The largest gain in life expectancy in human history happened during the twentieth century and resulted from public health achievements, not medical or economic ones. This first public health revolution significantly increased lifespan through public water treatment, food inspection, waste management, motor vehicle safety, and safe workplaces. Each of these changes came from policies and practices led by public health professionals.
It is time for a second public health revolution—one that prioritizes human health, well-being, and equity when making federal laws. The significant divide in our society can be broken down by race, ethnicity, age, geography, ability, and so much more, and illustrated by health disparities. Health inequities are pervasive and evidenced by the growing disparities in life expectancy that are so closely tied to where one is born and raised. Although its stealth formation has been centuries in the making, the “opportunity for health” gap in the United States has become obvious to everyone. The confluence of a global pandemic, economic collapse, and structural racism laid bare has finally brought our fundamentally unfair societal structure to light for so many White Americans and people in power.
Promoting Health Through Non-Health Policies
Although most policy makers don’t think of health when designing roads, crafting housing policies, or creating school district boundaries, these social determinants of health comprise approximately 80 percent of one’s opportunity to live a healthy, productive life. Care policies ought to prioritize the public’s general welfare and health. Prioritizing how these policies impact health would help advance health equity, which according to the Robert Wood Johnson Foundation means “that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.”
For almost 50 years the focus of federal legislation has been the projected monetary impact of a proposed law on the country. The Congressional Budget Office (CBO), the non-partisan fiscal referee of proposed legislation, is required to score any bill that is sent to the floor of the US House of Representatives or Senate for a vote. Only the monetary impact is scored, the population’s health is not considered when calculating the impact. We think that must change.
Need For A Health Score
Promoting and protecting the public’s health is arguably the most important role of government. In July 2020, Representative TJ Cox (CA-21) introduced H.R. 7510, the Assimilating Health and Equity Assessments into Decision-making (AHEAD) Act, to study the use of tools that assess a policy’s impact on population health and well-being. As part of the 2020 appropriations package, it will direct the National Academies of Sciences, Engineering, and Medicine to study the use of tools such as Health Impact Assessments or Health Notes to determine the potential impacts of federal legislation on health and equity.
While the AHEAD Act is an important step to placing health at the forefront of federal policy making, there is more that can be done. We argue for the creation of a new legislative branch agency, the Congressional Health Office, that would deliver an objective, understandable, credible health score—similar to the CBO score.
Example: The 2018 Farm Bill
How could this work? Let’s consider the next Farm Bill as an example. The Farm Bill is an omnibus law, which is renewed approximately every five years and governs agriculture and food programs. One aspect of the Farm Bill is a commodity subsidy for crops such as corn, wheat, soybeans, cotton, sorghum, and rice. This subsidy was initially meant to incentivize farmers to plant these crops during the great depression of the 1930s to alleviate widespread hunger. Originally devised as a safety net to protect farmers from significant price variations enabling a constant and abundant supply of the staples of the US diet, the subsidy over time has had some harmful and wide-ranging unintended consequences for health.
Commodity crops supply the main ingredients for processed foods. The subsidy of these crops incentivizes their production over fruits and vegetables. As a result, processed food is cheaper and more readily available than fruits and vegetables—which are mostly grown by small family farmers. The commodity crop subsidy prohibits recipient farmers from diversifying their crops to include fruits and vegetables, further exacerbating the disconnect between recommended nutrient-rich foods and availability of those foods for the consumer. This has contributed to the obesity epidemic, partially funded by taxpayers, and disproportionately impacting low -income communities and communities of color where fresh, affordable, healthy foods are not widely available.
During deliberations over the 2018 Farm Bill, the CBO score incorporated only the direct cost of commodity crop subsidies, not the indirect cost of promoting junk food over nutritious food. Imagine if a public health lens existed to depict the potential impact of the Commodity Programs and modeled the potential health impacts of replacing the commodity crop subsidy with a fruit and vegetable crop subsidy. A health score would incorporate these effects and examine how they relate to obesity rates and chronic illnesses such as diabetes and cardiovascular disease and related disparities, and health care costs. Omitting these health considerations during deliberations regarding the Farm Bill has converted a policy originally directed at hunger reduction into one that has unintentionally promoted obesity.
Laws That Promote Health
The Congressional Health Office we propose would help address these legislative miscalculations and promote health equity by providing policy makers with objective data to weigh the probable impact of legislation on overall population health as well as on specific groups before voting it into law, rejecting it outright, or amending it. This process could help identify bills that would exacerbate inequities before they are passed and adopted. Public health work merging large data sets depicting social and economic conditions of specific populations with simulated interventions provides an opportunity to match communities’ needs to policy solutions in a very targeted way.
There is no current mechanism for an analysis of potential health impacts during the arduous process of a congressional bill becoming a law. Hence, the laws we make frequently disregard and are misaligned with public health needs. Advisory groups and task forces are insufficient to change this procedural mismatch. Like the creation of the CBO, born of a crisis in a dysfunctional governing process, the Congressional Health Office would offer transformative improvements in making laws that optimize societal health and well-being.
The Society We Aspire To Be
The second public health revolution should promote cross-sector partnerships and center health equity during policy making. The National Academies of Sciences, Engineering, and Medicine commissioned report that will result from passage of the AHEAD Act will start this process by evaluating how public health tools could be employed to actuate this change during the federal legislating process.
Just as the CBO essentially created the discipline of budgetary economics and an iterative process of creating a fiscal legislative score, a Congressional Health Office could catalyze the convergence of diverse disciplines and the creation of a health score.
We find ourselves at a crossroads requiring a reckoning—of the society we actually are and the one we aspire to be. The current times call for bold action—action that supports health equity and that assures every person in this country has a just and fair opportunity to be as healthy as possible. Fundamentally changing how federal policies are evaluated so policy is aligned with health and well-being is an excellent place to start.
Authors’ Note
The views of Dr. Murphy and Dr. Pollack Porter are their own and not that of the Johns Hopkins University. Dr. Murphy is married to Congressman TJ Cox (CA-21).
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