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The fourth of five commentaries on “Bloomberg's Health Legacy: Urban Innovator or Meddling Nanny?” from the September-October 2013.


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  2. Abstract
  3. Exchange

Professor Gostin's description of Mayor Bloomberg's legacy is exactly on point. Bloomberg has implemented a series of public health interventions that have improved the lives not only of New Yorkers but also of people around the world, who are now able to point to his visionary efforts and say, “New York has done it. Why can't we?” As mayor, Bloomberg was uniquely willing to maximize the authority of his office to further public health. As the United States moves toward implementation of the Affordable Care Act, there is now more than ever a need for public health leadership of Bloomberg's caliber.

For states like Kentucky, which has fully embraced the ACA, public health measures must become integral to the discussion of the future of health care delivery. As the only Southern state that is both running its own health benefit exchange and expanding Medicaid, Kentucky is poised to be healthier and more economically competitive. But meaningful progress on health outcomes requires that all stakeholders think holistically to build on the ACA, moving beyond the traditional popular viewing of health primarily through the lens of personal responsibility, toward a more inclusive framework acknowledging the myriad socioeconomic and environmental influences on health.

A broad-based public health focus is not optional in a post-ACA world—the realities of health care cost control will demand it. Before, cost containment was achieved primarily through cost-shifting (in employer-based and individual market coverage), tightened eligibility standards (under Medicaid) and more limited benefits (in all these cases). With the ACA coverage requirements, these strategies will no longer be possible—under the ACA, we are all in this together, and the health of each of us (along with the attendant costs of poor health) influences the cost for everyone. And we will be better for it, because for the first time there is no viable option for long-term cost control but to improve health at a population level.

Make no mistake—access to health care is a critical precondition for health, as World Health Organization Director General Margaret Chan emphasized in stating that universal coverage is “the single most powerful concept that public health has to offer.” Kentucky has led many states in capitalizing on the ACA's potential. But access to care is insufficient for population health without critical public health measures addressing the socioeconomic determinants that so strongly influence health outcomes, creating the conditions in which people can lead healthy, fulfilling lives.

Bloomberg well understands this and continues to show tremendous leadership, most recently by successfully urging the City Council to raise to twenty-one the minimum age for tobacco purchases. New York now has among the lowest rates of youth smoking in the country—a dramatic improvement undoubtedly caused in significant part by the strong tobacco-control measures Bloomberg championed. In contrast, Kentucky's rate is among the highest, an unsurprising statistic given relevant sociocultural factors: tobacco taxes are low, less than 40 percent of the population is covered by comprehensive smoke-free workplace legislation, cigarettes are sold—and in some cases smoked!—in some government buildings, and tobacco has deep historical cultural significance in much of the state.

While the ACA requires coverage of tobacco cessation as a preventive service, the act changes none of the sociocultural factors influencing tobacco use. Without a systemic public health approach, Kentucky is likely to keep seeing lung cancer rates among the country's highest—only now, under the ACA, millions more will be spent on lung cancer treatments, most of which will be unsuccessful, given the notoriously low lung cancer survival rates.

We can and must do better. As public health advocates, we must continue to strengthen popular understanding of the linkages between health care, public health, and healthy lives, building on the momentum created by the ACA. As government, we should lead by example in structuring our workplaces and employee benefit packages.

We must reject reflexive antipaternalistic objections of “my health is none of the government's business.” This is patently false. As Gostin rightly observed, governments should be held accountable for the health of their inhabitants. And popular rhetoric to the contrary, no man is an island—our health, and our lives, are all intertwined. Bloomberg understood and acted upon this better than any elected leader in recent memory. Because of how he shifted the paradigm for the appropriate scope of government's role in promoting population health, leaders around the country and the world may now stand on his shoulders as they strive to create societies in which all people have the ability to lead healthy, fulfilling lives.

The views expressed herein are solely my own and do not necessarily represent the views of the Cabinet for Health & Family Services, Frankfort, KY, for which I am the executive director of the Office of Health Policy.