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标题：Regulatory Enforcement and Fiscal Impact in Local Health Agencies
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作者：Julia F. Costich ; Kristina M. Rabarison ; Monika K. Rabarison 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2015
卷号：105
期号：Suppl 2
页码：S323-S329
DOI：10.2105/AJPH.2014.302446
语种：English
出版社：American Public Health Association
摘要：Objectives. We used a cross-sectional, retrospective study design to analyze the association between local health agency regulatory activities and revenues from nonclinical fees and fines (NFF). Methods. We extracted data from the 2010 National Association of County and City Health Officials (NACCHO) Profile Survey, the most recent report including NFF information, and used 2-part multivariable regression models to identify relationships between regulatory activities and revenue. We also interviewed LHD directors on access to revenue from fines. Results. NFFs generated substantial revenue for most LHDs, increasing in scope and amount with jurisdiction size for all but the largest municipalities. The greatest proportion of net revenue came from public pools, campgrounds and recreational vehicles, and solid waste disposal. For small and mid-sized LHDs, enforcement activities generated revenue in a dose–response pattern, with higher returns for increased activities. LHDs in decentralized governance states collected more NFF revenue than those in centralized states. States vary regarding LHD access to revenue from sanctions. Conclusions. The fiscal impact of changes in regulatory activity needs careful assessment to avoid unanticipated consequences of applicable law. The constitutional authority of states to enact distinct laws that affect public health has given rise to natural experiments that can shed light on the relationship between statutory implementation and achievement of statutory goals. Like state statutory regimes addressing public health, local variations in public health law and practice are associated with variations in outcomes. Public health systems have a pivotal role in the enforcement of public health laws, and this role is deeply embedded in the services provided by local health agencies. The importance of enforcement is demonstrated by its status as the 6th of the Centers for Disease Control and Prevention’s 10 essential public health services: “Enforce laws and regulations that protect health and ensure safety.” 1 Specific types of enforcement activity may be required by state law, or local agencies may fall under a more general mandate to protect their populations. Enforcement can also provide local health agencies with a funding stream that, at least in theory, supports their regulatory activities or yields additional revenue. However, increased regulatory enforcement by public health agencies does not always yield increased revenue. For example, sanctions may be inconsistently imposed, fee revenue may be inadequate to fund the additional staff time required, or governing law may direct revenue away from the public health agency. In the following analysis, we identify the range of agency enforcement activities and related revenue, first locating the subject in its legal and behavioral context, then assessing the impact of variations in agency enforcement roles, and finally recommending strategies that could help agencies enhance the benefits they can derive from enforcing public health laws. Public health agencies’ enforcement of public health law takes many forms, including licensure, inspection, and a broad range of sanctions, from the encouragement of voluntary compliance to outright prosecution of violators. 2 The structural capacity of entities responsible for implementing public health laws—their access to resources and independence from countervailing influences—affects their ability to carry out their duties, along with their understanding of the law and their role in its implementation. 3 Approaches to regulatory implementation are inevitably influenced by policy considerations and political divisions. 4 Controversy can arise when public health laws are perceived as infringing on the ability of individuals to act in their own interests. 5 Woolf and Aron 6 identified erratic and inconsistent enforcement as a factor contributing to the inferior performance of all US health care—not just public health initiatives—in comparison with other industrialized nations: Opposition to rigorous enforcement applies to speed control, life-style choices, and restrictions on industry. Constitutional prohibitions restrict not only unreasonable searches but also proscribe interventions on gun possession. Resource limitations apply not only to law enforcement but also explain deficiencies in public health programs, the foods chosen for school lunch menus, and weakness in social and safety net services. 6 ^(p231) Implementation shortfalls have been further exacerbated by cuts in public health funding and staffing since 2008 that have reduced the complement of public health and safety staff available to execute enforcement duties. 7–10 As state and local public health budgets have faced ongoing constraints, the search for additional revenue streams has become increasingly urgent. Fees and fines associated with the traditional local health agency role in regulatory enforcement may present an opportunity for agencies; conversely, inadequate or uncollected assessments may make enforcement a losing proposition. We therefore used data from the 2010 National Association of County and City Health Officials’ (NACCHO’s) National Profile of Local Health Departments 11 to explore the following questions: Is a broader range of local health agency activity in licensing, inspection, and regulation associated with a larger amount of related revenue in the agency budget? Are specific categories of regulatory activity associated with larger proportions of related agency funds? We also conducted structured interviews with key informants in 3 diverse local health departments (LHDs) to provide qualitative information about the relationship between enforcement actions and revenue.