摘要：Objectives. We explored the association between the legal infrastructure of local public health, as expressed in the exercise of local fiscal and legislative authority, and local population health outcomes. Methods. Our unit of analysis was public health jurisdictions with at least 100 000 residents. The dependent variable was jurisdiction premature mortality rates obtained from the Mobilize Action Toward Community Health (MATCH) database. Our primary independent variables represented local public health’s legal infrastructure: home rule status, board of health power, county government structure, and type of public health delivery system. Several control variables were included. We used a regression model to test the relationship between the varieties of local public health legal infrastructure identified and population health status. Results. The analyses suggested that public health legal infrastructure, particularly reformed county government, had a significant effect on population health status as a mediator of social determinants of health. Conclusions. Because states shape the legal infrastructure of local public health through power-sharing arrangements, our findings suggested recommendations for state legislation that positions local public health systems for optimal impact. Much more research is needed to elucidate the complex relationships among law, social capital, and population health status. To understand law’s contribution to community health, we must identify the association between legal structures and population health indicators. This study addresses the broad legal foundations for public health improvement known as infrastructural public health law, those “laws that create and empower public health agencies and jurisdictions.” 1 (p17) The observation that public health systems vary in legal infrastructure and its expression is not new. In 1981, DeFriese et al. classified local public health systems as centralized, decentralized, or shared-control and observed that “statutes could not be relied upon to provide accurate indications of actual health department organization.” 2 (p1114) This insight foreshadowed a fundamental tenet of public health law research: the text of a statute or regulation alone cannot account for the full effect of law on population health. 3–5 Authority granted by state law to local agencies is a necessary but not sufficient condition of local decisional autonomy. 6 The Institute of Medicine’s 2003 report The Future of the Public’s Health in the 21st Century pointed to the need for research in this area by characterizing the legal foundation of public health as “replete with obsolete and inconsistent laws and regulations,” a “state of affairs [that] sometimes complicates rather than facilitates governmental contributions to the public health system.” 7(p26) Likewise, Mays et al. noted, Empirical studies are needed to describe the range of legal structures currently used for distributing governmental public health powers among state and local agencies and to compare the effectiveness of these structures.8(p263) Examinations of the nature, extent, and mechanisms of local public health systems’ impact on population health were infrequent until the emergence of public health systems and services research as a focused area of inquiry. 9,10 Public health systems research has now identified typological models that can support comparative studies to identify variation in performance. 11,12 A stronger evidence base for change can inform health law reform initiatives and improve their likelihood of success.
