Health
Community Challenges and Priorities
Cities are increasingly playing new roles in promoting resident health, whether via regulation, service implementation, or in response to emerging health crises. At the same time, longstanding challenges, such as gun violence, are being reframed as community and public health issues. This year’s Menino Survey therefore included a series of questions concerning mayors’ health priorities and perceptions to better understand how they respond to and promote community-wide well-being.
Mayors observe a wide range of significant health challenges in their communities ranging from obesity to mental health. Mayors identified, in response to an open-ended prompt, the top health challenge facing their cities. The most common (roughly one-fourth) concerns are obesity, diabetes, and heart disease. Another quarter of mayors highlight addiction — often opioids. Other common responses include access to healthcare (14 percent), environmental threats (10 percent) and mental health (8 percent).
Table 3. What is the greatest health challenge facing the city?1
Health Priority | Percent of Mayors |
---|---|
Obesity/diabetes/heart disease | 25% |
Addiction/opioids | 24% |
Access to/cost of care | 14% |
Environmental | 10% |
Mental health | 8% |
Access to healthy food | 4% |
Gun violence | 4% |
Poverty | 4% |
Aging | 3% |
Infant mortality | 2% |
Other | 2% |
Mayors believe that constituents hold them most accountable for traffic accidents, gun violence, and exposure to toxins, but also believe they are not held accountable for a wide range of other health issues and outcomes. Under 40 percent of mayors believe that they are held accountable for other health challenges featured in the survey, including obesity, mental health, asthma, substance abuse, and opioids. In some cases, like obesity and asthma, fewer than 20 percent of mayors perceived themselves as being held publicly accountable for important health challenges. At least some say that they should be held more accountable. Linking city efforts to reduce car culture, one southern mayor says that “constituents don’t hold me accountable for asthma and obesity, but they should.”
In contrast, mayors believe that some policy areas attract considerably more public attention. Just under 50 percent said they are held accountable for hunger/malnourishment and just over 50 percent say the same for gun violence. Most strikingly, almost 75 percent of mayors say that their constituents hold them accountable for traffic accidents. According to mayors, there is considerable variation in the extent to which the public links health issues with local policy actions. This may make it challenging in some arenas to push for policy change.
Figure 14: Accountability and Health Challenges
How much do you think constituents hold you accountable for each of the following health challenges in your city?
Mayors do not agree on any one set of policies that would have the greatest impact on resident health. When asked which of a set of plausible city actions — including public health campaigns, targeted interventions, community health centers, and regulation of risk factors — can have the greatest impact on resident health, the plurality of mayors (33 percent) selected “other.” Some of these responses reflect other tactics not captured in the response options. For example, some mayors said things such as “encouraging people to be active” or “strong hospitals.” Others chose not to identify one policy that could have the greatest impact because there were too many plausible options. Yet others opted not to choose any of the proposed options because they see health as a county or state issue and noted that the city has relatively little involvement (see Figure 18). A quarter opted for public health campaigns, while 18 percent selected targeted interventions and another 18 percent selected community health centers (Figure 15 excludes “other”). In short, rather than clustering around one particular policy option, the mayors highlighted a wide variety of policies, reflecting perhaps the diverse health concerns facing U.S. cities.
Figure 15: Impacting Resident Health
In what way can cities have the greatest impact on resident health?
Mayors would allocate money to fight opioids across a wide array of policy areas, but there is no one area to which they would target the bulk of these (hypothetical) new funds. Mayors were offered a (hypothetical) “large amount of money” to fight the opioid epidemic and were asked to allocate the money across four areas: (1) demand reduction/prevention (e.g., community development, post-incarceration support, education), (2) harm reductions (e.g., naxolone access, supervised use spaces, overdose surveillance), (3) supply reduction (e.g., Rx monitoring, policing, international/border interdiction), (4) and treatment (e.g., medication assisted treatment, Medicaid spending, drug courts). No one area stands out as receiving especially large amounts of (hypothetical) resources. Mayors, on average, would allocate 32 percent of their “large amount of money” to treatment, 29 percent to demand reduction, 21 percent to supply reduction, and 18 percent to harm reduction.
This question was adopted from the New York Times survey of 30 experts, including health policy specialists, politicians, and law enforcement.2 The average allocations of mayors were relatively similar to those of the experts, particularly for harm reduction and demand reduction. Mayors were more inclined to highlight supply reduction (21 percent) relative to the Times panel (11 percent.) In contrast, the Times panel emphasized treatment 15 percentage points more frequently, with 47 percent of the Times experts suggesting treatment, relative to 32 percent of mayors.
Figure 16: Allocating Money to Fight the Opioid Epidemic
If you could allocate a large amount of money to fighting the opioid epidemic, how would you allocate it across the following areas?
Mayors see a role for local government involvement in individuals’ choices around health and environmental matters, but their views around potential interventions in household-level choices vary considerably by issue. Mayors were asked whether they agreed that city government should stay out of individual decisions across a variety of issues. The responses speak to their views on certain potential health-related policies and their view of local government’s role in these areas relative to other areas of individual choice. Over 75 percent of mayors believed that city government should play a role in recycling and composting. Just over 50 percent felt that cities should be involved in regulating gun ownership. Under 50 percent of mayors expressed similar agreement concerning local government’s role in the consumption of healthy foods and in personal finances.
There was considerable variation by policy as to the extent to which mayors endorsed a strong government role. Many of those who supported interventions into things like finances and food choices, did so in a limited way. For instance, one mayor says that the “city should provide education and information but not regulate.” In general, mayors were much more amenable to government intervention into areas where the city is involved, even if that involvement is not necessarily in the personal choice realm. For example, many mayors explained their view that government should be involved in choices about energy and recycling because the city is already involved in trash collection. We frequently heard similar sentiments of the mayor who said it is “not the government’s place [in general],” but for recycling “it’s a different world because we own the landfill.”
Figure 17: Areas Where City Government Should Stay Out
Please rate how strongly you agree/disagree with the following statement: City government should stay out of shaping individuals’ decisions around the following issues:
Mayors see city government as the best place to make policy that affects their cities in many areas, but see higher levels of government as preferable for dealing with health and the environment. Mayors almost universally said that city government is the “ideal level” for making policing, housing, and economic development policy. However, most mayors report that the state or federal government rather than city government is the best venue for tackling health and environmental challenges. Mayors were quite divided on the best level of government involvement in education and transit decisions. Lastly, only a handful of mayors indicated that sub-city level institutions would be ideal in any of these policy areas.
Figure 18: Federalism and Policy Making
Which level of government would be the ideal level for making decisions that affect the city in each policy area?
- Mayors were asked to list their top challenge. Some mentioned more than one. We focus on the first they listed, but including all responses would not affect the results. [return]
- Katz, Josh. “How a Police Chief, a Governor and a Sociologist Would Spend $100 Billion to Solve the Opioid Crisis.” The New York Times, Feb. 14, 2018. [return]