- Hispanic Chamber of Commerce
- Hispanic Contractors of Colorado
- Pueblo Chamber of Commerce
- Denver Metro Chamber of Commerce
- Counties and Commissioners Acting Together
- Colorado Ski Town Association
- Colorado Hotel and Lodging Association
- Colorado Gaming Association
- Marijuana Industry Group
- Economic Development Council of Colorado
- CO PIRG
- Denver Area Labor Federation
- SEIU Colorado
- Healthier Colorado
- Colorado Cross-Disability Coalition
- Colorado Sierra Club
- Colorado AFL-CIO
- Chronic Care Collaborative
- Colorado Latino Forum
- Planned Parenthood of the Rocky Mountains
- Bicycle Colorado
- Mile High Connects
- The University of Colorado School of Medicine Student National Medical Association
- American Medical Women's Association
- American Medical Women’s Association at Colorado State University
- American Medical Women's Association CU Boulder Chapter
- Visit Colorado Springs
- VIsit Fort Collins
- Visit Pueblo Convention & Visitors Bureau
- Visit Aurora
- Visit Denver
- Vail Valley Partnership
- Visit Glenwood Springs
- Colorado Hospital Association
- Colorado Board of Health
- Colorado Association of Local Public Health Officials
- Janicek Media
- First Bank
- Frontier Airlines
- Aspen Chamber Resort Association
Despite the minority of loud detractors, the majority of Coloradans and many of the state’s most important advocacy organizations support the Governor’s mask mandate and mask wearing in general. Below is a list of just a few of those organizations who have voiced their support:
Opinion by Peter Manetta
The debates over how we pay for health care threaten to eclipse any other health-related topic in 2020. The Affordable Care Act (ACA) is again under threat from a lawsuit working its way through the courts. Democratic presidential candidates are debating financing schemes ranging from immediate and full public takeover of health insurance to more stepwise public-private arrangements. And our governor’s newly released “state option” will add some local gasoline to this national fire.
Those of us advocating for investments in public health prevention or addressing SDOH won’t be able to shout over the din. But the polarization surrounding health reform may be creating an advocacy opening. There seem to be many moderate-progressive politicians who dread questions about whether they support Medicare for all. On its face, it is popular with Democrats, but loses support when details are discussed, according to recent research from the Kaiser Family Foundation. On the other side, there are probably some conservative politicians who hesitate to provide a direct answer on axing the ACA, something that pleases their extreme base but could end up harming many of their constituents.
Can we position public health investment as a more politically neutral, “common sense” option for the wary legislator or candidate?
When asked “do you support Medicare for all?”, a progressive politician could answer: “While it’s important to address how we pay for health care, I think we need to refocus our attention on the high rates of preventable illness that are driving most of these costs. The best way to save people money on health care is make it less likely that they become sick in the first place. Investing in public health prevention is how we do that.”
A conservative politician asked whether they support repealing Obamacare could say the exact same thing. It seems like a dodge, but our national political obsession with how we finance health care has distracted the public, policymakers, and even policy wonks from the causes behind why we pay so much, and this needs to change. By invoking the thrifty, common sense, and evidence-based reasons for investing in prevention, politicians can claim a sensible middle-ground.
I think this approach could also appeal to many in the “exhausted majority” who are watching the extremes of each party with increasing alarm, disgust, or apathy. These are people who understand all too well that having coverage does not mean you won’t be bankrupted by medical bills, who scoff at an 18% reduction on a premium they couldn’t come close to affording anyway, and who are wondering just how many PhDs one might need to understand why a health care system is harming them so much. These are also people whose participation and leadership we need on a local level to create an effective and equitable public health system.
The upcoming holiday season is a perfect opportunity to test this on your family and friends. If you find yourself at a politically polarized table with a health reform debate threatening to ruin the evening, give the common-sense prevention argument a try.
By Peter Manetta,
There are several efforts underway at state and federal levels to secure adequate and predictable government funding for public health infrastructure that also supports primary, upstream prevention. Concurrently, the population health function of health care systems is taking on more upstream prevention roles addressing the social determinants of health (SDOH) that might otherwise be part of an adequately funded public health system – but typically restricted to their own patient and client populations. There seems to be an emerging tension over whether the growth of health care-based SDOH interventions is a good idea, and even if it isn’t, whether adequate government funding for public health can be attained even in “favorable” political climates.
We should not allow this distinction to become a false choice. Both approaches are necessary. Health care certainly has a critical role in building healthy communities, but relying entirely on medical treatment systems to fund and implement community-based upstream interventions has limited scaling potential and a host of equity concerns. This is especially the case when their efforts do not include aggressive, vocal lobbying for the large-scale systemic changes this country needs to move the needle, such as reforming the nation’s food systems.
With the (slow) transition to value-based care, providers have some incentive to prevent many costly outcomes for their patients by addressing individual social needs and investing locally in upstream health interventions. But medical treatment is a business. They have built their business models on an expected level of demand. Success in addressing upstream determinants of health through community-based prevention means significantly reducing that level. Does it make sense to ask a business, even a “non-profit” one, to be responsible for activities intended to significantly reduce demand for its services?
That inherent conflict of interest could exacerbate inequities and create harmful inefficiencies. Would a hospital system facing reductions in treatment revenue because their community is healthier feel compelled build a revenue stream – or a profit center – from addressing social needs and upstream determinants? If that happens, would those services be available to everyone in their community, or only those with health plans that cover the service?
Take healthy food prescription programs as an example. Once payers agree to cover it, a hospital can start billing payers more than the cost of the program in order to cover administration or offset falling revenue from somewhere else. With success, the program expands and food prescriptions become billable for a wider range of diagnoses. The hospital then needs more administrative capacity, charges payers more for that, and their program demands more fresh fruits and vegetables – potentially affecting local supply and prices. So now you have fresh produce potentially becoming more expensive and less available for other consumers. Some patients may benefit greatly and the hospital itself may realize significant ROI by preventing the costly outcomes, but this will have been achieved in the most inefficient way possible while potentially reducing access for those outside their patient populations. Proponents of food prescription programs should compare their cost-per-unit of healthy food delivered to government-funded SNAP benefits, especially when those benefits are combined with public health-driven efforts to improve healthy food access for everyone. Another efficiency concern is that food prescriptions are secondary prevention applied after an acute outcome or diagnosis. SNAP and community-based efforts to increase healthy food access can prevent that acute outcome or diagnosis.
I’m not arguing that something like this is inevitable, but we should be vigilant about scrutinizing health care’s SDOH interventions in communities where what’s really needed are wider systemic changes supported by governmental public health. And in the words of Health Affairs Editor in Chief Alan Weil at the 2019 Colorado Health Symposium, “everything health care touches becomes more expensive” (https://www.youtube.com/watch?v=5Hv4mvp3kjI, 10:40)
In the abstract, payers would seem to be the more logical entities to drive (and profit from) upstream investments. If their premium-paying client base generates fewer claims, payers’ margins increase. But payers seem hesitant to invest in SDOH efforts in their own communities, partially because their client populations churn. A neighborhood food desert intervention could help prevent someone from developing type 2 diabetes five years down the road, but by that time they may be on a competitor’s plan. If coverage rates start to fall with the demise of the individual mandate, the justification for direct, local investment becomes even less clear. Governmental investments in public health prevention and industry-wide lobbying for large-scale SDOH-related systems change would seem to be the best bet for payers. If successful, those investments should reduce claims across the board, without payers making the initial upfront investment.
In their chapter of the just released Practical Playbook II, John Auerbach and Karen DeSalvo point out that efforts to secure infrastructural public health funding aren’t likely to succeed anytime soon, and that we should further explore how the private sector, health care, and philanthropies can invest in public health prevention. I would argue that the best way for those entities to invest in public health prevention and intervene on the social determinants of health is to use their considerable political power to lobby for that infrastructural public health funding and the other systems changes we all desperately need.
By Peter Manetta
As we develop compelling ways to answer the question, “what is public health,” it is worth exploring concepts that can function as useful analogies, potential frames, or rallying concepts. Community resilience could be one such helpful concept for illustrating and supporting public health’s strategic role in community health. In some communities, it could also function as an operational guiding framework for advancing equity, fostering health in all policies, and moving public health upstream.
Some would dismiss resilience because it means many different things depending on your field, kind of like “sustainability.” But a quick review of definitions from different fields reveals a core mathematical concept that is applied metaphorically to systems with different scopes:
The core operational theme of recovering equilibrium after a shock is present across these definitions, but applied to different system levels – individual, community, and ecosystems. This is just a small sample of definitions, but more substantial reviews reveal the same shared theme.
This multi-level applicability could be an advantage when bringing a variety of partners to the table, which public health is already doing through its mandated preparedness efforts. The term “health” shares this multi-level quality (e.g. individual health, family health, community health), but “health” is too easily conflated with “health care.” Resilience does not share this problem, and individualist conceptions of resilience could be useful starting analogy for explaining community resilience. Because of the core theme, community members concerned about how well their families and neighbors will regroup after an evacuation have a common frame of reference with a business group worried about long-term labor shortages.
Working with a resilience lens could elevate perceptions of interdependence. Community-wide disasters can create shared circumstances for groups that rarely interact. To assess their own resilience, each group must consider system factors outside their typical sphere of relationships, including the health and welfare of people they may come to depend on or who need their support during a disaster. Strategizing around resilience can potentially force people to think about circumstances where they might experience the same inequities, insecurities, and stress that some their neighbors might experience all the time.
Efforts aimed at improving and measuring community resilience are taking a public health approach. Resilience proponents are advocating for multi-sector, “co-benefit” approaches combined with Community Based Participatory Research (CBPR) methods that are strikingly similar to our guiding principles for the future of public health: the Public Health 3.0 model, Chief Community Health Strategist, health in all policies, and advancing equity.
Using community resilience as a rallying concept might not work for every community, and may be more effective in communities that have recently experienced a disaster. Communities that are deeply concerned about the effects of climate change might be particularly receptive. We encourage public health professionals to explore this and other broad, systemic concepts as “flagship” ideals that can inspire more meaningful community participation in public health efforts.
By Shannon Kolman
Milwaukee County leaders recently signed a resolution declaring that racism is a public health crisis. Milwaukee County Executive, Chris Abele, said that “the resolution isn’t just about taking action but is designed to foreground race equity in all areas of county decisions.” The resolution vows to explicitly advocate for policies that improve the health of communities of color and expand understanding of how racism affects people (read more about it here).
Tony Iton, Senior Vice President of the California Endowment, also spoke about explicitly changing the narrative we use in public health at the 2019 NNPHI Annual Conference in May. He noted that the narrative is the story we tell ourselves and that in the U.S. there is a growing narrative of exclusion – that some people matter and some people don’t. And as we in public health well know, such narratives ultimately affect the health of those who are excluded.
For example, a new report from UCLA found that in Wisconsin K-12 schools suspend black high school students at a higher rate than anywhere else in the country and Wisconsin has the second highest disparity in suspension rates between white and black students. The state of Wisconsin also has the largest achievement gap between white and back students in the country. Of course, Wisconsin is not the only area in the U.S. to experience such disparities. One of the goals of the Milwaukee County resolution is to encourage other local, state and national entities to recognize the harmful effects of racism.
Tony Iton was among the first people to look at life expectancy by zip code, which clearly showed that systematic discrimination affects health outcomes and ultimately mortality. At the NNPHI conference, Tony Iton stated that public health professionals understand such data and it is the responsibility of public health professionals to translate such complex information into policy. He reminded us that power matters to public health practice because health is political and that health should be viewed as an investment and not an expenditure. Countries that have made substantial investments in social determinants of health have better health outcomes.
As CALPHO starts to dig into communications and messaging around public health, as part of public health transformation, we need to remember that narratives do affect policies and of course policies affect health. Developing the capacity to translate complex evidence and frame it effectively for all audiences will help us challenge harmful narratives and promote helpful ones.
By Shannon Kolman
CALPHO is actively supporting two bills currently being considered in the Colorado Legislature; HB19-1076 Clean Indoor Air Act Add E-Cigarettes Remove Exemptions, and HB19-1033 Local Governments May Regulate Nicotine Products. Both bills are critical for all Colorado communities trying to prevent kids from becoming addicted to tobacco products and protecting everyone in the state from the harmful affects of tobacco use and second-hand smoke.
HB19-1076 will modernize the Colorado Clean Indoor Air Act (CCIAA) by prohibiting the use of electronic smoking devices, known as e-cigarettes and often called vaping, in public spaces and workplaces, and would also remove some of the outdated exemptions in the Act. The vaping trend in Colorado is very real, especially among youth. Last month the Surgeon General declared youth vaping an epidemic, warning of serious health risks and calling for swift action to curb youth access. Yet, recent surveys show that only 50% of Colorado youth believe e-cigarettes are risky and Colorado has the highest rate of teen e-cigarette use in the nation.
Colorado passed the CCIAA in 2006 which prohibits smoking in enclosed public places. Marijuana smoking was added to the law in 2013. However, the CCIAA does not explicitly ban the use of “modern smoking devices” such as e-cigarettes and vaping devices. Such devices contain cartridges filled with a liquid that is vaporized by a battery-operated heating element. The aerosol is inhaled by the user and then exhaled into the environment. So if you are around someone who is using e-cigarettes you are likely breathing an aerosol of exhaled nicotine and other fine particles of toxins.
Fifteen states across the U.S. have already added e-cigarettes to their smoke free laws and dozens of local governments in Colorado have already adopted local restrictions on e-cigarettes. It is time for the entire state to modernize CCIAA to protect everyone’s right to breathe tobacco smoke/aerosol free air. It’s also time for local governments to have the freedom to regulate tobacco products including cigarettes and e-cigarettes. This is what HB19-1033 is trying to tackle.
In Colorado, if a locality chooses to license, access a fee, or tax cigarettes, they forgo their share of the cigarette tax revenue that exists in state law. This penalty is also assessed if a locality attempts to tax cigarettes through citizen initiative or referred measure. In addition, Colorado law defines different types of localities and thus counties and statutory cities are unable to regulate cigarettes in the same way a home-rule municipality can. HB19-1033 removes the fiscal penalty and will allow localities to make their own decisions on regulating cigarettes in terms of licensing, taxation, and assessing fees. The legislation also explicitly includes the authority of localities to raise the age of tobacco product purchase to 21, and to regulate those products’ purchase in the same manner as other controlled substances, such as marijuana and alcohol.
CALPHO is excited to join with many partners, including the organizations in the Colorado Tobacco Free Alliance, to update the Colorado Clean Indoor Air Act, and allow local governments to regulate all tobacco products, to help all people in the state to stay healthy and avoid a lifetime of nicotine addiction.
By Shannon Kolman
Many LPHAs are finding that issues around the lack of affordable housing and increased homelessness are toping the priorities uncovered through community health assessment processes. These issues have also risen to the top as a policy priority for The Colorado Trust’s Health Equity Advocacy Cohort. Following are potential bills that may be introduced in the upcoming legislative session to address housing issues.
Warranty of Habitability – Led by several organizations including 9to5, this bill would strengthen statute that requires landlords to keep their properties in habitable condition. Several public health professionals have been consulted on how to best include mold issues in the bill.
Prohibit Housing Discrimination, Source of Income – Led by several organizations including Colorado Center on Law and Policy (CCLP), this bill would ensure that a person’s source of income does not preclude them from accessing housing. This bill is also supported by Colorado Coalition for the Homeless.
Eviction Legal Defense – According to the Legal Services Corporation, 86% of the civil legal problems reported by low-income Americans in 2017 received inadequate or no legal help. In Colorado, this justice gap is particularly harmful for renters. This bill would require an appropriation to fund legal resources for low-income Coloradans who are facing eviction. This potential bill is supported by CCLP and the Colorado Coalition for the Homeless.
Clean Slate– This legislation would provide automatic sealing of certain criminal records so that they are not available to the public but can still be accesses by law enforcement, family courts, and victims of crimes. Under Clean Slate, the following would be sealed when people have remained free of misdemeanor and felony convictions for a period of time: charges that did not result in a conviction after 63 days; non-violent drug related misdemeanor convictions after 7 years; level 4 drug-related felonies after 10 years.
“Property Tax Circuit Breakers” – This bill would support low-income renters and homeowners with property tax relief by zeroing out homestead exemption and replacing it with a means-test. The bill is currently being led by the Colorado Fiscal Institute.
By Peter Manetta
Community participation and leadership is critical for advancing equity, addressing upstream determinants, and practicing public health generally. Assuring and supporting such participation is now and will continue to be a core capacity for LPH. But for many agencies, it is one of the most challenging elements of public health practice. As we are immersed in system transformation, these challenges raise a key question: is there a part of local government infrastructure that can promote sustained, equitable, and effective community participation and leadership?
This challenge is not only one of sound public health practice and equitable governance, it also relates to larger public health threats posed by a lack of community connectedness, social capital, and the decline of American civic life. This is a massively complex upstream determinant with impacts on other determinants as well as individual health behaviors. A sobering report from the National Conference on Citizenship shines a light on what they call “civic deserts,” framing it as a health problem. The report details how the decline of many socially-active institutions, such as places of worship and unions, are contributing to the erosion of shared values and accepted facts, trust of neighbors, and belief in the possibility of positive collective change.
While we are engaged in structural transitions, it is timely to think about how local government structure can promote or inhibit community participation. On its own, public health is clearly transitioning to models that have the potential to ameliorate the situation, though not always explicitly. To answer the question posed above, it may help to start recognizing that public health community and partnership engagement is in itself an intervention to improve equity and health, not just a way to support other interventions. If we apply the same upstream-ecological program design methods we increasingly use for other health interventions to community engagement, we may start seeing ways of making community participation more sustained and meaningful through systemic changes in government.
A recently adopted Health Equity in All Policies (HEiAP) resolution in Genesee County, Michigan (home of Flint) offers one example: an “interdepartmental body with representation from all sectors of community life” who receive training and technical assistance in considering equity and upstream determinants. This body serves their board of commissioners by
“1) considering any new governmental policy for which the likely health impacts are not clear; 2) considering current governmental policy whose negative health impacts have been called into question by the public; 3) analyzing the health impacts of any such policy; 4) providing recommendations to the governing body on any changes in these policies that would reduce negative health impacts.”
This appears to be an adaptation of a HiAP model resolution from Changelab Solutions, that included a similar body made of only government staff. There are not yet many details available on how this type of structure is initiated, its feasibility, or its impacts. And one wonders if just an advisory role is enough, or would such a body need specific authority to be effective.
There are also clear chicken and egg challenges with this approach. If a community lacks the social capital to engage in collective improvement efforts, how is it supposed to get enough citizens to serve on such a body? It would also need a structure that permitted members of all education levels and languages to participate and be able to accommodate those with limited time and transportation options. Some communities may have to consider preliminary social capital interventions before attempting to form a permanent and quasi-professional community advisory body.
Other models aim to use the existing interactions between government and community members to engage on issues that are related to the interaction topic but are broader and systemic in scope. An example might be asking survey questions about a community’s overall food systems while on a restaurant inspection. This may be a more practical stepping-stone to a formal advisory body, but such activities would require significant training and probably additional staff. It would also require a redesign of how certain services are provided, including new process workflows, updated forms, and investing in relational databases and assessment capacities that can tie all the information together.
I’ll be following this topic over the next year and hope to explore some more specific examples of how LPHAs and their governments can foster civic engagement. In the meantime, check out a recent research report from New America that tested some of the assumptions we make about the potential benefits of increased civic engagement and the tactics used to get there.
We often point to reduced smoking rates as an historic public health win, but new products and promotion strategies seem to be outpacing current youth tobacco control methods. Tobacco companies are pushing new ways to addict youth and young adults, including e-cigarettes like Juul that are engineered to deliver significantly higher levels of nicotine. Products that deliver more nicotine, are easy to use, are more socially acceptable, and that challenge existing regulatory rules or practices are a disturbing for many reasons.
There are many more dimensions to this increase in youth nicotine use, so this is not an exhaustive list of concerns. We need to be asking ourselves whether our current control strategies are nimble enough to respond to an industry that is constantly innovating ways to addict kids to nicotine.
There is already a lot of work being done in response to these developments. In 2016, the FDA began implementing broader enforcement under its “new” regulatory authorities granted under the 2009 Family Smoking Prevention and Tobacco Control Act. Their enforcement activities, notably including e-cigarettes, are primarily retail inspection and compliance checks (including stings using undercover minors). The FDA also has the authority to mandate the reduction of nicotine levels in all tobacco products to near zero, and advocates are waiting eagerly for news on whether they will move forward with that.
At the state level, CDPHE just opened access to a GIS (geographic information system)-enabled database of tobacco retailers, inspections, and violations, overlayed with myriad community attribute data (like school location). With this tool, called Tobacco Retailer Access Colorado (TRAC), LPHAs and communities can clearly see which of their local retailers have been caught selling to minors or violating other regulations. This will permit a new level of scrutiny on establishments that, in the words of one state tobacco policy expert, “are recruitment centers for new smokers.”
At our local level, more and more Colorado counties and municipalities are starting to regulate tobacco on their own. Eleven areas now have some level of regulation and enforcement, from T21 to taxes on all tobacco products.
This is not an exhaustive list of emerging tobacco control efforts. There are myriad lawsuits and campaigns on both sides of the fight that continue largely outside the public eye. To stay on top of these critical public health efforts, bookmark Tobacco-Free Colorado and visit often!
By Peter Manetta
Economic prosperity is an established upstream health determinant, but planning for and encouraging economic opportunity is well outside governmental public health’s core services. It is usually the responsibility of economic and community development organizations. These organizations are multi-sectoral and bring together partners with a variety of motivations and interests – a partnership process that is certainly familiar to local public health agencies. Economic and community development usually rely on structured strategic assessment and planning for long-term outcomes. With health and economic opportunity being so intertwined, and with the growing similarity between their partnering and planning processes, some alignment of strategic priorities between governmental public health and economic development could benefit both sectors.
Economic and community development overlap but typically play different roles. Economic development attempts to increase economic activity by attracting new business and cultivating existing business in its region, with job growth being the primary goal. Community development often has a narrower focus on creating affordable housing and encouraging economic opportunities in low-income communities, though it can also refer to the municipal or county planning agency. These organizations can be a governmental, mixed, or self-organized private sector interests. This is by no means an exhaustive description of these two activities, and they will look very different in each locality. For an agency seeking to identify these activities in their district, any entity working to promote economic opportunity should fit the bill.
There are many resources for broadly understanding the ins and outs of economic and development, but the best help you connect the concepts to your local circumstances. This webinar, from Pueblo County’s Department of Economic Development, provides excellent grounding in how regional economic development tactics are adapting to new circumstances and adopting a more systems-thinking approach. One of the more comprehensive resources is found at WealthWorks, which also provides a method for identifying equitable market opportunities. Their framework is also a good place to start if you want to map your own community’s economic assets, including types of capital.
If your agency doesn’t already have a relationship with economic or community development, starting one may require a partnering topic that non-public health folks clearly perceive as a public health issue. Below are some areas that are justifiably in the LPHA bailiwick:
Not all economic development is supportive of community health, and much of it has been exploitative of certain populations and damaging to the environment. LPH and its close partners can advocate for healthier alternatives that aim to build local wealth in addition to attracting new jobs. Supporting the development of cooperative businesses that are worker-owned and democratically controlled aligns well with these goals and with advancing health equity. Co-ops are less likely to uproot, tend to benefit lower-income communities, encourage social connectedness, and can increase self-reliance and entrepreneurialism – all of which can have mental and physical health benefits.
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