It's almost cliche at this point, but every year in January we all look at the things that we want to change. Perhaps it's drinking less. Eating less sugar. Exercising more. Whatever it is, it's not uncommon for us to consider ways that we could create a healthier lifestyle for ourselves.
The literature is fascinating when it comes to health behavior change. Actually making the changes that lead to a healthier lifestyle are indeed multifaceted and complex. But at the root of the issue is a recognition and a willingness to make that change.
This brings us full circle to the role of public policy. You see, so much of our health is entirely related to factors outside of health care. Yet, so much of public policy is entirely focused on health care.
So what can public policy makers do to help encourage healthier lifestyles and healthier communities? Or perhaps, maybe even the bigger more existential question, should public policy be involved in this at all?
There's a lot of interesting examples of where public policy gets involved in health. For example, consider the impact of taxation on health behaviors. Taxes, traditionally a tool for generating revenue, can also be powerful in shaping behaviors. The rationale is simple: by increasing the cost of unhealthy products, people may be less inclined to purchase them. People just don’t like to have their pocket books impacted too much.
Take tobacco as a prominent case. Numerous studies have shown that higher cigarette taxes are associated with reduced smoking rates. One analysis looking at taxes and smoking over a 14 year period found that each $0.25 increase in cigarette tax per pack reduced smoking prevalence by 0.6 percent on average, with a more significant reduction of 1.5 percent among young adults ages 18-24. The study also revealed that the impact of tax increases was less effective in lower-income groups, highlighting the need for additional smoking reduction strategies in these communities. Despite this, excise taxes consistently encourage quitting attempts across all income levels. Additionally, research indicated that state-level tax increases had effectively reduced smoking prevalence, independent of federal policies or other local smoking-reduction efforts.
Similarly, the idea of a 'sugar tax' on sodas and other sweetened beverages has gained traction. The goal here is to combat rising obesity rates, particularly in children. Oakland's local "soda tax" sparked a notable shift in health and financial outcomes, according to a UC San Francisco and UC Berkeley study. Since the introduction of the one-cent-per-ounce tax in July 2017, Oakland saw a significant 26.8 percent drop in sugar-sweetened beverage (SSB) purchases compared to cities without such a tax. This decline not only reflects healthier consumer choices but also translates into substantial savings for the city. The study, published in PLOS Medicine, highlighted the effectiveness of the tax in improving public health and reducing health care costs.
Another recent study in JAMA examined how implementing SSB excise taxes in five US cities led to a 33.1 percent increase in SSB prices and a corresponding 33.0 percent decrease in volume sales, with no evidence of cross-border purchasing changes in adjacent untaxed areas (people didn’t travel somewhere else to buy the same sugary goods for a lesser price). These findings, which align with previous studies and suggest that SSB taxation can significantly improve public health and reduce medical costs. It’s no surprise that multiple organizations have called for these taxes to be more common.
But it's not just about discouraging unhealthy habits; taxation can also be used to encourage positive health behaviors. For instance, one study that looked at offering subsidies or reduced taxes on fresh fruits and vegetables found an increase in people buying these foods.
Of course, the role of taxation in health behavior is not without controversy. Opponents argue that such taxes are regressive, disproportionately affecting lower-income groups. Others question whether it's the government's place to influence personal choices to this extent. Then of course there are the big businesses who lose when these taxes go into effect. Consider what happened in Montana when the state considered raising tobacco tax to help support their Medicaid expansion. Big tobacco, not surprisingly, spent over 26 million to successfully kill the bill; thankfully, Medicaid expansion continues in the state despite this.
It’s an over simplification to think that taxation alone is a panacea for health behavior change. Like most successful interventions, it must be part of a broader strategy that includes education, community support, and access to health care. And we have to get creative with the revenue generated from these taxes - not just use them to offset budget deficits, but to funnel much needed cash into public health programs, educational campaigns, or subsidies for healthier lifestyle choices.
The debate over the role of public policy in personal health decisions is complex. On one hand, there is a clear public interest in promoting a healthier population - reducing the burden on health care systems, increasing productivity, and improving quality of life. On the other hand, there are valid concerns about autonomy, equity, and the effectiveness of such interventions for all communities. But like many things in a capitalistic society, when you raise taxes and people stop buying products (no matter how good that may be for their health), you lose on revenue, which can be problematic for lawmakers.
The challenge for lawmakers is to balance the desire to promote public health with the need to maintain adequate revenue streams. This requires careful planning and consideration of the broader economic impacts of such taxes. In some cases, the revenue from these taxes is specifically earmarked for health-related initiatives or to offset the societal costs associated with the consumption of these products (like health care costs related to smoking or obesity). However, if the consumption decreases significantly, the revenue for these initiatives might also decrease unless alternative funding sources are identified.
The question remains: How can public policy strike the right balance between guiding healthier choices and making sure that there are adequate resources to continue to invest in big ticket items like health care and education?
The impact of community involvement and local activism in directing public policy shouldn't be underestimated. For me, it’s the gem on top of the crown. Beyond taxation and other top-down policies, the real driving force often comes from the ground up. Think about local efforts – whether it’s rallying for healthier options in school cafeterias, pushing for more community green spaces for exercise, or championing the availability of fresh, local produce through farmers' markets. These community-led endeavors are crucial in cultivating a health-focused mindset. By participating actively in our neighborhoods and supporting initiatives that promote well-being, we're not just advocating for policy changes; we're nurturing a culture of health that’s rooted in community and collective effort.
As we set our personal health goals, let’s also embrace our roles as community advocates, championing initiatives that bolster health for everyone. It’s a reminder that our health journeys are interconnected, and together, we can steer towards a future where healthy living is a collective achievement, not just an individual endeavor.
It's time to reflect on the influential role of public policy in shaping our health choices. While our efforts to drink less, eat healthier, and exercise more are commendable, they are often insufficient in isolation. Public policy has a critical role to play, extending well beyond health care into the very fabric of our daily lives, influencing the choices available to us.
This is where the conversation turns from academic to actionable. It seems that it’s our role to engage in this dialogue, understanding the implications of these policies on our health and autonomy. As we contemplate personal health resolutions, let's also advocate for informed public policies that create environments conducive to healthier choices for all communities. The goal is clear: to foster a society where healthier choices are not only easier but more appealing, ultimately leading to a healthier, more vibrant community. Let's make this year not just about personal resolutions, but about collective action towards a healthier nation. And yes, there may be some taxes to go along with that.
We must remember, however, that, if a valuable commodity is taxed too heavily, those who enjoy or depend on it will react negatively. For example, the American Revolution was entirely the result of the excesses of taxation in British colonies.
It also is not fair to blame a single component or ingredient of a product for the negative effect it may cause on a person's health. Sugar is used as an ingredient in far more foods than just soda, and it exists naturally in many "healthy" foods such as fruit. If it were a true "sugar" tax, it would reflect this and tax every food product with sugar in it regardless of the feelings of the manufacturers. As it stands, current "sugar" taxes exist only as vendettas against the soft drink industry, and that is a discriminatory usage of taxation.
“It’s an over simplification to think that taxation alone is a panacea for health behavior change. Like most successful interventions, it must be part of a broader strategy that includes education, community support, and access to health care.” Community!
In my narrow understanding of public policy, taxation, and health outcomes that’s the money shot of your piece. The word taxation is an anathema to most Americans and getting more so as the loudest voices rail against ‘No new taxes.” Kinda Sisyphus like exercise taxing things that harm us. I'm going raise my A1C in three years if I keep eating a sleeve of Oreo's twice a week. Shrug But dang .50 cents more for my Oreo's will enrage me to no end.
The reference to cigarette taxes was excellent and now we have vaping. With younger adults and teens being a key demographic for marketing. Policy cannot win easily against smart fully funded profit driven corporations. Never underestimate greed. Another note is how vaccine rates for older Americans is down. Close to 7m fewer adults have gotten their flu shot this season. Covid-19 vaccination is abysmal with only 17% of adults and 8% of children. Don’t even ask about RSV and seniors. (Face palm). Though when I saw my PCP for my annual and he asked if I got my RSV I said yes. He gave me a huge attaboy and a pat on my head. I will get it again next year. BMT in action in the community. Another consideration are the maternal mortality rates. Non-hispanic Black women are 2.6 time more likely to die from pregnancy-related complications than white women. And that does not improve with socioeconomic status for education level. Data from ’07 to ’16 show women with a college degree or higher, the pregnancy-related mortality ration was 5x higher for Black mothers compared with white mothers. How long will it take for policy changes in medical school and resident training take to save a Black woman giving birth?
I’m so not being a maudlin Mark here or au contraire mon frère. Policy and taxation have long horizons and longer outcomes. Correctly so, if we don’t do those things we are killing our future selves and our children. All healthcare is community as you said. Well a lot of it is. We trust those we trust and respect. The clashing and gnashing of voices opposing or agreeing are making us deaf. I’m not deaf to my neighbor who is sharing healthy recipes or telling me their A1C has fallen. That just amps up my competitive self.
IMHO communities can deliver outcomes a bit quicker. Black owned barber shops where BP measuring is done or PSA testing. For Black maternal health Black doulas or mid wives make a difference. Communities finding land to grow fresh produce help improve food deserts. Community centers for seniors having round tables about vaccinations. (Not to mention suicide prevention which is raising in older males). All of these community based ideas are part of the long term strategy. They are tactical executions as we work toward long term outcomes through policy and taxation.
I guess this is my full throated support for “The impact of community involvement and local activism in directing public policy shouldn't be underestimated.” Maybe less directing and more screw em we'll DIY.
Boots on the ground makes a beautiful sound for those who are near by.