Milbank Quarterly最新文献

Policy Points Ultraprocessed foods (UPFs) are engineered to heighten reward and accelerate delivery of reinforcing ingredients, driving compulsive consumption and disrupting appetite regulation. This is a growing challenge for health policy. UPFs share key engineering strategies adopted from the tobacco industry, such as dose optimization and hedonic manipulation. These parallels should inform how we classify and regulate UPFs. Policy tools that helped reduce tobacco-related harm, including restrictions on child-targeted marketing, taxes, improved labeling, limits on availability in schools and hospitals, and litigation, should be adapted to address the public-health threat posed by UPFs.

Context: Ultraprocessed foods (UPFs) now dominate the global food supply and are strongly associated with risks for heart disease, cancers, metabolic disease, diabetes, and obesity. UPFs are likely associated with rates of neurologic issues such as dementia and Parkinson's disease and predict premature death. Drawing on the history of tobacco regulation, we examine how the design, marketing, and distribution of UPFs mirror those of industrial tobacco products. Such information speaks to the sophistication and aims of food product manipulation and its consequences.

Methods: This review synthesizes findings from addiction science, nutrition, and public health history to identify structural and sensory features that increase the reinforcing potential of both cigarettes and UPFs. We focus on five key areas: dose optimization, delivery speed, hedonic engineering, environmental ubiquity, and deceptive reformulation.

Findings: Cigarettes and UPFs are not simply natural products but highly engineered delivery systems designed specifically to maximize biological and psychological reinforcement and habitual overuse. Both industries have used similar strategies to increase product appeal, evade regulation, and shape public perception, including adding sensory additives, accelerating reward delivery, expanding contextual access, and deploying health-washing claims. These design features collectively hijack human biology, undermine individual agency, and contribute heavily to disease and health care costs.

Conclusions: UPFs should be evaluated not only through a nutritional lens but also as addictive, industrially engineered substances. Lessons from tobacco regulation, including litigation, marketing restrictions, and structural interventions, offer a roadmap for reducing UPF-related harm. Public health efforts must shift from individual responsibility to food industry accountability, recognizing UPFs as potent drivers of preventable disease.

Policy Points Single indicators such as rural population percentage can misrepresent a state's rural character, leading to flawed policy comparisons and resource allocation. This study introduces a multidimensional rurality index that combines population share, land area, and population density to create a more comprehensive ranking of US states. Policymakers and researchers can use this index to better identify and compare states with similar rural profiles (e.g., Mountain West vs. Northeast), enabling more targeted and effective rural health policies and research.

Context: Inadequate descriptions of rurality limit comparisons across rural areas and can lead to overgeneralizations in health policy research. Single indicators of state-level rurality, such as rural population percentage or population density, are often used in isolation and fail to capture the multidimensional nature of rural character, obscuring important differences among states. A more holistic measure is needed to inform research on health care access, quality, and health disparities.

Methods: This study developed a composite state-level rurality index for the 50 US states for three indicators: rural population percentage, rural land area percentage, and rural population density. We used Borda count and dominance count ranking methods to integrate these indicators into a final ranking. Principal component analysis (PCA) was then used to visualize the data and identify states with similar profiles.

Findings: Mountain West states, including Alaska, Montana, and Wyoming, ranked highest in multidimensional rurality. States traditionally considered highly rural based on a single indicator, such as Vermont and Maine (owing to high rural population share), exhibited rural profiles more similar to states such as Mississippi and Arkansas. The PCA visually distinguished between states with land-based rurality (e.g., vast, sparsely populated areas) and those with population-based rurality (e.g., high proportion of residents in rural towns).

Conclusions: This multidimensional index provides a tool for health policy research, facilitating more targeted and meaningful comparisons among rural states. It can help guide the study of health care infrastructure, workforce challenges, and health equity by moving beyond less nuanced classifications and highlighting the diverse forms of rurality across the United States.

Policy Points Evidence suggests the 2021 temporary Child Tax Credit expansion reduced material hardship and improved parental mental health, but less is known about its effects on child well-being. Compared with the preexpansion period, advanced monthly payments were associated with short-term improvements in child behavioral health. However, these gains did not persist after payments ended, even with the lump-sum payment, likely reflecting stress and hardship tied to the policy's temporary nature, especially among lower-income and Black children. Policymakers may need to consider program design features, such as more frequent distribution of unconditional cash benefits, to better support child well-being.

Context: In July 2021, to alleviate material hardship, Congress temporarily expanded the Child Tax Credit (CTC), one of the largest income transfer programs in the United States. Prior research has linked the expansion to improvements in material hardship, food insecurity, and parental mental health. This study is among the first to examine its association with child well-being.

Methods: We analyzed data from 1,028 children in the 2020-2021 waves of the Child Development Supplement of the Panel Study of Income Dynamics, a national longitudinal data set. CTC exposure was defined based on benefit size calculated using eligibility rules. Outcomes included caregiver/self-rated child health, behavioral problems, and food security. We used individual fixed-effects models to estimate within-person changes in outcomes, comparing pre- and postexpansion periods while adjusting for time-invariant confounders. The 2021 PSID wave (November 2021-June 2022) included three CTC phases: 1) advanced monthly payments (November-December 2021), 2) expired monthly payments (January-April 2022), and 3) following the distribution of remaining lump sum (May-June 2022). Analyses were stratified by these phases to capture potential disparate impacts. We also conducted subgroup analyses by income and race/ethnicity.

Findings: During the monthly payment period, a $1,000 increase in CTC was associated with a 0.69-point reduction of behavioral problems in the overall sample (95% confidence interval [CI]: -1.31 to -0.067), corresponding to a 10% reduction from baseline. No associations were observed after monthly payments expired. Following the distribution of the lump sum, lower-income children had worse caregiver/self-rated health (-0.075, 95% CI: -0.14 to -0.010) and increased behavioral problems (0.95, 95% CI: 0.45-1.45) compared with higher-income children. Differences by race/ethnicity were also observed.

Conclusions: More frequent distribution of unconditional cash benefits may improve child behavioral health. These findings inform ongoing state and federal poverty policymaking and contribute to theoretical knowledge on income and child health.

Policy Points Antimicrobial resistance (AMR) is a pressing global health crisis driven by complex collective action challenges, requiring locally tailored and context-sensitive solutions. Drawing insights from environmental governance where collective action problems are familiar, we propose nine adaptable strategies for AMR governance, offering policymakers and scholars a flexible policy toolkit for addressing AMR. These strategies integrate the roles of state, market, and community actors to advance sustainable and equitable collective action across diverse global contexts.

Context: Antimicrobial resistance (AMR) is a pressing global health crisis rooted in complex collective action problems. Despite the urgency, policy responses have not kept pace with the escalating threat of drug resistance. By recognizing the similarities between AMR governance and other shared-resource challenges in environmental governance, this article examines potential strategies for AMR governance.

Methods: An analysis of 12 environmental governance frameworks identified three main approaches to collective action: market-driven, state-led, and community-centered strategies. From these strategies, we purposively selected three case studies to illustrate how each approach could inform AMR policy, focusing on: (1) market-based mechanisms in climate governance, (2) state-led initiatives in water management, and (3) community-led efforts in biodiversity conservation.

Findings: We propose nine policy options for AMR governance, drawing inspiration from established strategies in environmental governance. These include Pigouvian taxes, cap-and-trade systems, enhanced public-private partnerships with performance metrics and technology transfer, and access-and-benefit sharing agreements. Framed as adaptable strategies, we emphasize the importance of tailoring each option or a blend of options to the economic, political, and health care contexts unique to AMR challenges worldwide.

Conclusions: Although environmental governance has not fully resolved the global issues it addresses, its lessons offer valuable guidance for designing adaptive, equitable, and collaborative AMR governance frameworks. Our analysis highlights the importance of a balanced approach, combining state, market, and community engagement to achieve sustainable AMR solutions. Recognizing the limits of environmental governance, we emphasize that effective AMR strategies should integrate ongoing evaluation, international collaboration, and inclusive stakeholder engagement to foster global commitment and meaningful action.

Policy Points Community health workers (CHWs) recognize that health care and public health institutions and representatives value their roles, but these institutions are often unaware of the labor required to obtain the expertise that CHWs leverage. Despite a recognition of the value of the CHW role, CHWs feel their roles are not properly compensated or acknowledged, and they face other structural barriers that perpetuate the precarity of the role. As the CHW landscape for compensation and certification changes, these conditions need to be considered to better support and sustain this workforce.

Context: Community health workers (CHWs) are frontline public health workers who support the well-being and capacity building of residents disproportionately affected by health inequities. The purpose of this study is to examine diverse perspectives on the conditions for CHW success as CHWs were engaged in rapidly implemented, highly responsive education, vaccination, and recovery efforts during the COVID-19 pandemic in a large county in Southern California.

Methods: The Community Activation to Transform Local Systems (CATALYST) study leveraged a community-based participatory research approach to conduct a case study of CHW COVID-19 responses in Orange County, California. From 2023 to 2024, we conducted 16 semistructured, in-depth interviews and eight focus group discussions with CHWs (n = 60). Interviews and focus group discussions were recorded, transcribed, and analyzed following an adapted flexible coding approach, including inductive and deductive codes.

Findings: Findings highlight three key themes: 1) CHWs recognize that institutions value their expertise and capacity to build connections with community members, 2) CHWs' labor to build their expertise often goes unacknowledged, and 3) CHWs face financial and structural constraints that undermine the value ascribed to their contributions. Despite this, CHWs stress the importance of proper recognition and fair compensation to reflect the critical role CHWs serve in advancing community health.

Conclusions: Institutions recognize CHWs' impact; however, CHWs feel that the aspects of their work that build their expertise often go unnoticed and undervalued. To sustain CHWs as integral members of the public health workforce, especially during crises and recovery, institutions need to recognize the full extent of CHW roles and provide adequate financial and structural support essential to preserve the model's viability and impact. Findings from this case study may inform policies and practices for governmental and health care systems that rely upon and contract with CHWs to mitigate health inequities. Such practices include evolving CHW accreditation and reimbursement policies and initiatives.

Policy Points Despite the goal of "all communities thriving," health equity-focused scientists and advocates have inadvertently made it easier for those "opposed to equity" to falsely convince many White communities that health equity-promoting policies and programs do not benefit them or their health. At a time when policy proposals and executive orders are likely to have major and potentially unjust impacts on the health and well-being of US communities, including White communities, it is crucial that health equity-related definitions, measurement, framing, and community engagement efforts build narratives, messages, and relationships that allow more people to see themselves in the health-equity tent.

Policy Points The economics and outcomes of modern primary care are substantially driven by investment in interprofessional clinical team members aimed at delivering complex, population health-oriented care. Neither interprofessional primary care team investment nor the work products expected in return are well represented in current commonly used productivity metrics. Stakeholder perspective-guided scoping review followed by expert panel input on measure development showed the feasibility of applying economic methods for assessing primary care productivity relative to multiple high-value products.

Context: Current primary care productivity measures do not account for investment in interprofessional primary care teams in relation to primary care goals and thus are insufficient for assessing and improving primary care efficiency and productivity. We explored alternative productivity measurement methods.

Methods: We conducted a scoping review of English language literature between 2008 and 2023 to identify articles that assessed primary care practice productivity and efficiency. We reviewed the full texts of articles to assess their analytic models including inputs, outputs, and context measures. Using scoping review results to inform content, we conducted a modified Delphi expert panel to discuss potential use cases, analytic approaches, and data elements for new primary care productivity measures. Panelists anonymously voted on recommendations for guiding near-term measure development and testing.

Findings: Evidence review identified 25 included studies. The majority (76%, 19/25) used an economic model-based productivity calculation, predominantly estimated using data envelopment analysis (DEA), with stochastic frontier analysis accounting for most of the remainder. Primary care staffing was the most common input, included in 84% of the 19 economic model studies. As outputs, over half (53%) of studies included measures of quality of care, whereas the same proportion included numbers of clinical activities. No studies used patient-reported experiences of care. Expert panelists recommended that initial measure development focus on primary care practice efficiency improvement, building the measure on routinely collected health system data, accounting for the clinical team's full-time equivalent staffing, and incorporating quality of care. Panelists endorsed DEA while also acknowledging that other approaches had potential.

Conclusions: We identified measurement approaches that aligned with both economic and foundational primary care principles but none that were implemented for routine use. Opportunities exist to develop metrics that accurately reflect primary care structures, goals, and values.

Policy Points Local jurisdictions have some policymaking discretion related to immigration. Local immigration policy contexts are associated with differences in health insurance coverage among US-born, naturalized, and noncitizen Latinos. Entrenched immigration policy-related social inequities may have a greater influence on health insurance disparities than local policymaking.

Context: Federal and state immigration policies influence access to health insurance for Latino populations. Local jurisdictions also have immigration-related policymaking power, but there has been limited study of their influence on health care access. We examined the relationship between county-level immigration policy contexts and health insurance coverage of Latino adults and youth in California using two measures that capture local-level policy decisions and immigration policy-related social inequity.

Methods: We constructed two measures of local-level immigration policy contexts by developing seven indicators of local policy enactment and implementation and 11 indicators of immigration-related social inequity. We collected data on each indicator for California's 58 counties. We coded each indicator and scored counties to construct two indices. We merged the county data with a sample of Latino adults and youth in the 2021 American Community Survey (n = 249,979). We then conducted mixed-effects modeling to test the associations between the local policymaking and social inequity indices and health insurance and tested interactions by citizenship for both adults and youth. Predicted probabilities were estimated.

Findings: There were no significant associations or interactions by citizenship between county-level policymaking and health insurance for Latino adults or youth. In contrast, there were significant associations and interactions by citizenship between immigration-related social inequity and health insurance. Among adults, naturalized and US citizens had higher predicted probabilities of being uninsured in counties with high compared with low social inequity, but there were no differences for noncitizens. Among youth, noncitizens and those with noncitizen parents had higher predicted probabilities of being uninsured in counties with high social inequity.

Conclusions: Local policy contexts and social inequity related to immigration policymaking are associated with differences in health insurance coverage among US-born, naturalized, and noncitizen Latinos.

Policy Points Universal Design and Inclusion: Mandate all digital health platforms, devices, and services be built on universal design principles and codeveloped with people with disabilities, ensuring compatibility with assistive technology and emergency response features. Standardized Disability Data Collection: Implement mandatory, standardized disability data collection in electronic health records with robust privacy protections, addressing the Patient Protection and Affordable Care Act Section 4302 gaps while enabling personalized care and research. Accessibility as Civil Rights: Treat accessibility as a civil rights issue with strict enforcement of Section 508, Americans With Disabilities Act, and Section 1557, including the patient interoperability mandate, penalties for noncompliance, and legal recourse for patients. Funding and Incentives: Establish funding incentives prioritizing disability equity, digital literacy programs, value-based payment models, and workforce training for healthcare professionals using disability-inclusive digital health tools.