A new empirical paper from the University of Michigan examines behavioral responses to two forms of governmental authority that have direct relevance in public health: (1) the authority to act by exercising legal powers and duties that facilitate public goods production; and (2) authority as a presumed source of expert knowledge and information. While governmental public health agencies routinely use both mechanisms to promote health and prevent disease and injury, the authors of this new paper point out that the research community has paid insufficient attention to distinguishing these two forms of authority and studying how they affect behavior alone and in combination. In this post, I suggest that these distinct forms of governmental authority have particular relevance for the discussions about public health roles within population health improvement strategies and the increasingly popular concept of collective impact.
First, a quick recap of the public and policy discussions surrounding population health strategies. The Affordable Care Act has ushered in a period of enhanced enthusiasm for and experimentation with strategies designed to improve health status on a broad, population-wide basis – at the level of a city, county, neighborhood or other group definition. These strategies contrast with the one-person-at-a-time approach used in much of clinical health care delivery. Former CMS administrator Dr. Donald Berwick characterized these strategies as the third element of his Triple Aim approach to reforming the U.S. health system. Population health strategies aim to address fundamental determinants of health, often through the collective actions of multiple stakeholders that extend far beyond the traditional boundaries of medical care and public health programming – an approach popularized recently in a widely-read issue of the Stanford Social Innovation Review. The growing interest in population health strategies post-ACA even can be seen in Google Trends data for the term “population health”:
As I wrote in a recent discussion paper for the Institute of Medicine’s Roundtable on Population Health Improvement, governmental public health agencies have long advocated for population-wide approaches to health improvement, but they have not always been successful in securing the financial, human, and political capital necessary to implement such approaches successfully. After all, population health strategies are public goods. Convincing organizations to depart from their own institutional interests to undertake collective actions can be difficult, as economic game theorists and governance theorists have long cautioned. A growing discussion has focused on which actors are best positioned to function as integrators for population health strategies, providing the necessary convening, motivating and enabling processes that stimulate and support public goods production in health. As part of this discussion, some observers have questioned whether governmental public health agencies – particularly those functioning at state and local levels – can function successfully as integrators. My discussion paper suggests some economic principles that could inform how these agencies adapt to population health strategies, including adaptation through substitution, synergy, and independence. But, admittedly, empirical data on these issues are hard to come by.
Enter stage right, the new paper from the University of Michigan’s group of experimental economists and social scientists. The authors have strong theoretical reasons to hypothesize that the two types of authorities described at the beginning of this post – the “authority to” exercise legal powers and the “authority in” a relevant body of knowledge – may be important in motivating and enabling voluntary contributions to public goods projects. These same authorities are used widely in public health policy and practice, particularly the “authority to” powers in areas such as taxing tobacco products, licensing retail food vendors, and issuing quarantine and isolation orders for infectious disease control. The “authority in” elements of public health are perhaps a bit more subtle, such as issuing recommendations for vaccination and use of other preventive services, and collecting surveillance data on disease and risk factor prevalence so as to motivate and inform health improvement strategies.
Using a series of randomized laboratory experiments, the authors show for the first time that exercising both types of authorities in combination generates greater public goods contributions than using either authority by itself. How did the study show this? During the experiments, people recruited into the study were randomly sorted into groups, given an allotment of resources with actual cash value, and then confronted with a series of decisions over time regarding how to allocate resources between a group project (the public good) vs. a private project, with the pay-offs from these decisions being partly contingent on how other subjects in the experiment use their resources. In some decisions, subjects faced explicit incentives and penalties designed to steer decisions toward the group project (“authority to”), while in other decisions subjects were given information about suggested contribution amounts based on expert opinions about the pay-offs that would result (“authority in”), with different sources of expert opinion assigned randomly. In all decisions, the true production function that determined the payoffs from investments in group and individual projects remained unspecified to the subjects. The results from a series of decision-making experiments show that “penalizing non-social behavior without expert explanation does not increase voluntary contributions, nor does expert explanation without the threat of penalty, but together they induce more contributions than any other combination of policies.”
If these results generalize to the public goods problem of population health strategies, then they suggest governmental public health agencies may have key roles to play in mobilizing collective action. In many cases, public health agencies hold relevant regulatory and enforcement powers within their jurisdictions, and they also have the potential to function as neutral and credible sources of information about health risks and prevention strategies. Armed with the resources and training needed to use these authorities in support of population health strategies, public health agencies could function as powerful integrators.
Of course, all of the usual caveats surrounding laboratory decision-making experiments apply here, particularly the uncertainties about how the results may apply to real-world decision-making in public health policy and practice. Studies supported by our PHSSR research center highlight other complicating factors: governmental public health agencies vary widely in the legal authorities they are empowered to exercise (see for example this Minnesota PBRN study); and agencies also vary widely the resources they are given to carry out their authorities (see for example this Ohio PBRN study). PHSSR research has shown that agencies having both legal and fiscal discretion in exercising public health authorities tend to perform best in implementing the authorities.
Taken as a whole, the available research suggests that governmental public health agencies are well positioned to play key roles as population health strategy integrators using both their legal authority and their scientific authority. These roles, however, must be tailored to fit the degree of legal and fiscal discretion available to the agency. Moreover, the field of public health services and systems research (PHSSR) has important roles to play in strengthening the scientific authority of these agencies by producing reliable knowledge about the effectiveness of public health strategies and the “pay-offs” that can be expected. We also need more comparative research that examines public health agency roles within population health strategies and the health and economic results that are achieved, so as to determine whether and how Michigan’s laboratory results apply to real-world public health settings.