Landmark Public Health Laws and Court Decisions
LANDMARK PUBLIC HEALTH LAWS AND COURT DECISIONS
Over the years, public health and medical care services in the United States have expanded incrementally. Modern public health services and medical care programs have emerged from step-by-step actions to deal with specific problems and the needs of specific populations. This article traces the evolution of public health services and medical care programs by describing landmark legislation and court decisions that have strengthened public health and extended medical care to more people. In describing these signal legislative and judicial actions of the twentieth century, many important statutes and judicial decisions are omitted due to the limitations of space. This account is not a substitute for a thorough historical review of the growth of public health and medical care in the United States, but it may illuminate the possibilities of the characteristically American incremental approach for strengthening public health and medical care.
STATE POLICE POWER
In 1905, the U.S. Supreme Court upheld compulsory vaccination as a reasonable exercise of the state police power to protect the health, welfare, and safety of its citizens (Jacobson v. Massachusetts ). This seminal case on the nature of the police power—the legal basis for state authority in the field of public health—involved a compulsory vaccination regulation of the Cambridge, Massachusetts, Board of Health. The defendant refused to be vaccinated and contended that the requirement invaded his liberty and was hostile to "the right of every freeman to care for his own body and health in such a way as to him sees fit." But the Court held that
the liberty secured by the Constitution to every person … does not import an absolute right in each person to be at all times and in all circumstances wholly freed from restraint … it was the duty of the constituted authorities primarily to keep in view the welfare, comfort and safety of the many, and not permit the interests of the many to be subordinated to the wishes or convenience of the few.
Acknowledging that there is a sphere in which the individual may dispute the authority of a government, the Court stated
it is equally true that in every well-ordered society charged with the duty of conserving the safety of its members the rights of the individual in respect of his liberty may at times, under the pressure of great dangers, be subjected to such restraint, to be enforced by reasonable regulations, as the safety of the general public may demand …
One of the basic functions of public health is protection of the environment in which people live and work. The National Environmental Policy Act of 1969 (42 U.S.C.A. §4321 et seq.) marked a watershed in the development of environmental controls. In response to concerns about fragmented environmental programs among diverse federal agencies and lack of effective controls over the multiplicity of antipollution measures, the National Environmental Policy Act provides for an over-view of environmental protection efforts and a mechanism for integrating and coordinating the many environmental programs. An important provision of the statute is the requirement for environmental impact statements before any major federal projects expected to have significant impact on the environment can be undertaken. Many states have enacted state environmental policy laws modeled on the federal statutes.
In 1970, Congress enacted the Occupational Safety and Health Act (29 U.S.C.A. §§651–78) "to assure so far as possible to every working man and woman in the Nation safe and healthful working conditions and to preserve our human resources" (651[b]). The act covers every state and territory. It provides for the promulgation of standards by the Secretary of Labor, created the National Institute of Occupational Safety and Health (NIOSH) to conduct studies and research to develop standards, authorizes inspections of workplaces, supports worker training and education, enforces compliance with standards, and encourages state plans that meet the criteria for approval by the Secretary of Labor. In the thirty years that this comprehensive, national law has been in effect, tragic industrial deaths and diseases have been markedly reduced, and workers' health has been protected and advanced.
THE SOCIAL SECURITY ACT
The Social Security Act of 1935 (42 U.S.C.A. §1301 et seq.), according to William Shonick, "was the first substantial entry of the national government into the general field of social welfare and may be viewed as its founding charter." In addition to its provisions on social insurance for retirement benefits and unemployment insurance, the act provides for old age assistance (Title I), aid for dependent children (Title IV), and aid to the blind (Title X). The provision for grants to the states for state and local public health departments (Title VI) and for maternal and child welfare (Title V) led to vastly increased numbers of full-time local health departments, strengthened staffing to provide public health services, and improved support for maternal and child health services.
Over the years, the Social Security Act became the structure for important advances in medical care. In 1965, Congress enacted Medicare (Title XVIII), a social insurance program for hospital and physicians' care for persons over sixty-five and Medicaid (Title XIX), an expanded program paying for medical services for certain categories of low-income people, financed jointly by the federal and state governments. In 1972, Medicare was expanded to include persons of any age with end-stage renal disease and in 1973 disabled persons of any age as defined by Medicare.
Amendments to the Social Security Act have included, among others, the following: (1) measures for peer review of the quality of care (Professional Standards Review Organizations, 1972 and Peer Review Organizations, 42 U.S.C.A. § 1320c-3, §1154 [a][A], [B], [C]); (2) the Emergency Medical Treatment and Labor Act (EMTALA 1986, 42 U.S.C.A. §1395dd) requiring hospitals receiving Medicare payments and having an emergency department to serve and stabilize, before transferring, emergency patients and women in labor, regardless of ability to pay; (3) welfare reform (the Personal Responsibility and Work Opportunity Reconciliation Act, 42 U.S.C.A. §603 et seq.), which replaced the entitlement program, Aid to Families with Dependent Children (AFDC), with capped block grants to the states known as Temporary Assistance to Needy Families; and (4) the State Children's Health Insurance Program, enacted in 1997 as Title XXI of the Social Security Act. Much discussed is the expansion of the Social Security Act to add outpatient pharmaceutical benefits to the Medicare program.
THE HILL-BURTON ACT AND HEALTH FACILITIES
During the Depression of the 1930s and continuing through World War II, hospitals in the United States had been neglected and were in great need of repair. The Hill-Burton Hospital Survey and Construction Act of 1946 (42. U.S.C.A. § 291 et seq.) was a brilliant piece of legislation. It provided funds for private and public hospital construction. It launched organized planning of health facilities by requiring states to develop a state hospital plan and by providing funding for planning. It initiated regulation of health facilities by setting standards and requiring licensing of facilities. Thus, this tripartite legislation financed hospital construction on condition of planning and regulation of health facilities by the states.
In 1965, a landmark case established the liability of hospitals for negligence in monitoring and supervising the quality of care in their hospitals. Darling v. Charleston Community Memorial Hospital involved a malpractice action by an injured football player against the hospital where negligent treatment necessitated amputation of his right leg below the knee. The case held that a hospital has an independent duty to provide medical care to its patients, that it has a duty to provide more than bed and board, and that no longer is the hospital solely the doctor's workshop. Darling marked a turning point in the responsibility of hospitals for the quality of care provided in their facilities.
THE FOOD, DRUG, AND COSMETIC ACT
Legislation regulating food, drugs, cosmetics, and equipment is important because these resources essential for assuring health are produced entirely in the private sector. The Pure Food and Drug Act of 1906 prohibited the adulteration and misbranding of drugs. The Federal Food, Drug, and Cosmetic Act of 1938 (21 U.S.C.A. § 301 et seq.) required that the safety of a drug be demonstrated prior to its distribution. The landmark Drug Amendments of 1962 (21 U.S.C.A. § 355) required proof of efficacy before a drug could be marketed. In support of this legislation were the facts that consumers were wasting money on drugs without benefit and that reliance on ineffective drugs could be dangerous when safe and effective alternatives were available.
In 1996, the Food and Drug Administration (FDA) asserted jurisdiction over cigarettes and smokeless tobacco, finding that nicotine is a drug and that cigarettes and smokeless tobacco are drug-delivery devices affecting the structure and function of the body, within the meaning of the Food, Drug, and Cosmetic Act. The FDA issued regulations restricting the sale and distribution of cigarettes and smokeless tobacco in an effort to protect children and adolescents and reduce tobacco addiction in future generations. Although recognizing the great hazards to health posed by tobacco, the U.S. Supreme Court in a five-to-four decision held that the Food and Drug Administration lacked authority to regulate tobacco products and that such regulation was a matter for Congress to decide (Food and Drug Administration v. Brown and Williamson Tobacco Corp. ).
THE CIVIL RIGHTS ACT
Federal antidiscrimination laws have had a major impact on health facilities and, in fact, on all aspects of civil society. Title VI of the 1964 Civil Rights Act (42 U.S.C.A. §§2000d, 2000e) prohibits discrimination on the basis of race, color, or national origin in any program or activity receiving federal financial assistance. Title VII, as amended by the Equal Employment Opportunity Act of 1972, prohibits private employers and state and local governments from discriminating on the basis of age, race, color, religion, sex, or national origin.
The Civil Rights Act of 1964 is the centerpiece of a congeries of antidiscrimination laws that have made the U.S. public health system more ethical and equitable, including the Equal Pay Act of 1963 (29 U.S.C.A. §206 (d)), the Age Discrimination in Employment Act of 1967 (29 U.S.C.A. §621), the Rehabilitation Act of 1973 (29 U.S.C.A. §701 et seq.), the Americans with Disabilities Act of 1990 (42 U.S.C.A. §12101 et seq.), and the Individuals with Disabilities Education Act (20 U.S.C.A. §1400 et. seq.).
LEGALIZATION OF ABORTION
For a century in the United States, desperate women faced with unwanted pregnancies resorted to abortion that was illegal, clandestine, and dangerous. Nearly one-third of all maternal deaths were caused by illegal abortion. In 1973, in a dramatic response to a major health problem and social need, the U.S. Supreme Court held that old-style abortion laws, which made abortion a crime except when performed to save the life of the woman, were a violation of the woman's fundamental right of privacy (Roe v. Wade ) and also held unconstitutional reformed laws that allowed abortion on categorical grounds (Doe v. Bolton ).
In 1992, the U.S. Supreme Court reaffirmed its holding, stating that Roe v. Wade had acquired "a rare precedential force and could be over-turned under fire only at the cost of both profound and unnecessary damage to the Court's legitimacy, and the nation's commitment to the rule of law." But the Court held that the right of privacy is not a fundamental right that requires strict scrutiny of state legislation but rather that restrictive state legislation may be struck down only if it imposes an undue burden on the woman (Planned Parenthood of Southeast Pennsylvania v. Casey ). This is a new test that broadens the right of states to enact legislation restricting the right to choose abortion.
THE NEW YORK MENTAL HYGIENE LAW
Not all landmark legislation is enacted at the federal level of government. State legislation may be of singular importance in protecting the physical and mental health and the legal rights of the people.
The New York Mental Hygiene Law of 1964 revolutionized involuntary admissions to mental hospitals. This statute abolished long-standing judicial procedures for compulsory hospitalization of the mentally ill, which, though legalistic in form, provided only the illusion but not the reality of due process. Instead, the statute provided for initial medical admission on the recommendation of two physicians, like an admission to a hospital for a physical illness, followed by immediate and periodic judicial review so that no patient becomes a forgotten person. A key provision of the law was the establishment and funding of a new agency, the Mental Health Information Service, to inform the court of the patient's condition and to inform the patient of his or her legal rights.
Other states have also modernized their mental hospital admission laws. And, with the decline in hospitalization for mental illness, nearly all states have authorized involuntary outpatient admission to community mental health services.
FLUORIDATION OF PUBLIC WATER SUPPLIES
Fluoridation of public water supplies is an ideal public health measure because it requires minimal action by public health officials, a modest expenditure of funds, and no behavioral change by the public. Adjusting the fluoride content of the water supply to one part of sodium fluoride to a million parts of water yields enormous benefits in dental health—a reduction of sixty percent in dental caries in children who have drunk fluoridated water since birth, a benefit that lasts throughout their lifetime.
In 1965, the Illinois Supreme Court upheld a fluoridation ordinance of the city of Chicago, rejecting the contentions of the plaintiffs that the ordinance was an improper exercise of the police power because tooth decay is not a communicable disease, that the ordinance benefits only a segment of the population (children), and that it is mass medication in violation of the right of each individual to determine whether he or she wishes to be treated (Schuringa v. City of Chicago ). The court held the ordinance a proper exercise of the police power, although tooth decay is not a communicable disease, and not invalid as class legislation because the benefits carry over into adulthood. Even if considered medication, fluoridation is so related to the common good that the rights of the individual must give way. The U.S. Supreme Court refused review of Schuringa —the leading case on the constitutionality of fluoridation ordinances.
(see also: Abortion; Civil Rights Act of 1964; Community Water Fluoridation; Environmental Impact Statement; Environmental Movement; Environmental Protection Agency; History of Public Health; Immunizations; Medicare )
Barton, P. L. (1999). Understanding the U.S. Health Services System. Chicago, IL: Health Administration Press.
Grad, F. (1985). Environmental Law, 3rd edition. New York: Matthew Bender and Company.
McCafferty, G., and Dooley, J. (1990). "Involuntary Outpatient Commitment: An Update." Mental and Physical Disability Reporter 14(3):277–287.
McKray, G., and McKray, J. (1980). "Consumer Protection: The Federal Food, Drug, and Cosmetic Act." Legal Aspects of Health Policy: Issues and Trends. Westport, CT: Greenwood Press.
New York Mental Hygiene Law (1964). Section 9.01 et seq., McKinney's 1996.
Shonick, W. (1995). Government and Health Services: Government's Role in the Development of U.S. Health Services, 1930–1980. New York: Oxford University Press.
Smith, D. B. (1999). Health Care Divided: Race and a Healing Nation. Ann Arbor: University of Michigan Press.
U.S. Food and Drug Administration (1996). "Nicotine in Cigarettes and Smokeless Tobacco is a Drug and These Products Are Nicotine Delivery Devices under the Federal Food, Drug, and Cosmetic Act: Jurisdictional Determination." 61 Fed. Reg. 44619–45318.
—— (1996). "Regulations Restricting the Sale and Distribution of Cigarettes and Smokeless Tobacco to Protect Children and Adolescents." 61 Fed. Reg. 44396.
Darling v. Charleston Community Memorial Hospital, 33 Ill.2d 326, 211 N.E. 2d 253 (1965).
Doe v. Bolton, 410 U.S. 179 (1973).
Food and Drug Administration v. Brown and Williamson Tobacco Corp., U.S., 120 S.Ct. 1291 (2000).
Jacobson v. Massachusetts, 197 U.S. 11 (1905).
Planned Parenthood of Southeastern Pennsylvania v. Casey, 505 U.S. 833 (1992).
Roe v. Wade, 410 U.S. 113 (1973).
Schuringa v. City of Chicago, 30I11.2d 326, cert. den. 379 U.S. 864 (1965).
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