Milbank Quarterly最新文献

Policy Points States' overarching policy contexts are a meaningful yet overlooked predictor of adults' mental health, with more conservative contexts associated with worse mental health outcomes over a 30-year period. Counterfactual analyses suggest that widespread policy shifts could meaningfully alter the national prevalence of mental distress, positioning state policy contexts as important yet underutilized levers for improving population mental health. These associations are strongest among adults without a college degree, underscoring that state policy contexts may exacerbate existing educational disparities in mental health.

Context: Mental health among US working-age adults notably worsened during the COVID-19 pandemic, following a steady decades-long decline. The impact of states' COVID-19 policies on mental health has received much attention; however, less is known about the impact of a broader set of long-standing and overarching state policy contexts. This study examines how working-age adults' mental health was associated with states' policy contexts over 30 years. It also assesses whether the pandemic disrupted the association and whether the association is more pronounced among adults without a college degree.

Methods: We use nationally representative data on adults ages 25-64 in the 1993-2022 waves of the Behavioral Risk Factor Surveillance System (N = 5,891,073), merged with measures of three state policy indices. The outcomes are self-rated poor mental health days in the last 30 days and extreme distress (poor mental health in all 30 days). The main independent variable is an index that summarizes states' overarching policy contexts, on a liberal-to-conservative continuum, annually from 1993-2020. Two additional indices summarize states' COVID-19 policies, one on in-person restrictions and a second on economic supports, monthly from March 2020 to December 2022. We estimate the association between states' overarching policy contexts and mental health, net of covariates, fixed differences between states, and COVID-19 policies.

Findings: During the study period, each unit increase toward state policy conservatism was associated with 0.26 additional days of poor mental health and a 7% higher probability of extreme distress. The pandemic did not disrupt these associations. State policy contexts were a stronger predictor of poor mental health among adults without a college degree than adults with a degree.

Conclusions: States' overarching policy contexts are an important yet understudied predictor of mental health. Current and proposed changes in state policies may have important consequences for mental health among working-age adults, their families, and communities.

Policy Points This study examines the link between corruption and mortality. We find that corruption is associated with higher mortality, particularly in low-income countries. It is also linked to lower government revenue and distorted government expenditure patterns, which may contribute to resource misallocation and constraints in health financing. Our findings contribute to the literature on upstream determinants of health by highlighting the relevance of institutional and political economy factors for population health. The Sustainable Development Goals on combating corruption and improving health are found to be complementary. Efforts to address corruption could align with and support public health objectives.

Context: While public health research has examined the macro-level and structural determinants of health, the link between corruption and population health remains underexplored. This study investigates the relationship between corruption and mortality and explores potential pathways underlying this association. In doing so, it contributes to the broader literature on the political economy of health and the upstream factors associated with population health.

Methods: This study draws on country-level data from 102 countries spanning 2008-2018. We use econometric methods, including instrumental variables and the Mundlak approach. To mitigate endogeneity concerns, we employ an instrumental variable approach based on ancestry and oral tradition, using historical cultural factors plausibly related to contemporary corruption levels.

Findings: We find a significant relationship between corruption and higher mortality rates. Corruption is also linked with weaker fiscal capacity, reduced government funding for health care, distorted resource allocation, and patterns consistent with misallocation of public funds. Additionally, the association between corruption and mortality varies across levels of public goods provision.

Conclusions: This study expands existing research on social determinants of health by highlighting the relevance of institutional and political factors for population health. Addressing corruption could be recognized as a public health priority, given its association with health financing and population health.

Policy Points Our analysis indicated that permanent loss of Medicaid was associated with poorer health outcomes, higher mortality, greater out-of-pocket costs, and lower preventive health care use relative to those who kept Medicaid or had a temporary disruption. Addressing these coverage gaps can improve individual health and reduce systemwide costs. Policymakers should consider increasing eligibility criteria for Medicaid at age 65 years from 100% of the federal poverty level (FPL) to 138% FPL. Eligibility and outreach efforts for Medicare Savings Plans or introducing state-level Medicaid income disregards from 100% FPL to 138% FPL could mitigate the Medicare Cliff in the absence of federal eligibility reform.

Context: About 280,000 older adults experience the "Medicare Cliff" each year, becoming eligible for Medicare and losing Medicaid coverage when they turn age 65 years due to discontinuities in financial eligibility criteria. Yet, little is known about the long-term associations between a loss in Medicaid coverage and health status, health care utilization, and economic status in later life. Our study builds on previous research by longitudinally examining how health outcomes, health utilization measures, and out-of-pocket medical expenses change when people experience the Medicare Cliff compared with those who maintain their coverage and those who experience temporary disruptions in coverage.

Methods: Using longitudinal data from the Health and Retirement Study over the period 1998-2020, we tracked individuals over a 10-year follow-up period from when they first became eligible for Medicare.

Findings: Our analysis indicated that even though respondents with Medicaid prior to Medicare eligibility started with better health overall, permanent loss of Medicaid was associated with poorer health outcomes and higher mortality relative to those who kept Medicaid or had a temporary disruption. Permanent loss of Medicaid was also negatively associated with appropriate health care utilization and positively associated with higher out-of-pocket health care spending relative to those who kept Medicaid or had a temporary disruption.

Conclusions: Findings show that experiencing the Medicare Cliff is associated with a range of negative outcomes, including increases in overall health care expenditures relative to those who maintain Medicaid eligibility or only lose it temporarily. Addressing the Medicare Cliff issue would therefore lead to improved health outcomes and reduced health care costs. Our analysis provides a strong basis for policymakers to address this coverage discontinuity through specific policies related to Medicaid financial eligibility rules and access to Medicare Savings Plans to financially protect older adults.

Policy Points Changing structures, such as laws, policies, regulations, practices, and norms, in pursuit of health and racial equity is hard for any organization to do alone, including health departments. Health departments can advance health and racial equity by partnering with movements for fairer and more just social arrangements that often emanate from civil society through the work of community power-building organizations. This requires health departments to adopt an inside-outside strategy, which consists of practices needed internally to effectively participate in movements and practices needed externally to become allied in them.

Context: Disparities in health often arise due to unfair or unjust social arrangements making them inequities. These social arrangements are codified through structures-laws, policies, regulations, practices, and norms. Changing structures is generally considered the work of professional entities, such as health departments. However, inequities persist, which suggests new, more focused approaches are needed.

Methods: Health departments are not alone in pursuing fairer and more just social arrangements. There are also movements for social justice, which emanate from community power-building organizations (CPBOs). CPBOs benefit from being in relationship with organizations that know how to change structures, such as health departments.

Findings: For health departments to be in relationship with CBPOs and movements requires them to adopt an inside-outside strategy. Inside refers to the work needed to be done internally to effectively participate in movements. Outside refers to the work needed to be done externally to become allied in them. We describe two such strategies, one from California and one from Illinois.

Conclusions: Our examples illustrate how public health's careful participation in movements can advance health equity. Health departments need to think of themselves as part of an ecosystem of organizations pursuing fairer and more just social arrangements.

Policy Points Voting rights are the most common measure of power when studying structural determinants of health. Voting is a narrow conceptualization of community power and irrelevant for noncitizen populations who are vitally affected by health policymaking despite not being able to vote. We measure six factors related to community power, including laws, policies, and practices/norms at the county level that are applicable to counties with significant populations who identify as Latino. These measures act to either overcome or exacerbate historical power imbalances based on race, ethnicity, and citizenship status. These findings contribute to our understanding of the structural determinants of health and highlight the important ways that community power can be conceptualized and measured for specific racial or ethnic groups.

Context: We broaden our understanding of community power by going beyond traditional measures of voting and voting rights. Our objectives are to (1) create county-level measures of community power that are more expansive than voting and (2) explore the descriptive and geographic patterns of community power.

Methods: Six novel measures of community power were developed at the county level. Three were indicators of power-building activities that overcome historic power imbalances faced by Latino populations. These include measures on political representation, immigrant incorporation, and language accessibility for elections. We also measured three indicators related to immigration enforcement that act to exacerbate historical power disparities. Correlational and spatial analyses were conducted to better understand descriptive and geographic patterns.

Findings: We found little evidence that our measures are correlated; spatial analyses largely confirmed this. There was evidence of regional spatial autocorrelation, but inferences depended largely on the measure used. We generally found that counties with more than 10% of residents who identify as Latino have higher values on our power-building measures, suggesting that these areas are especially primed to amplify the voices of Latino residents. Interestingly, our measures related to immigration enforcement were largely unrelated to recent Latino population growth (e.g., "new destination counties").

Conclusions: Power is a fundamental driver of the conditions that produce or mitigate health disparities, but the process by which communities influence decision making may be difficult to measure. This work provides a blueprint for future scholars studying the link between community power and health equity across different races, ethnicities, and citizenship statuses.

Policy Points Primary care is undervalued and under-funded in many countries despite different care and payment models. High-quality, accessible primary care requires sustained and strategic investment. Team-based care, sustainable and engaged workforce models, and technology that enhances rather than fragments care are priorities that are shared across nations. Countries can adopt a principled approach by paying for primary care teams to care for people not physicians to deliver services; ensure that high-quality primary care is available to every individual and family in every community, and ensure that high-quality primary care is implemented with measurement and accountability.

Context: Primary care is the foundation of most health systems; yet across diverse countries, structures, policies, and payment models, it is under threat. Many high-income countries face shrinking workforces, worsening access, disrupted continuity, and reduced comprehensiveness.

Methods: Common drivers include underfunding and spending that is inefficient, leading to workforce crises and rising clinical and administrative burdens that drive burnout.

Findings: These shared challenges require shared solutions. Strengthening primary care means adequate funding that is wisely invested to increase workforce capacity-including general practitioners and other primary care team members such as nurses, pharmacists, and social workers-and promotion of sustainable models of care. Policies that impose unfunded mandates or devalue core functions such as continuity and comprehensiveness erode system performance and make it impossible for primary care to deliver on its promise for cost, utilization, satisfaction, and health outcomes.

Conclusions: Sufficient and efficient funding in team-based, person-centered primary care must be a political and policy priority.