FMPH 120

Evaluation questions

Come from logic model: - Did the policy contribute to a change in short-term outcomes? - Did the policy contribute to a change in intermediate outcomes? - Did the policy contribute to a change in long-term impacts? - What was the economic impact of the policy (costs, cost-effectiveness, cost-utility, or cost benefit)?

Unintended consequences of tax policies

Decreasing employment Economic burden to poor consumers Concern about the use of revenue Sometimes the tax fails to meet the revenue estimates Leading to illegal trade and production

Price elasticity of demand: How sensitive consumers are to price changes

Defined as the percentage change in quantity demanded corresponding to a one percent change in price. If the demand is elastic, this means demand significantly decreases when the price is raised - Purchasing behavior will change - Sensitive to Price = ELASTIC If demand is inelastic, demand changes little when the price is raised - people will continue to buy - Purchasing behavior will NOT change - Not sensitive to price = INELASTIC Price Elasticity = Price Sensitivity = Behavior Change

Interest groups

Definition = Organization that shares common objectives and has the goal of influencing policy and/or educating others about their views Strategies - Media campaigns - Coalition involvement (multiple interest groups convene around a specific policy) - Litigation - Lobbying Interest group examples - Profession: American Medical Assn, American Dental Assn, American PH Assn - Industry: American Hospital Assn, American Health Insurance Plans - Single issue: National Rifle Assn, Physicians for a National Health Program, MADD - Citizen: American Assn of Retired Persons (AARP), AFL-CIO Benefits of interest groups? - Raise general awareness and work to stimulate interest on certain issue(s) - Provide information to gvt officials - Provide channels for political participation - Keep pulse on gvt agencies and elected officials' interests and actions Limitations of interest groups? - Not always promote the views held by the majority - Use illegal tactics - Have unfair influence Lobbyists = attempt to influence legislative agenda or specific legislation - Over 3.2B industry; notably, healthcare lobbyists outpaced all industries (555K in 2017) - YouTube: https://www.youtube.com/watch?v=R2DUM6jVasw

Step 3. Prioritize policy options

Determine if all criteria will be given equal weight Identify the tradeoffs for each policy Potential outputs - Select one recommend policy and justify your choice - If there is a tie, then it may come down to cost as the tie-breaker - Present all 3 options and let decision maker choose the "winner"

Dimensions #4: Problem consequences

Frame the severity of the problem Range of possible outcomes: - Mortality impacts? - Quality of life impacts? - Economic impacts? Ex. Tobacco use - ~440,000 deaths per year - Increased lung cancer - Increased respiratory issues - $100B in direct medical costs, $100B in lost productivity (hard to detect with preventative measures)

Disease management programs

Program for people who have specific disease to help reduce the impact on their life Incorporate health risk reduction into the guidelines/protocols for disease management Incorporate multiple providers across providers across healthcare system to coordinate care - Ex. Kaiser congestive heart failure program (primary care drs, cardiologists, etc.) Evidence of effectiveness reported for (not limited to): - Diabetes - Hypertension - COPD - Anxiety and depression

Health promotion programs

Program to promote and maintain health and wellness Ex. meditation, exercise, smoking cessation, nutrition, etc. Ex. CA Smokers' Helpline (1-800-NO-BUTTS), 1st state quit line Typically offered by health plan, possibly through the employer, or via community groups Insurance or employer can subsidize all or some of cost to incentivize people to use it

Policy objectives

Prohibition: make behavior is illegal Decriminalization: remove of criminal penalties (arrest, jail time, criminal record) Legalization: legalize behavior Restrict: sales, purchases, & usage (e.g., zoning) Inform: provide information so people change behavior (e.g., warning labels, mas media campaigns) Incentivize: provide incentive to change behavior

Marketing and counter-marketing considerations

Responsible marketing should not: - Convey certain behavior is appropriate for all activities - Imply that behavior is a social norm - Glamorize negative behavior Effective counter marketing should: - Provide facts to allow the viewer to form their own opinion - Be memorable - Not be dismissive or disrespectful

Dimension #3: Causal model

Root cause requires making sure to investigate the underlying reasons of the problem Make sure the solutions address these root cause(s) Ex. Scenario where patients at a clinic were reported not receiving their preventive services - possible reasons? - Not enough physicians? - Clinic hours need to be expanded? - Turned out the reason was due to the bus route to get to the clinic was discontinued

Tobacco marketing strategies

Tobacco industry spends billions of dollars each year on cigarette and smokeless tobacco advertising and promotions* In 2018, it was reported that $9.06B was spent on advertising and promotion of cigarettes and smokeless tobacco combined - Equating to ~$25M daily and over $1M per hour! Less traditional venues; can still see on tv for exposure but not the specific brand Some advertising venues that have fewer limitations include marketing at point-of-sale locations (e.g., convenience stores, gas stations, grocery stores, etc.) - Product displays and at a certain height - Price discounts to retailers = accounts for 73.3% of all cigarette marketing (~$6.16B) so the retail price arecheaper for consumers

Purchasing behaviors when price is high

Use discount coupons Generic brands Purchase in another state or another country Purchase at Indian reservation Purchase at military bases Purchase larger volume

Policy and Health Disparities

"Health equity is achieved when every person has the opportunity to attain his or her full health potential and no one is disadvantaged from achieving this potential because of social position or other socially determined circumstances." "Health inequities are reflected in differences in length of life, quality of life; rates of disease, disability, and death; severity of disease, and access to treatment." Largest impact at the bottom (socioeconomic factors) - Driven by structural racism• Changing context to make individual's default decisions to be healthier - Fluoridation in water - Banning trans-fat - Smoke-free laws Long-lasting interventions - Ex. COVID-19 vaccination Clinical interventions - Medication for diseases Counseling & education - Affected by SES factors, food desert (food access), built env (lack of parks)

Lecture 1: Policy

"defined as a law, regulation, procedure, administrative action, incentive, or voluntary practice of governments and other institutions."

Health Policy:

"refers to decisions, plans, and actions that are undertaken to achieve specific health care goals within a society." Health policy can: Define vision for the future which helps to establish targets as well as benchmarks toward the targets Outline priorities for different sub-groups Build consensus and inform people

Sources of public law

1) Constitutions (framework of the state and federal governments) 2) Legislation via the Legislative Branch 3) Regulations via the Executive Branch 4) Case Law via the Judicial Branch 5) International Agreements

Lecture 9: Policy process: Healthcare financing tools Types of healthcare financing tools

1) Health insurance coverage 2) Health promotion programs 3) Disease management programs 4) Quality measurement (certain metrics that organizations measure & have to report) 5) Performance targets and guarantees (organizational incentive based on meeting quality metrics by the organization) 6) Patient incentives

Keep in mind when deciphering info

1) Resembles the press release that it is was based (public relations purpose?) 2) Information does not explain methodology or uses technical terminology 3) Information used for sensationalization or overreaching conclusions 4) Links research only tangentially relationship (weak association and not causal) 5) "Evidence" from an unknown source/organization, non-peer reviewed sources, etc. 6) Information based on conjecture and ideology rather than facts and science Separating legitimate sources of news can be challenging in society today!

Determinants of price elasticity of demand

1. Availability of Substitutes 2. Percent of Income 3. Degree of Necessity 4. Duration of Price Change 5. Brand Loyalty

Lecture 10: 4 P's of policy development

1. Problem 2. Politics 3. Participants 4. Policy Choices

SB 562: Health California (Atkins and Lara)

1. Problem - 3 Million people continue to be uninsured 2. Politics - Democratic super-majority in both chambers; Dem Gov 3. Participants - - Sponsored by CA Nurses Association - Supported by Labor Unions, Anti-Poverty, Dem Clubs - Opposed by Insurance Companies, CA Medical Association,CA Chamber of Commerce 4.Policy Choices - Status Quo; Expand eligibility of existing programs Inside the influencers: Speaker staff, Leg staff, civil servants, political appearances Outside influencers: Interest groups, Academics, consultants, media, public The death of SB 562: - Price tag: $400 billion - Create Bureaucracy and job losses - Threat of $200 billion in new taxes Rendon did not hold hearings or even consider amendments! Campaign Contributions? Insurance Companies - $50,000 Drug Companies - $100,000

AB 1611 - End balance billing (2019)

1. Problem - Gap between Emergency Room Costs and Insurance Coverage 2. Politics - Lots of Media Coverage; Dems in control 3. Participants - - Supported by Labor Unions, Retirees, Western Center on Law & Poverty - Opposed by Hospital Association and Medical Association 4. Policy Choices - Status Quo Inside influencers: Civil servants, Leg staff Outside influencers - Interest groups, academics X - Consultants, Media Detour

AB 615 - Smoking ban in child daycare (1993)

1. Problem - Kids exposed to secondhand smoke 2. Politics - Big tobacco losing battles; Dems in control 3. Participants - - Sponsored by American Lung Association Supported by American Association of Pediatrics, CA Congress of Parent & Teachers Unopposed 4. Policy Choices - Status Quo; Indoor Ban only; Indoor & Outdoor Ban Inside influencers: Civil servants, Leg staff Outside influencers: Interest groups, Academics Smooth road

Steps in policy-making process

1. Problem identification: 2. Policy analysis 3. Strategy and policy development 4. Policy enactment 5. Policy implementation Stakeholder engagement and education Evaulation

Considerations when drafting policies

1. What are the objectives of the policy? (i.e. what is policy trying to do?) 2. What is the policy landscape surrounding the policy as it is being drafted? (i.e. existing policies like in other states, other laws that interact with this policy, public opinion on this policy, etc.) 3. What is the historical context of the policy (e.g., has it failed before, policy previously debated, what were the issues brought up, etc.) 4. What is the policy lever? (i.e."lever" pulled to create individual or group behavior change whether it is via legislative, regulatory, voter initiative, etc.) Look at getting policy passed - elected officials, regulatory agencies that has oversight like FDA/EPA/CDC, put on the ballot via signatures, etc. 5. What level of government or institution will implement the policy? - City/county/state/federal 6. Where will the policy take place? - City/county/state/federal or within an organization - Who has jurisdiction 7. How does the policy work/operate? - Will policy be mandatory? - Will it require enforcement? - Penalty strategies? 8. When will the policy go into effect? - Is there an urgency clause (go into effect immediately) or ramp up implementation?

Impact of Berkeley soda tax (April, 2017)

10% reduction in sugar sweetened beverages 16% increase in water sales Raised $1.5 million to go to nutrition and health programs

Tobacco Industry Advertisement Restrictions

1965 = Cigarette Labelling and Advertising Act (warning labels) - 1964 Surgeon General's Smoking and Healthreport - Caution: Cigarette smoking may be hazardous to your health 1970 = Public Health Cigarette Smoking Act (stronger language on warning labels) - Ban cigarette ads on tv and radio - Warning: The Surgeon General Has Determined that Cigarette Smoking Is Dangerous to Your Health 1984 = Comprehensive Smoking Education Act ("Rotational Warning Act") - SURGEON GENERAL'S WARNING: Smoking Causes Lung Cancer, Heart Disease, Emphysema, & May Complicate Pregnancy - Smoking by Pregnant Women May Result in Fetal Injury, Premature Birth, & Low Birth Wt - Cigarette Smoke Contains Carbon Monoxide - Quitting Smoking Now Greatly Reduces Serious Risks to Your Health Side note: Study published in JAMA (1991) reported that Camel cigarettes' Joe Camel mascot was more recognizable than Mickey Mouse or Fred Flintstone among 5 & 6 years old 1998 = Master Settlement Agreement - Uncovering of documents that revealed tobacco industry was lying about the harms about tobacco - Lawsuits by states against tobacco industry to recoup tobacco-related costs - Agreed by industry because states agreed not to sue tobacco industry again (one-time payout) - Ban of cartoon characters, transit advertising, billboards, cannot offer branded merchandise, free product giveaways, event sponsorship, and advertising and marketing practices that targeted minors 2006 = US vs Philip Morris et al.court case - Concluded major US tobacco companies knowingly & fraudulently claimed "low tar"/"light" were less harmful; descriptors banned on cigarette packaging/advertising 2009 = Family Prevention and Tobacco Control Act ("Tobacco Control Act") - Granted FDA the ability to regulate the manufacturing, marketing, and distribution of tobacco products - Covered certain products (e.g., cigarettes, roll-your-own tobacco, and smokeless tobacco) were subjected to specific FDA regulations - Other tobacco products required FDA to issue regulations "deeming" these products to be subject to the Act ( "Redeeming Rules"); require public comment - In 2016, the FDA issued the Redeeming Rules to expand the definition of tobacco products because they contain nicotine (e.g., cigars, e-cigarettes, pipe tobacco, hookah tobacco, etc.) - However, these regulated products are not covered by the previous tv and radio advertising ban, but were required to carry health warning labels on both the packaging and advertisements of newly regulated products For example, graphic color images on packages: - Tobacco company sued them saying it infringed on their rights to free speech - FDA went back to the drawing board but only to be sued by public health groups for not upholding what was mandated in the Tobacco Control Act - In 2019, prototypes released by FDA for public comment to satisfy both sides (same color and font but different brands listed)

Menthol marketing among African Americans

African-American smokers reported that they prefer menthol cigarettes, and tobacco companies exploited this preference in their marketing efforts Internal industry documents from Philip Morris: "Marlboro would probably have a very difficult time getting anywhere in the young black market. The odds against it there are heavy. Young blacks have found their thing, and it's menthol in general and Kool in particular." Internal industry documents from RJ Reynolds: "Since younger adult Blacks overwhelmingly prefer menthol cigarettes, continued emphasis on Salem within the Black market is recommended. Salem is already positioned against younger adults. With emphasis on the younger adult Black market, Salem may be able to provide an alternative to Newport and capitalize on Kool's decline." Tobacco industry has aggressively marketed menthol products to young people and African Americans, especially in urban communities. Menthol has a cooling sensation that makes it to easier to start smoking, but the concern is facilitating a nicotine dependence; thus, more difficult to quit smoking Tobacco industry attempted to frame the marketing with a positive image when marketing among African Americans - Supporting cultural events - Making contributions to minority higher education institutions - Offer scholarships - Contributions to civic and community organizations Tobacco industry invested a larger amount of cigarette advertising in African American publications (thus, more exposure among African Americans) than ones more prominent among Whites Nationwide, census tracts with a greater proportion of African American residents have higher tobacco retailer density. A study conducted in 2015 in Washington, DC study found that illicit sales to minors were more common in retailers situated closer to high schools in African American neighborhoods A study conducted in 2014 in California found that stores in neighborhoods with more African American residents were less likely to request age identification Update: Governor Newsom signed into law SB793 inAugust2020prohibiting the sale of most flavored tobacco products, including menthol cigarettes As of January 1, 2021, tobacco products with a 'characterizing flavor' (defined as the presence of a distinguishable taste or aroma other than tobacco) can no longer be sold in retail stores across the state - Includes flavored e-cigarettes, smokeless tobacco, and cigars in all flavors (e.g., fruit, mint, candy, menthol) - Hookah tobacco and loose leaf/pipe tobacco, etc.

Dimension #2: Problem definition

After in agreement that there is a problem, we must define the problem Consider who is affected (specific groups or general population) How big is the problem (many people impacted) What are root causes of the problem (what is contributing to the problem) Where & when problem is most likely to occur Give numbers and facts to illustrate the problem (e.g., highlight the size of problem) Objective numbers used as "evidence" but look to see if it is not misused in the media (look at original source) Use these numbers to get the policymakers' attention since they have a lot of policies come across their desk How problem is changing over time and growing Use "stories" to garner support, and how it relates to the people in their constituency or target population

How soda tax would influence obesity rates?

All Soda Drinkers Soda drinkers who notice the tax Soda drinkers who are motivated to not purchase because tax created high price Soda drinkers who drink soda with some regularity Soda drinkers who are overweight or obese

Pretest-Posttest Control Group Design

Also known as classic experimental design, or a true experiment Allocation is unbiased and not determined by a pattern; equally distributes participant characteristics Common type = randomized controlled trials (RCT) A: R O1 X O2 B: R O1 O2

Cost-benefit analysis

Analysis converts benefits into dollars (monetary amount) Measured as a ratio of the value of the benefits to the value of the costs - $ of the Benefits : $ of the Costs (i.e. $3:$1) - Benefits: intended or unintended positive effects of a policy - Costs: intended or unintended negative effects of a policy Allow comparison of policy interventions with different type of health outcomes Need to assign monetary value to loss of life and life quality, which can be controversial (e.g., someone's earnings as a way to value his/her life)

Lecture 2: Difference between an initiative vs referendum Getting on the Ballot

Ballot measures via petition (collection of signatures) or legislature at the state and local levels (note there is no provision for ballot proposition at the national level) To-date, 24 states allow for use of this initiative process - 8 states allow initiatives to propose constitutional amendments - 21 states allow initiatives to propose initiative statutes California became the 10th state to adopt the initiative process on October 10, 1911 Through November 2014, 364 initiatives have qualified for the statewide California ballot (34% approval rating) and amended CA's Constitution 52 times this process Number of signatures to qualify in CA according to California Constitution, Article II, Section 8(b); Elections Code section 9035: - Initiative Statute: 623,212 signatures - Initiative Constitutional Amendment: 997,139 signatures CA Secretary of State website: https://www.sos.ca.gov/elections/ballot-measures/how-qualify-initiative Aside from Oregon, CA engages the most in this initiative and referendum process Examples of proposition passages pertaining to elected officials: Proposition 14 in 2010: voting system of top-two candidates from primaries Proposition 28 in 2012: term limits for state legislators As more initiatives are proposed and passed, so has the money spent on them CA process of getting an initiative on the ballot: https://oag.ca.gov/initiatives - Draft initiative draft, submit draft to Attorney General, circulate petition, submit petition with signatures to county election officials for verification if qualified (≥95%)

Cost-effectiveness analysis (CEA)

CEA is the most common type of evaluation utilized in public health Look at the policy costs given a specific health outcome Outcomes is the individual health benefit measured as quantifiable unit, such as: - Behavioral (e.g., numbers who stopped smoking) - Health outcome (e.g., coronary heart events prevented) - Healthcare utilization (e.g., hospitalizations) However, does not allow comparison across policies that use different measuring units (e.g., number of people who stop smoking vs number of lung illnesses)

Cost-utility analysis (CUA)

CUA is a specific type of CEA Provides a common measure of effectiveness Utility ranges from 0 (person is dead) to 1 (person has perfect health) Health outcomes expressed as standardized morbidity/mortality measures (e.g., QALY, DALY) QALY= quality-adjusted life year; measure of disease burden, which includes both the quality and the quantity of life lived - Measure of perfect health gained DALY= disability-adjusted life year - Measure of perfect health lost

Lecture 4: News and Media Bias

Chart of the political bias of most-read sources in America Left, center, and right leaning Center media bias rating does not necessarily mean neutral or unbiased - simply means source usually did not favor either end of the political spectrum (left = liberal & right= conservative) Another Media Bias Ex. (v6, 2020): https://www.adfontesmedia.com/static-mbc/ Some are either evidenced-based recording, mixed record, or ideologically driven/ poor reporting

Costs from different perspectives

Consider the "costs" and who bears the costs (costs to whom?) Perspectives - Societal (all costs taken into account-from medical, wage loss, productivity, mortality, non-medical out-of-pocket, costs, etc.) - Health-care system (from healthcare institutions would be concerned) - Third-Party Payer (from an insurer perspective of who is covered in the system, mortality costs if one of those covered dies and no longer contributes to system, etc.) - Business (from employer's perspective incl. employee coverage, productivity if self-owned business so providing coverage, etc.) - Governmental (what government would need to pay for such as Medicare, etc.) - Patient and/or their families (personal costs need to pay out-of-pocket, wage loss in the household, non-medical costs, etc.)

Types of Evaluations

Content evaluation - Does the content of the policy clearly articulates the goals? - Similar to other policies? Implementation evaluation - Was the policy implementation as intended? - Examine inputs, activities, and outputs - Gather information from stakeholders about their perceptions, etc. - Identify barriers and facilitators during the implementation process Impact evaluation - Did the policy produce the intended outcomes and impact of the policy? - Examine changes in key indicators

Program/policy cost analysts

Costs of the policy implementation Using Reading 15.1 (by Ong & Glantz) for this type of analysis: - Costs of the nicotine replacement therapy (NRT) = $130M - Costs of the smoke-free workplace = $8.3MQ. If we pick this type of analysis, which would you choose? However, smoke-free workplace is a less expensive option but is it more effective?

Economic evaluation

Economic evaluation looks at what is put in (inputs) into the policy after enactment, and then how does that compare in how much getting out after the policy has been implemented (outcomes/impacts) Remember that time frame of analysis and availability of data will affect the components of the logic model - Impacts can take a long time to detect so may have to infer based on trend data (e.g., intermediate outcome like quit rates in smoking cessation, but if we are interested in examining the reduction in lung cancer rates, this impact will take longer to observe) Not actually calculating anything for your group presentation but consider which type of economic analysis and what type of data is needed to conduct one Partial analysis (only focused as a cost analysis) - Cost-of-illness analysis (assess burden of disease from a cost standpoint) - Program/policy cost analysis (focused on inputs in logic model for implementation) Full analysis (includes costs and assess for health outcomes/impacts) - Cost-effectiveness analysis( CEA) (looks at same health outcome measures; e.g., at-home prep due today which looked at "quitters") - Cost-utility analysis(CUA) (examines different health outcomes so need to convert into a common unit to allow for a direct comparison) - Cost-benefit analysis (CBA) (take health outcomes and translate into a monetary amount; e.g., for every $1 invested, get X amount of benefit)

2. Legislation

Enacted via the Legislative Branch: - Federal level via US Congress, such as the House of Representatives & Senate (statutes, which is a formal written law that is passed by a legislative body) - State level via state legislature, such as State Assembly & State Senate (statutes) - Local level via City Council and County Board of Supervisors (ordinances) Examples related to federal legislation passed and related to public health: - Pure Food and Drugs Act that established the FDA and gave this agency the power to regulate our food and drugs to make sure they are safe (1906) - Clean Air Act that established the EPA and gave this agency the power to issue regulations to keep our air clean (1963) Examples related to local ordinances passed and related to public health: Zoning: Regulates where retail outlets can be located - Limit the number or density of retailers in certain zones (e.g., alcohol, tobacco, etc.; can compete & drive down prices) - Restrict how close retail outlets can be to each other - Restrict how close retail outlets can be to schools or residential areas Examples related to local ordinances passed and related to public health: Licensing: Requires business to purchase of government-issued retail licenses for permission to sell certain products under certain conditions - Sellers of tobacco, alcohol, marijuana, guns, food, etc. require licenses in order to sell these products - Meet minimum standards and safety levels (e.g., food) - Ex. CA has the strictest licensing requirements for retailers selling guns - Useful mechanism to help regulate the amount of product available and the conditions that they can be sold Examples related to local ordinances passed and related to public health: Location: Determines where certain products can be utilized or consumed - Ex. Alcohol, tobacco, and marijuana - Can bring gun inside a facility or not - Reduces second-hand exposure (e.g., tobacco or marijuana) - Reduces negative consequences (e.g., alcohol use on the beach due to negative events) - Minimizes negative impacts on social norms (e.g., normalize behaviors due to being commonly present/seen)

Evaluation designs

Evaluation design relates to the purpose of what is being evaluated (goals of the policy) and considers the constraints associated with time, money, and availability of participants 3 main types of evaluation designs: - Experimental design - Quasi-experimental design* - Non-experimental design * Used when randomization (experimental design) is not possible; uses comparison groups or time to control for some factors When using randomization, rule out confounding factors/bias on the effect - Allocation to groups is not predictable, no pattern, not affected by researchers Is random assignment used? - Yes = randomized or true experiment - No Is there a control group or multiple measures? - Yes = quasi-experiment - No = Non-experiment

Impact of cigarette taxes

Every 10% increase in the price of cigarettes reduces: Overall consumption by 3-5% Number of young-adult smokers by 3.5% Reduces number of kids who smoke by 6-7% Reduce smoking among pregnant women by 7% Why is consumption down more among kids than overall?

Consider the Purpose of the Evaluation

Ex. Hypothesis: Did policy result in a reduction in tanning bed usage? (can you randomize exposure?)

Consumption taxes

Excise Tax (Input Tax): Type of tax: Indirect (Indirectly paid by the consumer in the form of higher price from the producer) Tax based on: Unit/ quantity Included in the price: Yes Sales tax (Output tax) Type of tax: Direct (paid directly by the consumer) Tax based on: Price/ value Included in the price: No, added on at the point of sale

1. Constitutions

Executed at the state and federal Levels Examples of US Constitution related to public health: 1st Amendment = Freedom of speech, press, religion, assembly, and petition - Protect freedom of speech with legal fight with the tobacco industry & warning labels and advertisements 2nd Amendment = Right to bear arms - Issue regarding gun control State Constitutions authorize and provide requirements for ballot initiative process - 26 states have this process in place - California has the lowest requirements for placing issues on the ballot - State ballot initiatives database on National Conference of State Legislatures's website = http://www.ncsl.org/research/elections-and-campaigns/ballot-measures-database.aspx Ex. Drug, alcohol, or tobacco-related policies - Taxation, age of consumption, and sales location restrictions - Marijuana legalization (recreational, medical) Ex. Abortion-related policies: - Conditions under which abortion is permitted - Declaration of "sanctity of unborn life and rights of unborn children" - Limiting public funding of abortions

5. International agreements

Executed on the international level (voluntary basis when signing onto it) Examples related to public health: Paris Climate Accord (also known as "The Paris Agreement") - https://unfccc.int/process-and-meetings/the-paris-agreement/the-paris-agreement - Global mechanism to address climate change - International treaty on climate change that as adopted by 196 Parties in December 2015 WHO Framework Convention on Tobacco Control https://www.who.int/fctc/text_download/en/ - Global mechanism to try to address tobacco control efforts - Treaty adopted by 56th World Health Assembly (WHA) in May 2003 - Became the first World Health Organization (WHO) treaty adopted in the WHO constitution (article 19) Executed on the international level

3. Regulations

Executed via the Executive Branch Leading roles in charge are the President, Governor, and Mayor Regulation is a rule or directive that is executed by Executive Branch and mandated to be followed and are enforced by the government Defined as "implement laws and develop policies and guidance for industry, government and other organizations" Catalog of all regulations can be found at <regulations.gov> Ex. Clean Air Act established by legislation - Federal law that regulates air emissions to protect public health - With the establishment of a regulatory agency, regulations have to be within the scope of what the agency is authorized (not need Congress approval) - EPA can write regulations that explain technical, operational, and legal details necessary to implement the Clean Air Act, related to (otherwise new regulations have togo through Congress for changes/additions): - Defining specific emission limits - Monitoring compliance with limits - Enforcement (Waste, Chemical, and Cleanup)

4. Case law

Executed via the Judicial Branch Courts have to get involved to settle disputes; involves set of previous rulings by a judge (e.g., "X vs. Y" and settled in court) Examples of case laws related to public health: Burwell vs. Hobby Lobby (https://www.youtube.com/watch?v=4Gtq87CaztA) - Christian arts & crafts company that did not want to cover some contraceptives mandated by ACA, and SCOTUS upheld their right to religious beliefs Roe vs. Wade (https://www.youtube.com/watch?v=9HZj8Qp4p2A) = establish abortion rights

Policy solutions through a health equity lens

Existing policy may be a cause of disparities, or create larger or new disparity Remember that the policy solution need to address root cause of the disparity (e.g., healthier eating behaviors but not have access) Policy solutions directed at a targeted population may be needed (e.g., tobacco use) Policy solutions directed at entire population may not have equal impact on all due to various factors, such as - Structural racism - Economic barriers - Differential enforcement - Implementation challenges

Global Tobacco Policies

First global public health treaty by the World Health Organization (WHO) known as the Framework Convention on Tobacco Control (FCTC) - FCTC went into effect in 2005; 15 year anniversary FCTC identified that tobacco advertising was as one of the factors that "have contributed to the explosive increase in tobacco use" Article 13 of the FCTC promotes among the 182 Parties who signed on to the treaty to undertake "a comprehensive ban of all tobacco advertising, promotion and sponsorship" to help reduce tobacco consumption

Distinguishing Health vs Health care disparities

Health disparities - Higher prevalence of disease - Higher mortality rates Health care disparities (related to access of care and quality of care) - Routine medical care (access to regular/usual source of care/provider) - Quality of care (extent to which it is lower for certain populations) - Hospital re -admission rate (factors that influence admission rates) - Culturally appropriate care (discrimination in way care is provided; positive if provider is aware of cultural norms & cultural competence training; push for concordance of provider-patient by sex, race/ethnicity, culture)

Dimension #1: Problem identification

How do we know when there is a problem that needs to be addressed? What is a "problem"? - It is a special condition of severity where corrective action is needed and may be long overdue (e.g., may look at trends and their trajectory) So when does this condition become viewed as a "problem"? - Due to an event, such as perception of a crisis - Based on a measurement, which can help indicate when a condition has reached a level that is recognized as needing to be addressed Dimensions of a problem: A. Problem identification (is there a "problem"?) B. Problem definition (characterization of a "problem" - who, when, where, etc.) C. Causal model (root causes of the problem) D. Consequences (effects; why do we even care about this "problem"?) Measles was declared to be eliminated in the US in 2000 - i.e. no longer native in the US but continues to be brought in by returning travelers international or international visitors Measles outbreak among visitors to Disneyland parks in December 2014 - 1st case among an unvaccinated 11-year old girl - although unconfirmed source, genotyping of strain among those infected were the same as strain reported earlier in an outbreak in the Philippines - Numbers of cases spiked to 600+ cases by 2015 In 2019, 1,282 cases confirmed in 31 states (highest # of US cases since 1992)

Step 2. Assess policy options

How well does the policies address the problem/issue? What are the magnitude and distribution of the benefits and burdens? - i.e. What population(s) will benefit? How much (equally distributed)? - i.e.What population(s) will be negatively impacted (harms)? How much? Will the policy impact health disparities/health equity? How? Are there gaps in the data? (may affect evidence to support it; is more research needed?) What are the unintended consequences of the policy? (outcomes not intended to happen) Is the policy feasible (e.g., technically, legally, politically, socially, etc.)? What are the financial consequences of the policy? How expensive is it? Who will support as well as oppose the policy? Any interest groups (politically feasible)? Possible criteria: - Affordability (i.e.how much the policy costs) - Effectiveness (how well it addresses the chosen problem) - Legality (prohibition by law; possible legal challenges may arise) - Technically feasible/administrative ease (easy to administer) - Socially acceptable/infringement on personal rights/liberties (people's opinion) - Politically feasible (how different groups line up for or against it) - Equality/equity Equality: Everyone receives same support with the assumption that everyone benefits (equal treatment) Equity: Everyone receives level of support they need; according to CDC, "when everyone has the opportunity to be as healthy as possible" ("justice" -root cause of inequity is addressed & systemic barrier removed) It is important that resources are directed appropriately to support and to meet people where they currently are

3 branches of government

Important to know about the political structure and how the government operates, particularly related to funding and support for social policies Federal government players: 1. Legislative branch: Congress (House of Representatives and Senate); Speaker of the House & Senate Pro Tempore 2. Executive branch: President, VP, Cabinet, and Agencies that report to the President 3. Judicial branch: Supreme Court, appellate courts, district courts State government players: 1. Legislative branch: State Legislature (State Assembly and State Senate) - almost all states are bicameral; Assembly Speaker & State Senate Pro Tempore 2. Executive branch: Governor, Cabinet, and Agencies that report to the Governor 3. Judicial branch: State Supreme Court, courts of appeal, superior courts Public policies influence public revenues by increasing and decreasing taxes, and promote economy growth or decline Public policies are influenced by a variety of factors, including the economy, focusing events, public opinions, etc.

Status of ACA

In 2012, SCOTUS upheld the individual mandate of the ACA when its constitutionality was challenged by characterizing the penalty for not buying health insurance as a tax, which Congress is allowed to impose However,Congress enacted an amendment to the ACA with the passage of the Tax Cuts & Jobs Act of 2017 that set the penalty for not buying health insurance to zero (thus, gets rid of this individual mandate), but it left the rest of the ACA in place Texas leading the charge with other states and individuals filed a lawsuit in federal district court challenging the individual mandate again by arguing that since there was a zero penalty, it is no longer characterized as a tax and is unconstitutional California with other states joined the lawsuit to defend this individual mandate Oral arguments in Nov 2020 and the federal district court declared that the individual mandate was now unconstitutional and that as a result, entire ACA is invalidated U.S. Court of Appeals for the Fifth Circuit upheld the district court's conclusion, but is hearing whether any part of ACA survives in the absence of the individual mandate Oral arguments set for March 2021, and possible decision by Summer2021 Concern is that people may lose their health insurance, including people with pre-existing conditions

Mechanisms of obtaining health ins:

In March 2010, ACA (formally known as the Patient Protection and Affordable Care Act or informally as Obamacare) Marketplaces = consumers shop for private insurance coverage at federally subsidized rates Note: Not qualify for subsidies if over FPL 2020; in 2020 FPL an individual was $12,760 & ineligible if making >400% (~$51K) In CA, we have Covered California (https://www.healthforcalifornia.com); other states have their own marketplace or opt to use the federal one (https://www.healthcare.gov) Direct enrollment = consumers can buy directly from insurers because they now have protections, such as pre-existing conditions Parents = stay on parents' insurance up until the age of 25 years old Employers = large companies offering health care benefits (certain number of employees), but now marketplace offer options for smaller businesses Medicaid (38 states plus DC have expanded eligibility) as a vehicle for expanding health ins coverage (thus, leading to decrease in uninsured and increase in the enrollment); Pres. Biden may be looking into "coverage gap" for 12 non-participating states

Experimental designs

In general, experimental designs may be hard to design for policies Randomized controlled trials (RCT) is a common type of experimental design However for policy evaluation, the focus is on a broader impact and hard to section off certain people exposure (e.g., ssb tax in one county may not be feasible, so alternatively, can compare two counties where only one county has the tax) Additionally, it may not be ethical to randomize subjects into the groups (e.g., people to smoke and not smoke), randomization by characteristic (e.g., disease, age, etc.), and the policy should not have already been implemented and currently is in effect (e.g., not reasonable to ask people to not follow the law) Therefore, it is more common to use quasi-experimental designs For example, randomized controlled trials (RCT) are a common type of experimental design in research studies; but for examining policies, the scope can be on a broader impact and hard to section off certain people's exposure (e.g., ssb tax in one county but can be comparing two counties) Additionally, may not be ethical to randomize people (e.g., people to smoke and not smoke), randomize by disease, age, etc., policy should not have already been implemented and is in effect (e.g., not reasonable to ask people to not follow the law)

Quasi-experimental designs

In general, quasi-experimental designs are similar to the experimental designs However, this type of design is used when randomization is not possible based on "exposure" to the policy (for some reasons as mentioned) Indicator being measures is assessed before and after the policy is implemented 2 main types of quasi-experimental designs - Nonequivalent Comparison Groups Design - Time-series Design Nonequivalent Comparison Groups Design Also known as Pretest-Posttest Comparison Group Design (note: term used is "comparison" vs "control" group; latter term used in experimental designs) Presence of comparison group and pretest, but no randomization ("R") A: O1 X O2 B: O1 O2 Time-Series Design Can be used when there is not a good comparison group available; focus on one location (e.g., city, state, country-level; example can be helmet laws in VN) Also known as simple time-series design or interrupted time series design All involves multiple observations/measurements collected before and after the policy (based on historical data; to detect possible disruption in the trend) Requires more data; lack of consensus on set number of observations (also depends on type of data available such as monthly or annual data, how established was the trend in the data before the policy, etc.) A: O1 O2 O3 X O4 O5 O6

Step 1. Identify & Describe Policy solutions

Internet searches (e.g., search Google for "policy options for [Insert problem here]" Literature review in peer reviewed journals National Conference of State Legislatures: (policy database, but not cover all topics) https://www.ncsl.org/research/telecommunications-and-information-technology/ncsl-50-state-searchable-bill-tracking-databases.aspx•Advocacy groups for specific topics: Diseases-specific (see NOF-Policy Institute https://www.bonehealthpolicyinstitute.org) Reproductive Health (see Guttmacher Institute https://www.guttmacher.org) Tobacco(see American Lung Assn https://www.lung.org/policy-advocacy) Nutrition, physical activity, obesity (see CDC https://chronicdata.cdc.gov/Nutrition-Physical-Activity-and-Obesity/CDC-Nutrition-Physical-Activity-and-Obesity-Legisl/nxst-x9p4) American Public Health Association (see APHA https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database) What are the objectives of the policy? What is the policy landscape surrounding the policy? What is the historical context (e.g., was the policy previously debated)? What is the policy lever? (remember, mechanism of how the policy will be passed) - Legislative introduction, issued by regulatory agency, passed by voter initiative, private organization policy implementation, etc. What level of government or organization will implement? - Local, state, or federal (make sure solutions are relevant at the appropriate level) How does the policy work/operate? - Will it be mandatory? Will there need to be enforcement? How is it funded?

Policy implementation process

Interpretation: Translate policy into operational practice and define implementation standards - Provide specific rules and administrative regulations - Address what is the policy and to whom does it apply to Organization: Coordinate resources and build capacity of personnel to implement policy - Determine how policy be carried out and by whom will carry it out (assign responsibilities) - Ex. Resources/personnel needed for enforcement Application: Carry out the rules of the policy and enforce it - Take action based on what is now permissible due to the passage of the policy

Takeaways

Legislative Road is rarely a straight, smooth one Choose a champion Line up your coalition Be active throughout the process Follow the money If at first you don't succeed, try, try again!!!

Lecture 8: 4. Policy process: Legal tools 5. Healthcare financing tools

Legislative branch: (propose and pass laws) https://www.whitehouse.gov/about-the-white-house/the-legislative-branch/ Executive branch: (enforce and implement laws) https://www.whitehouse.gov/about-the-white-house/the-executive-branch/ Judicial branch: (interpret laws) https://www.whitehouse.gov/about-the-white-house/the-judicial-branch/

Evaluation design key in short notation

Let's visualize the design: - R= randomization - X= policy of interest (in research studies, it may be a new drug or intervention being evaluated) - O= observations of the indicators ("pretests" and "posttests" in research studies) (note: numbered in sequential order and matched with control/comparison groups) - A, B, C, etc. = number of groups (subjects gets allocated to one of these groups) Based on the O's, help detect the change between groups 'exposed' to the policy vs ones 'not exposed' to the policy; thus, the difference seen is assumed to be based as a result of the policy when controlling for other factors

Through a healthy equity lens

Look at the entire policy-making process through a health equity lens - What type of factors do we need to keep in mind to achieve health equity? - Major goal for PH workers is working to achieve health equity - Keep in mind that policy can be source of health inequity or solution to address it To achieve health equity involves identification of health disparities/inequities, assessment of root causes, and implementing policy solutions to address root causes Health disparities: identify health disparities (aware of problem) - Measurement indicates crisis level, focusing event, feedback from groups Root causes: pathway/mechanism responsible for creating disparity Policy solutions: address root cause of disparity to address

Association of a beverage tax on sugar sweetened and artificial sweetened beverages with changes in beverage prices and sales in chain retailers in a large urban setting - Roberto et al., 2019

Main Findings: Soda tax in Philadelphia had significantly greater increase in prices and larger declines in the volume of taxed beverages sold. This decrease was partially offset by increases in volume and sales in bordering areas (50% reduction was offset by increase in bordering areas for overall decrease of 38%) How do these results compare to those reported in Berkeley?Declines in Philadelphia > Berkeley Possibly due to higher tax in Philadelphia (1.5 cents vs 1 cent), greater poverty Greater pass through of tax to higher prices in Philadelphia

Market failure

Market does not come to an equilibrium (Equilibrium is where supply and demand meet) Government intervention is justified when resources are not produced or allocated efficiently due to: - Concentration of market powers - Imperfect information - Public goods - Externalities

Quality measurement

Measurement to signal importance or "value" to the purchaser Collection of standardized data across health plans and medical groups to show what kind of value health care provided to consumers Improves consumer information and ability to select a high quality health plan National Committee on Quality Assurance (NCQA) uses HEDIS (Healthcare Effectiveness Data and Information Set) measures for accreditation certain organizations based on certain level of quality

Soda tax

No Federal Soda Tax 34 States Sales tax - food stores; 5.2% (avg) 39 States Sales tax - vending machines; 5.3% (avg) Local Soda Tax - Berkeley, CA (2014, first city) 1. Berkeley, CA 2. San Francisco, CA 3. Oakland, CA 4. Albany, CA 5. Boulder, CO 6. Philladelphia, PA 7. Seattle, WA CA State Soda Tax Efforts?

Non-experimental designs

Non-experimental designs are not for the purpose of making causal inferences (i.e. not testing hypotheses) It is useful for exploratory or descriptive purposes

Pathways by which structural racism & interconnected systems that impact health

Pathways, public health problem, & policy solution in today's reading? Pathways of how structural racism can impact health: - reduced access to employment - reduced access to housing - reduced access to education - increased environmental exposures - increased targeted marketing of unhealthy substances - increased inadequate access to health care Physical injury and trauma from police violence for certain groups, as well as chronic exposure to discrimination on the physical body (chronic disease & stress) - Increased participation in unhealthy behaviors (e.g., coping mechanisms)

Public Policy:

Policies implemented by 'public' entities/organizations

Unintended consequences

Policies may not necessarily completely solve problems that they were intended to address Concept of unintended consequences is when policies can have unexpected results (possibly creating new problems) Ex. Rules requiring school lunches, but food may not be entirely healthy; of it they are "healthier," there is less caloric intake for food-insecure students Ex. Social Security created to help the poor, particularly senior citizens; however, there is a cost that comes out (payroll taxes) of working people's paychecks

Policy process: Policy analysis

Policy Solutions: 1. Think about how you would develop policy solutions to address public health problems (Policy Memo) 2. Look at goals of policy options 3. To define and provide examples of the policy options to impact risky health behaviors: prohibition, harm reduction, decriminalization, and legalization 4. To summarize the policy options in place in the U.S. to address drug use, marijuana use, alcohol use, and tobacco use.

Lecture 12: Policy analysis, strategy & development, and enactment

Policy analysis (Policy Memo) - Identifying policy options - Comparing these potential policy options (criteria) - Determine best policy option to pursue Policy strategy and development - Find out if there is pre-existing language that exists (new vs previous related policy) - Get stakeholders involved, such as people are affected by the policy, subject matter experts (SMEs), & people who understand the legislative process Policy enactment - Process of obtaining official approval ("green light") for the proposed policy - Stakeholders also involved at this stage (depends on the level of enactment), including elected officials, agencies, committees/boards, administrators, etc.

Structural racism & COVID-19

Problem identification for COVID-19: (how we knew there was a problem) - Rates of hospitalizations & mortality - 2x higher for Black American patients Root Cause: (via structural racism) - Increased COVID-19 exposure for Black Americans Working in service industries Living in cities with high population density - Increased hospitalizations & mortality due to Black Americans were less likely to have health insurance Black Americans were more likely to avoid health care system (historical experience)

3 streams in Kingdon's multiple streams model of policy adoption

Problem stream = problem recognition (define & frame the problem) due to focusing event, indicators, something not working (no improvement), etc.; agenda-setting Policy stream = process of identifying & formulating policy; potential policy solutions & alternatives to be debated; assess with criteria which policy is more favorable Politics stream = influence by public mood, political climate, political partisanship/change in administration, interest groups Ideally problem is identified, policy solution is developed, and there is favorable timing of the political environment Policy window opens with convergence of streams and "window of opportunity" opens, usually for a short time so action needs to be taken; may not open for a long time

Lecture 7: Follow-up about tobacco restrictions

Proposition 99, "Tobacco Tax and Health Protection Act," passed in 1988 Yes: 5,607,387 (58.17%) & No: 4,032,644 (41.83%) CA Constitutional amendment imposed an additional 25-cent excise tax on cigarette sales & ban on cigarette vending machines in public areas accessible by juveniles Revenue funds the California Tobacco Control Program*(CTCP), which is the longest-running comprehensive tobacco control program in the US In a study by Hu, Keeler, Sung, & Barnett , researchers reported that higher prices due to Prop 99 reduced cigarette consumption by 8-10% in the short run and 10-13% in the long run, while media campaign funded by Prop 99 had addl effect in further reducing cigarette consumption although weaker effects than a tax increase Proposition 10, "The California Children and Families First Act," passed in 1998 Yes: 4,044,126 (50.5%) & No: 3,964,008 (49.5%) CA Constitutional amendment imposed additional 50-cent excise taxon cigarette sales, as well as additional taxes on other tobacco products Revenue funds the state government created state and county commissions to establish early childhood development programs, such as First 5 California (created to help California's children prenatal through age 5 and their families) First 5 links: https://www.ccfc.ca.gov/& https://www.first5california.com/en-us/about/ Media campaign ("I am your child") leading up to Prop 10 initiated by Rob Reiner, and opponents spent about $30M compared to less than $10M by supporters Proposition 28 was a failed referendum to repeal Prop 10 in 2000 Yes: 2,017,425 (27.8%) & No: 5,230,734 (72.2%) Proposition 86, "Tax on Cigarettes," was a measure defeated in 2006 Yes: 4,136,358 (48.3%) & No: 4,425,689 (51.7%) Intended to increase excise tax on cigarettes by addl $2.60 per pack; revenues earmarked for expansion and creation of new services (e.g., hospital care for children & anti-smoking campaigns) Proposition 29, "The California Cancer Research Act," was defeated in 2012 Yes: 2,568,715 (49.8%) &No: 2,592,791 (50.2%) Intended to increase excise tax on cigarettes by addl $1 per pack with revenues earmarked to fund cancer research, smoking reduction programs, and tobacco law enforcement Proposition 56, "The California Healthcare, Research and Prevention TobaccoTax Act," passed in 2016 Yes: 8,980,448 (64.43%) & No: 4,957,994 (35.57%) Imposed an increase by $2 excise tax per cigarette pack & raised tax rate of other tobacco products to fund specific Dept of Health Care Services (e.g., Medi-Cal) Changed the definition of "other tobacco products" in the state law to include e-cigarettes; thus, Props 99 and 10 taxes now also applied to e-cigarettes Opponents (funded by 2 major US cigarette manufacturers, Philip Morris & RJ Reynolds) spent about $70.98M compared to $35.53M by supporters Polls leading up to November ballot showed the majority of the general public supported this measure

Patient incentives

Provide direct financial incentives to patients to influence behavior - Get patients to make appointments - Undergo preventive services (e.g., screenings, immunizations, etc.) - Encourage for them to go see doctors to manage their chronic disease(s) Can be in the form of a gift card or voucher More effective with low-income populations

Impact of alcohol taxes: result of a meta analysis

Public policies affecting the price of alcoholic beverages have significant effects on alcohol-related disease and injury rates. Doubling the alcohol tax would: - Reduce alcohol-related mortality by an average of 35%, - Reduce traffic crash deaths by 11%, - Reduce sexually transmitted disease by 6%, - Reduce violence by 2%, and - Reduce crime by 1.4%.

Tax

Purpose of tax: Collect revenue Change behaviors Address the cost of a negative externality Taxation: Federal level State level Some cities also have city level tax

Steps in the policy-making process 3. Economic tools (Economic Policy tools: Tax and Price)

Some basic economic principles: 1. Supply & Demand 2. Elasticity of Demand 3. Market failure

Supply & Demand

Supply is the amount of goods and services that producers are able and willing to sell at a given price over a given period of time. Cost of inputs Number of sellers Change in Technology Future expectations Increase in supply = Increase in quantity = increase in price; and vice versa Demand is the quantity of goods and services that a consumer is willing and able to purchase over a specified time Consumer income Consumer preferences Price of substitutes Price of complements Future expectations Decrease in demand = decrease in quantity = decrease in price; and vice versa

Lecture 6: Steps in the policy-making process: 2. Marketing tools

Terminology: Marketing = Overall strategy to encourage consumers to purchase or consume a given product or service - Advertisement: paid message intended to get your message across about your product to consumers - Promotion: special offer that create excitement or awareness of your product - Sponsorship: contribution to an event or celebrity with aim of promoting specific product Counter-marketing= activities trying to counteract marketing influences from industry and the messages delivered by a marketing campaign - PSA (public service announcement): paid message intended to get your message out, such generally used to regarding a harm to the public or promote a certain behavior - Warning labels: label on a product intended to inform the user about the risks with using the product or conditions under which the use of the product is not advised

Undermining government tax policies: by Ross et al., (2017)

The seven legal strategies that tobacco companies employ to decrease the impact of tobacco taxes. Please list and describe each strategy: 1. Stockpiling 2. Change product attributes or production process 3. Lowering prices 4. Over-shift tax increase 5. Under-shift tax increase 6. Strategic timing of tax increase 7. Price-related promotions

Policy evaluation through a health equity lens

Use evaluation methods are culturally appropriate - Include key community stakeholders in the evaluation planning process (emic perspective) Identify key populations to monitor effectiveness of policy in reducing disparities (e.g., some communities need more help than others) Identify appropriate indicators to evaluate the impact of the policy across populations in different settings (consider in group policy evaluation project about the changes in indicators to show if the policy has a positive/negative impact) Evaluation conclusions should include discussion of health equity impacts/policy implications on health equity(consider in group policy evaluation project)

Defining costs

What counts as a "cost"? Conceptualize into two categories (direct and indirect costs) Direct costs - Program-related costs (items listed for the "inputs" in the logic model) e.g., labor/personnel costs, raw supplies & materials, facilities, equipment, transportation costs, media expenses to inform people, educational and training materials, etc. Healthcare costs (e.g., hospital, physician, healthcare services, etc.) What counts as a "cost"? Indirect costs - Costs of lost productivity (e.g., person prematurely dies due to an illness so there is loss of certain number of years of productivity where they could have been contributing to the workforce) - Opportunity costs (i.e. "loss of potential gain from other alternatives when one alternative is chosen") Cost-of-illness analysis = can be separating into 2 categories (direct and indirect) Program/policy cost analysis = focuses only on direct costs

Performance targets and guarantees

When looking at certain quality measures as a target to improving performance - Negotiate the target - Tie it to a financial incentive to quality measures Incentives: - LOSE $ for not meeting the target (more impactful on the individual level) - GAIN $ for meeting the target (bonus earned)

Lecture 5: Problem definition helps determine

Who will be interested in the policy process? - e.g., such as an interest group like NRA, public health group, mental health community, schools for gun control (based on what is considered the root cause of the problem) What policy options will be used to solve the problem (such as gun control)? - e.g., lack of regulations on guns or lack of access to mental health services -different causal models so they imply different policy solutions How will policy be enacted or implemented depending on what type of policy? - Could be legislative process, ballot initiative, regulatory policies, etc. Which main values are important in policy? (determining criteria to assess the policy) - Liberty (people's individual rights) - Equity (equal or fair distribution of resources) - Security (promote safety and maximize health & wellness of the community) - Efficiency (getting the most output for a given input/resources) Understand there can be a tradeoff of a policy between these values! Examples of trade-offs? - Seat belts (infringe on one's liberty but keeping people safe) - Food subsidies (increase food security but with limited resources, use funds for something else so it can be a trade-off for efficiency) - Mask use during COVID-19 pandemic - Distribution of vaccines - trying to maximize so let's consider resources (e.g., how much to spend, what to spend it on, how equitably distributed, etc.)

Impact of cigarette packaging

Why do we care about the packaging? - Plain packs were rated the least appealing - Plain packs were rated as worse tasting - Removing flavor descriptions on packaging impacted perceived taste - Reduced acceptance of cigarette from plain vs. branded packaging