Local Legal Infrastructure and its Association with Population Health

Research Objective: The relationship between local public health's legal infrastructure and population health outcomes has generated much speculation but little evidence. An example of legal infrastructure is home rule, which gives officials broad governance over issues such as spending decisions. If we find that populations in jurisdictions with strong local control are healthier than those in jurisdictions with less autonomy, holding other relevant factors constant, public health leaders will have an empirical base for proposing statutory change. If specific demographic characteristics are associated with variations in outcomes, we will have evidence to support more nuanced approaches to local public health governance. Study Design: Dependent variables include premature mortality rates and other jurisdiction-level metrics from the Mobilize Action Toward Community Health (MATCH) database. Independent variables represent legal infrastructure: home rule, board of health power, and public health delivery system type. Control variables are included in a regression model that tests the relationship between legal infrastructure and population health status. Population Studied: We analyze 231 jurisdictions with at least 100,000 residents (n = 231) that have documented types of public health activity from 1998-2006. Principal Findings: Analyses show significant relationship between legal infrastructure and population health status through reducing the impact of negative social determinants of health. For example, home rule mediates the relationship between poverty and premature death rates. In jurisdictions without home rule, a one unit increase in poverty results in a significant increase in years of potential life lost before age 75 when compared with home rule jurisdictions.