The Role of the Legal System in the Flint Water Crisis.

Policy Points A major factor explaining government actors' failure to mitigate or avert the Flint, Michigan, water crisis is the sheer complexity of the laws regulating how governmental agencies maintain and monitor safe drinking water. Coordination across agencies is essential in dealing with multiple legal arrangements. Public health legal authority and intervention mechanisms are not self-executing. Legal preparedness is essential to efficiently navigating complex legal frameworks to address public health threats. The Flint water crisis demonstrates the importance of democracy for protecting the public's health. Laws responding to municipal fiscal distress must be consistent with expected norms of democracy and require consideration of public health in decision making. Context The Flint, Michigan, water crisis resulted from a state-appointed emergency financial manager's cost-driven decision to switch Flint's water source to the Flint River. Ostensibly designed to address Flint's long-standing financial crisis, the switch instead created a public health emergency. A major factor explaining why the crisis unfolded as it did is the complex array of laws regulating how governmental agencies maintain and monitor safe drinking water. Methods We analyzed these legal arrangements to identify what legal authority state, local, and federal public health and environmental agencies could have used to avert or mitigate the crisis and recommend changes to relevant laws and their implementation. First, we mapped the legal authority and roles of federal, state, and local agencies responsible for safe drinking water and the public's health-that is, the existing legal environment. Then we examined how Michigan's emergency manager law altered the existing legal arrangements, leading to decisions that ignored the community's long-term health. Juxtaposed on those factors, we considered how federalism and the relationship between state and local governments influenced public officials during the crisis. Findings The complex legal arrangements governing public health and safe drinking water, combined with a lack of legal preparedness (the capacity to use law effectively) among governmental officials, impeded timely and effective actions to mitigate or avert the crisis. The emergency manager's virtually unfettered legal authority in Flint exacerbated the existing complexity and deprived residents of a democratically accountable local government. Conclusions Our analysis reveals flaws in both the legal structure and how the laws were implemented that simultaneously failed to stop and substantially exacerbated the crisis. Policymakers need to examine the legal framework in their jurisdictions and take appropriate steps to avoid similar disasters. Addressing the implementation failures, including legal preparedness, should likewise be a priority for preventing future similar crises.

Learning from the Flint Water Crisis: Restoring and Improving Public Health Practice, Accountability, and Trust.

The Flint water crisis demonstrates the importance of adequate legal preparedness in dealing with complicated legal arrangements and multiple statutory responsibilities. It also demonstrates the need for alternative accountability measures when public officials fail to protect the public's health and explores mechanisms for restoring community trust in governmental public health.

Priorities for Investing in Community Health Improvement: A Comparison of Decision Makers in Public Health, Nonprofit Hospitals, and Community Nonprofits.

CONTEXT: As a result of additional requirements for tax exemption, many nonprofit hospitals have become more actively involved in community health improvement. There is an open question, however, as to how decision makers in hospitals decide which kind of improvement projects should receive priority and how hospital managers' priorities compare with those of decision makers in public health agencies and community-based nonprofits. OBJECTIVE: To understand the priorities that guide decision makers in public health, nonprofit hospitals, and community nonprofits when allocating resources to community health projects. DESIGN: We conducted an online survey with a discrete choice experiment, asking respondents to choose between different types of community health projects, which varied along several project characteristics. Respondents included managers of community health and community benefit at nonprofit hospitals (n = 225), managers at local public health departments (n = 200), and leaders of community nonprofits (n = 136). Respondents were located in 47 of 50 US states. A conditional logit model was used to estimate how various project characteristics led to greater or lesser support of a given health project. Open-ended questions aided in interpretation of results. RESULTS: Respondents from all 3 groups showed strong agreement on community health priorities. Projects were more likely to be selected when they addressed a health issue identified on community health needs assessment, involved cross-sector collaboration, or were supported by evidence. Project characteristics that mattered less included the time needed to measure the project's impact and the project's target population. CONCLUSION: Elements often considered central to community health, such as long-term investment and prioritizing vulnerable populations, may not be considered by decision makers as important as other aspects of resource allocation. If we want greater priority for ideas such as health equity and social determinants of health, it will take a concerted effort from practitioners and policy makers to reshape expectations.

Examining Whether The Health-In-All-Policies Approach Promotes Health Equity.

Scholars and public health advocates have expressed optimism about the potential for the health-in-all-policies approach to address social disparities in health, but little research has been done on whether it promotes health equity in practice. Based on sixty-five in-depth interviews with US officials in the public and private sectors conducted in five states in 2016-17, we found a relationship between the use of the approach and the prominence of health equity as a policy concern. In emphasizing the social determinants of health, the approach gives public officials and policy entrepreneurs a framework for promoting this goal. In some areas, we found a gradual transition in focus from health generally to health equity. Overall, we found that practitioners of the approach introduce equity selectively and strategically.

Public Trust in Health Information Sharing: A Measure of System Trust.

OBJECTIVE: To measure public trust in a health information sharing in a broadly defined health system (system trust), inclusive of health care, public health, and research; to identify individual characteristics that predict system trust; and to consider these findings in the context of national health initiatives (e.g., learning health systems and precision medicine) that will expand the scope of data sharing. DATA SOURCES: Survey data (n = 1,011) were collected in February 2014. STUDY DESIGN: We constructed a composite index of four dimensions of system trust-competency, fidelity, integrity, and trustworthiness. The index was used in linear regression evaluating demographic and psychosocial predictors of system trust. DATA COLLECTION: Data were collected by GfK Custom using a nationally representative sample and analyzed in Stata 13.0. PRINCIPAL FINDINGS: Our findings suggest the public's trust may not meet the needs of health systems as they enter an era of expanded data sharing. We found that a majority of the U.S. public does not trust the organizations that have health information and share it (i.e., the health system) in one or more dimensions. Together, demographic and psychosocial factors accounted for ~18 percent of the observed variability in system trust. Future research should consider additional predictors of system trust such as knowledge, attitudes, and beliefs to inform policies and practices for health data sharing.

Discordance between age- and size-based criteria of child passenger restraint appropriateness.

OBJECTIVES: In this study, we sought to accomplish the following objectives: to (1) calculate the percentage of children considered appropriately restrained across 8 criteria of increasing restrictiveness; (2) examine agreement between age- and size-based appropriateness criteria; (3) assess for changes in the percentage of children considered appropriately restrained by the 8 criteria between 2011 (shortly after updates to U.S. guidelines) and 2015. METHODS: Data from 2 cross-sectional surveys of 928 parents of children younger than 12 years old (n = 591 in 2011, n = 337 in 2015) were analyzed in 2017. Child age, weight, and height were measured at an emergency department visit and used to determine whether the parent-reported child passenger restraint was considered appropriate according to 8 criteria. Age-based criteria were derived from Michigan law and U.S. GUIDELINES: Weight, height, and size-based criteria were derived from typical restraints available in the United States in 2007 and 2011. The percentage appropriate restraint use was calculated for each criterion. The kappa statistic was used to measure agreement between criteria. Change in appropriateness from 2011 to 2015 was assessed with chi-square statistics. RESULTS: Percentage appropriate restraint use varied from a low of 19% for higher weight limits in 2011 to a high of 91% for Michigan law in 2015. Agreement between criteria was slight to moderate. The lowest kappa was for Michigan law and higher weight limits in 2011 (κ = 0.06) and highest for U.S. guidelines and lower weight limits in 2011 (κ = 0.60). Percentage appropriate restraint use was higher in 2015 than 2011 for the following criteria: U.S. guidelines (74 vs. 58%, P < .001), lower weight (57 vs. 47%, P = .005), higher weight (25 vs. 19%, P = .03), greater height (39 vs. 26%, P < .001), and greater size (42 vs. 30%, P = .001). CONCLUSIONS: The percentage of children considered to be using an appropriate restraint varied substantially across criteria. Aligning the definition of appropriate restraint use with current U.S. guidelines would increase consistency in reporting results from studies of child passenger safety in the United States. Potential explanations for the increased percentage of children considered appropriately restrained between 2011 and 2015 include adoption of the updated U.S. guidelines and the use of child passenger restraints with higher weight and height limits.

Collaborating for Health: Health in All Policies and the Law.

This article introduces and defines the Health in All Policies (HiAP) concept and examines existing state legislation, with a focus on California. The article starts with an overview of HiAP and then analyzes the status of HiAP legislation, specifically addressing variations across states. Finally, the article describes California's HiAP approach and discusses how communities can apply a HiAP framework not only to improve health outcomes and advance health equity, but also to counteract existing laws and policies that contribute to health inequities.

Health Law 2015: Individuals and Populations.

In this article, we assess two particular trends in judicial doctrine that are likely to emerge in the post-ACA era. The first trend is the inevitable emergence of enterprise medical liability (EML) that will supplant tort law's unstable attempt to apportion liability between physicians and institutions. Arguments favoring EML in health law date back to the early 1980s. But health care's ongoing consolidation suggests that the time has arrived for courts or state legislatures to develop legal doctrine that more closely resembles the ways in which health care is now delivered. This would result in a more appropriate allocation of liability to the institutional level. The second judicial trend will be the convergence of health law and public health law concepts. Because the ACA arguably stimulates closer engagement between health systems and public health departments, health systems will have greater responsibility for keeping their communities healthy along with obligations for individual patient care (i.e., individuals and populations). If so, courts will need to incorporate elements from health law and public health law in resolving disputes.

Assessing entrepreneurship in governmental public health.

OBJECTIVES: We assessed the feasibility and desirability of public health entrepreneurship (PHE) in governmental public health. METHODS: Using a qualitative case study approach with semistructured interview protocols, we conducted interviews between April 2010 and January 2011 at 32 local health departments (LHDs) in 18 states. Respondents included chief health officers and senior LHD staff, representatives from national public health organizations, health authorities, and public health institutes. RESULTS: Respondents identified PHE through 3 overlapping practices: strategic planning, operational efficiency, and revenue generation. Clinical services offer the strongest revenue-generating potential, and traditional public health services offer only limited entrepreneurial opportunities. Barriers include civil service rules, a risk-averse culture, and concerns that PHE would compromise core public health values. CONCLUSIONS: Ongoing PHE activity has the potential to reduce LHDs' reliance on unstable general public revenues. Yet under the best of circumstances, it is difficult to generate revenue from public health services. Although governmental public health contains pockets of entrepreneurial activity, its culture does not sustain significant entrepreneurial activity. The question remains as to whether LHDs' current public revenue sources are sustainable and, if not, whether PHE is a feasible or desirable alternative.

The courts and public health: caught in a pincer movement.

Public health practitioners are familiar with the general outlines of legal authority and with judicial standards for reviewing public health regulations. What may not be as familiar are 3 emerging judicial doctrines that pose considerable risks to public health initiatives. We explain the contentious series of judicial rulings that now place health departments' broad grant of authority in jeopardy. One doctrine invokes the First Amendment to limit regulatory authority. The second involves the Supreme Court's reinterpretation of federalism to limit both federal and state public health interventions. The third redefines the standard of evidence required to support regulations. Together, these judicial trends create a pincer movement that places substantial new burdens on the ability of health departments to protect health.

Evaluating hospitals' provision of community benefit: an argument for an outcome-based approach to nonprofit hospital tax exemption.

Nonprofit hospitals are exempt from federal income taxation if they pass organizational and operational tests, including satisfying the community-benefit standard. Policymakers, however, have questioned the adequacy of the community benefits that nonprofit hospitals provide in exchange for these exemptions. The Internal Revenue Service recently responded to these concerns by redesigning its tax forms for nonprofit hospitals. The new Form 990 Schedule H requires nonprofit hospitals to provide additional information about their community-benefit activities. This new reporting requirement, however, places an undue focus on input-based community-benefit indicators, in particular expenditures. We argue that expanding the current input-based reporting requirement to include not only monetary inputs but also population health outcomes would achieve greater benefit for society.

The role of networks in the European union public health experience.

Improving our understanding of how the public health system should be organized is important, because the system's organizational structure makes a significant difference to the public's health. How the system is structured influences a practitioner's ability to respond and the system's capacity to adapt to changing circumstances. In view of the scarce resources society is willing to expend for public health, it is essential to have a structure in place that most appropriately and efficiently allocates those resources. The articles in this issue offer considerable insight from a European context, that deserves attention from US public health practitioners, advocates, and policy makers.

The role of law in public health preparedness: opportunities and challenges.

We report the results of a study designed to assess and evaluate how the law shapes the public health system's preparedness activities. Based on 144 qualitative interviews conducted in nine states, we used a model that compared the objective legal environment with how practitioners perceived the laws. Most local public health and emergency management professionals relied on what they perceived the legal environment to be rather than on an adequate understanding of the objective legal requirements. Major reasons for the gap include the lack of legal training for local practitioners and the difficulty of obtaining clarification and consistent legal advice regarding public health preparedness. Narrowing the gap would most likely improve preparedness outcomes. We conclude that there are serious deficiencies in legal preparedness that can undermine effective responses to public health emergencies. Correcting the lack of legal knowledge, coupled with eliminating delays in resolving legal issues and questions during public health emergencies, could have measurable consequences on reducing morbidity and mortality.

Improving the population's health: the Affordable Care Act and the importance of integration.

Despite evidence indicating that public health services are the most effective means of improving the population's health status, health care services receive the bulk of funding and political support. The recent passage of the Affordable Care Act, which focused on improving access to health care services through insurance reform, reflects the primacy of health care over public health. Although policymakers typically conceptualize health care and public health as two distinct systems, gains in health status are most effectively and cost-efficiently achieved through their integration into a single health system. The Act does little to compel integration; however, there are numerous opportunities to encourage the coordination of public health and health care in the Act's implementation.