Dec 7, 2021
Colleen L. Barry, Ph.D., M.P.P., and Brendan Saloner, Ph.D.
In Policy Analysis and Management

Policy has been critical to achieving major public health advances, including in tobacco control, maternal and child health, and injury prevention.1 Policy — which includes legislation, rulemaking, and public campaigns — offers a set of tools for improving health at the population level. The opioid crisis — which has claimed more than 500,000 American lives since 1999 and contributed to declining life expectancy — illustrates five general steps essential for using public policy to produce substantial gains in population health. These steps are relevant to myriad public health challenges, such as climate change, gun violence, and the obesity crisis.

Essential Steps for Using Policy to Improve Population Health.

A first step in addressing a major public health challenge through policy change is defining the problem (see table). Problem definition dictates and constrains the types of policy solutions considered. For example, framing the opioid crisis as a criminal justice problem implies a law-enforcement response (e.g., stringent sentencing laws for drug possession), whereas framing it as a health problem implies a health services response (e.g., improved access to evidence-based treatments).

Quantifying a problem’s impact in morbidity or mortality terms is often the starting point for understanding its scope. Alarming numbers alone, however, may have counterintuitive effects on people’s will to act. As the toll of a crisis increases, public empathy and willingness to help tend to decrease. Studies by Paul Slovic illustrate this paradox: society often fails to respond to large-scale humanitarian crises while highly valuing a single life. Slovic’s studies underscore the challenge for human cognition of thinking about or connecting with millions of people.2

Although using storytelling to define societal problems can humanize them, it often backfires in public health. A child refugee may elicit empathy for people affected by a humanitarian crisis, but depictions of people who are obese, unemployed, or incarcerated or who sell sex or use drugs may not. Defining problems involves constructing narratives about who is to blame, emotional responses to the affected population, and moral judgments about deservingness, influencing perceptions about appropriate solutions. Narratives that fail to overcome the negative stereotypes can lead to support for punitive approaches (e.g., involving child protective services when a pregnant woman uses opioids rather than connecting her with effective treatment).3 Stigma against people who use drugs is further heightened when it intersects with race, given the deep-seated racial prejudices entangled with punitive attitudes toward drug use. Randomized experiments are being used to test which types of messages most effectively reduce stigma and shift attitudes toward public health–oriented policies and away from punitive, shaming policies.

Once a societal problem has been defined, a second step involves elevating it on the agenda to capture and sustain the attention of the public and policymakers. In his classic study of the issue-attention cycle, Anthony Downs describes the common failure to recognize dire conditions that stem from major societal problems, such as racism, poverty, and malnutrition.4 He describes the cycle of a problem suddenly leaping into prominence, remaining salient briefly, and then fading from public view — often as the underlying conditions that precipitated it remain largely unaddressed. This pattern is reflected in the history of U.S. drug policy: a largely invisible heroin crisis in poor urban communities of color suddenly gained prominence (and resources) when primarily White, suburban, middle-class communities were affected.

A central premise of Downs’s analysis of the issue-attention cycle is that a complex health problem is unlikely to remain in the spotlight indefinitely. Attention inevitably shifts when the costs of seriously confronting the problem are revealed or when a new crisis captures the public’s eye. An initial burst of optimism regarding society’s ability to overcome the drug crisis has diminished in recent years, with growing recognition of the size of the needed investment in hard-hit communities. Opposition has also calcified from powerful interests, including pharmaceutical companies and drug distributors with financial stakes in continuing the policies and practices that fed the crisis. Only with costly litigation have industry practices shifted to respond to the crisis. More recently, the Covid-19 pandemic has diverted attention from the drug crisis, even as overdose deaths continue climbing. It is therefore essential to take advantage of windows of opportunity to push through major policy action; making change using policy becomes harder after public focus shifts.

A third critical step involves selecting among alternatives for addressing the problem in question. Trade-offs often arise because policies rarely benefit all groups uniformly. In the face of trade-offs, a common strategy is selecting the option that produces the greatest health benefit, a utilitarian criterion. This strategy overlooks equity implications of policy choices, including the impact on the most vulnerable people or those in the most immediate danger. Should we prioritize policies targeting persons at highest risk for opioid overdose or direct resources to prevention programs targeting all young people? Should we focus on implementing policies to improve prescribed analgesic dosing or direct resources toward intensive outreach to overdose survivors? Each approach may have value, but limited time and resources often necessitate prioritizing one over the other.

The most powerful policy tools are those with a strong evidence base that can increase equity while efficiently targeting resources to people in greatest need. Certain harm-reduction policies — which enable people who do not wish to stop or who are unable to stop using drugs to make positive behavior changes while reducing their risk — can achieve these often-competing goals. Although some options require federal action (e.g., permitting the opening of “overdose prevention sites” where people can use previously purchased drugs under medical supervision), others can be pursued by local authorities collaborating with people directly affected. A standing-order law allowing pharmacists to dispense naloxone, which rapidly reverses an overdose’s respiratory effects, to any person is one evidence-based policy that can allow lifesaving resources to be distributed efficiently while enhancing equity by engaging people who are disconnected from traditional medical care.

Ultimately, the best policy tools are those that will achieve the greatest gains in population health. Thus, the fourth step is enacting policies that can be implemented at scale. Policy change is often plodding and incremental; most federal legislation that’s introduced is never enacted, and the regulatory process moves slowly and requires administrative resources for monitoring and enforcement. Litigation can serve a policy function when legislative action is insufficient or infeasible. For example, ongoing opioid litigation has sought damages against pharmaceutical manufacturers and distributors to fund abatement efforts.5 Litigation is costly, however, and often fails to prevent future harms. Even when policy change is possible, the instruments of policy — such as taxes, mandates, and public awareness campaigns — are often blunt, and they may achieve behavior change only at a high cost. Taxing opioid analgesics to pay for public drug treatment is a regressive policy that imposes a high financial burden on vulnerable and low-income patients.

Public health often takes a paternalistic, mandate-oriented approach in implementing policies at scale. The obvious challenge with paternalism is that people don’t generally appreciate being told what to do. Also, mandates require enforcement, which is costly and is often underfunded. Alternative policy approaches — including incentives and nudges — aim to persuade or steer people toward better choices rather than mandating them. Health insurance plans may use value-based design to try to drive consumers toward effective care (e.g., medications such as buprenorphine and methadone) and discourage use of low-value care (e.g., long-term residential treatment facilities not offering medication). Nudges, grounded in behavioral economics, aim to change the presentation of choices to direct people toward decisions that will improve their lives. In drug policy, barriers to care can be lowered by nudges such as offering buprenorphine induction in emergency departments after nonfatal overdoses or allocating resources to make mobile methadone treatment available outside jails and prisons to facilitate rapid access to treatment on release from incarceration, when the risk of overdose is heightened.

A final step is using rigorous evaluation to confirm that policies are leading to expected health improvements and to monitor for unintended consequences. Evaluating policy can increase the transparency of strategies’ overall costs, benefits, and equity implications and ultimately lead to better-designed approaches and increased public trust. The importance of rigorous policy evaluation should be anticipated early and incorporated into the implementation process (e.g., through mandated data collection and the designation of an independent evaluator). Even with good outcome tracking, establishing the causal impact of policies can be tricky because large-scale initiatives are rarely implemented with randomized, controlled trials. However, quasi-experimental research methods have increased understanding of the effects of opioid-related policies. Researchers have leveraged the variation in state laws to evaluate policies such as prescription-drug monitoring programs, naloxone access laws, and treatment coverage expansions. Close partnership between evaluators and policymakers can support policy refinements over time. Major initiatives such as the National Institutes of Health HEALing Communities grants, launched in four states and involving researchers, community members, and public officials, can suggest models for rapid-cycle policy evaluation.

Turning the corner on the opioid crisis has proven challenging. Despite multiple years of attempts to tackle the problem, overdose deaths reached historic highs in 2020 and show no signs of slowing. Consideration of these five steps may help explain why we have been unable to overcome this crisis: strong interventions often cannot escape the gravitational pull of a slow-moving political process, industry resistance, pervasive stigma, underfunding by states and localities, and a public wary of large government programs. A clearer understanding of the constraints on policy, however, can help leaders weigh trade-offs when taking policy action and develop credible evaluation and communication strategies to persuade the public that problems are solvable. Ultimately, most policy fixes are incomplete, but even imperfect solutions can build positive feedback loops for future progress.

Listen to an Interview with Dr. Colleeen Barry on using public policy to improve population heath here

Link to original Perspective in the New England Journal of Medicine here