriers remain for low- case examples of policy implementation, looks forward to identifying more income individuals to live healthier, and considerations for implementation. opportunities to support states interested longer, and more productive lives.7 Additionally, This report highlights a in making these policy changes. We will set of complementary policies for state continue to provide states with additional Emerging and Continuing officials to consider in recognition that resources to guide implementation, Health Issues the recommended policies alone may not support recommendations, and find new In recent years, life expectancy be able to achieve state and national goals strategies for better health. has decreased, which can be for health promotion. These evidence- Assessing what issues are affecting partly attributed to an increase in based initiatives have the potential to the state’s population is an important unintentional injuries, including improve population health and can first step for policymakers seeking drug overdoses, alcohol poisoning, be used as either a complementary to implement policy changes. In and suicide among young people.8 approach or as an alternative option to the following section, we highlight Current trends show obesity rates have the recommended policies. 6 TFAH • tfah.org not decreased in many parts of the Focusing on Determinants of Health in 5 Years initiative, which recommends country, and tobacco use remains the State policymakers often focus on nonclinical, community-wide leading cause of preventable death.9 improving health outcomes by approaches that make a positive health Despite spending $3 trillion on health expanding and ensuring access to quality impact, show results within five years, annually, too many Americans are health services. However, to address and are cost effective or cost saving.18 still dying of preventable diseases,and the shifting socioeconomic needs of With an overlap in recommended for some marginalized populations, an increasingly diverse population, to policies, each of these organizations is poor health outcomes and health improve health, and to uncover the root closely communicating and supporting disparities persist.10 causes of poor health, we must place a each other’s work—just as local and greater emphasis on the importance of state leaders should—to promote policy An Aging Population multisector solutions beyond healthcare. changes that result in improved health The number of Americans aged 65 This means looking past traditional outcomes for cities and states alike. and older is expected to grow from public health strategies and instead While state and local collaboration 15 percent to 17 percent by 2020. supporting healthy learning, promoting around policy has resulted in health By 2030, this population is likely healthy living through the built improvements across the country, to comprimise 20 percent of the environment, advocating for healthy there are instances when those with a total population.11 With age comes behavior, and endorsing fair economic vested interest have advocated for state increased risks of dementia, injuries opportunities for all. preemption laws that limit local authority from falls, and chronic diseases such on matters related to public health. as diabetes and heart disease, which Importance of State and Recent examples have involved the rights account for 95 percent of healthcare Local Collaboration of local communities to enact paid sick costs in the United States.12,13,14 The leave policies as a strategy to encourage States and municipalities are uniquely racial and ethnic disparities noted the appropriate use of healthcare positioned to enact policies that above are also reflected in this services and to reduce spreading illness address their residents’ most pressing population, with an elevated risk of in the workplace. A March 2016 study, for issues. Along with states, local death from chronic diseases and a example, showed that 68 percent of all municipalities are important innovators shortened life span among Black and workers have access to earned sick leave. of public health approaches in areas Native American older adults. However, only 41 percent of workers in like tobacco use, obesity, and access to clean needles for intravenous drug the bottom quartile of wages have access A More Diverse Nation to this benefit.19 As of July 2017, 20 states users. In numerous instances, states The United States is becoming more adopted laws and regulations only after have preempted local municipalities culturally, racially, and ethnically the approaches had proved successful from enacting earned or paid sick leave diverse than ever before. By 2020 the in local communities. State and local laws. Even for states that have enacted U.S. Census projects there will not be collaboration is thus a critical element paid sick leave laws, such as Maryland a single racial or ethnic group that to ensuring that local, state, and federal or Oregon, the legislation contains makes up the majority of children, and policy is effectively implemented. preemption clauses that prohibit local by 2045, this will be the case for the governments from requiring employers general U.S. population.15,16 Recognizing the importance of to provide more generous earned or synergy between local and state efforts, paid sick leave benefits.20 In this and States will need to address the needs PHACCS is collaborating with the de other instances, preemption laws have associated with these demographic Beaumont Foundation and Kaiser inhibited potential public health progress shifts. State decision makers will Permanente on their CityHealth in cities and other local municipalities. need to consider new and adapted initiative, which provides local leaders This report provides more details on the policies in order to improve the health with a package of evidence-based policy impacts of and potential strategies for and well-being of all populations, solutions.17 PHACCS is also aligning preemption in the “Related Policies and regardless of race, ethnicity, cultural with the Centers for Disease Control Other Issues” section (see page 62). background or age. and Prevention on the Health Impact TFAH • tfah.org 7 Health Is More Than Healthcare As was the case in the example of Mary Johnson that begin this chapter, the social determinants of health are the conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.21 The social determinants of health can be organized into the following domains: Economic Stability, Education, Health and Healthcare, Neighborhood and Built Environment, and Social and Community Context. Economic Stability: Economic stability is related to issues of employment, income, food security, and housing stability—all of which affect health outcomes. Economic stability is often tied to employment, which determines a person’s financial access to resources like food, housing, and healthcare. Lack of economic stability or job insecurity can lead to poverty, to an inability to secure necessities, and to increases in chronic stress—all of which can elevate a person’s risk for poor health. Alternatively, Source: Centers for Disease Control and Prevention economic stability from steady employment with a livable wage network as well as access to different types of support, such as can provide a person with the income and benefits necessary information sharing, emotional support, or instrumental support, to access quality resources, like nutritious foods, safe housing, like a ride to work.25 Social isolation, on the other hand, is and medical care. harmful to health, even more so than obesity or smoking 15 Education: Educational opportunities can have lasting effects cigarettes a day.26 Incarceration, can negatively impact the on a person’s health throughout one’s life and is one of health of individuals and communities. While incarcerated, the strongest predictors of health. Quality education from 22 individuals may not receive the healthcare they need, and once the earliest years through adulthood can shape cognitive they are released, they often face barriers while reintegrating development, problem-solving skills, and literacy—skills that into society. Additionally, more than half of fathers in state influence healthy behaviors. Educational attainment is also prison report being the primary income generator in their tied to future earnings and access to social networks. People families, which can lead to economic hardship.27 with higher educational attainment are less likely to experience Historical and Ongoing Structural Racism and Other unemployment or financial hardship.23 Discrimination: Discrimination can also significantly impact Neighborhood and Built Environment: A person’s neighborhood individuals’ and communities’ health.28 Individual and encompasses the natural and man-made physical environments structural discrimination, which are mutually reinforcing, can in which people live, including the air they breathe and the cause intentional and unintentional harm, whether or not water they consume. Neighborhoods overall, and physical it is perceived by the individual.29  Discrimination can be environments specifically, affect the options an individual or understood as a social stressor that has a physiological effect family has for housing, employment, food, transportation, on individuals, and it can be compounded over time and lead health and social services and being physically active. All these to long-term negative health outcomes, including higher blood factors, as well as trauma, crime and other environmental pressure, lower-birthweight infants, cognitive impairment, conditions like climate, contribute to health outcomes. For and mortality.30,31 Inequities resulting from discrimination are example, children and adolescents who are exposed to violence, a result of policies, often established without conscious or either as a victim, direct witness, or just hearing about a crime, malicious intent, that disadvantage communities of color.32 are at risk for poor long-term behavioral health outcomes.24 There are other determinants of health, such as access Social and Community Context: The nature of our social to health insurance and healthcare services. These social interactions and relationships with other people and our determinants of health are all connected, which is why community affect our health and well-being. A sense of improving health requires working across different sectors to community and social cohesion helps form a person’s social prevent the onset of disease. 8 TFAH • tfah.org Improving Health for All: State Opportunities to Advance Health Equity It is critical that states explore how to advance health equity by first identifying where differences in health outcomes exist and then developing policies to address these inequities. What Is “Health Equity”? We define “health equity” as “the state in which everyone has the chance to attain their full health potential and no one is disadvantaged from achieving this potential because of social position or any other defined circumstance.”33 Achieving health equity requires removing obstacles to health such Source: Robert Wood Johnson Foundation37 as poverty, discrimination, and their consequences, including powerlessness to opportunities, there will continue and a lack of access to good jobs with fair to be differences in health. Groups pay, quality education and housing, safe of people who are marginalized or environments, and healthcare.34 Health disadvantaged often have worse health. disparities are differences in health or And though individual behaviors the factors that influence health that play a role in health, many of the are closely linked with social, economic choices people make depend on the or environmental disadvantage. opportunities available to them. Policymakers can measure disparities in health and its determinants and use the With a strong understanding of the data to assess progress toward achieving needs of their residents, state leaders health equity.35 are in a good position to ensure that all individuals, of all backgrounds, have the The graphic above depicts the opportunity to be as healthy as possible. difference between equality and Every level of government has a set of equity. Equality provides the same responsibilities dedicated to protecting, opportunities for all, while equity preserving, and promoting the health recognizes that individuals require and safety of their residents. State more—not equal—effort and resources policymakers can work to improve the to level the field of opportunities due to health and safety of their population by historical and ongoing discrimination enacting laws, policies, and regulations, and marginalization.36 and they can distribute resources. A person’s health, including their Moreover, protecting the public’s health ability to make healthy choices, is and preventing the onset of disease impacted by where they live, how much can translate into cost savings and income they earn, their educational increased productivity statewide. To attainment, and differential access to address issues of health equity, states can and quality of care based on their racial develop policy solutions that increase and ethnic status. Unfortunately, as opportunities and remove obstacles to long as there are differences in access health like poverty and discrimination.38 TFAH • tfah.org 9 How Can Policy Advance benefits when each person can thrive. Health Equity? The Joint Center for Economic and Addressing health inequities means Political Studies estimates that between implementing policies and institutional 2003 and 2006, 30.6 percent of direct practices that increase opportunities medical care expenditures for racial for people to be healthy and make and ethnic minorities were excess costs healthy choices. It also means stemming from health inequalities. implementing strategies that remove The Center estimated that eliminating barriers to achieving better health. health disparities for minorities would have reduced direct medical care Discrimination is not always expenditures by nearly $230 billion intentional, but it is often built into over the four-year period examined. institutional policies and practices. Additionally, closing existing disparities This is referred to as “structural” or and creating additional opportunities “institutional” discrimination.39 Policies to advance racial equity can increase can give rise to unfair differences in economic output and consumer the social conditions that affect health spending.41 Raising the average earnings and result in health inequities. For of people of color to the level of example, deliberate discriminatory Whites by closing disparities in health, policies that were enacted decades education, and opportunity would ago resulted in residential segregation generate an additional $1 trillion in by race. Despite the fact that housing earnings and an additional $800 billion discrimination is no longer legal, many in spending.42,43 This research is just the racial and ethnic minorities continue tip of the iceberg, as reducing disparities to live in neighborhoods with poor- can not only focus on improving equity quality schools, housing, and services, among racial and ethnic groups; it can all of which affect their opportunity to also address other populations who may be healthy.40 Another example is how be marginalized or who may not receive diversion policies are administered for essential services, such as rural residents nonviolent, first-time criminal offenses. who lack access to many of the services If an offender qualifies for diversion, individuals in urban areas receive.44 they will not go to jail and will have the A separate analysis estimates that the offense expunged from their record, United States could realize an $8 trillion but only if they are able to pay certain gain in gross domestic product by 2050 as fees. As a result, people with lower a result of closing the racial equity gap.45 incomes are more likely to serve time in jail and have a criminal record How Will This Report Address compared with people with higher Health Equity? incomes who have committed the same Throughout this report, we identify or worse offenses, putting them at risk opportunities for state-level policymakers for unemployment in the future. to advance health equity and reduce disparities in their states through the The Business Case for development and implementation of Improving Equity and evidence-based policies. While some Reducing Disparities of these policies may be more directly The high economic cost of health targeted to vulnerable populations, all of inequities places a large burden on the policies in this report can facilitate states. Equity enables everyone to live health improvement for all individuals to their full potential, and all of society and communities. 10 TFAH • tfah.org Methodology methodology METHODOLOGY APPROACH To inform this initiative, TFAH identified and reviewed 1,500 evidence-based or evidence-informed policies, programs, and strategies by using several national databases, including CityHealth, the Win-Win Project, the Centers for Disease Control and Prevention’s (CDC) Health Impact in 5 Years (HI- 5), County Health Rankings and Roadmaps: Strategies that Work, the Pew- MacArthur Results First Initiative, and the Community Guide Task Force Recommendations.46,47,48,49,50,51 We removed clinical-based strategies from the list. Throughout the review process, TFAH assessed each potential policy for evidence of its impact on the reduction of health disparities and the promotion of health equity. We then applied a set of criteria to the policies, programs, and strategies to identify upstream, state-level legislative policies that improve health and well-being and control costs. Those criteria are: 1. Strong Health Impact and Economic Evidence We reviewed the health and economic results (that is, have a positive return on investment) or for each policy and strategy to ensure there was produced positive economic impacts over time. sufficient evidence to promote positive health We excluded policies that did not have supporting outcomes and control costs. Taking a broad view of health or economic evidence available. economic evidence, TFAH considered economic PHACCS employed an approach that blended the analyses such as cost avoidance, cost benefit, rating systems and evidence criteria from different return on investment, cost effectiveness, and cost databases to initially filter policies that had utility. Policies recommended in this report have positive health and economic evidence. demonstrated that they are either cost beneficial TABLE 1: Databases Reviewed and Evidence Categorization Required to be Considered for Initial Inclusion in PHACCS Initiative Types of Policies Included in PHACCS Review Are Those Designated: Community Guide Recommended Under the heading “government as the decision maker”: County Health Rankings & Roadmaps: • Scientifically supported Strategies that Work • Expert opinion • Some evidence HI-5 Interventions N/A: All 14 policies considered for inclusion Win-Win Project N/A: All 17 policies considered for inclusion • Highest rated Results First Clearinghouse • Second-highest rated FEBRUARY 2019 CityHealth N/A: All nine policies considered for inclusion 11 2. Population-Based Prevention Efforts regulatory rulemaking—rather than legislative PHACCS used the “Three Buckets of Prevention” action—as well as program-level interventions framework,52 which categorizes disease prevention and time-limited pilots. However, the importance and health promotion interventions and policies of well-crafted regulations to guide effective into three domains, or “buckets”. Buckets one and implementation of the policies recommended in two focus on traditional and innovative clinical this report should not be understated. prevention efforts, whereas bucket three focuses Legal Analysis on population-oriented interventions. PHACCS The Policy Surveillance Program of the Center defines a “population-based intervention” as for Public Health Law Research at Temple an intervention or policy that reaches whole University conducted a review of secondary populations. It includes interventions that legal resources for the policies that met the are not intended for a single individual or four inclusion criteria. The analysis assessed the all the individuals within a practice or even existence and complexity of each state law, the all beneficiaries covered by a certain insurer. extent to which the policy of interest was found Rather, the target is an entire population or in legal form, and the availability of existing subpopulation, usually identified by a geographic data or expertise on the law. Each policy was area. Interventions are based not in a healthcare analyzed to determine how widespread the policy settings but in neighborhoods, cities, counties, implementation was in the state, the degree of or states. Using this framework, we excluded variation, and the feasibility of tracking the policy policies and strategies that were not population- over time. In 2019, TFAH and the Center for based prevention efforts, (such as those related Public Health Law will release comprehensive to clinical practice or to Medicaid care delivery or datasets, based on publicly available data, for the reimbursement). recommended policies to assist state officials and other in better understanding the key aspects of 3. Primary and Secondary Prevention the laws and the extent to which they have been PHACCS is focused on upstream prevention adopted, and differ, in all 50 states. efforts that effectively address communities’ and populations’ underlying health needs. PHACCS Role of the Advisory Group uses the CDC’s definitions of primary and We consulted an esteemed group of subject- secondary disease prevention.53 Policies were matter experts from education, public health, excluded that we did not consider a form of health economics, healthcare, philanthropy, primary or secondary prevention. fiscal policy, health equity, housing, and public health law to provide guidance on the selection Primary Prevention: intervening before health of the recommended policies in this report. The effects occur, through measures such as Advisory Group considered the following criteria vaccinations, reducing risky behaviors (poor for each potential policy as decisions were made eating habits, tobacco use), and banning about those policies included in this report: substances known to be associated with a disease current policy landscape, strength and availability or health condition. of health and economic evidence, feasibility Secondary Prevention: screening to identify diseases for enactment, and potential implementation in the earliest stages, before the onset of signs and barriers. A key area of consideration proposed by symptoms. the Advisory Group addressed how each of the recommended policies advance health equity. 4. Role for State Legislative Action Through the application of the four criteria We reviewed evidence to ensure that the state and with input from the advisory group, TFAH legislature was responsible for enacting and selected a set of recommended policies and implementing each policy. We excluded policies several secondary or complementary policies for that were implemented by administrative or inclusion in this report. 12 TFAH • tfah.org 1 Support the Connections Between GOAL 1: Support the Connections Between Health and Learning Health and Learning Goal There is increasing evidence that the presence of healthy environments for learning lead to positive health and economic outcomes throughout a child’s entire life. Despite significant progress, many families and children continue to face enormous challenges in accessing developmentally appropriate quality early care and education in safe and healthy settings. A range of options are available for families, from center-based to home-based care, pre-K programs in public schools and Head Start programs. Education and Child Development While brain science demonstrates the importance environmental hazards, suicidal thoughts and of early childhood education, significant attempts, teen pregnancy, alcohol and drug investments and supports for pre-kindergarten misuse, sexually transmitted diseases, aggression (pre-K) learning environments have lagged.54 and violence, domestic violence and rape, not Investments in high-quality early childhood acquiring key parenting skills or child-care education, including pre-K programs, can support, and difficulty securing and maintaining reduce the risk for: chronic illnesses, shorter and a job.55,56,57 Despite the evidence, families lack less healthy lives, obesity and eating disorders, access to quality, affordable early care and difficulty in maintaining healthy relationships, education programs. While federal resources lower academic performance, behavioral for some early care and education programs problems in school, high school drop out, the have increased in recent years and federal, state, need for special education and child-welfare and local support for state-funded preschool services, mental and behavioral health problems programs, specifically, has not grown significantly like depression and anxiety, exposure to harmful in recent years nationwide. LEARNING CURVE Key Statistics on state funded pre-K Access and l S tate funding per child was $5,008, a slight decline Resources from 2015–2016 when adjusted for inflation. l N ationally, only 33 percent of 4-year-olds and l M ost states’ programs have not kept pace with 5 percent of 3-year-olds were enrolled in state- inflation. Five states decreased their spending funded preschool.58 per child when considering unadjusted dollars. l O nly 29 states served 3-year-olds in some form l S pending per child is directly related to program of state-funded pre-K programming in 2017. quality, as it determines what resources are available, including the likelihood of retaining S tate funding for preschool rose 2 percent to FEBRUARY 2019 l qualified teachers.59 about $7.6 billion since 2015–2016. Source: The State of Preschool 201760 13 and school performance that are difficult to ameliorate.61 Children who received high-quality care in the first few years of life scored higher in measures of academic and cognitive achievement when they were 15 years old, and they were less likely to exhibit challenging behavior than those who were enrolled in lower-quality child care.62 The quality of preschool programs depends on a variety of inputs, including the workforce, the environment, and the programming. Research shows that better education and training for teachers can improve Source: The State of Preschool 201760 the interaction between children Even for children who have access to special needs. High-quality, intensive and teachers, which in turn affects early education programs, it is also pre-K programs for low-income children’s learning. Class size and staff- important to ensure programs are high children have led to lasting positive child ratios are also a factor, because quality. Research shows the positive effects, such as greater school success, smaller classes and fewer students benefits for all children in high- higher graduation rates, lower rates of per teacher gives children more quality, intensive pre-K programs and crime among youth, decreased need opportunities for interaction with adults the harmful effects of inferior-quality for special education later, and lower and more individualized attention. care. These effects—both positive and adolescent pregnancy rates. Inferior- In addition, quality programs include negative—are magnified for children quality care, however, can have harmful evidence-based early learning standards from disadvantaged situations or with effects on language, social development, and comprehensive services.63 POLICY Universal pre-K is publicly funded to all children, it has a larger impact preschool offered to all 4-year-old on low-income families of color and RECOMMENDATION 1a: children regardless of family income, English-learner students.67 Universal High Quality Universal the child’s abilities, or any other pre-K can also alleviate the financial Pre-Kindergarten eligibility factor, although definitions burden on families with young of what is truly universal may vary.64 children.68 These findings show how Research indicates that high-quality important it is for policymakers to pre-K programs not only better understand and consider the difference prepare students for the transition to between equity and equality when kindergarten but can also have positive making determinations on how to impacts later in life, such as academic allocate resources to support universal success and lower poverty rates.65 It pre-K programs. is critical that states ensure effective State legislatures can provide state- transitions from pre-K to primary funded, high-quality pre-K programs school, including through curricula to children throughout the state. alignment. An inadequate transition Furthermore, state law governs many from pre-K to primary school can impact of the requirements related to the a student’s academic performance and provision of pre-K, such as funding, their emotional and social adjustment.66 eligibility, hours, and health and While universal pre-K can be a benefit learning standards. 14 TFAH • tfah.org Health and Educational Evidence of pre-K participants, the children’s that access to universal pre-K There is strong evidence that universal future earnings could exceed the cost programs can benefit children across pre-K programs improve cognitive of the pre-K program. A benefit-cost socioeconomic backgrounds.77,78,79,80 outcomes/academic knowledge for analysis conducted by the Washington Policy Landscape disadvantaged children.69 But such State Institute for Public Policy found that state and district funded The levels of funding and sources of programs aren’t only beneficial for pre-K education programs have a revenue streams for pre-K programs vary low-income children. Universal high- social benefit-to-cost ratio of $4.63:1. greatly from state to state.81 Nine states quality pre-K programs benefit children That includes benefits for program include pre-K funding in their K–12 across all income levels. Children who participants, taxpayers, and others in funding formulas, thus tying it to the attend state-sponsored pre-K, universal society.75 The analysis took into account budgetary process for K–12 education.82 or not, show improved language, math, the cost of the program compared Other states fund pre-K through general and reading skills.70 The longer-term with the benefits of reducing crime block grants or local programs, which benefits of universal pre-K include and increasing high school graduation are less secure revenue streams.83 Nine reductions in teen birth and interactions rates, academic test scores, special- states and the District of Columbia with the criminal justice system education placement, and grade provided state-funded pre-K to nearly throughout a participant’s lifetime.71,72 In retention. A more detailed analysis of 50 percent or more of their state’s Oklahoma, state-funded universal pre-K the monetary benefits of preschool 4-year-olds; four of those states and the demonstrated stronger effects for Latino, programs in Los Angeles conducted District of Columbia served more than Black, and poor children.73 Georgia’s by the Win-Win Project found that 70 percent.84 Federal funding can also universal pre-K program expanded access approximately half of the cost of such play a role in funding pre-K, such as to care and benefited disadvantaged rural a program would be directly recouped through the Head Start program, Pre- children the most, including through through reduced public spending on School Development Grants, and other improved test scores in math and reading Medicaid and other social programs competitive grants. Across all state and which helped close achievement gaps in as a result of health improvements federally funded programs, about 44 children’s education later in life.74 associated with preschool expansion.76 percent of 4-year-olds are enrolled in some form of preschool education.85 Six Economic Evidence While the strongest effects are states, as of 2017, provide no funding for In Oklahoma, research showed that projected for children of lower-income pre-K programs.86 based on the academic performances backgrounds, research also demonstrates CASE EXAMPLE West Virginia’s Universal Pre-Kindergarten Program87,88,89 West Virginia passed legislation in 2002 requiring the state Key outcomes: to make prekindergarten available to all 4-year-olds in the l D uring the 2016- 2017 school year, approximately 65% of state by the 2012-2013 school year. West Virginia Code §18- the state’s 4-year-olds and approximately 11% of 3-year-olds 5-44 mandates that the West Virginia Board of Education, in were enrolled in West Virginia’s Universal Pre-K program. collaboration with the Secretary of the West Virginia Department of Health and Human Resources, ensure that every eligible l I n 2013, West Virginia aimed to improve program quality by child has access to high quality pre-K. West Virginia requires requiring all new lead teachers in nonpublic settings to have that a minimum of half of the programs operate in collaborative at least a BA degree in Early Childhood or a related field. settings with private prekindergarten, child care centers, or l B eginning in the 2016-2017 school year, each pre-K Head Start programs in order to facilitate expansion of the classroom must provide at least 1,500 minutes of program. To date, the West Virginia Universal Pre-K program is instruction per week and 48,000 minutes of instruction available in all 55 counties of the state. West Virginia is home annually, and programs must operate no fewer than four to one of three state-funded pre-K programs that met all of the days per week to meet annual and weekly operational National Institute for Early Education Research’s new quality requirements. benchmarks in 2017 (see insert on page 16). TFAH • tfah.org 15 Considerations for Effective Design and Implementation90,91 l P romote universal access to state- l E stablish an adequate, stable funding Education Research’s standards in funded pre-K for all 3- and 4-year- stream, and ensure sufficient funding the box below). olds. For states unable to fund to provide high-quality services. l P ermit and support bilingual pre-K for all 3- and 4-year-olds, l E nsure instructional alignment instruction and other related policies emphasize serving those with with kindergarten curricula and to support dual-language learners, higher needs, particularly students instructional practices and curricula including conducting outreach and from low-income families, when that are developmentally appropriate, communicating to families in the resources are limited. address social and emotional language spoken at home. l S upport full-day programs. Full-day learning, and are culturally and l E nsure that local zoning and land-use programs maximize children’s time linguistically appropriate. regulations are consistent with the to learn and play and minimize l E ncourage the implementation expansion of preschool capacity near disruptions to parents’/caregivers’ of high-quality standards (see where parents live and work. work schedules. the National Institute for Early BEST IN CLASS NIEER Preschool Policy Standards learning, language development, and have annual written, individualized and Program Quality cognition and general knowledge. professional-development plans. The National Institute for Early Finally, states should provide 2. urriculum Supports. States should C Education Research (NIEER) developed some professional development provide (a) guidance or an approval a rating system for 10 preschool policy through coaching or similar ongoing process for selecting curricula, and standards related to program quality classroom-embedded support. (b) training or ongoing technical to help state leaders enhance and assistance to facilitate adequate 7. aximum Class Size. State policy M support high-quality early education. implementation of the curriculum. should require class sizes to be To do this, they benchmark state limited to 20 children at most. programs against acknowledged 3. eacher Degrees. Lead teachers in T leading programs. The benchmarks every classroom should be required 8. taff-Child Ratio. State policy S provide a coherent set of minimum to have at least a bachelor’s degree. should require that classes be policies to support meaningful, permitted to have no more than 10 4. eacher Specialized Training. State T persistent gains in learning and children per teaching staff member. policy should require specialized development that can enhance later training in early childhood education 9. creenings and Referrals. State S educational and adult achievement. and/or child development. preschool programs should ensure Using these policies will make it more children receive vision, hearing, and likely that pre-K programs will achieve 5. ssistant Teacher Degrees. Assistant A other health screenings and referrals. their goals. teachers should be required to hold a Child Development Associate 10. Continuous Quality Improvement 1. arly Learning and Development E certification or have equivalent System. State policy should—at a Standards. States should have preparation. minimum—require that (1) data on comprehensive Early Learning and classroom quality are systematically Development Standards that cover 6. taff Professional Development. S collected at least annually, and (2) all areas identified as fundamental Both teachers and assistant local programs and the state both by the National Education Goals teachers should be required to use information from the Continuous Panel: physical well-being and motor have at least 15 hours of annual in- Quality Improvement System to help development, social-emotional service training. Lead and assistant improve policy or practice. development approaches to teachers should also be required to 16 TFAH • tfah.org Complementary Policies minority populations. States should consider one or a combination of the following high school–completion programs and select programs that are evidence-based: school-based health centers, vocational training, alternative schooling, social-emotional skill building, college-oriented programming, dual enrollment, mentoring and counseling, school or class restructuring, supplemental academic services, attendance monitoring, community service, and case management. An analysis for Los Angeles County found that several of these programs have internal rates of return to the state of $1 or more for every $1 spent.102 School-Based Violence Prevention Full-Day Kindergarten. Full-day High School Completion Programs. Programs. Youth violence is a substantial kindergarten operates five days per week High school completion programs, public health concern: youth commit and lasts approximately five or more or dropout-prevention programs, are violent acts at a higher rate than hours per day. While supporting access initiatives that increase the likelihood any other age group. Over the past to high-quality pre-K aids in a child’s that students will receive a high school two decades, youth ages 10 to 17, development, states can also support diploma or a general educational who make up less than 12 percent other policies to ensure the gains made development (GED) diploma.98 Rates of of the population, were offenders in in pre-K programs are not lost as a high school completion decline among approximately 25 percent of serious, child progresses through the education low-income families and some racial/ violent victimizations.103 Childhood system. Full-day kindergarten is more ethnic minority populations. In 2017, experiences, positive and negative, beneficial for near-term academic for example, the national graduation have a tremendous impact on both success than half-day kindergarten, rate for White students was 88.3 percent, future violence victimization and and the impact is strongest in urban significantly higher than both Latino perpetration, as well as on lifelong areas and for programs lasting at least (79.3 percent) and Black (76.4 percent) health and opportunity. Initiating six hours.92 Studies show that children students.99 Students who met the state violence-prevention programs in with disabilities and English-language criteria classification of “economically schools is key; there’s no better place learners particularly benefit from full- disadvantaged” had a graduation rate of for near-universal access to children day kindergarten programs.93,94 Children 78 percent.100 Studies show that a failure than through educational institutions.104 who participate in full-day kindergarten to complete high school is associated To reduce or prevent violent behavior programs show higher gains in literacy with significantly lower economic in youth attending school, states and math scores compared with earnings, while also leading to increases should enact legislation that provides children in half-day kindergarten in costs related to healthcare and the violence-prevention efforts in schools. programs.95,96 To sustain academic gains criminal justice system.101 Approaches can include cognitive for children from low-income families Therefore, one strategy to advance programs, behavioral programs, social- beyond third grade, researchers suggest health equity and health outcomes is emotional skills training, and counseling following full-day kindergarten with to focus on high school–completion or therapy.105 Each approach attempts to additional interventions as children programs, especially those that target address the social or emotional factors continue through school.97 high-risk, low-income, and racial/ethnic linked to aggressive behavior. TFAH • tfah.org 17 Importance of Child Nutrition and Physical Activity Trends in Obesity Prevalence among Adults aged 20 and over (age adjusted) Like many adults, most children in the and youth aged 2-19 years: United States, 1999-2000 through 2015-2016 United States are not eating enough nutritious foods or getting enough physical activity.106,107,108 Between 2015 and 2016, 18.5 percent of children ages 2 to 19 had obesity, which is the highest rate ever documented by National Health and Nutrition Examination Survey.109,110,111 The rate varies among different age groups and rises as children get older. Kids: Who Has Obesity? l 1 3.9 percent of 2- to 5-year-olds. l 1 8.4 percent of 6- to 11-year-olds. l 2 0.6 percent of 12- to 19-year-olds Source: Centers for Disease Control and Prevention112 Data from the CDC also show One in six, or 13 million, children supporting access to high-quality meals substantial differences in obesity rates in the United States lives in a food- for children. More than 30 million among children of different races and insecure household and does not have children nationwide participate in the ethnicities. Obesity rates are higher consistent access to enough foods to National School Lunch and School among Latino children (25.8 percent) live healthy lives.116 Child hunger and Breakfast Programs. For children from and Black children (22 percent) than food insecurity impact rural and urban low-income families, school meals among White children (14.1 percent) areas: 85 percent of counties with high are an especially critical source of and Asian children (11 percent). child food insecurity are rural, and affordable, healthy foods; 51 percent of Latino boys (28 percent) and Black approximately 800,000 food-insecure American children now qualify for free girls (25.1 percent) are most likely to children live in Los Angeles and New and reduced-price school meals.119 have obesity.113 York City. Research shows that as Obesity costs the United States $149 children reach school age, hunger, Today’s children are at greater risk of billion in medical expenses annually— poor nutrition, and food insecurity developing certain diseases like type with about half of those expenses paid can harm academic performance and 2 diabetes and high blood pressure. If by publicly financed Medicare and lead to an increased need for mental current trends continue, more than Medicaid programs.120,121,122 Indirect health counseling and an increased half of today’s children will have obesity costs from obesity also run into the risk of having behavioral problems.117 by age 35.114 Research also shows that billions of dollars due to missed time Hungry children also get sick more children with obesity perform lower in at school and work, lower productivity, often and are more likely to be school and have a higher risk of being premature mortality, and increased hospitalized. Ensuring that children bullied and depression.115 Poor nutrition transportation costs.123 Taking steps to have access to regular and nutritious can result in both hunger or obesity— ensure all children have the opportunity meals has significant economic increasing a child’s risk for physical, to grow up at a healthy weight— implications: an average pediatric mental, behavioral, emotional, learning, including by having access to nutritious hospitalization costs $12,000.118 and oral health problems—making foods and time for active play—can help it hard to perform basic tasks and to The federal government, along with more kids reach their full potential. regulate social-emotional behavior. states, are playing an increasing role in 18 TFAH • tfah.org POLICY While the federal government plays a that all students can eat free.124 States strong role in the regulation of food can also establish stronger, additional RECOMMENDATION 1b: quality and nutritional standards via the requirements for the nutritional content. Increase Access to, National School Lunch Program (NSLP) Evidence shows that in most cases, Utilization of, and and School Breakfast Program (SBP), implementing nutritional standards does states can establish policies to strengthen not decrease school revenue and, in Nutritional Quality of or augment requirements related to some cases, increases revenue.125,126 School Meals the nutritional value of foods served The label “competitive foods” stems in school settings, including school from the fact that students may choose meal programs and competitive foods. to eat these foods instead of the Competitive foods include any foods nutritionally balanced meals provided sold to students outside of federally by the SBP and the NSLP.127 But state reimbursable meals, such as vending law also regulates the nutritional machines or à la carte food options. content and availability of competitive States can enact policies that support foods. Even though they are sold increased healthy food consumption and outside of federally reimbursable improve the school food environment. meals (which must offer meals The Healthy, Hunger-Free Kids Act that meet strict federal nutritional of 2010 set minimum standards to standards in order to receive federal increase access to healthy foods for low- reimbursement),128 state laws can income children. But state law can still require competitive foods and be vital to the proliferation of the SBP beverages to meet certain nutritional and the NSLP. States have passed laws standards, too (such as banning encouraging or requiring schools to anything that contains trans-fats). participate in these programs. Through States can take a broad approach to funding legislation, states are able to regulating nutrition by implementing more fully support meal programs “healthy school” initiatives. They are and eliminate reduced-price meals so often a broad range of strategies, but at a state level, healthy school lunch initiatives often hold the NSLP foods to an even stricter standard than the federal mandate requires. For the truly innovative features of school lunch initiatives, look to the local level.129 Some laws address the regulation of meal times (for example, California passed “Adequate Time to Eat” legislation130), food allergies, and farm-to-school programs, as well as reimbursements and funding incentives. Broad school food policies may also include limits on foods for celebrations and rewards, restrictions on food and beverage marketing in schools, and incentives for school gardens.131 TFAH • tfah.org 19 Health Evidence Economic Evidence in the total, as they require schools Improving access to, and the A majority of the economic evaluations to offer at least one meal (breakfast nutritional content of, school meals examining the financial impact of or lunch) per day.155 There are seven and other foods reduces school meal implementing school nutritional states that fall within this gray category disparities. These programs have standards shows that these policies do of potentially requiring breakfast.156 increased the availability of more not decrease school revenue and, in At least 20 states require all or some nutritious items and helped close the some cases, increase revenue. schools to offer the NSLP. This tally meal disparity gap associated with does not include states with legislation l A n evaluation of California’s school size, location, and student race that encourages schools to offer it or nutritional standards for competitive and ethnicity makeup.132 states that do not specify NSLP. For foods found that 10 of the 11 schools Access to school breakfast programs reporting financial data had revenue example, Georgia is not included in can improve academic achievement increases of more than 5 percent the total as they require public schools and cognition, especially among from meal program participation, to offer at least one meal (breakfast or malnourished or food-insecure which offset the decreases in revenue lunch) per day.157 Fourteen states do children.133,134 School breakfast from à la carte food options.148,149 not explicitly regulate the NSLP. programs can also increase healthy l I n West Virginia, after the state Competitive Foods food consumption and improve restricted the sale of foods with low breakfast nutrition.135,136,137 Student At least 28 states have passed legislation nutritional value and soda, 80 percent participation in school breakfast regulating competitive foods.158 of the principals surveyed reported programs reduces students’ body mass little or no change in revenue after indexes and may reduce weight gain.138 Nutritional Standards implementation.150 In 2007, 17 states set nutritional There is some evidence that healthy l T wo other studies found that standards that were stricter than school lunch initiatives increase the lowering the price of fruits, existing U.S. Department of Agriculture selection and consumption of healthy vegetables, and low-fat snacks (USDA) requirements.159 Many states foods, and improve students’ eating resulted in a significant increase in followed suit—passing their own behaviors. These programs can also the sales of these foods without a regulations once the Healthy, Hunger- improve childhood nutrition.139 Like decrease in total revenue.151,152 Free Kids Act of 2010 was implemented. healthy school breakfasts, healthier In 2017 alone, 34 states introduced school lunches are linked to improved l I n a study of 20 secondary schools, school nutrition legislation.160 academic outcomes and reduced researchers determined that school absences due to illness.140 promoting the sale of low-fat food Since the start of the 2018 state options and increasing the availability legislative sessions, there are trends There is strong evidence that of these options resulted an increase emerging in school nutrition, such nutritional standards for both in sales for these foods with no impact as legislation that addresses unpaid school meals and competitive on overall food-service revenue.153 school meals and ensures that every foods increase fruit and vegetable child gets a meal; legislation that uses consumption and improve school food Policy Landscape incentive funds to support schools environments.141,142,143 Research shows School Meal Programs that establish or expand programs that reducing unhealthy food options Thirty states and the District of to increase student participation in increases students’ purchases of healthy Columbia require all or some schools meal programs; and “Breakfast After and neutral foods and decreases to offer School Breakfast Programs.154 the Bell” legislation, which expands unhealthy food consumption.144,145,146 This tally does not include states with opportunities to eat breakfast.161 In Comprehensive state laws that regulate legislation that encourages schools to the last year, six jurisdictions enacted the nutritional content of competitive offer it or states that do not specify SBP. Breakfast After the Bell legislation.162 foods may reduce increases to adolescent body mass index.147 For example, California is not included 20 TFAH • tfah.org CASE EXAMPLE Colorado’s Breakfast After the Bell Program163,164 In 2013, Colorado passed House Bill eligible for free or reduced-price meals school year, gives more than 80,000 13-1006, which required public schools to further expand the program’s impact. additional children in the state access that have 80 percent or more students The bill exempts public or charter to a breakfast served after the first bell. who are eligible for free or reduced-price schools that do not participate in the As a result, in the first year the law was meals to offer breakfast at no charge. NSLP and school districts with fewer implemented, Colorado went from being This threshold was later reduced to 70 than 1,000 students. The law, which ranked 20th in the country in school percent or more of students who are was implemented in the 2014–2015 breakfast participation to 11th. Considerations for Effective Design and Implementation165,166,167,168, 169 l E xpand flexible breakfast programs, and beverage advertisements on l C onduct outreach, provide such as second-chance breakfasts, school campuses meet Smart Snacks education, and support school breakfast on-the-go, and breakfasts nutritional guidelines. districts’ implementation of the in classrooms. Strategies that move Community Eligibility Provision, l O ffer breakfast and/or lunch at no breakfast out of the cafeteria and into which allows qualifying high-poverty charge to all children as a strategy to the classroom are the most successful schools to offer breakfast and end stigma for participating children, at overcoming barriers to participation. lunch at no charge to all students to boost participation among hungry without having to collect and process l S upport and implement local children, and to eliminate the individual meal applications. school-wellness policy rules, burden of collecting fees. including the provision that all food Complementary Policies Enhanced Physical Activity. Most school before lunch, that can involve varying physical-education (PE) classes do not types of supervised games or activities.173 meet the CDC’s recommendation that The primary goals of active recess students spend 30 to 60 minutes in include an increase in physical activity PE class per day, according to a 2016 and structured inclusivity in order to report.170 States can adopt policies to improve health, academic success, social support school-based PE enhancements, skills, and emotional well-being.174 The which include lengthening existing U.S. Department of Health and Human classes, adding new PE classes, Services’ physical-activity guidelines for increasing physical activity during 2018 recommend that all children get class, training teachers, and updating 60 minutes of daily physical activity.175 PE curricula. Laws supporting school- In order to meet this recommendation, based PE enhancements can increase the CDC, Shape America, and other physical activity and physical fitness organizations recommend that all among school-age children. Increases elementary school students be provided in physical activity have been shown to with at least one daily session of recess improve academic outcomes.171, 172 for at least 20 minutes.176 There is strong evidence that active recess is a Active Recess. Active recess, previously direct solution and increases physical referred to as “structured recess,” is activity for schoolchildren.177,178 a break from the school day, typically TFAH • tfah.org 21 2 Employ Harm-Reduction Strategies to GOAL 2: Employ Harm-Reduction Strategies to Prevent Substance-Misuse Deaths and Related Diseases Goal Prevent Substance-Misuse Deaths and Related Diseases In the past decade, more than one million Americans died from drug overdoses, alcohol poisoning, and suicides.179 Addressing the current rise in drug and alcohol misuse is now a national priority. Additionally, the increased use of illicit drugs—like heroin and opioids and the more potent fentanyl and carfentanil—has made the situation even more dire and complicated. The increased use of heroin and opioids, which l T he highest rates of new HCV diagnoses are often injected, means more individuals and were highest in Appalachia, the Midwest, and new populations are at higher risk of contracting New England. infectious diseases, such as the hepatitis C virus l M ost new cases of HCV are not diagnosed since (HCV), hepatitis B virus (HBV), and human symptoms often develop as people age, likely immunodeficiency virus (HIV) through shared representing an increase of tens of thousands of and unclean syringes.180 Injection drug use is a undiagnosed cases of HCV.185 risk factor for contracting blood-borne diseases like HIV and HCV, and sharing syringes provides l I n 2017, Black Americans represented 13 percent a direct route of transmission.181 The symptoms of the population but accounted for 43 percent of HIV and HCV often do not appear for years, of HIV diagnoses (16,694). Latinos represented so individuals may continue to spread diseases to 18 percent of the population but accounted others without even knowing they are infected. for 26 percent of HIV diagnoses (9,908). Black People who inject drugs are the highest-risk Americans have the highest rate of HIV diagnoses group for acquiring HCV, and each individual compared with other races and ethnicities.186 who injects drugs with HCV is likely to infect 20 l I n 2017, gay and bisexual men accounted for 66 other people.182 Having another blood-borne percent of all HIV diagnoses (25,748).187 disease increases a person’s risk of getting or transmitting HIV. For people living with HIV, l I n Kentucky, Tennessee, Virginia, and West getting HBV or HCV can increase their risk for Virginia, acute HCV infections increased by 364 life-threatening complications.183 percent from 2006 to 2012—a majority of those infected were White adolescents and adults The use of heroin and opioids in areas where under 30 who inject drugs.188 laws and policies make it difficult to access sterile syringes has contributed to a dramatic rise in HIV In addition, disparities in diagnoses and and HCV infections: treatment of blood-borne diseases persist, where racial and ethnic minorities, sexual l I n 2016, 3,425 HIV diagnoses (9 percent) were minorities, and low-income individuals bear a attributed to injection drug use.184 higher burden of disease. For individuals who FEBRUARY 2019 l F rom 2010-2016, HCV diagnoses increased 3.5- inject drugs, these disparities are compounded fold nationwide—from 850 new cases in 2010 by stigma, discrimination, and differences in to 2,967 new cases in 2016—in tandem with socioeconomic status, which can affect access the increases in heroin and fentanyl use and to quality healthcare, like screenings and increases in overdoses. treatment. In a study of cities with high levels of HIV, more than half of HIV-positive people l T he highest rates of new HCV diagnoses were (56 percent) who inject drugs reported being among 20- to 29-year-olds who inject drugs. 22 homeless, 25 percent reported being White, 31 percent (1,063) were Black, incarcerated, and 16 percent did and 21 percent (708) were Latino.190 not have health insurance in the last These alarming rates have pushed year.189 In 2016, among people who policymakers to reexamine syringe- inject drugs and received an HIV exchange policies as an effective strategy diagnosis, 43 percent (1,466) were to reduce rates of infectious disease. HIV Diagnoses Among People Who Inject Drugs, by Transmission Category, Race/Ethnicity, and Sex, 2016 – United States Source: Centers for Disease Control and Prevention191 STATE OF EMERGENCY Indiana’s Response to an HIV Outbreak In March 2015, then–Indiana Governor spreading into nearby communities, Mike Pence declared a Public Health officials established a needle-exchange Emergency in Scott County in response program, facilitated in part by the to an HIV outbreak. By May 2015, governor’s State of Emergency and the investigators had identified 135 HIV- comprehensive public health response.192 infected people in a community of 4,200 Following the implementation of people. By June 2015, public health the needle-exchange program, officials identified more than 480 people researchers interviewed 200 people who were named as sharing needles who injected drugs both before with or having sexual contact with HIV- and after the establishment of the infected people. The majority of those program and found that as a result with HIV were linked to syringe sharing. of the exchange, needle sharing fell Additionally, more than 90 percent of by 85 percent and the frequency those individuals were also co-infected of reusing the same syringe also with HCV. To curb the spread of HIV and declined significantly.193 HCV in the area and to prevent it from TFAH • tfah.org 23 POLICY State policies that support access to infectious disease transmissions among clean needles and syringes prevent individuals who inject drugs. RECOMMENDATION 2a: disease and save lives by removing Syringe Access Programs barriers and facilitating access to sterile l I n New York City, following the legalization of syringe-exchange syringes. The legality of distributing programs, between 1990 and 2002, or possessing a syringe for illegal drug the HIV prevalence among studied use is governed by regulations that intravenous drug users decreased address drug paraphernalia, syringe from 50 percent to 17 percent.199 prescriptions, controlled substances, and pharmacy practices.194 Policies that l A nother study of New York City’s authorize the legal sale and exchange of syringe-exchange program between sterile syringes aim to reduce the rate of 1990 and 2001 found the prevalence of infectious diseases—like HCV, HBV, and HCV among people who inject drugs HIV—among intravenous drug users. fell from 80 percent to 59 percent. Many law enforcement officials l F ollowing the District of Columbia’s support these policies as an effective lift of the congressional ban on harm-reduction strategy to limit the syringe-exchange programs, which adverse effects associated with drug allowed the D.C. Department of use to individuals and communities Health to initiate an exchange and to limit the exposure of police, program, there was a 70 percent emergency workers, healthcare decrease in new HIV cases among providers, and others in the community injection drug users and a total of 120 to contaminated needles.195 HIV cases averted in two years.200 Health Evidence Economic Evidence Syringe access programs are one of the Expanding syringe-exchange programs most effective and scientifically based can yield costs savings within a single year. methods for reducing the spread of HIV Treatment of HIV, HCV, and other blood- and hepatitis—and do not contribute borne diseases can be costly. In 2010, to increased drug use.196,197,198 While the lifetime cost of one person’s HIV establishing programs to increase access treatment was estimated to be $379,000.201 to clean syringes can be a politically In 2014, the cost of HCV treatment contentious issue, the evidence ranged from $84,000 to $96,000.202 supporting the effectiveness of these People who inject drugs can reduce programs is overwhelming. States should their risk of acquiring and transmitting make additional efforts to overcome blood-borne infections by using sterile these long-held misperceptions so they syringes for every injection. What’s more, can further reduce the number of advancing policies to increase access to sterile syringes can be cost saving.203 In New York City, for example, the needle- The Prevention Payoff exchange program resulted in a baseline It is estimated that an annual increase of l $ 75.8 million in lifetime HIV one-year savings to the government of $10 million to expand access to sterile treatment costs would be avoided. $1,300 to $3,000 per client, reduced syringes would have the following results l T here would be a return on investment HIV treatment costs by $325,000 per on a national level in a single year: of $7.58 for every $1 spent. case of HIV averted, and averted four to l 1 94 HIV infections would be averted. seven HIV infections per 1,000 clients, producing a net cost savings.204 24 TFAH • tfah.org Policy Landscape In December 2015, Congress partially laws in recent years as a result of syringe-exchange programs. As of lifted restrictions on the use of the opioid epidemic, including: in 2018, there are 320 syringe-exchange federal funds to support syringe- 2015, Colorado, Illinois, Indiana, programs in 40 states, the District of exchanges, allowing states and and Kentucky; in 2016, Florida, Columbia, and Puerto Rico.­ 214 communities to use federal funds to North Carolina, and Utah; and in States laws about syringes and pay for operational costs of syringe- 2017, Montana, New Hampshire, distribution vary: some states regulate exchange programs.205 As of July 1, and Virginia.208,209,210,211,212,213 This the retail sale of syringes; sometimes 2017, all 50 states and the District does not reflect other states that a prescription is required; sellers of Columbia have laws regulating may have removed legal barriers to may have to get certain information syringe access.206 At least 26 states syringe programs but do not directly from a syringe buyer; and, of course, and the District of Columbia have authorize them. some states vary on whether syringe- laws supporting syringe-exchange Even without legislative authorization, exchange programs are even allowed programs.207 This includes a number many states and localities operate and under what circumstances.215 of states that have changed their CASE EXAMPLE North Carolina’s Safer Syringe Initiative In 2016, North Carolina legalized syringe on to identify legislation that the law Services (NC DHHS) noted that Medicaid exchanges. Years of collaborative enforcement community would find charges for HCV treatment increased efforts that focused on harm reduction helpful and would ultimately support. In from $3.8 million in 2011 to $85 million broke down the historical resistance to addition, advocates made the case that in 2016. Following the legalization of the syringe exchanges and resulted in the needle exchanges could save the state syringe exchanges, NC DHHS developed decriminalization of needles. Advocates money by reducing the number of HCV the Safer Syringe Initiative and registered performed demonstration projects and cases in the future. The North Carolina 22 syringe programs in the first year of worked with law enforcement early Department of Health and Human the law, reaching 19 counties. Considerations for Effective Design and Implementation l A uthorize syringe programs that participants or administrators of Programs should consider providing explicitly allow access to needle- syringe access programs to access and or connecting participants to medical, exchange programs statewide to possess clean syringes social, mental health and substance prevent and control the spread of use disorder services, and treatment. l O ffer resources for technical assistance, infections. States should consider capacity building, or support from l E nsure data-collection procedures do what type of organizations will be experienced harm-reduction staff to not cause an undue burden on the authorized to run these programs, help execute and sustain syringe-access program or participants. Programs such as local health departments, programs long term. should also ensure anonymous nonprofits, community-based participation and confidentiality of organizations, pharmacies, or others. l M ake educational materials and other involvement in program activities to services, including access to treatment, l E xempt syringes and needles from increase participation. available to people who inject drugs. drug-paraphernalia laws to allow TFAH • tfah.org 25 Complementary Policies As Americans struggle with addiction, programs can be in the form of one- many policy strategies focus on drug day Take Back events, in-person drop- overdoses and decreasing the supply of offs, mail-in programs, or permanent illicit and prescription drugs that can be collection receptacles. Drug disposal misused.216 There are numerous factors laws vary across states, namely whether that contribute to substance misuse and the state authorizes drug disposal, it is important to implement evidence- disposal locations, disposal methods, based policies and programs that and provide funding. promote mental health and well-being. Good Samaritan Laws: Good The legal and social policies set in Samaritan laws reduce legal penalties place to address substance misuse have for an individual seeking help for major consequences for the individuals themselves or others experiencing and communities affected. Successful an overdose.217 In 30 states and the public health approaches to substance District of Columbia, Good Samaritan misuse are multifaceted: laws prevent an individual who seeks medical assistance for someone, l A ddress the underlying social including themselves, experiencing determinants (such as poverty and a drug-related overdose from trauma). being prosecuted for possession of l P romote resiliency and skill building a controlled substance. However, and bolstering protective factors to 21 states, including Alaska, North help individuals cope with difficulties Carolina, and Virginia, do not protect in a healthy manner. such individuals from being charged. l P rovide individuals with support and Provider Education and Informed connections to treatment and recovery. Practices: Education for practitioners is a critical component to reducing l R educe the supply of drugs and prescription drug misuse—including support appropriate uses of support for continuing education, prescription medicines. particularly as the field and l T reat addiction as a public health guidance may change over time.218 issue and not a criminal justice issue Recommended subject matters and avoid compounding the negative include: treating pain in a holistic impact for families. manner, prescribing appropriately, using critical-thinking skills, using l P romote community-based programs state prescription drug monitoring rather than high-cost and ineffective programs, identifying addiction, and approaches within the criminal referring to treatment. Many medical, justice system. dental, nursing, pharmacy and other Drug Disposal Programs: Drug professional schools provide only disposal programs allow people to limited training on substance misuse drop off expired, unwanted, or unused and pain treatment. medicines for proper disposal. These 26 TFAH • tfah.org 3 Promote Healthy Behavior GOAL 3: Promote Healthy Behavior In 2016, the CDC reported that the top five leading causes of death in the Goal United States were (1) heart disease, (2) cancer, (3) accidents (unintentional injuries), (4) chronic lower-respiratory diseases, and (5) stroke (cerebrovascular diseases).219 Many Americans are dying prematurely and some of these deaths can be prevented.220 For the five leading causes of death, some of the major risk factors include tobacco use, secondhand smoke exposure, poor diet, drug and alcohol use (including prescription drug misuse), and lack of physical activity, among other factors.221,222,223,224,225 While these risk factors impact all Americans, certain individual behaviors, like smoking, can be there are significant racial and ethnic disparities. harmful to people who do not engage in those For example, American Indians and Alaska behaviors themselves, such as by exposing them Natives have the highest smoking rate of any to secondhand smoke. Increasing the price of racial or ethnic group (31.8 percent)—compared tobacco products can help discourage individuals with Blacks (16.5 percent), Latinos (10.7 from consuming tobacco, while implementing percent), and Whites (16.6 percent).226 While smoke-free laws can protect nonsmokers from Black smokers have comparable smoking rates exposure to secondhand smoke. to Whites, more than 77 percent smoke menthol cigarettes, which make it easier to start smoking Tobacco and more difficult to quit, compared with 23 Tobacco use continues to be a leading cause of percent of White smokers.227,228,229 Additionally, preventable death in the United States, known individuals below the federal poverty level have to cause cancer and other harmful health a smoking rate of 25.3 percent compared with conditions.233 Every year, smoking costs the 14.3 percent of individuals at or above the federal United States approximately $170 billion in poverty level.230 Through policy change, states can healthcare expenditures.234,235 Tobacco use is help reduce these risk factors for populations that established primarily during adolescence: an are disproportionately impacted and promote estimated nine in 10 smokers first tried cigarettes health equity. before the age of 18.236 These risk factors are influenced by the social, Every year, smoking-related illnesses cost the demographic, environmental, economic, and United States more than $300 billion. This geographic characteristics of the places in which includes approximately $170 billion in medical people live and work.231 Modifying environments care, more than 60 percent of which is paid for by to make it easier for people to make healthier public programs like Medicare and Medicaid.237 choices can lead to better health outcomes Additionally, the United States loses $156 billion however, many individuals do not have the means in lost productivity, including $5.6 billion in or know-how to improve health on their own.232 lost productivity due to secondhand smoke Policymakers can modify the conditions in their exposure.238,239 FEBRUARY 2019 states to support opportunities for residents to make healthy choices. States can use financial Two sets of policies—smoke-free regulations and incentives and disincentives to encourage or increased tobacco prices—can promote health discourage behaviors, some of which might be while also generating a substantial savings for harmful and costly to taxpayers. Additionally, government and the private sector. 27 POLICY States should enact legislation to Health Evidence prohibit smoking in designated RECOMMENDATION 3a: spaces. Policies can apply to indoor Implementing smoke-free policies decreases smoking behavior, reduces Smoke-Free Policies areas, outdoor areas, and multiunit exposure to secondhand smoke, and housing.240 Smoke-free policies are improves health outcomes.247 There designed to improve public health by is no safe level of secondhand smoke reducing secondhand smoke, reducing exposure.248 Secondhand smoke is tobacco use, encouraging smokers to associated with adverse health outcomes quit, reducing the initiation of tobacco such as respiratory infections and use, and reducing tobacco-related asthma attacks.249 Secondhand smoke morbidity.241 Smoking in federally- exposure from e-cigarettes can also assisted housing is prohibited by federal have negative health impacts. A recent law.242 States have recently expanded report from the National Academies of smoke-free policies to include electronic Sciences, Engineering, and Medicine cigarettes (e-cigarettes) and prohibit found conclusive evidence that their use in certain establishments.243 e-cigarette use increases airborne Smoke-free policies for indoor areas are concentrations of particulate matter the most common and tend to cover and nicotine in indoor environments.250 smoking in workplaces, restaurants, Smoke-free policies reduce asthma and bars. They can also include partial attacks and related hospitalizations, as bans that limit smoking to designated well as to reduce total hospitalizations areas. Although most states have enacted and mortality associated with other smoke-free indoor-air laws, not every cardiovascular and respiratory jurisdiction has comprehensive laws.244 diseases.251,252 Indoor-smoking policies The CDC considers a smoke-free law to can lower smoking rates and encourage be comprehensive if it prohibits smoking current smokers to quit.253 Following in all indoor areas of private workplaces, the implementation of smoke-free restaurants, and bars, with no exceptions. policies in indoor areas, smoking rates Smoke-free policies for outdoor areas among younger populations appear cover smoking outside, including on to be decreasing faster compared with worksite property and outdoor public older adults.254 areas, such as parks and beaches.245 Implementing outdoor smoke-free Smoke-free policies for multiunit policies can help reduce smoking housing cover smoking in apartments, in designated areas. Smoke-free duplexes, and similar residences. They indoor-air policies reduce cigarette can apply to common areas, individual consumption, prevent secondhand units, and adjacent outdoor areas. smoke exposure, promote smoking These policies tend to focus on public cessation, and improve health and subsidized housing.246 However, outcomes.255 However, smoking in these policies must be enforced in a designated outdoor smoking areas way that does not jeopardize stable located next to indoor smoke-free housing for low-income people. settings can increase secondhand Residents must be provided with smoke concentrations in both resources and multiple chances to quit settings.256 Restricting smoking in smoking. Overly punitive enforcement outdoor public spaces, such as parks risks exacerbating homelessness and and beaches, appears to reduce health inequities. smoking in those settings.257 Additional 28 TFAH • tfah.org evidence is needed to confirm these effects and their impact on health outcomes. Prohibiting smoking in public places is an evidence-based, recommended strategy to prevent tobacco use among youth.258 Implementing comprehensive campus smoking bans that include outdoor areas appears to reduce smoking among college students within one to three years.259 Applying smoke-free multiunit housing policies can reduce exposure to secondhand smoke and thirdhand smoke. A Portland, Oregon study found that smoking bans in multiunit housing were associated with positive changes in smoking cessation and reduced exposure to secondhand smoke.260 After implementing a Outdoor smoke-free housing policy in Canada, In a cost analysis of implementing and respondents reported an increase enforcing a smoke-free outdoor-space in outdoor smoking and overall ordinance, a Canada-based study found reductions in smoking.261 that no additional enforcement staff were hired and that promoting a smoke- Economic Evidence free outdoor-air policy did not create Indoor significant burdens on staff or budgets.264 Smoke-free policies can be cost effective by reducing secondhand Multiunit Housing Units smoke exposure and related medical It is estimated that implementing expenditures. An economic analysis smoke-free policies in public housing estimated that implementing smoke- could save $496.82 million per year, free policies will save between $0.15 including $310 million in averted health million and $4.8 million per 100,000 costs, $133.77 million in renovation people in healthcare costs.262 A year expenses, and $52.57 million in after Florida implemented a smoke- smoking-attributable fire losses. The free indoor-air policy, the state saved same analysis found that cost savings $6.8 million in averted medical by state ranged from $0.58 million to costs. It is estimated that in the long $124.68 million.265 Other research shows term, Florida will save $220 million that implementing national smoke-free annually—$196 million in savings policies in public housing would save an from former smokers and at least $24 estimated $183 million to $267 million million from reduced exposure to from reduced medical expenditures and secondhand smoke.263 averted losses in productivity.266 TFAH • tfah.org 29 Policy Landscape States that Preempt Local Smoke-Free Laws According to the American Lung Association, 28 states and the District of Columbia have passed comprehensive smoke-free laws. Nine states and the District of Columbia have added e-cigarettes to their smoke-free laws.267 As of June 30, 2018, 37 states and the District of Columbia are 100 percent smoke-free in at least one of three locations (bars, restaurants, and private worksites).268 The remaining states either do not have smoking laws, allow smoking in designated areas, or require separate ventilation for areas that allow smoking. There is variation on whether the smoking ban covers bars, restaurants, States in orange preempt local government control of smoke-free policies. private worksites, or a combination of the three. Despite states’ progress enacting Source: Grassroots Change271 and implementing smoke-free laws, there are instances where states are preempting often as extensions of indoor smoke- owned or funded, and 12 states localities from protecting individuals free policies. One issue surrounding prohibit or restrict smoking in common from secondhand smoke exposure. State these laws is how outdoor spaces areas of privately owned housing legislation preempts local government should be defined. There are currently facilities. Hawaii and Oklahoma restrict control of smoke-free policies in 12 no states that have enacted outdoor smoking in the individual living areas states.269 Smoking in federally-assisted smoke-free policies.272 of government-operated buildings, housing is prohibited by federal law.270 and some communities in California As of 2015, 15 states prohibit or restrict prohibit smoking in individual units of Outdoor smoke-free policies are smoking in common areas of multiunit some or all multiunit housing.273 typically also enacted at a local level, housing facilities that are government CASE EXAMPLE Wisconsin’s Smoke-Free Law In July 2010, Wisconsin enacted a of all deaths in Wisconsin.276 After the economic impacts were either statewide smoke-free law that applies implementing a comprehensive neutral or positive.278 to enclosed places of employment smoke-free law, researchers found the l S tudies found that there was no and to enclosed public spaces, such following effects on residents’ health difference in the number of liquor as restaurants, hotels, theaters, and and local economies: licenses for establishments to serve other facilities.274 The statewide law l T hree to six months after the alcoholic beverages before and after does not apply to outdoor areas. implementation of the statewide the local laws took effect.279 However, local authorities can choose smoke-free law, nonsmoking bar to restrict smoking in outdoor public l T he Wisconsin Restaurant Association workers experienced a significant properties but not private property, supported the enactment of the decline in respiratory symptoms such as restaurants or bar patios. 275 An statewide smoke-free law to protect caused by secondhand smoke.277 estimated 6,966 people die annually all restaurant and bar workers from from illnesses directly related to l L ocal smoke-free laws were found not the dangers of secondhand smoke.280 smoking, which is nearly 15 percent to harm the local economies. In fact, 30 TFAH • tfah.org Considerations for Effective Design and Implementation281,282 l E nsure that smoke-free air laws do l U se clearly defined terms— associated with tobacco use and not preempt local law. especially the definitions of exposure to secondhand smoke. “restaurant” and “bar”—to support l M andate 100 percent smoke-free l P rohibit smoking in outdoor unambiguous interpretation by environments to maximize health places, including parks and other those responsible for implementing benefits, minimize confusion, and recreational areas, restaurant patios, and enforcing the policy. facilitate compliance. This should bus stops, public-event sites, and include bars, restaurants, workplaces, l P rovide no, or minimal, exemptions common areas of multiunit housing. casinos, and common areas of that may result in legal challenges. l R equire “No Smoking” signs to multiunit housing facilities. l S pecify procedures, penalties, and be posted. l E xpand current or enact new smoke- funding mechanisms for enforcement. l C ouple enforcement with robust free air laws to include the use of l U se the latest scientific information resources to help people quit smoking. electronic nicotine delivery systems documenting the health risks and marijuana. POLICY Increasing tobacco pricing is a sound rates, and reduces disparities.284,285 strategy to deter youth from using Generally, the effects on tobacco RECOMMENDATION 3b: tobacco products, to promote quitting consumption are proportional to the Tobacco Pricing Strategies tobacco, and to reduce tobacco use. increase in the price of the tobacco Research shows that higher prices product. Research suggests that a 20 decrease tobacco consumption and percent increase in the unit price of increase rates of tobacco cessation. That’s tobacco reduces tobacco consumption particularly important in low-income by 10 percent.286 Government tobacco- neighborhoods, which have a higher control policies decreased smoking concentration of tobacco retailers and prevalence and increased smoking are more likely to have a store that sells cessation rates among youth after the tobacco near schools.283 Additionally, price of tobacco products was raised. higher tobacco prices can generate cost Higher tobacco prices have a greater savings and avoid lost productivity due to effect on adolescents, young adults, poor tobacco-related health outcomes. and lower-income populations.287 All states have a tax on some tobacco It should be noted that implementing products, but the products and their tobacco pricing strategies that apply associated tax rates vary. The revenue to only a limited set of products may generated from taxing tobacco encourage users to substitute one products may be used to fund tobacco tobacco product with a lower-priced interventions or other public health one. For example, if the price increases programs. To promote health equity, are narrow in scope and only apply this spending can be directed to those to one type of tobacco product (for communities most affected by the tax. example, cigarettes but not smokeless tobacco), users may use price- Health Evidence minimization strategies, such as buying Increasing tobacco prices decreases lower-priced tobacco or discounted tobacco consumption, increases quit products, to avoid the price increase.288 TFAH • tfah.org 31 Economic Evidence STATE CIGARETTE TAX RATE Because increased tobacco prices approaches and rates of taxation differ State Cigarette Tax Rate deter people from initiating tobacco greatly throughout the country.290 As Alabama $0.68 Alaska $2.00 use and promote tobacco cessation, of December 2018, just eight states and Arizona $2.00 states can generate cost savings in the the District of Columbia have cigarette Arkansas $1.15 form of lower healthcare expenditures. tax rates per pack greater than $3.00. California $2.87 The revenue from increasing tobacco Further, the rates differ by state for Colorado $0.84 taxes can also be used to fund tobacco- different types of tobacco products, Connecticut $4.35 control programs in the state. Research with some states including, and some Delaware $2.10 D.C. $4.50 shows that increasing tobacco prices excluding, e-cigarettes. There is also Florida $1.34 by 20 percent results in healthcare cost differentiation in tobacco taxation Georgia $0.37 savings ranging from -$0.14 to $90.02 beyond retail, with some states taxing Hawaii $3.20 per smoker per year in addition to tobacco with inventory or floor-stock Idaho $0.57 averted productivity losses.289 taxes, and some states taxing tobacco on Illinois $1.98 a wholesale level.291 There is variation Indiana $1.00 Iowa $1.36 Policy Landscape in the allowance of local taxation on Kansas $1.29 All 50 states and the District of tobacco, as well as in the penalties for Kentucky $1.10 Columbia, have enacted a tobacco tax evasion and contraband trafficking. Louisiana $1.08 pricing policy. There is a high degree As of 2016, 21 states prohibit local Maine $2.00 of variation across states when it comes governments from imposing taxes on Maryland $2.00 tobacco products and seven states allow Massachusetts $3.51 to these policies. While all jurisdictions Michigan $2.00 have an excise tax on cigarettes, the localities to adopt such a tax.292 Minnesota $3.04 Mississippi $0.68 Missouri $0.17 CASE EXAMPLE Montana $1.70 Nebraska $0.64 New York’s Tobacco Tax Nevada $1.80 Between 2000 and 2010, New York 17.1 percent.296 In 2017, 5.5 percent of New Hampshire $1.78 state raised the cigarette excise tax New York high school students smoked New Jersey $2.70 New Mexico $1.66 three times to decrease tobacco at least one day in the past month New York $4.35 consumption among adults and youth. compared with the national average of North Carolina $0.45 In 2000, the state first implemented 8.8 percent.297 North Dakota $0.44 a $0.55 cigarette excise tax increase, Ohio $1.60 However, as with many other states raising the tax rate of cigarettes to Oklahoma $2.03 across the country, only a modest $1.11 per pack.293 Currently, New York Oregon $1.33 fraction of New York’s tobacco tax Pennsylvania $2.60 has one of the highest cigarette excise revenue is dedicated to tobacco- Rhode Island $4.25 taxes in the country, charging $4.35 cessation programs or even to public South Carolina $0.57 in excise taxes per package of 20 South Dakota $1.53 health in general. According to the CDC, cigarettes, compared with the national Tennessee $0.62 states cumulatively appropriated only average of $1.78 in excise taxes per Texas $1.41 2.4 percent of their tobacco revenue pack.294 To put this into perspective, Utah $1.70 for tobacco-control efforts, including Vermont $3.08 New York annually collects more than tobacco cessation.298 Because the Virginia $0.30 $1.2 billion in tobacco taxes.295 As New tobacco tax is inherently regressive, only Washington $3.03 York increased taxes on cigarettes, West Virginia $1.20 more robust spending on the needs of the state’s smoking rate fell below Wisconsin $2.52 the low-income population can prevent the national average. In 2016, 14.2 Wyoming $0.60 the tobacco tax from having negative percent of adults in New York smoked ≤ $0.999 14 states consequences for health equity. $1.00 – $2.99 28 states compared with the national average of ≥ $3.00 8 states & D.C. 32 TFAH • tfah.org Considerations for Effective Design and Implementation299 Complementary Policies l M odernize tobacco-related policies that improve health, such as Minimum Age for Tobacco: Often definitions to recognize new tobacco supporting the expansion of the state called “Tobacco 21” policies, enacting products, including e-cigarettes. earned income tax credits. legislation to increase the purchase age for tobacco to 21 is another strategy l T ax non-cigarette tobacco products at l I ncrease state support for cessation to promote better health and curb a tax rate that it is equivalent to that services through the expansion of “quit- healthcare costs associated with tobacco of cigarettes. lines,” nicotine-replacement therapy, use. About nine in 10 cigarette smokers texting programs, and other services. l P eriodically review tobacco tax rates first tried smoking before the age of and adjust for inflation. l P rovide flexibility to municipalities to 18.300 Studies suggest that 95 percent of tax tobacco products, and remove any adult smokers began smoking before l D edicate a portion, or a greater existing preemption policies. age 21.301 Some states have raised the proportion, of tax revenue for state minimum age from 18 to 19, and tobacco-control and prevention l I f tobacco taxes are below the others have raised it to 21. programs, and specifically target national average, raise them. these programs to low-income l I ncrease penalties for tobacco tax individuals and other vulnerable evasion and contraband trafficking, populations. Any remaining revenue and strengthen enforcement. should be dedicated to other POLICY States can impose higher taxes on About 88,000 people die of alcohol- alcoholic beverages to reduce excessive related causes per year, making excessive RECOMMENDATION 3c: drinking, underage drinking, and alcohol consumption the third leading Alcohol Pricing Strategies alcohol-related deaths. Increasing cause of preventable death in the United alcohol taxes reduces both excessive States.302 About one in six American alcohol consumption and alcohol- adults binge-drinks about four times a related harms. Some states already month.303 Binge-drinking behavior is have taxes targeting alcoholic most common among young adults ages beverages, but the effects of the tax 18 to 34, but adults ages 35 and older can erode over time if the tax does not consume more than half of the total keep up with inflation. number of binged drinks.304 Underage drinking is also a significant issue. In 2015, about 7.7 million people ages 12 to 20 reported drinking alcohol in the past month.305 In 2010, excessive drinking cost the nation $249 billion in healthcare expenditures, workplace productivity, and other expenses.306 Implementing mechanisms to reduce alcohol misuse can save states billions of dollars. Because states have the flexibility to apply tax policies that best suit their budget and needs, state legislatures can take action to reduce excessive drinking, underage drinking, and alcohol-related deaths and save costs associated with alcohol misuse. Sorbis / Shutterstock.com TFAH • tfah.org 33 The Impact of Federal, State and Local Alcohol Taxes Source: ChangeLab Solutions.307 Health Evidence An analysis of more than 100 studies the government paid $100.7 billion (40.4 the effects of the tax have been eroding found that as the price of alcohol percent) of those costs.311 The median over time because they have not kept up increases, alcohol consumption cost per state was $3.5 billion, and more with inflation rates. decreases.308 Imposing higher alcohol than 70 percent of the costs were related taxes leads to reduced overall alcohol to binge-drinking. States have varying Policy Landscape consumption, reduced consumption excise tax rates per type of alcohol, and As of January 1, 2017, all 50 states and and binge-drinking among youth, many states also apply sales taxes on the District of Columbia have some type reduced alcohol-related motor-vehicle alcoholic beverages.312 Higher alcohol of tax on alcohol. States have a high crashes, reduced mortality from liver prices have a positive effect on the alcohol degree of variation among relatively few cirrhosis, and reduced alcohol-related consumption of low-income individuals, variables, namely excise (volume-based) violence.309 State alcohol tax increases youth, and heavy drinkers.313,314 versus ad valorem (value-based) taxes, are also likely to reduce disparities.310 type of alcohol, and tax amounts. For While evidence supports the effectiveness of taxing alcohol as a way to example, Colorado has a $0.08 excise Economic Evidence tax on beer compared with Georgia’s curb alcohol misuse, inflation-adjusted In 2010, excessive alcohol use cost the alcohol taxes have declined since the $1.01 excise tax.316 As of January 1, United States an estimated $249 billion 1950s.315 This means that although many 2015, 31 states preempt local authorities in medical care (or $2.05 per drink), and states already tax alcoholic beverages, from imposing any alcohol taxes. 34 TFAH • tfah.org STATE ALCOHOL TAX RATE State Beer Wine Spirits CASE EXAMPLE Alabama $1.05 ** ** Maryland’s Alcohol Tax Alaska $1.07 $2.50 $12.80 Arizona $0.16 $0.84 $3.00 In January 2011, Maryland increased the excise tax for Arkansas $0.24 $0.75 $2.50 alcoholic beverages, which had not changed in 40 years.317 California $0.20 $0.20 $3.30 In 1956, the last time the liquor tax was raised, the tax Colorado $0.08 $0.32 $2.28 on distilled spirits earned Maryland an estimated $51.3 Connecticut $0.24 $0.72 $5.40 Delaware $0.16 $0.97 $3.75 million in revenue.318 Years later in 1973, when Maryland D.C. $0.09 $0.30 $1.50 increased the tax on beer and wine, the state earned $52 Florida $0.48 $2.25 $6.50 million.319 However, the value of the taxes did not keep up Georgia $1.01 $0.42 $1.89 with inflation, and in 2009, the state earned just $29.2 Hawaii $0.93 $1.38 $5.98 million in revenue. (The taxes were pegged per gallon rather Idaho $0.15 ** ** Illinois $0.23 $1.39 $8.55 than as a percentage tied to inflation.)320 Indiana $0.12 $0.47 $2.68 On July 1, 2011, Maryland raised the sales tax on Iowa $0.19 $1.75 ** Kansas $0.18 $0.30 $2.50 alcohol by three percentage points, from 6 percent to 9 Kentucky $0.08 $0.50 $1.92 percent.321 Despite claims by the Distilled Spirits Council Louisiana $0.40 $0.76 $3.03 of the United States (DISCUS), the tax increase did not Maine $0.35 ** ** cause a substantial drop in consumption: 18 months after Maryland $0.09 $0.40 $1.50 Massachusetts $0.11 $0.55 $4.05 implementation, Maryland saw a 3.8 percent decrease in Michigan $0.20 $0.51 ** sales of total alcohol compared with the expected sales had Minnesota $0.15 $0.30 $5.03 the tax not been in effect.322 The net increase in tax revenue, Mississippi $0.43 ** ** even with the minor drop in consumption resulting from the Missouri $0.06 $0.42 $2.00 tax increase, is estimated at $38 million annually. Montana $0.14 ** ** Nebraska $0.31 $0.95 $3.75 Nevada $0.16 $0.70 $3.60 New Hampshire $0.30 ** ** New Jersey $0.12 $0.88 $5.50 New Mexico $0.41 $1.70 $6.06 Considerations for Effective Design and New York $0.14 $0.30 $6.44 Implementation323 North Carolina $0.62 $1.00 ** l G roups with less disposable income, such as underage North Dakota $0.16 $0.50 $2.50 drinkers, may be more sensitive to changes in alcohol Ohio $0.18 $0.32 ** Oklahoma $0.40 $0.72 $5.56 prices than those with more disposable income. Oregon $0.08 ** ** l W hile raising alcohol taxes may provide an important Pennsylvania $0.08 ** ** Rhode Island $0.11 $1.40 $5.40 source of revenue for governments, industry groups and South Carolina $0.77 $1.08 $2.96 consumers may resist such tax increases. South Dakota $0.27 $0.93 $3.93 Tennessee $1.29 $1.21 $4.40 l P ublic support for higher alcohol taxes increases Texas $0.19 $0.20 $2.40 substantially when tax revenues are specifically directed to Utah ** ** ** fund prevention and treatment programs instead of being Vermont $0.27 $0.55 ** used as an unrestricted source of general revenue. This Virginia $0.28 ** ** Washington $0.76 $0.87 $14.25 is also viewed as a more fiscally responsible option since West Virginia $0.18 ** ** alcohol tax revenue grows more slowly over time and may Wisconsin $0.06 $0.25 $3.36 decrease due to reduced alcohol sales. Wyoming $0.02 ** ** ≤ $0.15 $0.16– $0.75 ≥ $0.76 Beer 16 states + D.C. 16 states 17 states ≤ $0.42 $0.43– $0.87 ≥ $0.88 Wine 12 states + D.C. 13 states 13 states ≤ $2.50 $2.51– $5.49 ≥ $5.50 Spirits 9 states + D.C. 13 states 11 states TFAH • tfah.org 35 Complementary Policies Alcohol Outlet Density Restrictions: Dram Shop Liability Laws: Dram shop Alcoholic-beverage “outlets” liability laws are designed to promote include any bars, restaurants, clubs, responsible beverage service by reducing grocery stores, discount stores, sales to intoxicated or underage and convenience stores that have persons. These policies hold licensed alcohol licenses. Alcohol outlet establishments legally responsible if a density restrictions reduce the person drinks too much and then causes concentration—or at least limit harm as a result of their intoxication— increases to the concentration—of even if the intoxicated person has left retail alcohol establishments in a the licensed establishment. Harm, for given geographic area. These policies example, could include death, injury, or are often implemented through a other damages from an alcohol-related car licensing or zoning process and vary accident. Drinking in bars and restaurants by state depending on the alcohol- is strongly associated with binge-drinking control system in place.324 Density and alcohol-impaired driving.326 About restrictions reduce excessive alcohol one in six American adults binge-drinks consumption and related harms.325 about four times a month.327 36 TFAH • tfah.org 4 Promote Active Living and GOAL 4: Promote Active Living and Connectedness Connectedness Goal Physical inactivity and obesity are two of the most significant health problems in the United States. As states continue to explore cost-effective policies to address these underlying causes of chronic diseases, such as diabetes and cardiovascular diseases, some solutions can be found in how cities, municipalities, and neighborhoods are designed. Both physical activity and obesity are linked with Recognizing that many individuals may not the physical makeup—the built environment—of have the time or resources to engage in physical neighborhoods and communities. As state and activity during their leisure time, altering the local governments are primarily responsible built environment provides a solution that for most of the country’s public capital, owning increases physical activity by making places more more than 90 percent of non-defense public- walkable, more accessible to bikes, and more infrastructure assets, there are many opportunities connected to parks and public transportation. for state officials to promote health and reduce However, improving the walkability and bike- medical expenditures by implementing policies ability of communities comes with a set of safety that improve safety conditions, improve air and challenges. In 2017, the Governors Highway water quality, and encourage physical activity Safety Association estimated that 5,984 people where individuals live, work, learn and play.328 were killed while walking.332 The National Complete Streets Coalition, a leading organization People who are physically active tend to live that promotes a smart-growth approach to longer and have a lower risk for heart disease, development, found that that people of color stroke, type 2 diabetes, and some cancers.329 Yet, and older adults are more than 50 percent more according to the CDC, only about one in five likely to be struck and killed while walking in adults meet the recommended guidelines for the United States.333 Additionally, death rates for weekly physical activity, and fewer than three in Latino and Black bicyclists are 23 to 30 percent 10 high school students get at least 60 minutes of higher than for White bicyclists.334 Most U.S. physical activity per day.330 Physical activity trends streets and roads are designed for vehicle speed are also linked to individuals’ education level and in free-flowing conditions, using a standard called socioeconomic status. Adults with more education Level of Service that prioritizes maximum vehicle are more likely to meet the recommended throughput. This standard leads to roads that guidelines for aerobic activity than adults with are not only unsafe for walkers and cyclists, but less education, and adults whose family income also challenging for small businesses sited along is above the poverty level are more likely to meet roadways, due to a lack of pedestrian traffic. the physical activity guidelines for aerobic activity Replacing the speed-related Level of Service than adults whose family income is at or near standard with design principles that recognize the poverty level.331 These differences are not the multiple uses of streets would promote public surprising: low-income people often need to work health, local economic activity, and the expressed FEBRUARY 2019 long hours or multiple jobs, limiting their ability needs of the community.335 to engage in leisure-time physical activity. 37 POLICY Complete Streets is an approach to States can pass legislation to codify transportation that addresses the Complete Streets to strengthen RECOMMENDATION 4a: needs of all road users, including transportation systems, promote Complete Streets pedestrians, bicyclists, motorists, physical activity, improve outcomes, and and transit riders, regardless of reduce costs associated with chronic their age or ability. It emphasizes diseases. Making the built environment regular consideration for different more pedestrian-friendly and improving transportation modes into everyday connectivity can decrease barriers to transportation planning, design, and physical activity, can improve pedestrian operation decisions. Complete Streets safety, and can help people lead more policies support a transportation active lives. Research also suggests system that protects vulnerable road that including one or more of the users, provides mobility options, and components from the table below can creates livable communities. help increase physical activity. TRANSPORTATION SYSTEM AND LAND USE/ENVIRONMENTAL DESIGN INTERVENTIONS Transportation System Example Intervention Designs to increase street connections, create multiple route Street connectivity options, and shorter block lengths Pedestrian infrastructure Sidewalk, trails, street lighting, and landscaping Bicycle infrastructure Bicycle systems, protected bike lanes, trails, lighting, landscaping Public-transit infrastructure Expanded transit services, times, locations, and connections Land Use and Environmental Example Design Intervention Land use that is physically and functionally integrated to provide Mixed land use a mix of restaurants, office buildings, housing, and shops Communities with affordable housing, relaxed planning Increased residential density restrictions, and strategies to reduce urban sprawl Proximity to community or Stores, health facilities, banks, and social clubs close to each neighborhood destination other and more accessible to the public Park and recreational Public parks, public recreational facilities, and private fitness facility access facilities Health Evidence The Community Preventive Services and lower rates of residents who are Task Force found that Complete Streets overweight or have obesity. Improved strategies and policies increase physical bicycle infrastructure alone can activity and make being active easier.336 increase cycling by modest amounts,338 Improved bicycle and pedestrian and improved bicycling and pedestrian infrastructure and connectivity infrastructure—like bike lanes, increases physical activity and active bicycle paths, and walking trails—can transportation.337 Residing in a promote physical activity among both neighborhood with greater walkability, experienced and unexperienced more streetlights and bike paths, cyclists.339 These same design elements and other related streetscape design also can increase a neighborhood’s elements is associated with higher levels sense of community, reduce crime and of walking, increased physical activity, stress, and improve green space.340 38 TFAH • tfah.org Economic Evidence Enacting Complete Streets and other vehicle-on-cyclist, vehicle-on-pedestrian, District of Columbia, have policies that complementary streetscape design and cyclist-on-pedestrian incidents.)342 include mandatory requirements with policies can not only improve the clear action and intent.344 Complete Streets policies also have physical well-being of individuals but also the potential to benefit a community There is a moderate degree of variation help avoid costs for public (Medicaid economically. By increasing accessibility, among state policies, including: (1) the and Medicare) and private payers. improving safety, and improving the type of policy (for example, state law, The annual healthcare costs associated aesthetic appeal of an area, a community executive order, or agency policy); (2) with inadequate physical activity is an can promote business growth, increase the purpose outlined in the policy; (3) estimated $117 billion.341 Incorporating access to already existing businesses, who is tasked with implementing the strategies to alter built surroundings and draw visitors.343 Complete Streets policy; (4) reporting requirements; and through transportation policy and policies are often developed as part of (5) funding.345 environmental design can increase already existing budgets and are not physical activity and reduce these costs. Much of the variation involves which additive costs. Integrating Complete state agency is tasked with developing Additionally, this policy improves safety Streets approaches requires a shift in or implementing the Complete Streets and reduces vehicle collisions. “Traffic planning and development rather a policy. For example, Louisiana’s calming,” an outcome of Complete budget line item. law directs the Department of Streets policies that use physical design Transportation to adopt and maintain and other measures to improve safety Policy Landscape a “Complete Streets Policy,”346 whereas for motorists, pedestrians, and cyclists, Across the country, 29 states and the Nevada’s law allows boards of county can reduce the number of collisions, District of Columbia, have adopted highway commissioners to adopt a injuries, deaths, and property losses. Complete Streets policies with mandatory policy for Complete Streets.347 (Collisions include vehicle-on-vehicle, requirements; 16 of those states and the CASE EXAMPLE Considerations for Effective Design and Implementation349 Washington’s Complete Streets l S pecify the Complete Streets users and for approval from a high-level The Washington State Department modes, and include people of all ages transportation official and with a of Transportation determined that and abilities who are walking, riding transparent process. Limit these a Complete Streets process would bicycles, driving cars and trucks, and exceptions to cases in which safety save an average of $9 million per riding public transportation. will genuinely be served. project, or about 30 percent, when l E nsure Complete Streets policies apply l S tates should consider a wide variety rehabilitating roadways that serve as to all possible projects, including new of options when considering how to small-town main streets. The pilot roadway construction; capital projects, pay for infrastructure improvements, project incorporated sidewalks, safe such as reconstruction work or road- including: borrowing, taxes and crossings, on-street parking, and widening projects; and rehabilitation fees, federal grants, and public- other features important to small and maintenance efforts that involve private partnerships.350 Each of these towns, resulting in savings accrued changes to the right-of-way or signal options has its own merits, and state through reduced schedules, scope, operations. governments should consider a blended and budget changes.348 approach that addresses their needs l C learly define exceptions to while supporting fiscal responsibility. the policy with a requirement TFAH • tfah.org 39 STREET SMARTS The National Complete Streets Coalition’s 10 Ideal Policy Elements351 1. ision and Intent: Includes an V 4. lear, Accountable Expectations: C 7. and Use and Context Sensitivity: L equitable vision for how and why Makes any exceptions specific and Considers the surrounding the community wants to complete sets a clear procedure that requires community’s current and expected its streets. Specifies the need high-level approval and public notice land use and transportation needs. to create complete, connected, prior to exceptions being granted. 8. erformance Measures: Establishes P networks, and specifies at least 5. Jurisdiction: Requires interagency performance standards that are four transportation modes, two of coordination between government specific, equitable, and available to which must be biking or walking. departments and Complete Streets the public. 2. iverse Users: Benefits all users D partner agencies. 9. roject Selection Criteria: Provides P equitably, particularly vulnerable 6. Design: Directs the use of the specific criteria to encourage funding users and the most underinvested latest and best design criteria and prioritization for Complete Streets and underserved communities. guidelines and sets a time frame for implementation. 3. ommitment in All Projects and C their implementation. 10. mplementation Steps: I Phases: Applies to new construction, Includes specific next steps for retrofitted or reconstruction projects, implementation of the policy. maintenance, and ongoing projects. Complementary Policies Safe Routes to Schools programs with public investments in walking and bicycling infrastructure can reduce transportation expenditures for school districts and families.353 Shared-Use Agreements: States can enact legislation to promote or enable shared-use agreements, which promote physical activity by allowing communities to access existing recreational facilities like fields, gymnasiums, and playgrounds. A shared-use agreement is a formal contract between two or more entities outlining the terms and conditions Safe Routes to Schools: Often city planning and legislative efforts to for how the property will be shared, considered when implementing a make walking and biking safer, and including costs and liability. By Complete Streets policy, Safe Routes it provides resources and activities to using existing facilities, shared-use to Schools promotes walking and help communities build sidewalks, agreements are a cost-effective way to biking to school through education bicycle paths, and other pedestrian- expand neighborhood access to play and incentives. The program supports friendly infrastructure.352 Nationally, and exercise spaces. 40 TFAH • tfah.org 5 Ensure Safe, Stable, Healthy, and GOAL 5: Ensure Safe, Stable, Healthy, and Affordable Housing for All Affordable Housing for All Goal The connection between housing and health is well established.354 Over the past century, officials at the national, state, and local level have implemented numerous housing policies to improve the access to and safety of people’s homes. Many of these strategies have resulted in better health through reductions of injury and death, but there is still a growing need to ensure that all individuals have access to and are able to maintain a safe and affordable home regardless of race, ethnicity, income, or any other factors, such as sexual orientation or religion.355,356 DANGER ZONE Housing-Related Health Hazards: Costs to the U.S. in Billions Annually l Asthma: $56 billion l ead Poisoning: $50 billion L l atalities from Carbon-Monoxide Poisoning: $500 million F l adon-Induced Lung Cancer: $2.9 billion R l nintentional Injuries: $200 billion U Home Safety racism that have resulted in decades of residential As of 2017, 40 percent of U.S. houses have segregation. This segregation remains prevalent at least one health or safety hazard.357 Many in many areas of the country and impacts the well- households in the United States are currently being of individuals and communities. Research experiencing a dual crisis: affordability of shows that a fundamental cause of health residential housing and quality of residential disparities in the United States is the residential housing. Many housing conditions—from poor segregation of different races and ethnicities.363,364 insulation to the presence of lead paint or mold Residential segregation is linked to poor outcomes and other safety hazards—can impact health.358,359 for a variety of health conditions like a lack of Lower-income families are especially vulnerable economic opportunity and upward mobility.365 to unhealthy housing conditions.360,361,362 Additionally, living in poor-quality housing and disadvantaged neighborhoods is associated Residential Segregation with lower kindergarten readiness and lower developmental-assessment scores.366 States can Not only is there an inadequate supply of quality address this pressing issue with policies that and affordable homes, but there are lingering FEBRUARY 2019 improve access to and the quality of housing. issues related to structural and institutional 41 Energy Efficiency Rural Energy Burden By Region Low-income households spend a greater percentage of their income on utility costs compared with higher-income households. This is partly driven by low-income households having less income overall; higher energy consumption, as a result of structural deficiencies that cause air leakage; older and malfunctioning heating and cooling systems; and less efficient appliances. Rural families face the highest energy burdens of any household group in the United States, and they spend a larger percentage of their income on electric and gas bills than the average American family.367 Homelessness While those who can afford their rent or mortgage may Source: “The High Cost of Energy in Rural America”368 struggle with maintaining a safe and healthy home, there is a portion of society who does not have access to a home at all. The most recent national estimate of homelessness in Renters’ Incomes Haven’t Caught Up With Housing Costs the United States, identified 553,742 people as experiencing Percent change since 2001, adjusted for inflation homelessness.369 This is a drastic uptick in the number of homeless Americans, with an overall increase of 0.7 percent between 2016 and 2017.370 Research shows that being without a stable home is detrimental to an individual’s health. People who chronically experience homelessness have higher physical and mental health morbidity and increased mortality rates.371 Poor health outcomes are not exclusive to individuals experiencing homelessness; those who face housing instability also have poorer health outcomes. Housing instability is associated with health problems among youth, including increased risks Source: Center on Budget and Policy Priorities373 of early drug use, depression, and teen pregnancy.372 With an aging population, states need to develop additional households utilizing federal rental assistance has steadily strategies to adjust to evolving demographics. Based on risen. According to the Bipartisan Policy Center Health demographic trends, homelessness among people ages and Housing Task Force, the share of federally assisted 65 and older is expected to more than double by 2050, households headed by someone 50 years of age or older has from 44,000 in 2010 to nearly 93,000 in 2050.374 Reflecting increased from 45 percent in 2004 to 55 percent in 2014 and the graying of the general population, the age of those is expected to continue to rise.375,376 CLOSE TO HOME Two Major Characteristics of At-Risk Populations 2. ndividuals in poor households who are doubled up with I 1. enter households that pay more than 50 percent of their R family and friends. income toward housing. In 2016 (the latest American Community Survey The number of households facing this burden totaled more estimates), more than 4.6 million people in poor than 6.9 million in 2016. This is 3.1 percent lower than households were doubled up with family and friends, one 2015 but still 20.8 percent greater than 2007. of the most common prior living situations for people who end up experiencing homelessness. This is 5.7 percent lower than 2015, but still 30 percent greater than 2007. 42 TFAH • tfah.org POLICY States can enact legislation and allocate times more than the costs of installing budgetary resources to provide funding the insulation.382 A separate study found RECOMMENDATION 5a: to repair and/or improve homes, or that fitting insulation significantly Housing Rehabilitation to remove health or safety hazards reduced days off school or work, visits Loan and Grant Programs from homes. Housing rehabilitation to physicians, and hospital admissions loan and grant programs mainly serve for respiratory conditions; and heating low- and median-income families, and costs.383 Home loan and grant policies sometimes give priority to households have the potential to not only be cost with young children or older adults. effective and reduce state government outlays for healthcare costs but also to Housing rehabilitation programs may provide low-income individuals with focus on individual aspects of the home, more income for other necessities, as a such as heating, plumbing, lead, or result of lowered energy bills. mold. Alternatively, they can take a comprehensive housing improvement Policy Landscape approach. Evidence shows that housing improvements result in positive health States authorize, allocate funds for, and outcomes. In addition, housing administer housing rehabilitation loan rehabilitation efforts in declining and grant programs in coordination neighborhoods may have positive effects with municipalities and local housing on neighborhood quality and stability.377 and community-development offices. These programs also exist at the federal Health Evidence level through the U.S. Department of Housing and Urban Development There is strong evidence that housing (HUD) 203(k) program, the USDA rehabilitation loan and grant programs, Section 504 Home Repair Program, especially those focused on taking and the USDA Housing Preservation energy-efficient measures, yield health Grants Program.384 Original research benefits.378,379 Housing improvements indicates that thirty-nine states and that increase warmth in particular, the District of Columbia have laws like new or better insulation, show related to housing rehabilitation loans positive effects on overall physical and and grants. At least six of these states mental health, respiratory outcomes, have laws that provide some details and other measures of well-being.380 regarding one or more of the following: These improvements also reduce eligibility; interest rates; and terms of hospitalizations, doctor’s visits, and the loans and/or grants. However, most absences from school and work. of the laws appear to simply allow or Housing rehabilitation and loan grant require state agencies or municipalities programs designated for low-income to use funds for housing rehabilitation, families and individuals can decrease without providing much detail about disparities in access to quality housing program regulation. Further, nine and associated health outcomes.381 states have laws that allow a state agency or local municipality to use funds for Economic Evidence housing rehabilitation (among other Research shows that the benefits derived purposes), but do not specifically from improvements to health and energy mention a program or fund to be used efficiency are one and a half to two for rehabilitation. TFAH • tfah.org 43 CASE EXAMPLE Maryland’s Housing Rehabilitation Program385 The Maryland Housing Rehabilitation Eligible Applicants. Household income Program’s purpose is to preserve and of owner-occupants of single-family improve single-family properties and homes and all residents of financed one- to four-unit rental properties. It is rental housing cannot exceed 80 percent a program designed to bring properties of the statewide or district Metropolitan up to applicable building codes and Statistical Area median income. Interest standards. rates range from 0 percent to 6 percent and are based on the applicant’s ability to Eligible Types of Housing. Program pay. Deferred loans are available to some funds may be used to assist in the borrowers who require health, safety, or rehabilitation of owner-occupied accessibility improvements. For rental single-family homes and rental units, income determines requirements housing with one to four units. for loan deferment or repayment. Considerations for Effective Design and Implementation l F ocus programs on specific l P artner with nonprofits to develop population groups, such as older community-development initiatives at adults, veterans, families with the local, county, and state levels. children (including those with l G enerate funding for these and asthma), or low-income individuals. similar programs through the l S pecific health and safety hazards, creation of, or additional investment such as poor ventilation or a lack in, a state housing trust fund. of proper insulation, should be addressed by the program. Complementary Policies Lead-Paint Abatement: Lead-paint Integrated Pest Management: Integrated abatement programs eliminate lead- pest management (IMP) programs based paint and contaminated dust. use a range of methods to minimize States can enact legislation to create potential hazards to people, property, and bolster lead-paint abatement and the environment. State policies programs that can improve health that support IMP can reduce exposure outcomes. Examples of state laws to certain allergens and reduce asthma include: requiring screening and exacerbations, especially among children. reporting of elevated blood lead levels; IMP involves the following four steps: (1) authorizing fees, loans, or grants to setting action thresholds, (2) monitoring cover abatement costs; and requiring and identifying pests, (3) prevention, and the disclosure of lead-based paint (4) pest control. Generally, IMP starts hazards in certain homes. with methods that involve fewer health risks, such as trapping, then moves to the use of pesticides if other approaches are unsuccessful. 44 TFAH • tfah.org POLICY Rapid re-housing programs provide Health Evidence temporary support services that help RECOMMENDATION 5b: people experiencing homelessness There is strong evidence that Housing First policies reduce homelessness Rapid Re-Housing move quickly into permanent housing. and hospital use for populations with Programs/Housing First The core components of such behavioral health issues, including programs usually include housing persistent mental illness, substance identification, rent and moving misuse, and addiction.391,392,393,394,395 assistance, and case-management Housing First policies reduce disparities, services.386 The Housing First improve housing stability, advance mental approach is a method that quickly health and well-being, and facilitate and successfully connects people access to treatment for substance misuse experiencing chronic homelessness and addiction.396 When paired with with permanent housing—without strong case management, Housing First preconditions such as sobriety, policies can improve participants’ ability treatment, or service participation— to function within their communities.397 along with ongoing supports and treatment.387,388 Rapid re-housing programs decrease rates of homelessness, decrease the Housing First programs recognize that length of time families and individuals individuals experiencing homelessness remain homeless, and increase access can more easily find and maintain to social services.398 Participation in a employment and achieve health goals rapid re-housing program may also lead when they have a permanent place to increased food security, improved to live. Removing barriers to housing physical and mental health, and allows people to address their health increased income.399 Evaluations of rapid and lifestyle issues in a more effective re-housing programs targeted to military manner. To that end, participants have veterans and their families show that access to a range of community-based more than 80 percent of participants services, including medical and mental have permanent housing without healthcare, substance use treatment, assistance after exiting the program.400 case management, vocational training, and life-skills training. However, Economic Evidence participants are not required to avail Housing First policies decrease costs to themselves of these services, and their shelters and reduce emergency room participation does not impact their use and costs.401,402 A pilot evaluation ability to enter or stay in the program. showed that the rapid re-housing The U.S. Department of Veterans component of Housing First policies can Affairs adopted the Housing First reduce costs associated with acute care approach as a national policy for services for individuals with persistent its homelessness programs.389 In mental illness and substance misuse addition, in 2016, HUD issued a problems, including reduced hospital notice encouraging all recipients of its admissions and jail bookings.403 The Continuum of Care Program, which same study estimated that the difference provides funding for permanent in costs for participants and comparison supportive housing, to follow a group members was $36,579, which far Housing First approach when outweighs the program costs of $18,600 possible.390 per person per year.404 TFAH • tfah.org 45 Policy Landscape In addition to administering rapid municipalities have all implemented re-housing programs in coordination rapid re-housing programs.408,409,410,411,412 with municipalities and nonprofit Many of these programs are also organizations, states can specifically administered by local nonprofit authorize and allocate funds. States organizations. Original research also often use state rental-assistance indicates that nine states have enacted programs to provide rent supports laws that specifically address rapid re- to those in rapid re-housing or in housing. This number does not include permanent supportive housing.405 states that have directed funds to rapid The federal government supports re-housing initiatives via larger pieces these programs by providing funding, of legislation. The laws included in this initially through HUD’s Homelessness policy domain either allow, encourage, Prevention and Rapid Re-Housing or require the use of a rapid re-housing Program and currently through approach to help people experiencing the Emergency Solutions Grants homelessness obtain housing. program.406,407 States, counties, and CASE EXAMPLE Connecticut’s Rapid Rehousing Program409 The Connecticut Rapid Rehousing Key outcomes: Program is a statewide initiative that l C lients in both the survey sample helps residents with housing relocation, and the total Connecticut Rapid Re- stabilization services and financial Housing population were on average assistance, and help homeless placed in housing in less than two individuals and families quickly transition months and close to half (50% and to permanent housing. After the success 56%) of each group was placed in of the 2010 Homelessness Prevention housing within one month. and Rapid Re-housing Program (HPRP), l A t the time of program exit, eighty- the Connecticut Department of Housing four percent (84%) of the Connecticut (DOH) established the Connecticut Rapid Re-Housing population clients Rapid Re-Housing program to administer exited to permanent housing with assistance funds to rapid re-housing only five percent (5%) returning to providers. literal homelessness. An evaluation found the Connecticut l F or the Connecticut Rapid Re- Rapid Re-Housing Program to be Housing population, it was found successful in approaching or meeting that at twelve months post-program the benchmarks set by the National exit, ninety-two percent (92%) had Alliance to End Homelessness for not returned to a shelter and at quickly moving homeless clients into twenty-four months out, eighty-nine housing and permanent housing. percent (89%) had still not returned Clients assisted through Rapid Re- to a shelter. Housing were also significantly less likely to return to a shelter. 46 TFAH • tfah.org Considerations for Effective Design and Implementation413,414,415 l L everage Medicaid dollars to l P revious involvement with the enhance tenant screenings and criminal justice system should not housing assessments, to assist with impede participation. housing applications, to provide l T reatment plans and related services education and training on tenants’ should be voluntary. and landlords’ roles, and to develop agreements with local housing and l C ase management should be provided community-development agencies to to help individuals secure and support access to housing resources. maintain housing. l A pplicants should be allowed to enter l P rograms should recruit landlords the program without income. continuously, regardless of their current housing needs, to ensure l P rograms should accept participants future availability. regardless of their sobriety. l R ent and move-in assistance should be provided to help individuals secure a place to live. Complementary Policies: Promoting State and Local Efforts to Improve and Maintain Affordable Housing Because many cities and states across that require developers to set aside the country are dealing with a lack of a portion of housing units for low- affordable housing, it’s important for and moderate-income residents. policymakers to consider state-level Known as “inclusionary zoning,” recommendations. these policies increase access to quality, promote affordable States should support, and not housing, and boost neighborhood preempt, efforts by cities and socioeconomic diversity.416 municipalities to address affordable Currently, seven states preempt housing issues. Local governments localities from implementing are often in the best position to inclusionary zoning policies. States enact policy solutions that meet the can support local governments needs of their populations. While by explicitly not preempting states can develop complementary or any policies aimed at increasing separate policy proposals to address affordable housing stock.417 affordable housing statewide, state policymakers should not preempt l upport city and municipality rent- S cities and municipalities from control policies. States should developing innovation solutions. preserve affordable housing units Specifically, states should: through rent controls. Currently, 25 states prohibit local governments l efrain from preempting local R from enacting laws that limit or governments. States should not control rental prices.418 preempt local planning ordinances TFAH • tfah.org 47 l rovide legal assistance to tenants P to address specific housing needs. facing eviction. Unlike criminal Known as a “qualified allocation courts, there are no requirements plan,” states can address the social for cities or states to provide legal determinants of health by requiring counsel to individuals in civil development near transportation proceedings. With the share of rented or high-performing schools.420 households at its highest percentage State housing finance agencies (36.6 percent) since the 1960s and an administering the LIHTC can create increasing percentage of households incentives for developers to build spending a majority of their income units targeted to the highest-need on housing and transportation costs, populations and can work with states should provide funding, or developers to avoid concentrating allow for cities to provide funding, units in high-poverty neighborhoods. to support legal-assistance funds for l upport state and local housing S tenants facing eviction proceedings.419 trust funds. States should identify These policies can promote economic revenue sources to support a state stability for individuals and also help housing trust fund and should alleviate homelessness. also encourage or enable local l romote right-of-first-refusal laws. P governments to dedicate public States should allow tenants or funds to local housing trust funds. nonprofits to have a right of first These trust funds support affordable, refusal to purchase properties quality housing production by subject to foreclosure or short creating or maintaining low-income sale at fair-market value. Right-of- housing, subsidizing rental housing, first-refusal policies help alleviate and supporting nonprofit housing the lack of affordable housing developers. Evidence to date shows units by supporting the purchase that housing trust funds increase of residential properties by non- affordable housing in both rural and commercial stakeholders. These urban areas.421 laws can also be incorporated into l dopt tax incentives and laws A the criteria related to low-income prohibiting discrimination against housing tax credits (LIHTC) as a housing voucher holders. States way to incentivize affordable housing should implement strategies to development. improve the availability and location l ncorporate health and social criteria I of housing stock for use in voucher into LIHTC. Although LIHTC programs. Expanding participation guidelines are established by the of landlords in high-opportunity Internal Revenue Service (IRS), the areas via tax incentives can improve credits are administered by each educational outcomes and future state’s housing finance agency, which earnings for children whose families provides states with the flexibility to participate in housing voucher include requirements for developers programs.422 48 TFAH • tfah.org 6 Create Opportunities for Economic GOAL 6: Create Opportunities for Economic Well-Being Well-being Goal The factors that influence health are multifaceted. However, the relationship between health and income is well documented. Income and socioeconomic status often lead to differences in access to resources and opportunities for individuals and families. Generally, people with higher incomes have better health outcomes than those with lower incomes. Americans in the top 1 percent of households by income live 10 to 15 years longer than those in the bottom 1 percent.423 These differences are concerning—there are about 39.7 million people living in poverty in the United States—and they have important implications for public health and healthcare expenditures.424 The health impact of living in poverty can span what foods and housing options they can afford, multiple generations. Low-income households which ultimately affect their health. Low-income can have pronounced effects on infant and child neighborhoods, for example, are less likely to development that can last into adulthood. For have places where children can be physically instance, children who live in poverty or in low- active and less likely to have access to fully stocked income families are more likely to face difficulty supermarkets with healthy, affordable foods— securing stable employment and more likely to have contributing to higher rates of obesity and poor poor overall health as adults.425 The strain associated nutrition.427,428,429 Similarly, a person’s health may with living in poverty can increase the risk for impact their ability to work or to access a job that toxic stress, which can disrupt healthy physical, provides economic security. Creating opportunities psychological, and behavioral development.426 for Americans to move out of poverty and achieve economic security reduces barriers for people Economic security and health are uniquely to lead productive, healthy lives. Furthermore, related in that they can each impact the other. An increasing economic opportunities by individual’s economic well-being can be a driver supplementing low wages and expanding programs of health, while an individual’s health can also that bolster family income can help parents provide impact their economic well-being. For example, for their families and lift them out of poverty. an individual’s economic situation can impact Todd A. Merport / Shutterstock.com FEBRUARY 2019 49 POLICY States can offer an earned income Health Evidence tax credit (EITC) to support the RECOMMENDATION 6a: financial stability of low-income To date, research on the benefits of an EITC has focused mainly on the effects Earned Income Tax Credit workers, particularly families with on children and families. The benefits children.430 The EITC assists families are more pronounced for mothers and in some states, adults without and especially their young children, dependent children, by reducing as these benefits follow children into qualifying taxpayers’ tax liability based adulthood. Among children in families on income level, marital status, and the who receive EITC, there is evidence number of dependent children.431 A of better home environments, more state EITC can supplement the federal educational attainment, and higher EITC, a federal tax credit for low- and lifetime earnings in adulthood. moderate-income workers and their Expanding the EITC is associated families. A state EITC applies the same with decreased low-birthweight principles as the federal program but births, increased breastfeeding provides a state-level tax credit. EITC rates, and improved maternal and tax credits can be refundable, meaning child health.434,435,436,437 Each time individuals can receive the full value the EITC increased by 10 percent, of their credits, regardless of the taxes infant mortality dropped by 23.2 per they owe.432 Without the refundable 100,000.438 Infants whose mothers feature, state EITCs may fail to offset were eligible for the largest federal the other substantial state and local tax credit increases, or who lived in taxes low-income workers pay. Workers a state with a state EITC, tended to generally receive a credit equal to a experience the greatest improvements percentage of their earnings up to a in birthweight, a strong predictor of maximum, dependent on family size— children’s long-term health outcomes, with larger credits for families with educational attainment, and economic more children.433 success.439,440,441 Additionally, mothers living in a state that recently enacted or increased a state EITC reported having The Impact of EITC less mental stress and lower smoking rates during pregnancy, both of which also contribute to improvements in birthweight.442,443,444,445 Federal and state EITCs are also linked to declines in child maltreatment among single mothers, including fewer cases of physical neglect and failure to provide a child’s basic material needs.446 l A child in a family eligible for the largest EITC expansion in the early 1990s had a 7.2 percentage-point increase in high school completion. l E ligible children also had a 4.8 percentage-point higher chance of completing one or more years of Source: Health Affairs 449 50 TFAH • tfah.org college by age 19, an improvement comparable to other educational interventions such as reductions in classroom size.447 l E ITC reduces disparities, and the benefits of larger EITC benefits extend to children of all racial and ethnic groups, especially children of color, boys, and younger children.448 Economic Evidence By supplementing the earnings of low-wage workers, the EITC helps lift millions of families out of poverty each year. In 2017, 27 million working families and individuals across the country received the EITC.451 The IRS estimates that the EITC helped lift 9.4 million of them out of poverty, including more than five million children.452 Additionally, the credit Source: Center on Budget and Policy Priorities 450 reduced the severity of poverty for an additional 18.7 million families, including 6.9 million children.453 dollar of income received through the EITC refunds to meet basic needs, Implementing an EITC increases tax credit, the real value of the child’s repay debts, repair vehicles, or obtain employment and income for future earnings increases by more than additional education or training.466,467 participating families.454,455,456,457,458 The one dollar.461 The study suggests the EITC also encourages single mothers There is some evidence that a cost of expanding the tax credit may to enter the labor force (some older supplementary state EITC is cost-effective be offset by children’s future earnings. studies show a smaller effect on and less expensive compared with other Additionally, the children of EITC- married women staying home to care tax credits.468 State EITCs have almost eligible families are more likely to for their children).459 And the EITC no cost when it comes to determining attend college—not only because they contributes to the financial stability eligibility, because in many cases the have increased academic readiness, but of less-educated women by increasing same tax filers who qualify for the also by making college more affordable. their likelihood of qualifying for federal EITC also qualify for the state High school seniors whose families retirement benefits. The Congressional credit. Currently, refundable EITCs in received an EITC were more likely to Budget Office estimated that the states with income taxes cost less than enroll in college, further impacting EITC increased the lifetime average 1 percent of state tax revenue annually. future employment and earnings.462 earnings for less-educated women by Since the state EITC is directed toward 17 percent, which in turn increased The EITC is also associated with low- and moderate-income working their likelihood of qualifying for Social generating economic activity at the families, the cost is lower compared with Security retirement benefits.460 local and state level.463,464 An evaluation other tax credits states might consider. of the economic impact of the federal While a state may have a sizable number In addition to higher academic EITC in California found that EITC of low-income households, they make up achievement, the children of EITC- payments to state residents contributed a smaller share of tax revenue. However, eligible families are also likely to have to more than $5 billion in business a refund of a few hundred dollars for higher lifetime earnings. For these sales and added approximately 30,000 each family can have a major impact children, it is projected that for every jobs.465 Recipients tend to use their without being a huge cost for the state.469 TFAH • tfah.org 51 Policy Landscape As of April 2018, 29 states and the District fully refundable if the amount is greater of Columbia, have an EITC law.470 The than the taxes owed.473 In six states, federal EITC has been in place since the EITC can only reduce a person’s 1975, and Rhode Island enacted the first tax liability, not provide a refund.474 statewide EITC in 1986.471 Three states (California, Maryland and Minnesota) and the District of Columbia There are a number of ways in which offer state EITC to workers without state EITC policies vary across states. dependent children. New York and the All states except for Minnesota set their District of Columbia also offer their state credits based on the federal credit; EITC to non-custodial parents. Similarly, however, the percentages used vary the variables can differ based on family greatly from state to state.472 There is also size, particularly the number of children, variation as to whether the EITC operates and the marriage status of the taxpayer, as a refund or as a reduction. In 23 states adding greater variation to the policies. and the District of Columbia, credits are CASE EXAMPLE Vermont’s Earned Income Tax Credit The state of Vermont offers a fully eligible taxpayers. The increase was refundable state EITC that is 36 largely aimed at reducing the financial percent of the federal credit.475 All burden for low-wage working families.476 Vermont taxpayers who qualify for the In FY 2015, prior to the state credit federal EITC are eligible to receive the increase, more than 44,000 Vermont state credit. Vermont first enacted taxpayers received $27.1 million in a state EITC in 1988. In June 2018, state EITC payments in addition to their Vermont enacted a state budget for federal EITCs.477 In 2014, the average Fiscal Year (FY) 2019 that increased recipient received $600 from the state the state’s EITC from 32 percent to of Vermont and $1,900 from the IRS, 36 percent of the federal credit for raising their family income by $2,500.478 Considerations for Effective Design and Implementation479 l M ake the state EITC refundable like l C onduct outreach to increase the federal EITC. This allows working awareness of the state EITC credit. households to keep the full value of l E xpand EITC eligibility for childless their credit that even if it exceeds workers. States should consider their income tax liability. This means expanding the EITC for low-income the credit can help offset taxes they workers without children as it will owe and the rest is refunded to them. help lift more workers out of poverty, l I ncrease the value of the state EITC. As increase employment rates, and of 2017, 13 states have a credit that is 10 narrow the income gap for low- percent or less of the federal EITC.480 income workers. 52 TFAH • tfah.org Complementary Policies Child Tax Credit: The Child Tax Credit (CTC) in combination with a state EITC has the potential to lift even more families with children out of poverty. The federal CTC offsets the cost of raising children by offering up to $2,000 in tax credits from the total amount of federal income taxes they would owe for each eligible child.481 The CTC also operates as a refund, up to $1,400, so many working families benefit from the credit even if their incomes are so low that they owe little or no federal income tax in a given year.482 A number of states have followed suit and enacted CTC programs of their own.483 Increasing the amount can be used by the state to reimburse of tax credits for poor families is itself and used by the federal linked to improved test scores among government to help pay for the TANF those families’ children. Improved program. However, states are given the test scores, of course, are associated option of allowing some of the child- with other positive outcomes, such support payments to be passed through as higher earnings, an increased to the parent and child and afterward probability of attending college, be disregarded when calculating the reduced teenage birth rates, and parent’s TANF assistance. This means improvements to the quality of the that the amount of child-support neighborhoods where these students assistance would not be considered live in adulthood.484 The federal child income in order to determine tax credit lifted approximately 2.7 TANF eligibility under these “pass- million people, including 1.5 million through” and “disregard” policies.487 children, out of poverty in 2016. It What’s disregarded is the amount also reduced poverty for another 12.3 of child support that the family can million individuals.485 keep without lowering their TANF Full Child-Support Pass-Through benefits.488 In many states, the amount and Disregard: Under federal is $50 per month, but other states law, families receiving Temporary have made their amounts higher. Pass- Assistance for Needy Families (TANF) through and disregard policies can also must cooperate with child-support aid in lifting children out of poverty. regulations and enforcement efforts.486 In 2013, child-support payments Families receiving TANF funds must represented 40 percent of income for assign their rights to child-support the poor custodial families who receive payments to the state. The child them, and these payments kept 740,000 support collected on behalf of TANF children out of poverty.489,490 TFAH • tfah.org 53 POLICY State policies that support earned sick an estimated seven million people, leave allow employees to take time off including 41 percent of Black men RECOMMENDATION 6b: from work to recover when they are ill and 36 percent of Black women do Earned Sick Leave or need to visit a healthcare provider, not have access to earned sick leave.495 without fear of lost wages. According Earned sick leave mandates at the city to the U.S. Bureau of Labor Statistics, level increased access to paid sick leave about 38 percent of workers do not among economically marginalized have access to earned sick leave.491 This workers. Following implementation means that workers without earned sick of San Francisco’s paid sick leave leave may go into work while they are ordinance, Latino workers and low- ill and risk exposing their workplace wage workers were among those who to infectious diseases for fear of losing benefited most from the law, and the wages or their jobs. majority of workers who used paid sick days did so for their own health needs, Despite their participation in the such as visiting a doctor or dentist.496 workforce, some populations are less likely to have access to earned sick States can protect workers and save leave than others. Offering earned costs for employers by enacting earned sick leave can help decrease health sick leave policies. Offering earned disparities by expanding benefits sick leave can help prevent the spread to vulnerable and low-income of diseases, increase job stability, and populations. People who lack access to increase use of preventive health earned sick leave tend to be low-wage services. While employers may express workers, working women, some racial concerns over costs, it can be costlier and ethnic minorities, and employees for employers to have sick employees at with lower educational attainment..492 work than to offer paid sick leave. Aside Research shows that even when family from protecting workers, employers and medical leave is available, low-wage benefit from earned sick leave policies workers are less likely to take leave if it by increasing worker productivity and is unpaid.493 An estimated 54 percent reducing turnover. Overall, earned sick of Latino workers are unable to earn leave laws help employers ensure they paid sick leave through their jobs.494 have a healthy, productive workforce, About 38 percent of Black workers, resulting in cost savings. 54 TFAH • tfah.org Health Evidence Economic Evidence the United States $1.1 billion annually States that pass earned sick leave There are minimal costs to employers in medical costs, including $500 million laws expand access to sick leave for who offer earned sick leave to workers. in public insurance programs.507 When workers who otherwise might not It actually costs employers more to have workers show up to work sick, they are be offered paid sick leave, such as sick employees at work instead of letting less productive and can spread disease. It low-wage and part-time workers, them recover at home.503 Having sick is estimated that presenteeism, which is decreasing disparities.497 Workers employees in the workplace can spread defined as productivity loss resulting from without earned sick leave are less disease, lower productivity, and increase health issues, costs the national economy likely to use preventive healthcare emergency room visits.504 Offering more than $160 billion annually, or about services, like a cancer screening or earned sick leave to employees can $218 billion when adjusted for inflation.508 flu shot.498 When employees who help employers save money by reducing previously did not have access are turnover. Granting employees earned Policy Landscape granted paid or unpaid sick leave, sick leave and retaining workers is less Currently, 10 states and the District of rates of flu infections decrease by 10 costly than hiring and training their Columbia have an earned sick leave law. percent.499 Employees without earned replacements. Employers can spend an Michigan also has a paid sick leave law sick leave were three times more likely estimated 20 percent of an employee’s that will go into effect in April 2019.509 to forgo their own medical care and annual salary to replace them; this There is a high degree of variation among 1.6 times more likely to forgo medical includes advertising the position, the states in their earned sick leave laws. care for their family compared interviewing, and training new workers.505 Policies differ in the maximum length with workers with paid sick leave.500 A cost-benefit analysis of an earned sick of paid sick leave, generally ranging When workers go to work instead of leave ordinance in Austin, Texas, found between 40 and 50 hours per year, and accessing medical care when they are city businesses would save $4.5 million in the eligibility requirements for the sick, minor illnesses can worsen and per year from reduced turnover, and an program.510 There is also variation in how become more costly. additional $3.7 million from reduced flu fast workers can earn paid sick days; who infections, fewer emergency room visits, is covered by the policy among full-time, Lack of access to earned sick leave and other public health benefits.506 part-time, public, private, and temporary can increase employees’ risk of employees; and what types of companies, illness and the spread of infectious An analysis of National Health Interview organizations, and employees are exempt diseases.501 This can be especially Survey data found that workers who had from the law.511 concerning for employees who work access to earned sick leave made fewer in close quarters with one another emergency room visits. An estimated 1.3 Currently, 23 states have laws in or with the public, such as restaurant million hospital visits could be prevented place that explicitly prohibit local workers. An estimated 87.7 percent each year if workers across the country governments from requiring earned of restaurant workers reported not had access to earned sick leave, saving sick days to workers.512 having earned sick days, and more than 63 percent of all restaurant Variation in State Earned Sick Leave Laws workers reported cooking and serving • ome states have exemptions for providing earned sick leave for S food while sick.502 This puts the Exemptions for Job certain job sectors. Types and Sectors • ome state earned sick leave laws do not apply to certain types of S workers, businesses, and customers employees, such as independent contractors or temporary workers. at risk of becoming ill. By offering • ccrual of earned sick leave can differ by business size or job sector. A earned sick leave, employees can Accrual Rates vs. Maximum Accrual • tate paid sick leave laws vary in the maximum number of hours of S recover from an illness or seek sick leave an employee can accrue. medical care instead of delaying • ome states allow employees to take earned sick leave to care for a S Family Members sick child or loved one. care or exposing other employees to Covered • tates vary in which family members are covered under their earned S infectious diseases. sick leave laws. TFAH • tfah.org 55 CASE EXAMPLE Arizona’s Earned Sick Leave Law513, 514 In November 2016, voters in Arizona of the employee’s status as a full-time, approved the Fair Wages and Healthy part-time, or seasonal worker. Families Act, a ballot initiative that Employees can use earned sick leave for: requires all Arizona employers to provide earned sick leave, effective July l A n employee’s or family member’s 2017. The law guarantees 40 hours of health condition, injury, or illness. annual earned sick leave to employees l C are, treatment or diagnosis for the of companies with 15 or more workers, employee or a family member and 24 hours of leave to employees of l A ddressing domestic or sexual companies with fewer than 15 workers. violence, abuse or stalking. Employers are required to provide one l A closure of a child’s school or place of hour of sick leave to each employee care or other public health emergency. for every 30 hours worked, regardless Considerations for Effective Design and Implementation515,516,517 l C onsult with stakeholders to write an l S upport legislative and administration effective interpretation of the law to coordination to ensure that the law increase employees’ and employers’ can be implemented effectively once understanding of the law’s key it goes into effect. components. l P rovide flexibility to employers to l D edicate funding to support use existing policies as long as they employer and employee outreach meet the minimum requirements as through multiple channels, including required by law. business associations and chambers l C onsider allowing employees of commerce, to raise awareness of working for exempt businesses (for the relevant fair-practice hiring laws example, those below the minimum and how the earned sick leave law number-of-workers threshold) to applies to them. earn job-protected, unpaid sick time, l E nsure effective enforcement unless their employers choose to mechanisms and provide a range offer paid sick days. of relief options, including civil l P ermit employers to require penalties, fines, back pay, and certification if an employee uses reinstatement. more than three paid sick days in a l A llow any individual or organization row to minimize employer impact to submit a complaint to the while enabling employees to use appropriate enforcement agency. consecutive days of earned sick leave. 56 TFAH • tfah.org POLICY State polices that support paid family and their babies. Paid family leave leave allow employees to take paid policies reduce the likelihood of having RECOMMENDATION 6c: time off for events like a recent birth low-birthweight babies and pre-term Paid Family Leave or adoption of a child, taking care births.525 In other developed nations, of a parent or spouse with a serious where access to paid, job-protected medical condition, or caring for a sick parental leave is available, there is child. The United States currently reduced infant and child mortality, does not guarantee paid leave to new with longer durations of leave linked parents.518 However, the Family Medical to greater reductions in death among Leave Act (FMLA) is a federal law that infants and young children.526,527,528 provides up to 12 weeks of unpaid leave Paid maternity and parental leave can during a one-year period to care for a also increase breastfeeding initiation and newborn, adopted, or foster child.519 duration, as well as increase the time The FMLA allows states to set their parents spend with their infants following own standards as long as they are more birth.529,530,531 Mothers who have a longer expansive than the federal law. States delay returning to work after giving may pass statutes or regulations that birth may experience fewer depressive protect employees by extending FMLA symptoms and better mental health coverage to ensure paid family leave is compared with mothers who return to available to employees. A small number work earlier.532,533 Additionally, access to of states have taken this opportunity paid family leave can improve economic to enact their own paid family leave security for the family and contribute to and paid sick leave policies; however, better mental health for caregivers.534,535 only 13 percent of private-industry employees have access to paid family Economic Evidence leave through their employers.520,521 Offering employees paid family leave Approximately two-thirds of women are can increase employee retention and employed during their first pregnancy save employers the cost of training and those without access to paid family new hires.536 It costs employers leave must either take unpaid leave, quit approximately 20 percent of an their jobs, or return to work shortly after employee’s salary to hire and train childbirth.522 Some states and employers their replacement.537 Paid family leave have expanded access to paid family leave policies increase the likelihood that for new parents and caretakers, but only mothers remain in the labor force after about half of working women received childbirth, particularly mothers without paid leave, including only three in 10 bachelor’s degrees.538,539,540 Access to working women with less than a high paid family leave can offer economic school diploma.523 Paid family leave allows security to caregivers while they take new parents to bond with their child, leave from work. Women who took improves maternal and child health, and paid family leave after giving birth were reduces the risk of falling into poverty.524 more likely to work nine to 12 months later and 40 percent less likely to Health Evidence receive public assistance compared with Paid family leave policies decrease women who did not take leave.541,542 disparities and improve maternal and Paid family leave policies in California child health by reducing the risk of and New Jersey show no negative birth-related health issues for mothers impacts on employers but do show TFAH • tfah.org 57 increased hiring and mobility among District of Columbia, Washington program.549 The funding methods young women.543,544,545 However, it state, and Massachusetts) of these for the program also differ among should be noted that other studies seven jurisdictions have paid family states, as do details on the size of the highlight the potential for minor laws that are enacted, but some employer covered by the policy: some decreases in employment and hiring sections of the law, such as premiums states exempt small businesses, and and increased unemployment among and benefits, are not operative until a others include a larger percentage of young women.546,547 future date.548 businesses in the state.550 There is a large variation in the benefit amount There is a high degree of variation Policy Landscape employees receive for paid family leave, among the states in their regulation Six states (California, New Jersey, as well as in the maximum weekly of paid family leave. Policies differ in Rhode Island, New York, Washington, benefit amount.551 Additionally, some the maximum length of paid leave, and Massachusetts) and the District states protect a worker’s job during their generally ranging from four weeks of Columbia have a paid family leave paid family leave, while other states do to 12 weeks, and in the eligibility law. As of August 2018, three (the no more than the FMLA requires.552 requirements for qualifying for the CASE EXAMPLE Rhode Island’s Family Leave Policy In 2014, Rhode Island became the (TDI) program: it is fully employee-funded Approximately 34,000 claims were filed third state to enact a statewide paid and allows eligible employees to take up for Rhode Island’s paid family leave family leave policy. Under federal law, to four weeks of caregiver leave with a program from 2014 to 2017, more than the FMLA allows employees to take 12 60 percent wage-replacement rate.554 All three-quarters of which were approved weeks of unpaid leave to care for a new private-sector employees who pay into to bond with a new child.557 A survey child. Rhode Island implemented the Rhode Island’s TDI program are eligible of employees who took leave through Temporary Caregiver Insurance (TCI) to take leave under the TCI program, the TCI program reported more wage program, which extends beyond FMLA which covers about 80 percent of the increases after leave and fewer absences coverage to offer eligible employees state’s workforce.555 Rhode Island’s from work compared with other leave four weeks of paid family leave.553 The program differs from other states in takers; they also reported lower levels of TCI program is an extension of Rhode that it includes job protections for the stress, better physical health, and longer Island’s Temporary Disability Insurance caregiver while they are on leave.556 breastfeeding times.558 Considerations for Effective Design and Implementation559,560,561 l D etermine how workers will become employee’s income compared with l B roaden the definition of “family eligible to take part in the statewide the state’s average weekly wage members” to include siblings, paid family leave program and consider and adjust rates as needed to grandparents, grandchildren, or financial eligibility requirements, wages provide greater supports to low- parent-in-laws to reflect shifting earned, and hours worked. income workers. caregiving responsibilities. l A llocate funding for and conduct l O ffer 12 weeks of paid leave to l I nclude nondiscrimination provisions outreach and awareness activities care for a new child, to care for a in paid family leave and job focused on low-income workers. family member with a serious health protection laws to ensure employees condition, or to care for their own do not face retaliation or job loss l S upport a high-wage replacement health condition or disability. while they are on leave. rate, taking into consideration the 58 TFAH • tfah.org POLICY States should adopt fair hiring exacerbate disparities. BTB policies do protections, such as Ban the Box not prohibit employers from conducting RECOMMENDATION 6c: (BTB) laws, which give applicants with background checks; instead they require Fair Hiring Protections criminal records an opportunity to employers to do so later in the hiring be considered for jobs based on their process. Additionally, implementing qualifications not their conviction BTB policies has minimal impact on the history. BTB policies remove conviction- cost of employers’ hiring processes, can history questions on job applications positively impact the economy, and can and delay criminal background checks possibly reduce recidivism. until later in the hiring process. States BTB policies can increase employer can adopt BTB laws to reduce biases callback rates, but they do not fully against people involved with the address racial bias in hiring.566 Research criminal justice system and to help shows that applicants with a felony individuals reenter the workforce and record are about half as likely to be contribute to the economy. called back for an interview compared Currently, about one in three American with other applicants without a felony adults have a criminal record, creating record.567,568 When separated by race, a barriers to employment, housing, study found stark differences between and public programs.562 Even a minor the callback rates between White and criminal history can be an obstacle for Black men, with and without a criminal successful reentry to the workforce record. White men with a felony record and can therefore hinder economic were about half as likely as Whites mobility for justice-involved individuals without a record to receive an interview and their families. Approximately callback after applying for work, while 60 percent of to individuals who Blacks with a felony record were about were formerly incarcerated. remain one-third as likely to receive a callback unemployed one year after their compared with Blacks without a release.563 Notably, men of color are record.569 Additionally, the study noted most negatively affected. Black men are that Blacks without a criminal record six times as likely to be incarcerated as were still less likely to receive a callback White men, and Latino men are more compared with White applicants with a than twice as likely to be incarcerated criminal record. Recent studies note that as non-Latino White men.564 While BTB policies might have unintended federal law does not prohibit employers negative consequences for people of from asking about criminal history, color by reducing callback rates for employers can have a negative bias Black applicants and employment rates toward justice-involved individuals and for young men of color.570,571 While be less likely to hire them.565 more research is needed to confirm the effects of BTB policies on marginalized Implementing fair-chance hiring populations, implementing BTB policies that allow people with a policies with other considerations, conviction history to reenter the such as greater enforcement of equal- workforce can help them increase employment protections and employer- their earnings, which is linked to liability protections, can help improve better health, and contribute to the the effectiveness of these policies economy. Special attention should be while eliminating the unintended given to equity to ensure such policies consequences. are implemented in a way that does not TFAH • tfah.org 59 Health Evidence Implementing BTB policies can lead to increased employment opportunities for justice-involved individuals.572 Following the implementation of BTB laws in the District of Columbia; Minneapolis, Minnesota; Atlanta, Georgia; and Durham County, North Carolina, there were increases in employment among formerly incarcerated individuals.573 Accessing employment opportunities is a critical step in achieving economic well-being, which is a driver of health. Securing a good-paying job can help individuals access more nutritious foods, better housing, and healthcare, all of which applicants may still be rejected later chance laws or policies, with 11 of these impact a person’s health. However, in the hiring process, which could states’ laws applying to private-sector an evaluation of the Massachusetts have been avoided if they had asked employers. Also, more than 150 cities and law Criminal Offender Record about criminal history earlier.577 counties have adopted a BTB policy580— Information Reform, which included However, after the District of Columbia but five states preempt local governments a BTB provision, appears to have led implemented BTB policies, most from enacting BTB policies.581 to a reduction in employment for employers reported it had minimal BTB laws can vary according to (1) individuals with criminal records.574 impact on their hiring processes.578 whether the law applies to public- or Other research from New York and BTB policies can benefit the economy private-sector employers; (2) how New Jersey found that while BTB as justice-involved individuals are more long an employer must wait before policies may increase employer likely to reenter the labor market. asking about conviction history; (3) callbacks to applicants with criminal This not only positively impacts their what positions the BTB law applies records, it may also have resulted in individual lifetime earnings, but to; (4) what must be considered a significant decrease in callbacks to their employment also increases state along with the conviction history Black men without criminal records, income tax contributions. A study (for example, mitigating factors); thus potentially offsetting any gains to found that adding 100 justice-involved and (5) whether notice of the Black men with criminal records.575 individuals back into the workforce reason for rescinding a job offer is There is also evidence suggesting that would increase their lifetime earnings required.582 For example, California BTB policies can curb recidivism. A by $55 million, increase their income law applies to all employers—public study found that criminal defendants tax contributions by $1.9 million, and and private—who have more than five prosecuted in Honolulu for a felony increase sales tax revenues by $770,000, employees.583 Further, California law crimes were 57 percent less likely to have while saving taxpayers more than $2 prohibits employers from inquiring a subsequent criminal conviction after million annually by keeping them out into conviction history until after a implementation of Hawaii’s BTB law.576 of the criminal justice system.579 conditional offer of employment is made.584 By contrast, Colorado law only Economic Evidence Policy Landscape applies to public-sector employers, and According to the National Employment background checks may be performed Opponents of BTB policies argue that Law Project report, 33 states and the once the agency determines that the delaying criminal-history inquiries District of Columbia, have BTB and fair- applicant is a finalist for the position.585 increases hiring costs because 60 TFAH • tfah.org CASE EXAMPLE Nebraska’s Ban the Box Law In 2014, Nebraska enacted legislation counties and cities. Law enforcement that prohibited public employers from positions and other roles that require inquiring into a job applicant’s criminal a background check are exempted, as history until after they determined are school districts. The language was the applicant met the minimum job added to comprehensive prison-reform requirements. The legislation applies legislation aimed at reducing the to the state of Nebraska, including all inmate population. Considerations for Effective Design and Implementation586,587,588 l D o not preempt local governments from l R educe occupational licensing barriers. enacting and implementing their own l I ncrease employment services for BTB and other fair hiring protections. people with criminal records. l E nforce and improve civil rights and l E liminate racially identifying equal employment protections. information in applications. l R educe liability from negligent hiring l P rovide expungement or sealing by providing protections to employers options for people convicted of with concerns regarding liability. their first offenses not related to l P rovide training for employers, and serious crimes (examples of serious provide outreach to people with crimes include, sex crimes or other criminal records. serious violence). l I mprove the accuracy and reliability of background checks. Complementary Policies Transitional Jobs: Transitional job welfare recipients who are unable to programs provide short-term, wage- find work on their own, justice-involved paying jobs, support services, and individuals, noncustodial parents, or job-placement help to individuals who the recently unemployed, depending have difficulty getting and holding on the state’s policy.590 There is jobs in the regular labor market in strong evidence that transitional and rural and urban areas.589 Transitional subsidized jobs programs increase job programs can help people with employment and earnings for impacted limited or no job history and can populations, such as low-income help participants overcome barriers adults, unemployed individuals, and to employment and increase their job formerly incarcerated individuals opportunities. Individuals enrolled for the duration of their subsidized in transitional job programs could be position.591,592,593 TFAH • tfah.org 61 Related Policies and Issues RELATED POLICIES AND ISSUES As highlighted in the previous sections, health is determined by a multitude of factors, including where individual live, work, learn and play. While the PHACCS initiative focuses on highlighting nonclinical policies that can improve population health, we recognize that there are other contributing factors to an individual’s well-being. This section highlights a few cross-cutting policies and areas that are critically important for states to consider as they develop strategies to support individual and community well-being throughout the country. Promoting Equitable Access to Health Services Through Coverage Expansion, Workforce Growth, and Adoption of New Technologies Coverage Expansion As of November 7, 2018, 36 states and Status of State Action on the Medicaid Expansion Decision the District of Columbia have expanded Medicaid under the Affordable Care Act. An additional three states (Nebraska, Utah, and Idaho) recently passed ballot initiatives to expand Medicaid. Numerous studies confirm that Medicaid expansion states have seen significant coverage gains and reductions in uninsured rates among minority, vulnerable, and low-income populations. Additionally, Medicaid expansion has also had a disproportionately positive impact in rural areas of expansion states.594 Medicaid expansion can serve as a tool to reduce health disparities among major racial and ethnic groups and to help close Source: Kaiser Family Foundation596 the urban-rural divide. A study published in May 2018 shows that expanding Medicaid in the 19 non-expansion states that meet the needs of their populations While there is significant variation in (at that time) would have a substantial and make Medicaid expansion politically terms of the coverage level, benefits impact: 4.5 million more people gaining viable. These waivers give authority to provided, and participation requirements, coverage in 2019, the uninsured rate the secretary of the U.S. Department the remaining non-expansion states dropping from 16.9 percent to 12.6 of Health and Human Services and the should assess the following considerations percent, and uncompensated care administrator of the Centers for Medicare when determining whether to expand decreasing by $8 billion.595 and Medicaid Services (CMS) to approve Medicaid or address other healthcare States have taken different approaches to experimental, pilot, or demonstration access issues: FEBRUARY 2019 Medicaid expansion, which can serve as programs that promote the objectives Work Requirements for Medicaid a model to the remaining 14 states that of the Medicaid program. Currently, Beneficiaries have yet to expand coverage. One avenue seven states (Arizona, Arkansas, Indiana, for expanded Medicaid is through Section Iowa, Michigan, Montana, and New Studies of the theory behind Medicaid 1115 waivers, which provide flexibility Hampshire) have expanded Medicaid work requirements show that they to states to develop innovative solutions through their Section 1115 waivers. do not improve long-term economic 62 TFAH • tfah.org well-being.597 Research on the TANF Medicaid under the Affordable Care program shows that imposing a work Act, it should at a minimum consider requirement on Medicaid would expanding Medicaid eligibility to 100 likely not yield the desired outcomes percent of the Federal Poverty Level to of increasing long-term employment ensure that parents are able to access or reducing poverty among Medicaid public or private health insurance. beneficiaries.598 Recent research Behavioral Health examining the expansion of work requirements for the Supplemental Two new federal laws set important Nutrition Assistance Program and the requirements for certain public and introduction of work requirements for private behavioral health coverage that Medicaid beneficiaries found that a often had been missing. Specifically, have implemented incentive programs the Affordable Care Act requires majority of individuals exposed to these for healthy behaviors. These programs individual and small-group health requirements were already attached to use financial incentives or penalties to insurance plans to cover behavioral the labor force and would be unable to promote or discourage specific health health services starting as of 2014, and meet the 20-hours-per-week threshold behaviors. The evidence supporting the Paul Wellstone and Pete Domenici as a result of persistent health issues.599 these programs is limited, states should Mental Health Parity and Addiction Additionally, these policies may be strongly consider the impact healthy Equity Act of 2008 requires behavioral unnecessary as a majority of the behavior incentive programs may have health services to be covered on parity population of Medicaid expansion on beneficiaries. While behavioral- with physical, medical, and surgical beneficiaries are already working or economics theories may point to care under individual, group, and in school (62 percent) or looking for penalties being a stronger incentive Medicaid expansion plans.603 work (12 percent). Just 13 percent to yield change among beneficiaries, of adults covered by Medicaid’s penalties may cause great harm to However, despite these requirements expansion are not working, looking individuals and prevent them from around coverage, legacy systems and for work, or in school.600 However, accessing needed health services; it may practices continue to make access and states have and may continue to also disproportionately harm low-income availability of services challenging. impose work requirements for people and members of racial and Additionally, public and private certain Medicaid beneficiaries. ethnic minority groups.601 insurance policies still vary significantly, If a state imposes Medicaid work and covered services may be insufficient Close the Coverage Gap for to meet recommended standards of requirements, it may want to consider Select Populations in States Not care. For instance, a 2015 Government the following approaches: (a) pair Expanding Medicaid Accountability Office report showed these requirements with employment States that choose not to expand significant variation in the types of and job-training services that will Medicaid should consider closing the behavioral health services provided have to be paid for with other coverage gap for parents who have to Medicaid beneficiaries in different resources, as CMS prohibits Medicaid incomes above Medicaid eligibility states.604 In addition, the parity law funds from being used for training limits but below the lower limit for only applies to employers that provide or supportive services; (b) make marketplace premium tax credits.602 mental health coverage and have 50 processes for documenting exemptions As of June 2018, more than two or more employees. With enforcement and employment simple and easily million uninsured adults fall into falling largely on states, there is a need accessible; (c) set reasonable penalties the coverage gap as a result of their to improve consistency of oversight and for noncompliance rather than total state not expanding Medicaid. These enforcement of insurers’ compliance benefit loss; and (d) conduct rigorous individuals do not qualify for Medicaid with existing mental health parity laws. evaluations focusing on intended and benefits and are not eligible to receive For example, states lack consistent unintended consequences. premium support, thus making definitions of what constitutes “mental Healthy Behavior Incentives insurance coverage unaffordable and health” and “substance use disorders” Many state Medicaid programs and greatly restricting their access to health and what is required to be covered by Medicaid Managed Care Organizations services. If a state does not expand health insurance. TFAH • tfah.org 63 There is also a significant movement American College of Physicians, and the … fewer interpersonal conflicts, greater toward more integrated approaches to American Society of Addiction Medicine, workplace productivity, reduced physical and mental health, focused on recommend an integrated approach to infectious disease transmission and evidence and practices showing strong physical and behavioral healthcare.606 fewer drug-related accidents, including interconnections and the effectiveness of The U.S. Surgeon General noted the overdoses and deaths.”607 Despite the fact a “whole person” approach for improved question is “no longer whether but how that 68 percent of patients with a mental results, including for reducing depression this much needed integration will occur,” health disorder also have a medical and improving experience of care.605 and “net benefits of integrated treatment issue, mental health and substance A range of experts and organizations, include improved healthcare outcomes use disorders have traditionally been including the Office of the Surgeon and reduced healthcare costs, as well as treated in separate systems from physical General, Substance Abuse and Mental reduced crime, improved child welfare, healthcare—often with separate coverage Health Services Administration, the and greater employment productivity and payment policies.608 Workforce Health Professional Shortage Areas – Primary Care According to the Association of American Medical Colleges, the United States could see a shortage of up to 120,000 physicians by 2030. This includes a shortage of between 14,800 and 49,300 primary care physicians.609 This shortage has resulted in a significant number of Americans lacking access to a provider of any type; this issue is especially prominent in rural areas. While there are many different strategies to address physician shortages, states have a unique role in granting practice authority for nurse practitioners (NPs) and other advanced practice professionals who can help improve patient access to much- needed health services. Source: Rural Health Information Hub610 As of 2018, 22 states and the District of Columbia grant NPs full practice authority, meaning that NPs can Nursing Practice Act and Model The behavioral health workforce must practice to the top of their licensure Nursing Administrative Rules be expanded to support the needed and training.611 The National Academies (Article XVIII, Chapter 18). availability of providers who can treat of Medicine (formerly known as the and provide services for substance Institute of Medicine) also recommends l R equire third-party payers that use disorders—including supporting that advanced practice registered nurses participate in fee-for-service different service delivery models, such should be able to practice to the full payment arrangements to provide as expanding the use of community extent of their education and training.612 direct reimbursement to advanced health workers, paramedics, and peer For state legislatures, the National practice registered nurses who are counselors and expanding or building on Academies of Medicine recommends: practicing within their scope of primary care. Some models for bolstering practice under state law. l R eform scope-of-practice regulations workforce areas include incentives and to conform to the National Council loan repayments for professionals. of State Boards of Nursing Model 64 TFAH • tfah.org Telehealth Another way for states to support access and quality of care, especially access to health services for rural for children, older individuals and residents is through policies that those living in rural areas.613 However, facilitate telemedicine. There is Medicaid telemedicine reimbursement growing evidence that telehealth can varies from state to state. lower healthcare costs while improving LINKED IN Center for Connected Health Policy’s State Telehealth Laws and Reimbursement Policies (fall 2018)614 l 4 9 states and the District of l 2 3 states limit the type of facility Columbia, provide reimbursement for that can serve as an originating site. some form of live video telehealth l 1 5 states explicitly allow schools to in Medicaid fee-for-service. be originating sites for telehealth Massachusetts remains the only delivered services (with some state that does not offer live video restrictions) reimbursement. l 3 4 state Medicaid programs offer l 1 1 states provide reimbursement for a transmission or facility fee when store-and-forward, which supports the telehealth is used. collection and electronic sending of l 3 9 states and the District of clinical information to another site. Columbia currently have a law that l 2 0 state Medicaid programs provide governs private-payer telehealth reimbursement for remote patient reimbursement policy. monitoring. TFAH • tfah.org 65 Supporting City and Municipality Policies: Ensuring the Appropriate Use of State Preemption Policies to Promote Health and Well-Being ON THE LEVEL Preemption 101615 Degrees of Preemption local governments and is of general What is Preemption? l F loor: State legislatures can pass concern to local governments as l P reemption is a legal doctrine in a law to establish a uniform set of it restricts their ability to address which a higher level of government minimum requirements, and localities pressing public health issues beyond may limit, or even eliminate, the can choose to exceed or build on the requirements set forth by the power of a lower level of government these set requirements. This allows state legislature. to regulate a certain issue. the state legislature to create a l N ull: State legislatures can prohibit base level for all local governments Types of Preemption local governments from passing to follow and enforce, while also l E xpress Preemption: A form of laws or regulations in a specific providing flexibility to localities to preemption that explicitly states it field without enacting state-level impose more stringent requirements. is meant to preempt a lower-level legislation on the topic. This can be authority. l C eiling: State legislatures can prohibit a troublesome form of preemption local governments from requiring as the state is not acting on an l I mplied Preemption: A form of anything more than the specified important issue and also not preemption that may invalidate lower- law, or any differences in the law. allowing local governments to act level laws without explicitly including This type of preemption establishes on the issue and develop innovative preemptive language. standards that cannot be exceeded by policy solutions. Over the past few decades, preemption jurisdictions and even local lawmakers l W hen considering policies with laws have been used to both promote that advance policies in conflict with public health implications, states and hinder public health efforts on state restrictions. should explicitly not preempt local the federal, state, and local level. governments from passing higher or These more recent efforts are similar For example, the school nutritional more restrictive standards. It should to the same strategies the tobacco standards included in the Healthy, be the goal of all policymakers to industry has used, and continues to Hunger-Free Kids Act of 2010 set a support the health and well-being use, to impose restrictions on tobacco- floor of nutritional requirements that of all individuals, and hindering control efforts.617 For example, the states and localities can build on. local governments’ ability to develop tobacco industry has supported the However, state legislatures have passed innovative solutions to important passage of state laws that limit the sales ceiling and null preemption policies, health needs will impede population of tobacco products to youth while also which hinder local governments’ health improvement in both the preempting local governments from ability to effectively address public near and long term. passing higher age requirements.618 health and issues of social and l W hen state laws prohibit action economic well-being, including Preemption laws that restrict local to promote health, policymakers smoke-free environments, tobacco government innovation to advance should at a minimum explore policy and alcohol taxation, paid leave, health, well-being, and equity can options to remove preemption fair-chance hiring, and inclusionary have far reaching consequences. Many language from state statutes. An ideal zoning. Over the last several years, preemption campaigns and laws are policy would not only remove the state preemption has more often funded and supported by business preemptive language but also include been of the null variety, creating and industry in order to dilute minimum standards that local a regulatory vacuum, and it has consumer protections and protect governments can build on. increasingly included penalties for corporate interests. 66 TFAH • tfah.org NULL AND VOID California’s Statewide Soda Tax Ban616 l A pproved on June 28, 2018, that had already been passed and Assembly Bill 1838 banned new implemented intact, it does not allow local taxes on soda and other sugar- for any future policies to be passed. sweetened beverages in California l I n the case of California, the state until 2031, and it prohibited soda prohibited local governments from tax measures that would have passing soda taxes and did not pass a taken effect in 2018. While the soda tax of its own (null preemption). bill does leave soda tax measures TFAH • tfah.org 67 STATES WITH EFFECTIVE LEGISLATION AS OF 12/31/18 Policy Policy Policy Policy Policy Recommendation Policy Recommendation 1b Recommendation Recommendation Recommendation Recommendation 1a 2a 3a 3b 3c Universal School Nutrition: School Nutrition: School Nutrition: Syringe Access States Pre-Kindergarten School Breakfast School Lunch Competitive Smoke-Free Laws Tobacco Taxes Alcohol Taxes Programs Programs Program Program Foods Alabama 0 0 0 0 0 0 1 1 Alaska 0 0 0 0 0 0 1 1 Arizona 0 0 1 1 0 1 1 1 Arkansas 0 1 0 1 0 0 1 1 California 0 0 0 1 1 1 1 1 Colorado 0 1 0 1 1 1 1 1 Connecticut 0 1 0 1 1 1 1 1 Delaware 0 1 1 0 1 1 1 1 D.C. 1 1 0 1 1 1 1 1 Florida 1 1 0 0 0 0 1 1 Georgia 1 1 0 0 0 0 1 1 Hawaii 0 1 1 0 1 1 1 1 Idaho 0 0 0 0 0 0 1 1 Illinois 0 1 1 1 0 1 1 1 Indiana 0 1 0 1 1 0 1 1 Iowa 1 0 1 0 0 1 1 1 Kansas 0 1 0 1 0 1 1 1 Kentucky 0 0 0 1 1 0 1 1 Louisiana 0 1 1 1 1 0 1 1 Maine 0 0 1 1 1 1 1 1 Maryland 0 1 1 1 1 1 1 1 Massachusetts 0 1 1 1 1 1 1 1 Michigan 0 1 1 0 0 1 1 1 Minnesota 0 1 0 0 0 1 1 1 Mississippi 0 0 0 1 0 0 1 1 Missouri 0 1 0 0 0 0 1 1 Montana 0 0 0 0 1 1 1 1 Nebraska 0 0 0 0 0 1 1 1 Nevada 0 1 0 0 1 0 1 1 New Hampshire 0 0 0 0 1 0 1 1 New Jersey 0 1 1 1 1 1 1 1 New Mexico 0 1 0 1 1 1 1 1 New York 1 1 1 0 1 1 1 1 North Carolina 0 0 1 1 1 0 1 1 North Dakota 0 0 0 0 1 1 1 1 Ohio 0 1 1 1 1 1 1 1 Oklahoma 1 0 0 1 0 0 1 1 Oregon 0 1 0 1 0 1 1 1 Pennsylvania 0 0 0 1 0 0 1 1 Rhode Island 0 1 1 1 1 1 1 1 South Carolina 0 1 1 1 0 0 1 1 South Dakota 0 0 0 0 0 1 1 1 Tennessee 0 1 1 1 1 0 1 1 Texas 1 1 0 1 0 0 1 1 Utah 0 0 0 0 1 1 1 1 Vermont 1 1 1 0 1 1 1 1 Virginia 0 1 0 1 1 0 1 1 Washington 0 1 1 1 1 1 1 1 West Virginia 1 1 1 0 0 0 1 1 Wisconsin 1 0 0 0 0 1 1 1 Wyoming 0 0 0 0 0 0 1 1 Total States 10 31 20 28 27 29 51 51 States that support state- Statewide legislation States that have Rates vary and higher Rates vary and higher funded pre-K to nearly 50 explicity authorizing passed comprehensive taxes are generally taxes are generally more percent or more of their syringe access smokefree laws, per more effective. effective. state’s 4-year-olds programs the American Lung Association 68 TFAH • tfah.org STATES WITH EFFECTIVE LEGISLATION AS OF 12/31/18 Policy Policy Policy Policy Policy Policy Policy Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation 4a 5a 5b 6a 6b 6c 6d Housing Rapid Re-Housing Earned Income Tax Fair Hiring Protections States Complete Streets Rehabilitation Loan Paid Sick Leave Paid Family Leave Laws Credit (Ban the Box) and Grants Alabama 0 1 0 0 0 0 0 Alaska 0 1 0 0 0 0 0 Arizona 0 1 0 0 1 0 1 Arkansas 0 0* 0 0 0 0 0 California 1 1 1 1 1 1 1 Colorado 1 1 0 1 0 0 1 Connecticut 1 1 1 1 1 0 1 Delaware 1 0* 0 1* 0 0 1 D.C. 1 1 1 1 1 1 1 Florida 1 1 1 0 0 0 0 Georgia 1 1 0 0 0 0 1 Hawaii 1 1 0 1* 0 0 1 Idaho 0 1 0 0 0 0 Illinois 1 0* 0 1 0 0 1 Indiana 1 1 0 1 0 0 1 Iowa 0 1 1 1 0 0 0 Kansas 0 1 0 1 0 0 1 Kentucky 0 1 0 0 0 0 1 Louisiana 1 1 0 1 0 0 1 Maine 1 1 1 1 0 0 0 Maryland 1 1 0 1 1 0 1 Massachusetts 1 1 0 1 1 1* 1 Michigan 1 1 0 1 1* 0 1 Minnesota 1 1 0 1 0 0 1 Mississippi 1 0* 0 0 0 0 0 Missouri 1 0* 0 0 0 0 1 Montana 0 0* 0 1 0 0 0 Nebraska 0 1 0 1 0 0 1 Nevada 1 1 0 0 0 0 1 New Hampshire 0 1 0 0 0 0 0 New Jersey 1 1 0 1 1 1 1 New Mexico 0 1 0 1 0 0 1 New York 1 0* 1 1 0 1 1 North Carolina 1 1 0 0 0 0 North Dakota 0 1 0 0 0 0 0 Ohio 0 1 0 1* 0 0 1 Oklahoma 0 0 0 1* 0 0 1 Oregon 1 1 1 1 1 0 1 Pennsylvania 0 1 0 0 0 1 Rhode Island 1 1 0 1 1 1 1 South Carolina 1 1 0 1* 0 0 0 South Dakota 0 0* 0 0 0 0 0 Tennessee 1 1 0 0 0 0 1 Texas 0 1 1 0 0 0 0 Utah 1 1 0 0 0 0 1 Vermont 1 0* 0 1 1 0 1 Virginia 1 1 0 1* 0 0 1 Washington 1 1 0 1 1 1** 1 West Virginia 0 1 0 0 0 0 0 Wisconsin 0 1 0 1 0 0 1 Wyoming 0 0 0 0 0 0 0 Total States 30 40 9 30 12 7 34 * These states have a law allowing a *States with non- *Mich. Comp. Laws § * (H. 4640 § 29, 190th Gen. Court, Reg. Sess. (Mass. 2018) state agency or local municipality to refundable EITCs 408.963 adopts paid (enacted) use funds for housing rehabilitation sick leave as of March Enacted 2018, effective July 2019 (premiums) and January (among other purposes) but do not 29, 2019 2021 (benefits) specifically mention a program or **(S.B. 5975, 65th Leg., 3rd Special Sess. (Wash. 2017) fund to be used for such purposes. (enacted)) States may also fund such programs Enacted 2017, effective January 2019 (premiums) and in the absence of statewide legislation January 2020 (benefits) TFAH • tfah.org 69 Endnotes 1 raveman P, Arkin E, Orleans T, et al. “What B 12 Alzheimer’s Association. “2018 Alzheimer’s 23 Zimmerman E, Woolf SH, and Haley A. 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