Written by Walker Kahn and Maria Manansala
What's the Problem?
America faces an ongoing healthcare crisis. In 2018, before the COVID pandemic, total national healthcare spending was $11,172 per capita, totaling $3.6 trillion and representing more than 17 percent of GDP (CDC). In 2020, the first full year of the COVID crisis, total healthcare spending reached $4.1 trillion and 19.7 percent of GDP (CMS). While COVID has been a major driver of increased mortality and healthcare costs, America's epidemic of chronic diseases like cancer, heart disease, obesity, and diabetes remain the largest drivers of healthcare costs and mortality in the United States. While discussions of health outcomes tend to focus on individual behavior, the social determinants of health—the environment in which people are born, live, work, and age—account for between 30 percent and 55 percent of all health outcomes and are strongly linked to chronic disease.
While local governments have little power to address the provision and costs of healthcare (which are largely determined largely by state and federal policy), local governments can and should address collective structural health problems that drive chronic disease, disparate health outcomes, and have worsened the COVID-19 pandemic. In fact, many local governments have taken progressive efforts to improve health outcomes by establishing wellness plans and health-impact assessments to guide action across departments, implementing Health in All Policies (HiAP) programs that integrate health considerations into policymaking in every areas (such as transportation, infrastructure, and safety), increasing access to fresh foods, facilitating daily active living, and providing the outreach and education to promote these efforts. To fight the community spread of COVID-19, local governments can enact paid family and medical leave, strengthening building fresh air and ventilation codes and standards, developing mask and home test distribution programs, and applying vaccine requirements for high-risk, indoor settings.
What are People Currently Doing?
COVID-19 is the most pressing public health emergency in recent American history. Cities and counties across the county have implemented innovative and effective policy responses to protect the lives and livelihoods of their community members from COVID-19. Vaccine mandates are among the most effective steps policymakers can take towards limiting COVID-19’s impact. San Francisco, CA and Milwaukee, WI are two of many cities that require employees to be vaccinated, while proof of vaccination was previously necessary to enter high-risk indoor settings such as restaurants in New York City, NY and New Orleans, LA. Vaccine mandates are especially successful when combined with mandatory mask mandates, as has been done in Madison, WI and Rochester, MN. While many emergency face covering orders have been rescinded, municipalities can distribute mask and at-home tests to households, and thousands of free masks and tests have been distributed to community members in Meriden, CT, New York City, NY, Chicago, IL, and Boulder, CO.
Further, the COVID-19 pandemic has highlighted the need for better preparedness against communicable disease. Local governments, where possible, should enact paid sick leave ordinances, enabling sick workers to recover rather than working while sick and thereby reducing disease transmission in the workplace (see our Home Rule and Wages & Benefits policy roadmaps for more on paid leave laws and navigating state law preemption).
Building codes should be revised to strengthen fresh air, ventilation, and infiltration standards, such that airborne exposures are reduced. This is especially important in schools, colleges, and universities, which tend to have inadequate ventilation relative to the number of occupants in a building. Municipalities can model their reformed air or ventilation standards based on recommendations provided by the Washington State Department of Health and the City of Portsmouth, NH. They can also enact ordinances which mandate compliance with ventilation codes (as seen in Richmond, WI) or employ Ventilation Bureau Inspectors to ensure compliance with ventilation codes (as seen in Chicago, IL).
Even with COVID-19 at the forefront of public health discussions, it is critically important that local governments take steps to address chronic disease. Many of these diseases, such as diabetes and heart disease, can be avoided or ameliorated by improving access to healthy foods. Policymakers can enact an ordinance that requires food retailers to sell a certain baseline of nutritious foods: Minneapolis’ Staple Foods Ordinance and ChangeLab Solutions Model Licensing Ordinance are excellent examples of this type of legislation. When this is not possible, cities and counties can incentivize retailers to stock nutritious food and beverages by offering tax reductions or exemptions, lowering store owners’ costs for healthy products, and expanding access to government loans or grant programs. A report by ChangeLab Solutions provides a guide to developing different types healthy food incentives. In addition to retailers, municipalities can also incentivize buyers to purchase nutritious foods by offering rebate and providing discounts; this can be seen in the Double Up Food Bucks program in Santa Clara County and Alameda County in California, and the city of Boston, MA.
Where food deserts exist—where communities that lack access to grocery stores that sell a wide range of healthy food—cities and counties can establish community-owned grocery stores, as seen in Oshkosh, WI and Oakland, CA. Policymakers can also adopt or update land-use or zoning ordinances to permit and protect local food sources like farmers’ markets and community gardens in more areas; PHLP has developed model ordinances for both. Lastly, public transportation access should be expanded to ensure that every person has a safe and accessible route to grocery stores.
Local governments can also combat chronic disease by facilitating community members’ physical activity. Philadelphia’s Green2015 program will transform 500 acres of empty or underused land into green space in underserved neighborhoods. Similarly, the KABOOM! Program has addressed playspace inequity in Boston by collaborating with local communities to build thousands of playgrounds across the city. Walking and biking can also be encouraged by establishing Complete Streets policies, which make these activities easier and safer; Seattle, WA enacted a Complete Streets ordinance in 2007. It is especially important that children have safe routes to walk and bike to schools, when considering the simultaneous increase in death via road traffic amongst children, along with children’s rising physical inactivity. See Progov21’s Recreation roadmap for more on creating equitable access to recreational spaces and physical activities.
Ultimately, if a locality chooses to adopt any of these suggestions, health-impact assessments (HIA) should be conducted to determine the impacts of any proposed policy on a population’s health. In conjunction with these policies, municipalities should also establish programs to sign people up for Medicare or Medicaid to remove some barriers to healthcare for the elderly and low-income populations.
Taking it to the Next Level
Health in All Policies (HiAP) is a collaborative approach that integrates health considerations into all sectors of policymaking to improve the health of all communities and people. Policies in areas like economic development, transportation, and waste management can impact population health and health equity. By incorporating community health and health equity into policymaking as an equal priority to return on investment, cost, economic impact, and public opinion, local governments can begin to systematically address the social determinants of health that play an outsized roll in health outcomes. ProGov21's sister organization, the Mayors Innovation Project, has published a guide advising mayors and city staff looking to incorporate health equity in their decision-making through a HiAP approach.
At its core, HiAP requires data-driven decision-making to take place among stakeholders both within and outside of government. Data from the community must be collected to identify existing health needs and disparities. While some communities are included in the Robert Wood Johnson Foundation’s City Health Dashboard (which provides more than 35 health metrics for 750 cities across the United States), many communities – including smaller communities not represented in this kind of data – will need to rely on or collect local data to inform their work. Some traditional activities that can help gather and assess data include stakeholder meetings, community focus groups, surveys, interviews with community leaders, and working with your local health department to gather data; more advanced or formal tools include Root Cause Mapping and Health Impact Assessments (HIA). Counties often routinely conduct Community Health Needs Assessments – a data-driven effort to assess the health priorities and issues in a county – which can be another good source for data.
Beyond developing and accessing new sources of information, successfully implementing a HiAP program necessitates changing local government’s standard operating procedures—never an easy task. Interdepartmental collaboration can be institutionalized by creating interdepartmental teams and regular interdepartmental meetings. These meetings should be used to discuss the most significant health and equity issues facing the community, identifying the departments that can impact those issues, improving data collection, and creating processes to apply a health and equity lens to all areas of policy. Local governments can also create multisector community health coalitions linking local organizations, community groups, and individuals invested in improving wellness. These coalitions drive resource and information sharing to enable greater breadth and scope of response to public health. The Healthy King County Coalition, a POC-led community health coalition based in King County, WA, was formed in 2010 and has led programs to create smoke-free living for residents in King County public housing among other initiatives.
Helpers, Allies, and Other Useful Organizations
● ChangeLab Solutions - ChangeLab Solutions is a nonprofit organization that partners with communities across the nation to improve health equity by changing harmful laws, policies, and systems.
● Mayors Innovation Project - The Mayors Innovation Project is a national learning network for mayors committed to shared prosperity, environmental sustainability, and efficient democratic government.
● COWS - The Center on Wisconsin Strategy (COWS) is a research and policy center that promoted “high-road” strategies to improve economic performance and living standards in the State of Wisconsin and nationally.
● Safe Routes Partnership - Safe Routes Partnership is a national nonprofit that works to create livable, sustainable communities where all people can be healthy and physically active through safe walking and bicycling.
● The Greenlining Institute - The Greenlining Institute is a nonprofit organization that seeks to advance economic opportunity and empowerment for people of color through advocacy, community and coalition building, research, and leadership development.