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3rd Summer Institute on Migration and Health Use of data in the formulation of public health policy June 30

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Title: 3rd Summer Institute on Migration and Health Use of data in the formulation of public health policy June 30


1
3rd Summer Institute on Migration and Health Use
of data in the formulation of public health
policyJune 30 July 4, 2008Puebla, México
Laura Tobler, MPP Melissa Hansen Laura.Tobler_at_
ncsl.org Melissa.Hansen_at_ncsl.org
2
How to make your voice heard in state legislatures
  • Why State Legislatures are Important
  • Public Health and Health Policy within State
    Legislatures
  • Your Role and the Role of Your Research
  • Messaging to Legislatures
  • Health Reform in the states 2006-2008

3
Why are State Legislatures Important? States as
Health Policy Drivers
  • States are investing in data and research
  • States are learning to use clinical evidence to
    guild policy-making
  • "People's Branch" of Gov't
  • Control the purse Strings
  • Establish programs
  • Enact requirements
  • Provide oversight

4
What does a State Legislature Look Like?50
Different Examples
  • If youve seen one legislatureyouve seen one
    legislature!
  • Variety of different powers, rules, political
    make-up, etc.
  • California
  • Full-time job, high pay
  • Large staff (non-partisan, partisan, personal)
  • Wyoming
  • 40-day general session, 20-day budget session
  • Low pay
  • No personal staff few full-time professional
    staff

5
Legislator Compensation 2007
State Salary Per Diem
Arkansas 14,765/year 130/day (V) plus mileage tied to federal rate.
California 113,765/year 162/day for each day they are in session.
Connecticut 28,000/year No per diem is paid.
Delaware 42,000/year No per diem is paid.
South Dakota 12,000/two year term 110/legislative day
Texas 7,200/year 139/day
6
Dual Employment
  • Most state legislators are "citizen legislators,"
    meaning that, in addition to their role as
    legislator, they have a full or part-time job.
  • 10 States have full-time legislators.
  • 26 states place no restrictions on state
    legislators holding another job at the state or
    local level.

7
State Legislators Are Generalists
  • Dozens of topics A to Z
  • Hundreds of bills
  • Cant be experts in all
  • Good News Most Legislators see themselves as
    Students

8
Underestimated but BIG Challenge Turn-over and
Term Limits
2002 2004 2006
MI Senate 71 MI House 34 MI House 21
Missouri House 45 Missouri Senate 29 Missouri Senate 9
Arkansas Sen 31 Arkansas House 36 Arkansas House 29
Florida Senate 30 Okla House 28 Calif House 33
Montana Senate 30 Okla Senate 27 Calif Senate 30
9
Public Health and Health Policy within State
LegislaturesPublic Health Issues by the
Dozens(and dozens)
  • Medicaid
  • Insurance/mgd care
  • Pharmaceuticals
  • Long-term Care
  • Health disparities
  • Uninsured
  • Health professions
  • Health Facilities
  • Environmental
  • Public health
  • SCHIP
  • Prenatal Care
  • Emergency services
  • Nutrition
  • Oral health
  • Injury prevention
  • Mental Health
  • Disabilities
  • Substance Abuse
  • etc. ...

10
Overload!!!Demasiado Informacíon!
  • Going through all this information we have here
    is kind of like trying to drink from a fire
    hydrant. Colo. Rep. Mark Paschall
  • "Tratando de analizar tanto informacíon es como
    trantando de beber de una boca de riego."
    Diputado Mark Paschall, Estado de Colorado, EEUU

11
!Demasiado Informacíon! Overload!
  • "Mí compañero en él senado me informo que era un
    projecto de ley dañado. Votaba "No" para este
    projecto de ley hasta que me dí cuenta que era mí
    propío projecto de ley." Senador Ray Powers,
    Estado de Colorado, EEUU
  • My seatmate told me this was a bad bill. I was
    going to vote no on it until I realized it was my
    own bill. Colo. Sen. Ray Powers

12
State BudgetsWhere does the money go?(National
average state general funds, FY 2007)
  • Education (K-12) 33.4
  • Medicaid 15.9
  • Higher Ed 10.6
  • Corrections 6.1
  • All other 34
  • Source NCSL "State Budget Actions FY 2006 and
    FY 2007," Jan. 2007

13
Distribution of the Average States Budget for
Health Services, 2003
Source Milbank Memorial Fund, National
Association of State Budget Officers and The
Reforming States Group, 2002-2003 State Health
Expenditure Report (New York Milbank Memorial
Fund, 2005), http//www.milbank.org/reports/05NASB
O/index.html
14
All these Issues Compete For Legislators
Attention
(Your Favorite Issue)
A BLIP ON THE
POLITICAL RADAR
SCREEN
15
Your Role and the Role of Your Research
  • The blip enlarger !
  • You're the Expert
  • You're the Information Resource
  • You're the Advocate

16
Public Priority
Health care costs rank near the top of American's
personal economic concerns, outranked only by
paying for gas and finding a good paying job.
28 of respondents said that they or their
families have had serious problems paying for
health care or health insurance premiums. -
Source Kaiser Family Foundation Health Tracking
Poll Election 2008 (conducted April 3-13,
2008).
17
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18
What is Evidence Based Medicine?
  • evidence based medicine means integrating
    individual clinical expertise with the best
    available external clinical evidence from
    systematic research.
  • David Sackett

19
Research to Policy Success Stories
  • Trans Fat
  • Research in recent years shows that consumption
    of saturated fat, trans fat, and dietary
    cholesterol raises low-density lipoprotein (LDL),
    or "bad cholesterol," levels, which increases the
    risk of coronary heart disease (CHD).

20
Resulting Policy Action Trans Fats
  • Bills to restrict or ban trans fats were proposed
    in 23 states (as of June 2007)
  • Included statewide bans on trans fat in in retail
    food establishments or chain restaurants
  • Limits or bans on trans fat in schools or
    state-run cafeterias
  • 20 states proposed bills to require restaurants
    to list trans fat content of menu items
  • Resolutions in Georgia, Hawaii, New Mexico
    recognized the relationship of trans fat to
    cardiovascular disease (a direct result of
    research!) and called for study of trans fat
    bans.

21
Research to Policy Success Stories
  • Obesity
  • At least 15 of adults in every state are obese
    over 25 of adults are obese in WV, MS, AL
  • Obesity rates have quadrupled for kids age 6-11
    and tripled for youth 12-19.
  • Research has proven the link between obesity and
    chronic conditions like Type 2 diabetes,
    hypertension and cardiovascular disease

22
Resulting Policy Action Obesity
  • Bills include mandating nutrition standards of
    food in school cafeterias requiring schools to
    enact wellness policies requiring vending
    machines in schools to offer nutritious options
    setting physical education requirements
    encouraging walk-able communities cheeseburger
    taxes limiting liability of food vendors to
    reinforce personal responsibility insurance
    mandates for treatment of morbid obesity,
    including surgery.

23
Research to Policy Success Stories
  • Breastfeeding
  • Research says a minimum of 3.6 billion in
    medical expenses in the US could be saved if
    number of children breastfed for at least 6
    months increased by 50.

24
Resulting Policy Action Breastfeeding
  • 21 states exempt breastfeeding mothers from
    public indecency laws
  • 13 states have laws related to breastfeeding in
    the workplace
  • 12 states exempt breastfeeding mothers from jury
    duty
  • 4 states (and the Federal government) have
    implemented of encouraged development of
    breastfeeding awareness education campaigns

25
Why these Success?
  • Chronic diseases are the leading causes of death,
    illness and disability.
  • Issues captured the spotlight
  • Financial costs are staggering
  • In 2003, medical expenses for obesity were 75
    billion taxpayers paid for half these costs
    through Medicaid and Medicare
  • Breast feeding advocates and mothers never quit!
  • Many policy actions are low- or no-cost to states
  • Effective policies promise cost-savings
  • Many options do not require dramatic change in
    the health care system
  • Address "big picture" needs
  • Address media/public outcry

26
Whats Your Role?
  • Develop an Action Plan
  • Identify strengths
  • Identify barriers
  • Identify solutions

27
Craft a Message
  • Presentation Matters! concise, easy to read,
  • ex. postcard
  • Create a Message and Stick to It
  • Make your issue part of the big picture
  • Determine shared values/make allies/recruit
    champions
  • Use Visual Language
  • Metaphors
  • Word choice matters avoid jargon and advocate's
    terms--simplify
  • Use social math
  • Order your facts
  • Don't start with what you don't want them to hear

28
Ask Yourself Some Questions
  • What are your goals?
  • What level of government is involved?
  • Who are your likely partners? Do you have a
    champion?
  • How much community/media awareness exists?
  • Can others help (e.g., private sector, faith
    community)?

29
Gather Key Information
  • Who are your legislators? Other key policymakers?
  • Who holds the power?
  • Who else can you work with?
  • How can you get your message across?
  • Seek advice from these key people
  • Remember that politics makes strange bedfellows!

30
What Is Good Evidence?
  • Systematic Review
  • Careful question formulation
  • Global search
  • Grading evidence
  • Synthesis of good evidence
  • Peer review
  • Full Disclosure

31
What Is Good Evidence, Continued
  • Hierarchy of Evidence
  • Systematic Reviews
  • Randomized Controlled Trials
  • Observational Studies
  • Case Series
  • Quality varies among all types of studies

32
DO
  • Get involved (year round)
  • Be accurate, reliable, and honest
  • Be concise!
  • Build relationships early
  • Build broad coalitions
  • Fit your issue into the "Big Picture"
  • Reach out to new members
  • Offer to be a resource
  • Be inclusive of others
  • Have written materials
  • Personalize the issue/take a field trip
  • Thank your audience

33
Dont
  • Assume you dont count
  • Mislead or give falseinformation
  • Make enemies
  • Wait until session begins to start talking
  • Be too narrowly focused
  • Refuse to compromise
  • Go on and on . . .
  • Give up

34
2006-2008 Reform Efforts
  • Coverage (especially children)
  • Quality
  • Chronic Disease
  • Prevention
  • Personal Responsibility

35
Health Reform Drivers
  • 47 million uninsured
  • Growth in health care spending still outpacing
    wage increases.
  • In the United States, health insurance coverage
    is built on an employer system. Employer
    insurance fell from 60.2 in 2006 to 59.7 in
    2007.
  • Global competitiveness for employers.

36
Challenges
  • Financing/Budgets.
  • The growing number of uninsured.
  • Fragmented health care system.
  • Many powerful and well organized entities depend
    on "their piece of the health care spending pie"
    for their survival and success.
  • No broad consensus on how to fix the system.
  • Debate over the role of government both state and
    federal.
  • Medicaid is counter-cyclical with enrollment and
    costs increasing in weak economies

37
State Year-end BalancesAs a Percentage of
General Fund Expenditures
Recession
Projected
Source NCSL surveys of state legislative fiscal
offices, 1982-2007.
38
Current State Budget Feedback
  • Dire revenue forecast (Arizona)
  • A grim outlook (California)
  • Pretty bleak (Rhode Island)
  • Severe belt tightening (Florida)
  • The news is sobering (New Hampshire)
  • A very difficult budget year (South Carolina)
  • Bleak economic outlook and difficult choices
    (Tennessee)

39
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