By Peter Manetta
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​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:

• American Psychological Association: “Resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress”
• CDC: “Resilience is the sustained ability of communities to withstand and recover from adversity”
• Organization for Economic Co-Operation and Development: “Resilience refers to the capacity of a natural system to recover from disturbance.”

 
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. 

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).
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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. 
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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.
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“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.

• A consensus report from the National Academies of Sciences, Engineering, and Medicine (NASEM) concluded that “There is substantial evidence that e-cigarette use increases risk of ever using combustible tobacco cigarettes among youth and young adults.” This conclusion was reached through studies of vaping product that deliver lower nicotine levels than Juul and Juul-like products.
• While speed of addiction is highly context-dependent, higher nicotine levels have been an established tobacco industry method to addict more people, faster.  We can assume that higher nicotine levels in e-cigarettes is very likely resulting in substantially higher addiction rates in our youth.
• More Colorado youth are vaping compared to the national average (Aspen Times story).

 
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
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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:
 

• Environmental health: Many LPH environmental health services are imbedded in their region’s land use decision making entities along with economic development partners, and others are involved through certifying onsite wastewater treatment systems (OWTS) or strategizing for better waste diversion. Environmental health staff also regularly interact with business owners through retail food inspection. To make themselves more of a partner (as opposed to being seen just as a regulator), they have begun systematically weighing the employment or economic consequences of their inspection decisions and promoting the business case for food safety. These activities could be “feet in the door” for expanded LPH involvement in economic development.
• Food access: Several Colorado LPHAs are actively promoting the expansion of healthy food options in certain communities or engaging in comprehensive food system assessments. Since they involve local systems of production, distribution, and consumption, these activities should benefit (or may require) the participation of chambers of commerce or regional economic development corporations. Learn more about promoting food access with economic development partners from this report by ChangeLab Solutions.
• Advocating for adequate care services:  The adequacy and availability of non-medical care, from childcare to assisted living, is an urgent challenge for most communities. Care professionals are underpaid and often need better support and training, and many other forms of care are entirely uncompensated and unsupported. Along with its health care and community partners, LPH can advocate for transforming and growing the local “care economy” so that it both adequately matches demand and becomes more equitable for care professionals. Expanding a community’s care capacity is an economic development opportunity to both grow a source of employment and provide an increasingly demanded service. Care cooperatives that are worker owned offer a promising route. Learn more through the University of Wisconsin’s Center for Cooperatives, which contains excellent informational resources on child care cooperatives and home care cooperatives.

 
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.
 

By Shannon Kolman

CALPHO members and staff can now breathe a sigh of relief as the 2018 Colorado legislative session ended on May 10th with mostly good news for local public health. The session was full of intrigue, with more than 700 bills being introduced, many late in the session. Close majorities, an election year, term limits for key leaders, Colorado’s booming economy and a large budget surplus also added to the hectic session. Overall for Colorado, much needed transportation investments were secured, PERA was safeguarded, and school funding received a boost. CALPHO staff and Frontline Public Affairs kept busy juggling 48 positions on bills and budget items (see the full list here). CALPHO took 33 positions to support various bills and budget items and of those 21 (64%) were passed. Of the seven items CALPHO opposed, four failed, one never became an issue (Air Quality Division budget), and two passed.
 
Following are some highlights of CALPHO’s achievements this session and the continued fight on two bills we hope to see vetoed.

• CALPHO saw its four biggest wins early in the session as the two bills with Actively Oppose positions were defeated, another was stopped from being introduced, and one of the marijuana club bills was killed:
  
  • SB18-045 would have repealed the successful and environmental friendly Paint Stewardship Act
  • SB18-139, from the tobacco industry, would have required some licensure requirements for retailers selling tobacco products but would have taken significant funds from tobacco prevention efforts and preempted local efforts at comprehensive licensing
  • A proposed cottage foods bill was stopped from being introduced through a stakeholder process
  • SB18-211, Marijuana Consumption Club License, was a good defeat for public health as it would have allowed exemption from the Colorado Clean Indoor Air Act for “fully ventilated” facilities”

 

• Health equity advocates in the state, including CALPHO, had a major win in the defeat of SB18-214, which would have implemented self-sufficiency provisions to Colorado’s Medicaid program.

 

• CALPHO supported seven bills which passed that expanded safeguards and prevention efforts related to opioid misuse, substance abuse, and behavioral health care: HB18-1003, SB18-022, SB18-024, HB18-1136, SB18-071, HB18-1007, HB18-1357.

 

• CALPHO along with the organizations in the Colorado Tobacco Free Alliance worked diligently to defeat SB18-179, Extend Credit for Out-of-State Tobacco Sales, and HB18-1258, Marijuana Accessory Consumption Establishments, however the two bills passed and are now sitting on the Governor’s desk. CALPHO and the Alliance have sent letters to the Governor asking that the bills be vetoed, and Amy Winterfeld, with Tri-County Health Department, joined CALPHO staff and other Alliance members on May 14th to request veto on HB18-1258 in a face-to-face meeting with the Governor’s office.  Stay tuned in June for the Governor’s decision on those two bills.

By Tracy Anselmo
On April 4th CALPHO and about half a dozen public health professionals participated in the Call to Action to Promote Healthy Communities Symposium along with representatives from approximately 16 cross-sector organizations. The Symposium, sponsored by The Colorado Health Foundation and the American Planning Association Colorado Chapter, gathered to begin developing a network of professionals in Colorado to operationalize the Promote Healthy Communities Joint Call to Action.  
 
In preparing my remarks for the event, I reflected on several issues and came to some conclusions that I wanted to share with you all.
 
CALPHO has been engaged for over 12 months in efforts to understand and promote Health in All Policies (HiaP), a specific way of approaching health equity using a wide range of community policies and applying a health impact lens in traditionally “non-health” sectors.
 
Health equity and social determinants of health (SDoH) are an increasingly important aspect of governmental public health work, and CALPHO supports local public health agencies (LPHAs) in defining their role in health equity work and identifying the best strategies to move toward health equity in their communities.
 
Since social and environmental determinants of health, such as education, transportation, finance, and justice “live” in sectors other than public health and health care, and inequity exists across the systems we all work in, public health policy development needs to occur in all sectors and across many systems.
 
All LPHAs have power to influence health at various policy levels. For example, a 2016 survey of Colorado LPHAs (n=47) revealed that approximately 30% reported working on land use planning policy. CALPHO believes that a HiaP approach can help broaden policy target areas and bring in a wider variety of sectors – such as those present at the Symposium, elected officials, and others – to the table, and bring forth a common understanding of all sectors’ roles in community health.
 
LPHA’s are required by law to conduct a community health assessment (CHA) and develop a Public Health Improvement Plan (PHIP) every 5 years. This entails using data on key health indicators (such as suicide rates, tobacco use, and diabetes prevalence), and engaging the community in setting top priorities to work on over the next 5 years. In this current fiscal year, almost 70% of LPHAs are working on their CHAs and 21% are working on their PHIPs. There is tremendous opportunity for multi-sector networks all to engage in the dialogue in a meaningful and productive way.
 
Let me share with you a quote that I found particularly interesting while researching these comments.
 
“Planning is not an academic exercise, it affects things and real people. You affect matter of health through your choice of streets, parks and infrastructure project.”
--John Morck AICP past president of the American Planners Association, North Carolina Chapter.
 
HiAP aspires to promote health equity through the consideration of the health impacts in every type of policy decision, in every type of organization, so that any public or private entity can take health into account.
 
Through engagement, building the relationships, sharing expertise, establishing health goals, and developing comprehensive strategies to improve health, we create windows of opportunity, promote intersectoral collaboration, and develop innovative, community derived strategies that will make Colorado a healthier place to live.
 
To learn more about HiAP work at CALPHO, please visit www.calpho.org. Look for curated resources on our website, as well as the original postings on the national sponsoring organizations and others such as NACCHO, American Planning Association, Public Health Institute, American Public Health Association, The American Institute of Architects. 

By Peter Manetta

​Health care reform debates will continue to swirl around cost. The most vocal participants across the political spectrum rail about the chunk of our GDP dominated by health care, the bills that bankrupt families, and the lack of affordable coverage options. Whether they believe in private or public-sector solutions, they all recognize that changes must be made. But such debates rarely include discussions about the demand-side, namely the role of preventable chronic diseases as both adriver and amplifier of costs. If fewer people develop these conditions, demand will go down.  Public healthneeds to be making this point loudly. Every time there is a politically divisive argument over single-payer vs. private insurance, or market self-correction vs. regulation, public health advocates need to be there saying “there is a better way to make this system manageable.”
 
While economists will tell us that it is difficult to predict exactly what effect demand reduction would have on our incomprehensible health care “marketplaces,” economic theory indicates that this would reduce costs. What’s more evident is that demand reduction would be immediately beneficial for public and private payers. Most importantly, preventing chronic disease will dramatically reduce the economic burden for consumers themselves, freeing up their resources for other life essentials. The prevention argument is simple to make: “let’s focus on not needing so much health care in the first place.” It is an obvious point that appeals directly to core American values of thrift and common sense.  So why isn’t it a part of the debate?
 
Pundits don’t talk about demand because the experts they listen to also don’t talk about it. A February 2018 report from the Network for Regional Healthcare Improvement (NRHI) comparing cost drivers across five states is a great example. Entitled Healthcare Affordability: Untangling Cost Drivers, the authors do not even mention chronic diseases as a cost driver. The report is entirely focused on factors they see as within the health care system, despite the absurdity of considering anything external to an industry that dominates nearly 20% of our economy. The closest they come to mentioning demand is discussing disparities in use patterns, for which there is not yet a clear explanation:
 
“Outpatient resource use in Colorado was 25 percent above the benchmark, the highest percentage above the average in any category in any participating state. Coloradans also had the highest utilization of prescriptions, at 23 percent above the benchmark.”
 
It might be important to find which structural inefficiency is causing this disparity, but the burden of preventable disease that is likely behind most of this pattern is undeniably the more critical factor. The authors seem to be ignoring this. Also, what guarantee do we have that the cost reductions resulting from increasing efficiency in health care delivery will be passed on to consumers or even payers?
 
Pundits aren’t the only people paying attention to such reports. Policymakers rely on them when planning reform efforts. An alliance of seven governors, including Colorado’s, just released their new plan called the Blueprint for Improving Our Nation’s Health System Performance.  Most solutions they propose are also limited to similar within system factors found in reports like NRHI’s that realign incentives and increase efficiency. The plan contains only the vaguest nod to the demand-side, suggesting that reforms should “encourage responsible              choices by empowering      consumers with useful information and incenting healthy lifestyles.” This statement at least hints at more demand-side considerations, but it certainly does not reflect current thinking in primary prevention. It echoes sentiment from public health 1.0, which prioritized individual behavior change over addressing systemic factors.
 
As a hopeful if not substantive gesture, both approaches do claim to be considering many factors at once. The NRHI references the “health care cost balloon” metaphor, which describes how squeezing one side just moves air to another. As one of its core beliefs, the Blueprint states that “the best strategies to improve our health care system address multiple objectives simultaneously.” This indicates that both pundits and politicians perhaps are open to a more systems-thinking approach that at the very least doesn’t ignore the obvious.
 
How do we meaningfully enter the conversation? To start, we can openly criticize reports like NRHI’s. Public health can directly answer their myopic conclusions with op-eds and articles in academic journals. Public health can also join politically charged debates in the mainstream press on health care reform. Our message is simpler and saner, and for most people it will be a breath of fresh air. Concurrently, public health can continue to demonstrate its value at the local level by involving more community members in its programs and planning, so they can recognize and celebrate its successes. If they are involved in community health prevention efforts, then such efforts will no longer be invisible to them.