Research

CityHealth Initiative Improved Dozens of Health Policies in US Cities

In a new article in the American Journal of Public Health, David Jernigan explores how the nonprofit CityHealth promoted a set of urban health policies that led to 86 policy changes on housing, tobacco regulations, and more in the 40 largest US cities. 

Cities are primed for health policy innovation, as they are home to more than 80 percent of the United States population, and often the first to confront emerging health issues. In today’s highly politicized climate, cities are also uniquely positioned to advance legislation that may be stalled by bureaucracy or partisan motives at the federal or state level.

In a new article in the American Journal of Public Health, David Jernigan, professor of health law, policy & management, examines a health advocacy initiative by the nonprofit CityHealth that guided the nation’s 40 largest cities to implement 86 health policy changes in its first five years.

From 2017-2021, CityHealth, an initiative of the de Beaumont Foundation and Kaiser Permanente, used legal epidemiology to identify, score, and promote 9 policies (since updated and expanded to 12 policies) that detailed evidence-based policies that city leaders could tailor and implement in their jurisdictions to improve key social determinants of health such as housing, food access, education, and transportation.

“Cities see public health problems emerging literally on the ground and, historically, have been great laboratories for testing solutions to them,” says Jernigan, who is also CityHealth’s senior policy advisor.

To develop and hone “best practices” for cities in the policies, CityHealth utilized existing research to learn the health effects of specific public health policies, taking care to identify specific components of these policies that were vital in making them effective. They took into consideration factors such as bipartisan support, return on investment, and feasibility.

The resulting nine policy packages focused on education, housing, employment and income, food and nutrition, active living and transportation, mental health and substance use, tobacco control, public safety, and environment and air quality. 

The team initially expected that ranking and publicizing cities’ success of these policy implementations (by awarding gold, silver, or bronze medals) would garner enough positive media coverage to drive advocacy efforts, but after conversations with focus groups and city leaders, they realized they needed to take a “grasstops” approach—a more active approach to convey to city leaders the public health benefits of each set of policies.

“It soon became clear that we needed to complement the press generated by the medals with intensive outreach to city officials to educate them about the full package, and help them get to overall medals by passing these policies,” Jernigan says. Cities received overall gold for at least five gold medals, overall silver for five gold or silver medals but falling short of five golds, and bronze for four gold, silver, or bronze medals. 

Compared to suburban or rural areas, the effects of city policies “are often immediately visible,” he adds, citing Tobacco 21—one of the initiative’s initial policies that advocated for raising the minimum legal sale age of tobacco products to age 21. As data show that 95 percent of adult smokers begin smoking before they turn 21, this type of policy could—and did—yield swift and beneficial changes in limiting younger people’s access to smoking. In 2019, 25 out of 40 cities received a gold medal for their Tobacco 21 policies.

“When we adopted the Tobacco 21 policy, it was ahead of the curve, but it swept through cities and by the time the first years were finished, it had become national law,” Jernigan says.

Learn more about the CityHealth initiative and each of its policies here.