COVID-19 Brings New Urgency to Building Health Equity: Soda Taxes are One Solution

Photo by NeONBRAND on Unsplash

by Irene Farnsworth and Fiona McBride

Sugar consumption, particularly through drinks like soda, is putting peoples’ lives at risk as obesity and Type II Diabetes proliferate at alarming rates. Due to systemic racism and classism, low-income communities of color suffer most from diet-related illness which has devastating impacts on life expectancy and quality of life. The COVID-19 pandemic is illuminating the urgency of this diet-related disease epidemic, as individuals with diet-related diseases are more likely to develop severe complications from the virus. Moreover, black and brown people in particular are dying of COVID-19 at disproportionate rates. This highlights the need for greater public investment in the health and wellbeing of historically marginalized people, to ensure community resiliency regardless of income and race. 

Approximately 70 percent of Americans are overweight or obese and nearly 10 percent are sick with diabetes. The problem continues to intensify: the New York Times recently reported that half of all Americans will be obese by 2030. The effects of this epidemic are devastating not only for individual health but for our collective wallets. Obesity, prediabetes, and diabetes cost the nation over $450 billion dollars each year. 

Low-income communities of color are most burdened by the diet-related disease epidemic because of structural and institutional racism, including:

  • Housing discrimination that segregates low-income people of color into lower quality housing with low-to-no access to healthy food and safe recreational opportunities; 
  • Racism in real estate, education, banking, and workforce development which has prevented communities of color from accruing and maintaining wealth, thereby limiting mobility and healthy choices; 
  • The healthcare industry which does not always meet the needs of people of color;
  • Healthcare that is unaffordable to many, forcing people to choose between medications and other essential goods; and 
  • Companies that target minorities by marketing soda and unhealthy food more aggressively to these communities. 

It is no surprise given this long history of inequity that people of color face higher rates of both obesity and diabetes. In Berkeley alone, Black residents have diabetes at a rate four times higher than white residents, and are hospitalized for the disease at 14 times the rate. Race and income are major determinants of health outcomes, which is particularly stark during the COVID-19 pandemic. Soda taxes are a critical step towards addressing these inequities; however, it is imperative that these taxes prioritize people hit hardest by diet-related illness while reinvesting financial and material resources in those communities. The specifics of policy design and implementation are critical in ensuring that soda taxes actually meet these goals. By building a greater baseline of wellness for all through well-designed policies, like a health equity-focused soda tax, we can cultivate resilient communities, even during times of crisis. 

Soda taxes have emerged in reaction to the worsening diet-related illness epidemic, as consuming liquid calories in the form of sugary drinks is a central driver of weight gain and is a central driver of Type II diabetes. Consumption of just 1-2 sugary drinks or more per day increases one’s chances of developing Type II diabetes by 26%, and regular sugar-sweetened beverage consumption is correlated with 20% higher risk of heart attack. 

Nearly everyone has an opinion about soda taxes: public health advocates champion their efficacy, soda companies invest millions to block them, and community members and activists are polarized on the issue. In debating the merits and drawbacks of soda taxes, nuance is critical. The minutiae matter, and when soda taxes are designed thoughtfully, they can influence not only consumption behavior, but more importantly, produce a powerful revenue source to support greater health and economic equity.

A common critique of soda taxes is that they are regressive taxes on working-class people and disproportionately affect communities of color. In response, Shakirah Simley, Director of theOffice of Racial Equity for the City & County of San Francisco, says:

“What’s regressive is the obscene amount of money being poured into political campaigns by the American Beverage Association, which influences policy and budgetary decisions later on. What’s regressive is that these same communities bear the brunt of millions of dollars of targeted, relentless marketing from Big Soda; especially youth of color. What’s regressive is that these same communities suffer from the highest rates of Type ll diabetes, tooth decay, obesity/overweight and other chronic illnesses without access to proper healthcare…Our kids’ life expectancy has severely dropped over the past decade, due to diet-related illnesses. Their lives are on the line, which is a dire price we shouldn’t be comfortable paying.”

The Bay Area soda taxes—passed in Albany, Berkeley, Oakland, and San Francisco—offer a useful case study that illuminates both best practices and pitfalls for achieving health equity goals and long term sustainability.

Bay Area Soda Taxes Offer Lessons on Designing for Health Equity

Across the country, jurisdictions trying to pass sugary drinks taxes have faced intense opposition from the soda industry, and the Bay Area was no exception. In the Bay Area, soda companies and related opposition groups spent over $10 million on advertising opposing the Bay Area initiatives, far outstripping the cities’ campaign budgets. The Bay Area sugary drinks taxes (which include all sugar-sweetened beverages, not just soda) that have passed in Berkeley, San Francisco, Oakland, and Albany serve as examples to jurisdictions around the country for how to pass, implement, and sustain these efforts with a focus on public health equity. 

Lessons on the Political Feasibility of Passing Soda Taxes

  • Passing soda taxes as ballot measures creates community support and sustainability. The most politically sustainable sugary drink taxes are those that are 1) passed by the voters and 2) allocate revenues towards programs that improve health outcomes. Passing sugary drinks taxes as a ballot measure, rather than as a city council measure, worked well in the Bay Area cities because it required drumming up immense community support. Bay Area campaigns involved leadership by people of color from the most impacted communities, ensuring that implementation of the taxes was set up to prioritize equity and represent the needs of communities impacted by diet-related illness. This community support has been critical to stand up to the pressures of large soda companies during the campaigns, as well as to ensure that the resulting tax revenues continued to translate into public health investments once passed. 

  • Despite increasing political feasibility, general taxes complicate investments in public health. General taxes only require 50% approval to pass, but the resulting revenue goes into the municipality’s general fund, and cannot be set aside for specific purposes; specific taxes require two-thirds majority, and have the advantage of designating how the revenue will be spent. The first time San Francisco tried to pass a specific soda tax, it failed to reach the two-thirds support needed; once Berkeley passed their general tax measure in 2014, each of the other cities followed suit and similarly succeeded. While these wins may have been possible because they were passed as general taxes, this has meant a much more convoluted process to ensure that the tax revenue has equalled the funding promised to public health initiatives. To ensure that cities are accountable to these investments, ongoing advocacy and accountability has been needed to make sure that cities support these new public health priorities, not spend the increase in revenue on other city budget priorities. Finally, passing a general tax with the intention of diverting the tax revenue to a specific purpose may set a bad precedent for future initiatives, and raises questions about the integrity of specific versus general taxation measures. 

Lessons on Implementing Soda Taxes

  • Equitable processes in implementation are critical to reach equitable outcomes. To create equitable outcomes in public health, the tax revenue distribution process should involve close collaboration with impacted communities. San Francisco, Oakland, and Berkeley intentionally built an equity framework into the designs of their administrative structures and grantmaking. For example, Oakland and San Francisco designated seats on their committees for community members impacted by diet-related diseases; Berkeley and San Francisco designed alternative grantmaking processes to allocate grants to harder-to-fund organizations and projects.
  • Tax language should emphasize equity, but be flexible enough to adapt to implementation challenges. Well-intentioned efforts to make processes equitable did not always result in equitable outcomes. For example, San Francisco’s commission requires a youth member, but did not anticipate that a teen might not feel comfortable in a room of adults, or that committing to monthly meetings would not be possible for them. Creating equitable processes and outcomes does not just require good intentions — it also requires the flexibility and self-reflection to change course and adapt to new information and perspectives. 

Lessons on Sustainability and Public Health Impact

  • Tying the tax revenues to valued community programs increases support and impact. The Berkeley soda tax campaign made an explicit promise to use revenues to restore the Berkeley school gardens program, a beloved city program, and the city has followed through on that promise. Because Berkeley was able to quickly show the public that their tax was having an impact in the community, their tax may be more politically sustainable than other cities that haven’t been able to distribute their revenue as quickly or publicly. 

  • Ensuring that revenue goes to the most-impacted communities is critical to meet public health equity goals. While it is too soon to assess the impact that the Bay Area soda taxes have had on diet-related diseases and other health inequities, channeling dollars to organizations and individuals who are the most impacted by these inequities is key to fulfill the promises made by these tax measures.

One Step to Solving the Diet-Related Disease Epidemic

Soda taxes are not a panacea. They will not solve diet-related diseases alone, and they will not fix the underlying racism and classism that prevent all Americans from accessing high quality food, housing, medical care, and other social determinants of health. However, when designed and implemented well, they can effectively curb soda consumption and provide needed investments in health for the most impacted communities. To do the most good, we recommend that future jurisdictions a) involve community from the get-go to design, pass, and implement the taxes; b) try to pass a specific tax (with two-thirds majority), which will make the investments flow more easily and directly to public health; and c) make soda taxes part of a suite of investments and policies to ensure that we radically transform the health equity picture in the United States.

Irene Farnsworth and Fiona McBride are second-year MPP students at the UC Berkeley Goldman School of Public Policy.

The research for this post is based on the May 2019 report “Bay Area Sugar-Sweetened Beverage Taxes: An Evaluation of Community Investments” by Goldman students Sydney Bennet, Nick Draper, Irene Farnsworth, and Fiona McBride. 

The views expressed in this article do not necessarily represent those of the Berkeley Public Policy Journal, the Goldman School of Public Policy, or UC Berkeley.