Tag Archives: Economics

‘New age trade’ could mean rollbacks on public health – what we found from doing an HIA on the proposed TPP in Australia

Today’s guest blog is by Katie Hirono from the Centre for Health Equity Training, Research and Evaluation at UNSW Australia. She is one of the co-authors of an HIA on the Trans Pacific Partnership Agreement (TPP).

Negotiators from the 12 TPP countries are convening this week in Atlanta for attempted last-stage negotiations, with ministers expected to meet from 30th September. Over the past five years, many public figures have commented on the TPP, including Senator Elizabeth Warren, Nobel Laureate economist Joseph Stiglitz, and reputable organisations like Doctors without Borders and the AFL-CIO. As we near the potential conclusion of negotiations, what can we say will be the impacts of this “21st century trade agreement?”

What is the TPP?

The TPP, or Trans Pacific Partnership Agreement, would be the largest free trade agreement (FTA) in the world. It will include 12 Pacific rim nations – Australia, Brunei, Canada, Chile, Japan, Malaysia, Mexico, New Zealand, Peru, Singapore, United States, Vietnam – and will potentially encompass 36% of world gross domestic product. Unlike most ‘old school’ FTAs that set rules related to the import and export of goods between countries, the TPP seeks to standardize domestic rules related to everything from copyright infringement to pharmaceutical patents. It has been argued that the TPP is a mechanism for the U.S. to impose domestic standards and agendas onto other countries. Note the exclusion of China from the current agreement. Once the TPP is finalized, any additional countries that want to join will have to agree to the rules already set in place.

Why should we be concerned?

Despite the broad and far-reaching implications of these trade provisions, the TPP is negotiated without public involvement and draft texts are confidential. Even members of Congress have restricted access to reading the text. Witnessing the effects of other trade agreements, many organisations are concerned with the TPP’s potential effects on health and human rights.

To understand the potential impacts, a team of researchers in Australia conducted a health impact assessment (HIA) on the proposed TPP. Using leaked draft texts, we determined what the potential provisions could be, and then mapped them out onto public health policy scenarios that could be implemented in the future. Keep in mind the TPP will only affect future policies, not ones that already exist. We then looked at how changes to those policies could affect health in Australia, particularly looking at who would be affected most.

Working with a technical and advocacy advisory committee, and knowing that there are no formal channels for the HIA to be supplied to decision makers, we decided to disseminate our findings to advocates who could then use them to inform their efforts.

What did we find?

In a nutshell, we found that the TPP has the potential to harm the health of people in Australia in four areas we looked at: access to medicines, changes to tobacco control policies, changes to alcohol control policies, and the regulation of food labelling.

In the area of medicines, we found that the extensions to monopoly periods which the U.S. is pushing for, would be likely to lead to increased out-of-pocket costs for consumers. This often leads to people taking less of their medication (or not at all) and is associated with higher hospitalizations and declining health, particularly for low income people or people with chronic conditions who are less able to accommodate rising costs.

Although tobacco control is far more advanced in Australia than the U.S., we found that additional policies, such as restrictions to tobacco marketing and regulation of e-cigarettes could be hindered by the TPP. This could happen through TPP provisions that protect intellectual property or protect against barriers to trade. Most concerning is the TPP’s investor state dispute settlement (ISDS) mechanism, which allows foreign companies to sue governments when they feel that their investments have been infringed upon by domestic policy. ISDS has been used to attack public health policy in the past. For example, Philip Morris used the ISDS provision of an investment treaty between Hong Kong and Australia to sue the Australian government over its implementation of tobacco plain packaging. While plain packaging is considered a best practice in tobacco control, Philip Morris’ use of the ISDS clause has cost Australia millions in defending the policy. Although it is extremely unlikely that Philip Morris will win, public health regulations can be put at risk through ISDS. In countries that can’t afford high litigation expenses, even the threat of using ISDS can have a chilling effect in which countries choose not to pursue innovative policies for fear of retribution. This is particularly troubling for populations that have high smoking rates, and that are in need of new and innovative anti-smoking policies.

We also considered how the TPP could impact future alcohol control measures, particularly restrictions on alcohol availability, bans on alcohol advertising, and pregnancy warning labels. We found similarly that TPP provisions may restrict the ability of the Australian Government to implement new alcohol control policies. Rules in the cross-border services chapter may prohibit governments from limiting the number of licensed alcohol outlets per geographic area. The public health evidence clearly shows that when alcohol is more available, people are more likely to drink, and to have higher rates of violent assault, drunk driving, and pedestrian injury. These impacts are particularly relevant to adolescents who have higher rates of risky drinking.

Lastly, front-of-pack nutrition labelling is not mandatory at this stage in Australia. Rather, it relies on industry compliance with a voluntary scheme. TPP provisions could require greater involvement of the processed food industry in policy decision making, which could influence the effectiveness of food labelling systems. Without adherence to best practices in food labelling, it is likely that there will be no change to the current high rates of overweight and obesity in Australia and their associated health effects, which is particularly relevant to low socioeconomic populations who often have high rates of obesity but lower health literacy rates.

While we focused on the particular impacts that could occur in Australia, it is likely that similar impacts, including those we did not assess, could take place in many of the 11 other countries involved, including the U.S.

What can we do about it?

We developed recommendations that could be applied to the current negotiations to avoid the potential harms we identified. For example:

  • The TPP could include strong and clear public health exceptions which would prevent public health policy from being affected by trade concerns. They could also completely exclude harmful and unnecessary provisions like ISDS.
  • HIA should be conducted after the final text is available to fully understand the potential impacts from the trade provisions.
  • To improve the trade negotiating process in general, there should be greater transparency and public involvement, and formal channels for involvement of public health experts. This could include the release of draft texts and publication of the government’s negotiating position on issues of public interest.

Our advocacy partners used the findings and recommendations to put pressure on the political bodies involved in the negotiations. In some ways, we have seen great success from this – with Minister of Trade Andrew Robb refusing to agree to any monopoly extensions for some medications. Yet he still hasn’t ruled out having the ISDS clause apply to Australia.

Although negotiations have gone through 20 rounds, with many claiming to be “the final round,” it behoves us to consider the Atlanta negotiations as a key opportunity to inform the discussion. The U.S. Congress will need to approve the trade agreement once negotiations are final – so make sure you let your congress person know how you feel about the TPP! You can also throw your support towards many of the existing advocacy campaigns that are taking place in the U.S. Or simply read the findings from the full HIA report to keep yourself informed.

The Health Impact Assessment of the TPP was conducted by:

Katie Hirono and Fiona Haigh, Centre for Health Equity Training, Research and Evaluation, UNSW Australia

Deborah Gleeson, School of Psychology and Public Health, La Trobe University

Patrick Harris and Anne Marie Thow, Menzies Centre for Health Policy, University of Sydney

For more information about the TPP HIA in Australia, contact: Katie Hirono (k.hirono@unsw.edu.au).

The Greater Health Impacts of the Affordable Care Act

My son had an accident and broke his leg and I found a lump for which a routine biopsy was needed.

When these things happened to my family, I was relieved I had health insurance to help meet our medical needs. But it’s been an expensive and confusing experience – even quality health insurance coverage (procured through my partner’s employer) is proving inadequate at sparing my family the negative health effects of high medical bills. It made me wonder – how has the expansion of health insurance through the Affordable Care Act impacted peoples’ economic security? How much farther do we have to go to ensure that people can access health care without significant financial stress?

While our health issues were serious enough to require treatment, they were not unusual. I had to spend $1,500 (after insurance paid what they would) to discover my lump was, thank goodness, totally fine from a cancer perspective. Not so, from a financial perspective. Then recently, my son was playing with his cousins, fell, and broke his leg. Not sure what the total bill for this is going to be yet, but I’m guessing it also will be around $1,000 after insurance. In the health insurance world, these are probably considered moderate costs for a “consumer” who also pays health insurance premiums every month. But for a household with a tight and perpetually stretched budget like ours, this extra expense causes a great deal of stress.

This financial stress has a number of additional impacts to our family’s health and well-being. My partner and I have to make decisions about the things we will forgo in order to pay these bills. These are not fun conversations and I could see how over time they might end up putting too much stress on a relationship. For couples that separate, there is a cascade of health effects that happen: isolation, depression, anxiety, and negative impacts on children are well documented in the research.

There’s also research that looks at the long-term “economic scarring” that happens (such as during a recession) when families have to make tough choices about spending money on basic needs and medical bills, rather than on things like educational achievement, investments, or starting a small business. When scores of families are forced to make these trade offs (such as during a recession) our whole economy suffers. Our current system of health insurance not only does not protect people’s right to be healthy and productive, but when one of us gets sick or injured in the current system, we all pay.

In HIA, we seldom look at the health impacts of health care policy. We usually focus our policy efforts more upstream, and think of health care as a safety net after upstream efforts have failed. Health care becomes relevant when we aren’t able to change the unhealthy places where we live, work, go to school, and play. Yet through my personal experiences with the financial burdens of health care, I am gaining a different perspective on the greater health impacts of inadequate health insurance. It’s informing my research on the health impacts of financial stress through a new HIA project in our Economic Security Program that I’m leading with our partners, ISAIAH, in Minnesota.

Although the ACA represents a leap forward, we still have a long way to go towards ensuring everyone has health care that doesn’t come with a heavy dose of financial stress. I believe that health care could and should be considered a human right rather than a commodity, as it is now. We should all have the ability to be healthy and lead productive lives, without living in fear of having an accident, or being stricken with an unwanted illness and not being able to afford diagnosis and treatment. We are still far from this ideal.

Good Jobs For All Would Boost Health, Reduce Inequities

Last week several national organizations launched the Putting Families First: Good Jobs For All campaign to bring the issues of jobs, poverty, and inequality to the center of the national debate. “Today, our country is more aware than ever before that our entire economic system is out of balance. We have reached a time in history where the need, the opportunity, and the energy are all here to create an economy that works for our families—now we need the will and the dedication of the American public to make it happen,” wrote Deepak Bhargava, Executive Director of the Center for Community Change.

The campaign will mobilize people around the country – especially poor people and people of color – to advocate for a national agenda focused on:

  1. Guaranteeing good wages and benefits, including a $15 minimum wage, access to paid sick days and paid family leave, and protections from wage theft;
  2. Valuing families by making high quality, affordable early education and child care available to all working parents and their children;
  3. Building a clean energy economy through large-scale investment to substantially reduce our reliance on carbon-based energy and to repair and rebuild our infrastructure;
  4. Unlocking opportunity in the poorest communities by channeling federal investments to communities with high unemployment and low wages to help rebuild their local economies and provide access to jobs and wealth-building opportunities; and
  5. Taxing concentrated wealth, including eliminating differences in taxation of capital gains and income, strengthening the estate tax, increasing taxes on the highest incomes, ending the ability of corporations to defer US tax payments on offshore income, and taxing corporations for wage inequality.

This is a bold and ambitious agenda that would create over five million new jobs a year by directing government to take an active role in guiding our economy through investing and shaping new and emerging sectors. These investments would be targeted to help those who need it most, closing racial and gender inequities, and be paid for by changes in our tax system that reward those who create wealth in this country – hard working people.

While those leading the campaign – the Center for Community Change (whose board I am chair of), the Center for Popular Democracy, Jobs with Justice, The Leadership Conference for Civil and Human Rights, and the Working Families Organization – are thinking about this as a jobs campaign, it is also a campaign to improve health and reduce health inequities. Several speakers at the launch event, including Senator Sherrod Brown of Ohio and SCOPE Executive Director Gloria Walton, noted the impacts of income on health and lifespan, but health is still an underutilized frame when talking about social and economic policy.

The Putting Families First campaign aligns with HIP’s new Economic Security Program, which will bring public health data, framing, and voices to social movements advancing a range of economic security policy campaigns.

As we’ve said before, no single factor is more important for healthy living than an adequate income, and none is more harmful to health than persistent poverty. Economic security is necessary for people to thrive, successfully manage stress, and prevent disease. Overwork, poor quality food, housing insecurity, and other consequences of low wages and unemployment contribute to physical and mental health problems including high blood pressure, diabetes, heart disease, and depression.

Economic security requires guaranteeing that work is available, safe, and pays a decent wage. Ensuring that families have a decent standard of living is one of the most powerful tools we have to protect and promote health.

Transit Policy Gets Moving in Columbia, Missouri with Help from HIA

By Jason Wilcox

“Believe it or not, when I started working on transit, I had hair.”

Mayor Bob McDavid of Columbia, Missouri, joked about the stressful discussions surrounding the city’s public transit system. The conversations kept circling back to whether the financial impact of public transit was positive or negative. City representatives and pro-public transit groups searched for ways to keep the transit system economically feasible, while many opponents wondered why the city continued to subsidize what they saw as a non-essential service.

To take a new approach, in 2013 a Health Impact Assessment was conducted, providing an opportunity to present information through a health lens – not the usual frame for discussing public transit. The Columbia/Boone County Department of Public Health and Human Services focused the HIA on the potential impacts of expanding the public transit system on physical activity, mobility and access to jobs, health care, employment, and social capital.

With the release of the HIA, transit policy started moving. Within three months, Columbia Transit presented a draft of a new, budget-neutral public transit system, COMO Connect. The new system would feature neighborhood routes, as recommended by the HIA, ensuring access to essential services. New routes would run near large employers, health care facilities, and stores that offered healthy food options. After a year of public input, COMO Connect began running the new routes on August 4, 2014.

After completion of the initial HIA, a subsequent assessment was performed to focus on the potential health impacts of a transportation utility fee to help fund COMO Connect. The fee would be tacked on to residents’ utility bills, allowing them to ride the bus without paying a fare. The assessment found that the additional fee could hurt low-income households. Interviews with local residents discovered that many in the community already go without food or medical care due to high utility bills. This potential funding source is still being considered by the City, with a likely vote in 2016.

The completed HIAs have not only strengthened existing partnerships between the health department and community organizations, but have also allowed for the creation of new relationships. The interest in HIAs continues to grow in the community, with various City departments choosing to approach issues from a health perspective. The value of seeking out changes that impact the City’s overall landscape and infrastructure, as well as changes that positively impact citizen health, is becoming clearer.

Jason Wilcox is a Senior Planner with the Columbia/Boone County Dept. of Public Health & Human Services in Columbia, Missouri.


The Sequester: A Public Health Nightmare Waiting to Happen

The impacts of the budget sequester – the across-the-board spending cuts imposed when Congress and President Obama couldn’t come to agreement about how to reduce the deficit – hit home last week, when furloughs at the Federal Aviation Administration caused flight delays around the country. Cutbacks in air traffic control could have meant serious concerns for safe travel. Planes could have crashed, with loss of life more horrifying that an epidemic.

Because the airline industry and well-off executive travelers were hit, Congress rushed to fix the problem – within days, bipartisan legislation was drafted, passed and signed. A public health nightmare for the 1% was averted.

Governments around the world are embracing austerity, deeply cutting spending on everything from public health to education. These cuts are touted as a cure to real or imagined fiscal crises that are the result of bad choices about how to manage the economy. But the evidence supporting austerity has been discredited; many, including Nobel Prize-winning economist and New York Times columnist Paul Krugman, argue that austerity is actually the exact wrong thing to do.

What are the public health impacts of austerity broadly and the sequester in particular? We dodged the bullet on air safety for business travelers, but what about those who can’t get Congress’ attention? What about the unemployed, parents with kids in public school or preschool programs, or families who have trouble putting food on the table?

The Body Economic: Why Austerity Kills, a new book by David Stuckler and Sanjay Basu show how austerity is seriously bad for health. The numbers are startling: 10,000 suicides. Up to 1 million cases of depression. Tripling rates of HIV/AIDS, primarily as a result of increased drug abuse. Five million Americans who have lost access to healthcare. Ten thousand newly homeless families in the UK.

All of these scenarios are as scary as planes falling from the sky. Congress acted properly in moving quickly to ensure continued safe air travel. Perhaps Congress should think about other impacts before the impending public health nightmare becomes reality?