The Turning Point Model State Public Health Act (Turning Point Act) project is part of a historical legacy. Released in September 2003, the Turning Point Act is, in one sense, a continuation of a long tradition of initiatives to improve public health practice through model laws. At the same time, however, the project breaks sharply with the past in its comprehensive approach, thoroughgoing transparency, and planned and ongoing self-evaluation and accountability. The works of Meier and colleagues1 and Merrill and colleagues,2 published as companion pieces in this issue, should be considered part of the continuing heritage of the Turning Point project and as a window into the more general potential of legal reform to improve public health practice.

History and the Role of Model Laws

"Model laws" have played an important role in the advancement of American legal jurisprudence. While federal law provides and enforces uniformity, state laws may vary significantly from one another. On one hand, this approach has allowed for flexibility, experimentation with different doctrines and structures, and construction of locally relevant solutions. On the other hand, diverse state law on similar topics can lead to inconsistent and inefficient approaches to what has increasingly become a socially and economically integrated country. As early as the first decade of the 20th century, economic, academic, and legal leaders spearheaded a movement, still underway, to modernize and unify state law and to harmonize state law with the overarching federal law. Besides uniformity, such an approach was thought to exploit the best minds and most current insights on the law and its particular subject matter. This initiative was led by the Model Act Project of the National Conference of Commissioners on Uniform State Laws3 and the Restatements of Law Project of the American Law Institute. Over the last century, these and other groups, both academic and private, have offered "model codes" and "uniform laws" to provide consistency across states.4

The model law movement has affected public health law as well. Scores of model public laws were sponsored during the 20th century in the quest to influence legislators and policy makers. Virtually all focused on discrete public health questions or legal problems, for example, vaccination policy, food service standards and inspection, and emergency preparedness. While many model acts have advanced debate and the practice of public health law over the decades, the recommendations suffered, according to some observers from three main limitations. First, those who drafted the model public health laws seldom identified individuals, information, and methodology on which they relied to construct their recommendations. Second, insufficient attention was frequently paid to how many jurisdictions chose to enact the model public health laws. As a result, there was frequently little evidence to distinguish the mere academic exercise from the socially useful endeavor. Third, only rarely did sponsors of model public health laws attempt to evaluate the impact of the recommendations in jurisdictions where they had been adopted. Consequently, it was difficult to discern if the model acts had provided the benefits in efficiency and improved public health that their sponsors had anticipated.5

From its genesis, the Turning Point Act was designed to remedy the limitations of the past in both content and procedure.

Monitoring and Measuring the Turning Point Act

In contrast with previous model public health law proposals, the Turning Point Act identified and publicized the state representatives, individuals, and national organizations and governmental agencies that participated in the project. As importantly, the project began with a clearly articulated set of principles and methodologies.6

In another break with the past, Meier and colleagues, in this issue, evaluate the degree to which the 6 "mission descriptions" and the 10 "essential services" identified as the accepted standard for the delivery of public health service are reflected in state public health enabling statutes. This approach is based on the reasonable premise that clear articulation of mission and essential services is crucial to the sustainability of public health agency efforts for disease prevention and health promotion. The specific goal of this study, however, was to assess the degree to which modernization efforts such as the Turning Point Act have affected the language contained in state enabling statutes. While the authors found that modernization efforts have not been "universally" effective in sparking the inclusion of specific authority for mission and essential services, it is clear that the language of the Turning Point Act has become the basis of many recent state public health law reforms. For example, 17 state statutes were found to be "highly congruent" with the essential services articulated in the Turning Point Act, 26 state statutes as "congruent," and only 7 state statutes as "divergent." The fact that few enabling statutes specifically identified essential public health services in a 2000 study suggests that the Turning Point Act has had, in the authors' words, a "dramatic" impact on reforming the statutorily defined mission and services of state public health agencies. The study by Meier and colleagues is significant because it attempts to monitor the degree to which a model act has a real-life impact on state legislative action, an evaluation only infrequently attempted with such care on other legal reform proposals. The study presents the data with honesty, care, and specificity rather than with general claims or presumptions of effectiveness.

Similarly, Merrill and colleagues explore the association between modern statutory language relating to mission and essential services and the empirical evidence of the performance of health agencies as measured by National Public Health Performance Standards data. The authors' findings are complex, nuanced, and fascinating. The authors reason that their analysis, overall, "suggests some positive association" between local health system performance and the existence of defined mission and essential service language of the type contained in the Turning Point Act. Such a correlation suggests that the goals of the Turning Point Act are materializing. But the authors' data also suggest that in some areas, a high congruence between a state's statutes and recommended mission statement resulted in "decreased odds" of performing above the national mean. The authors' speculation on why this counterintuitive result may have surfaced is both honest and insightful and underscores the deep complexity of such evaluations. The long-term value of the study is not in its absolute demonstration of a direct correlation but rather is in its vigilant and responsible attempt to uncover the association between legal reform and public health performance and its illustration of the intricacies of that dynamic.

Critics and the Continuing Importance of Self-evaluation

The Turning Point Act has not been attacked with the vigor that characterized some of the commentaries on the Model State Emergency Health Powers Act.7 Still, both friends and skeptics of the Turning Point Act project should continue to weigh the critiques made by observers who implicitly or explicitly question the wisdom of applying an overarching and detailed model public health law.

Richards and Rathbun,8 for example, contend that there is little evidence that state public health statutes are outdated or ineffective. Hence, they question the need for wide-ranging and detailed model public health acts. Moreover, while the uniformity represented by model acts may be beneficial for commercial exchanges, it is less beneficial for public health law that tends to have context-specific factors that require state and local regulation. Richards and Rathbun's critical analysis of the Turning Point Act approach has stressed that it is important to view public health law in the context and justification of administrative law. From this perspective, broad and general enabling statutes are preferable to the more specific codifications that sometimes characterize model laws. State administrative public health agencies can augment general enabling statutes with regulations that are nimble and responsive to both local and topical conditions and concerns. As a practical matter, administrative regulations can be more easily adapted than statutes as working public health practitioners refine their views of a particular public health threat in a specific context. Not only do broad general statutory mandates provide sufficient discretion and authority to state public health agencies, but, according to Richards, "In almost all cases where state agencies responding to threat are found to have insufficient power it is because the legislature has either over specified the agencies duties and responsibilities or taken power away from the agency by specific legislation."8

The Turning Point Act might also find implicit, if not explicit, critics among those commentators who are concerned that the "new" public health is unwisely and unjustifiably extending the reach and authority beyond the prevention of infectious disease (the "old" public health) to the social and economic determinates of population-wide health.9 To the extent that its mission statement supports a broad vision of disease prevention and health promotion through the creation and assurance of "the conditions in which people can be healthy," the Turning Point Act might be said to represent the "new" public health.10 Indeed, in discussing the Act, James Hodge, a consultant on the project, has noted that "public health law is no longer viewed narrowly as a subset of health law focused on the practice of laws concerning communicable diseases, public health nuisances and sanitation."11 Similarly, the Executive Summary of the Turning Point Act explains that its provisions reflect the "current scientific and ethical principles at the forefront of modern public health practice."12^(p2) While creating the conditions for healthy populations can be construed as a legitimate governmental "public health activity," some observers have questioned whether it is the appropriate province of "public health law." As Hall has argued, for example, "public health law is much more limited than public health science [horizontal ellipsis] the scientific boundaries of public health are not coextensive with its legal and regulatory boundaries."13(pS202, pS204)

The implementation of the Turning Point Act in many jurisdictions and the broad agreement in the public health academic and professional literature suggest that as a matter of political success and cultural reality, the "new" public health has been widely accepted. The summary of these contrarian sentiments here is presented not to suggest that the Turning Point Act is ill-advised or that the "new" public health is misguided. Instead, the recognition of divergent views is an important part of the ongoing evaluation of any innovation or intellectual shift. Intellectual integrity demands that "backbencher" critiques be taken seriously even if they do not ultimately carry the day politically or academically.

At this juncture, these and similar critiques cannot easily be incorporated into the kinds of monitoring and evaluation currently undertaken by Meier and Merrill. But future studies regarding the relative virtue of general versus specific enabling acts and continuing debate on the scope of public health law should help clarify whether such warnings and concerns have merit.

Conclusion

The goal of the model statute movement in public health is not merely to create a coherent academic model; it is to generate change and improve performance. It would be cavalier and irresponsible to support such a campaign without a robust and good-faith effort to monitor and measure outcomes, empirically if possible. The work of the sort presented here by Meier, Merrill, and colleagues represents such an effort and should serve as the pioneering foundation for other such projects that attempt to measure outcomes that sometimes appear to defy measurement.

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