THE POLITICS OF PUBLIC HEALTH IN FLORIDA: INSIGHTS FROM DEBATES OVER MEDICAL CANNABIS AND NEEDLE/SYRINGE EXCHANGE LEGISLATION Tamara Y. Demko A dissertation submitted to the faculty of the University of North Carolina at Chapel Hill in partial fulfillment of the requirements for the degree of Doctor of Public Health in the Department of Health Policy and Management in the Gillings School of Global Public Health. Chapel Hill 2020 Approved by: Pam Silberman Catherine McCann Kathleen Kaney Jonathan Oberlander Tom Ricketts © 2020 Tamara Y. Demko ALL RIGHTS RESERVED ii ABSTRACT Tamara Y. Demko: The Politics of Public Health in Florida: Insights from Debates Over Medical Cannabis and Needle/Syringe Exchange Legislation (Under the direction of Pam Silberman) This study examined the question of why some health-related legislative bills in the state of Florida pass into law while others do not. Using a retrospective, sequential, mixed methods case study design that included in-depth, key informant interviews, I explored how sociopolitical factors and stakeholder actions influenced policymakers and the outcomes of two Florida bills on medical cannabis and needle/syringe exchange. Both bills were considered during the 2014 election year by a Republican majority legislature. The medical cannabis bill passed, and the needle exchange bill died in return messages at the end of the legislative session. Several sociopolitical and policy themes influenced the outcome of the bills: window of opportunity; persuasive health and/or economic arguments; effective grassroots mobilization with active, in-person citizen/constituent advocacy; influential legislative relationships (predominantly member-to-member and family members); and constituents and legislators acting as policy entrepreneurs and issue champions. However, certain expected themes were less influential: professional lobbying, state health agency influence, and pre-passage support by the governor’s office. The medical cannabis bill had unique favorable factors that helped it pass compared to the needle/syringe exchange bill: the threat of a constitutional amendment that might increase Democratic voter turnout and further influence a gubernatorial election; a CNN documentary on medical cannabis; strong iii majority party sponsorship; and a sympathetic focus on sick children, viewed as blameless relative to injectable drug users. This work provides insights into Florida legislative processes and can be used as a roadmap for success for future public health legislation. An advocacy checklist for public health and health-related professionals and organizations provides recommendations on how to strategically invest their resources when pursuing health-related legislation. iv To the One who makes all things possible To my beloved mother, who is in hospice To all my loved ones who have gone before & To Charlotte Figi, who passed away at the age of 13, just as this dissertation was being submitted v ACKNOWLEDGEMENTS It is with the deepest appreciation that I thank my infinitely patient and talented dissertation committee. Tom Ricketts, Jonathan Oberlander, Kathleen Kaney, and Catherine Howard-McCann provided invaluable guidance over many years of work. As committee chair, Pam Silberman ensured my successful completion with just the right mix of feedback and encouragement. Thank you all for helping me to climb this mountain. I am grateful for the constant love and support of my parents, Dr. Charles and Maria Yang. Thank you to my beloved sons, Cole and Josh Demko, for giving me the inspiration to continuously learn and grow. A special thank you to my husband, Rob Siedlecki, Jr., for giving up many date nights so I could finish this dissertation. I would also like to thank Ed and Ronnie Demko, Thomas Yang, Angela Yang, Karen Halperin Cyphers, Diosa Moran, and Alrica Goldstein for countless years of support and encouragement. Thank you to the many wonderful teachers I have had in my life, to all study participants and advisors, to Virginia Gray, to my favorite cohort C7, and to everyone who has encouraged me to keep going on the unexpectedly obstacle-ridden paths of dissertation writing and life. Perseverance, persistence, resilience. vi TABLE OF CONTENTS LIST OF TABLES ................................................................................................................... xii LIST OF FIGURES ................................................................................................................ xiii LIST OF ABBREVIATIONS...................................................................................................xiv CHAPTER 1: INTRODUCTION ................................................................................................1 Overview of Dissertation .................................................................................................1 Discussion: Loss of Health Ideas When Health-Related Legislation Fails to Pass .............................................................................................................................3 Main Research Question & Contextual Scope of State Health Legislation........................4 State Selection: The Fate of Health-Related Policy Ideas in Florida .................................5 About Florida ..................................................................................................................5 About Florida Health Legislative Processes .....................................................................6 Health-Related Legislation—Topic & Bill Selection ...................................................... 10 SB 1030 (2014)—Cannabis (Low-THC Cannabis/Charlotte’s Web) .............................. 12 Health Significance................................................................................................. 12 Bill Purpose ............................................................................................................ 12 Recent Prior Legislative Attempts........................................................................... 13 Brief 2014 Bill History ........................................................................................... 13 SB 408 (2014)—Infectious Disease Elimination Pilot Program ...................................... 14 Health Significance................................................................................................. 15 Bill Purpose ............................................................................................................ 15 Recent Prior Legislative Attempts........................................................................... 16 vii Brief 2014 Bill History ........................................................................................... 16 CHAPTER 2: LITERATURE REVIEW ................................................................................... 18 Time Period Selection.................................................................................................... 18 Sources Used ................................................................................................................. 18 Selection Criteria: Inclusion and Exclusion .................................................................... 19 Keywords and Search Strategy ...................................................................................... 20 Search Process ........................................................................................................ 20 Emergent Themes & Focus in the Literature .................................................................. 22 General Policy Themes ........................................................................................... 23 Health Policy Distinction Themes ........................................................................... 25 The Legislative Stage in the Policymaking Spectrum .............................................. 25 Importance of Health Policy Focus at the State Level ............................................. 26 Discussion of the Literature ........................................................................................... 27 Convergence of Political Policymaking Paradigms with Public Health Theories ................................................................................................................. 27 Emergent Overarching Themes in Health Legislation ............................................. 27 Additional Key Themes in the Case Studies ............................................................ 34 Gaps in Research and Knowledge/Bridging the Gaps ..................................................... 37 Search Strategy Limitations and Weaknesses ................................................................. 37 Informing a Dissertation & Conclusion .......................................................................... 38 CHAPTER 3: METHODS ........................................................................................................ 39 Study Design ................................................................................................................. 39 Data Collection Procedures ............................................................................................ 40 Online Qualtrics Survey (Quantitative Focus) ................................................................ 41 Key Informant Interviews (Qualitative Focus) ............................................................... 43 IRB Approval ...............................................................................................................