Milbank Quarterly最新文献

Policy Points In 2021, young adults without children became (temporarily) newly eligible for the earned income tax credit, the largest US poverty alleviation program. This 2021 expansion was associated with fewer poor mental health days and modest improvements in physical health. This study suggests the importance of providing economic support for young adults at this critical juncture of the life course, when they are ineligible for many other social safety net benefits.

Context: In 2021, Congress expanded the earned income tax credit (EITC)-the largest US poverty alleviation program-to young adults without children who had previously been ineligible. The EITC improves health by targeting poverty as a social determinant of health, but no studies have examined health effects of the 2021 expansion on this newly eligible population during this critical period of their life span. This study addresses this gap in the literature.

Methods: We used 2021-2023 serial cross-sectional data from the Behavioral Risk Factor Surveillance System (N = 11,137), restricting the analysis to low-income young adults without children. We used quasi-experimental difference-in-differences and event study models to evaluate the impact of the EITC expansion on self-reported health and health behaviors. We considered (newly eligible) young adults aged 18 to 24 years without children to be exposed and those aged 25 to 34 years (already eligible) to be unexposed. We compared those interviewed during the EITC expansion to those interviewed before the expansion and after its expiration. Outcomes included mental and physical health in the past 30 days and binge drinking. Models were adjusted for self-reported demographic covariates and month and state fixed effects. We carried out numerous sensitivity analyses.

Findings: In difference-in-differences models, the 2021 EITC expansion was associated with fewer poor mental health days (-1.08; 95% CI -1.94 to -0.23). Event study models confirmed this and also demonstrated modest improvements in physical health. There were no effects on binge drinking. Effects were similar among various subgroups (i.e., sex, race/ethnicity). Results were robust to sensitivity analyses.

Conclusions: Expanding the EITC improved the health and well-being of young adults without children, a group often left out of US safety net programs during this key juncture of the life course. This study informs ongoing decisions regarding EITC policy design at the state and federal levels.

Policy Points Scalability and policy pathway: The universal access to health and social care provided by Neighborhood Nursing can be sustained by states leveraging existing policy frameworks like States Advancing All-Payer Health Equity Approaches and Development (AHEAD). Trust in health systems: With the United States at a low point for trust in expertise, Neighborhood Nursing can improve community trust in medical expertise using longitudinal relationships with trusted nurses and community health workers. Transformative impact: Neighborhood Nursing offers a framework that integrates multiple governmental levels for expanding health care policy from treatment-focused in health facilities to prevention-focused in people's homes and communities.

Context: Despite spending more per capita on healthcare than any other nation, the United States experiences declining life expectancy and increasing chronic disease burden-a paradox reflecting fundamental limitations in the current treatment-centered, facility-based care system. This paper introduces Neighborhood Nursing, an innovative universal care infrastructure designed to shift the US healthcare toward proactive, prevention-centered care organized geographically in neighborhoods.

Methods: Neighborhood Nursing connects every person within defined geographic areas to interdisciplinary teams of nurses and community health workers who provide promotive, preventive, and restorative services in homes and community hubs. The infrastructure operates in an institutional architecture that integrates activities across three levels: neighborhood services, state-level operational platforms, and a national center supporting research and thought leadership, operational excellence and growth, systems design and evolution, and policy orchestration and advocacy.

Findings: Drawing on international evidence-based models like Costa Rica's EBAIS and other community-oriented primary care approaches, Neighborhood Nursing addresses three core challenges in US healthcare: the prioritization of provider expertise over lived experiences, the system's reactive nature focused on treating illness rather than promoting health, and inequitable access that perpetuates mistrust in health systems, especially in marginalized communities.

Conclusions: This paper introduces Neighborhood Nursing, contrasts it with the current US system, examines international precedents, discusses implementation within value-based payment ecosystems, and outlines evaluation approaches for assessing health outcomes, community trust, and system efficiency.

Policy Points Funding that states' Long-Term Care Ombudsman Programs (LTCOPs) receive must cover all activities in that state related to the care of all individuals in nursing homes (NHs) and board and care (i.e., residential care communities, assisted living, and similar care homes); over time, duties and demands have expanded without similar increases in funding. States are contributing more to their federally mandated LTCOPs than they have historically. Evidence from this study suggests that increased spending on LTCOPs is associated with improved NH resident care, supporting the National Academies of Sciences, Engineering, and Medicine's recent call for increased funding to LTCOPs.

Context: Funded partially by the Older Americans Act, state Long-Term Care Ombudsman Programs (LTCOPs) provide a critical role in serving as advocates for older adults in long-term care (LTC) facilities. Ombudsmen regularly visit residents, resolve disputes, and assist with discharge planning. In 2022, the National Academies of Sciences, Engineering, and Medicine called for increased LTCOP funding to improve nursing home (NH) quality. However, it is unclear how changes in program funding are associated with the care provided to NH residents. Based on the functions that the LTC Ombudsmen are intended to provide, we hypothesized that increases in LTCOP spending would be associated with improved care in NHs.

Methods: We examined 20-year trends in funding for the LTCOP (2000 to 2019). Using 2011-2019 data from the National Ombudsman Reporting System, LTCFocus.org, Centers for Medicare & Medicaid Services Care Compare, and the Area Health Resource File, we examined the relationship between LTCOP spending per LTC bed at the state level and NH outcomes, controlling for year, state, facility, and market characteristics.

Findings: Overall, LTCOP funding increased over 20 years. However, the share of federal contributions to the LTCOP has decreased from 58.8% in 2000 to 46.9% of the total program's budget in 2019. The LTCOP spent an average of $37.30 per LTC bed in 2019, with wide state variation. In 2011, the average share of residents receiving antipsychotics was 25.4%, the share of those who were physically restrained was 2.9%, and the share of those with low-care needs was 13.5%. For every $100 annual increase in total spending per bed, there was a statistically significant 1.32, 1.13, and 2.95 percentage-point decrease in the share of residents receiving antipsychotics, those who were physically restrained, and those who with low-care needs, respectively.

Conclusions: States that have increased funding for their LTCOP observe better NH resident care. These findings support calls to increase funding for LTCOPs.

Policy Points We can leverage data science and artificial intelligence to inform state and local resource allocation for overdose prevention. Data science and artificial intelligence can help us answer four questions: (1) What is the impact of laws on access to interventions and overdose risk? (2) Where should interventions be targeted? (3) Which types of demographic subgroups benefit the most and the least from interventions? and (4) Which types of interventions should they invest in for each setting and population? Advances in data science and artificial intelligence can accelerate the pace at which we can answer these critical questions and help inform an effective overdose prevention response.

Policy Points State and local governments are receiving over $50 billion in opioid settlement funds over 18 years to mitigate the harms from the opioid crisis. Lessons learned from the Tobacco Master Settlement of the 1990s can ensure that funds are administered according to best practices and are spent on evidence-based interventions. Recent efforts to track opioid settlement spending around the country shed light on encouraging trends such as overdose rate reductions, unmet challenges like reducing inequities, and areas in need of continued vigilance and improvement like transparency and evaluation.

Policy Points Risk-based firearm removal laws are an effective policy tool to reduce firearm-related suicides. Unlike 21 other states with such laws, Maine's firearm removal statute applies only to persons who have been detained by law enforcement in a short-term mental health hold, and it requires an assessment for dangerousness by a medical provider. Maine's approach illuminates barriers to implementation and use of risk-based firearm removal policies. Legislative changes are necessary to bring Maine's program in line with 21 other states for which evidence shows that risk-based firearm removal laws can save lives.

Context: Extreme Risk Protection Orders (ERPOs) are an effective legal tool for reducing firearm suicide by temporarily removing access to firearms for certain individuals who exhibit dangerous behavior. Unlike most state laws restricting access to firearms based on status, ERPOs are predicated on the assessment of future risk of harm to self or other, as determined by civil court file finding. Emerging research indicates that separating those in crisis from lethal means reduces firearm mortality. We assess Maine's unique approach and consider whether it is a replicable policy option for other states or should be modified to comport with other states' more broadly applicable model.

Methods: We conducted semistructured interviews with stakeholders in Maine and in three comparison states-Connecticut, Maryland, and Vermont. Interviewees included law enforcement officers, prosecutors, mental health practitioners, medical practitioners, and educational leaders and researchers. We utilized qualitative analysis software and grouped results into themes, concepts, and recommendations that addressed implementation barriers and facilitators.

Findings: Maine's statutory approach to risk-based firearm removal provides an opportunity for comparison with other ERPO states. Maine's requirement that a person be deemed mentally ill excludes other dangerous people from involuntary firearm seizure. Additionally, Maine's mandated provider evaluation promotes tension between law enforcement and the medical community, as many providers are disinclined to perform the required evaluations. Maine's efforts to separate those at risk of self-harm or harm to others could be improved through adoption of more traditional ERPO policies.

Conclusions: No policy alone can eliminate gun violence in the United States. However, many lives can be saved by a state law that authorizes time-limited, civil court-ordered removal of firearms. Maine's narrower version, a risk-based firearm removal law, could be amended to comport with other states' ERPO laws, which have been shown to prevent many suicides.

Policy Points Improving care for people with mental health (MH) and substance use disorder (SUD) conditions is a top priority for Medicaid leaders. Medicaid has often led the way for Medicare and other payers in coverage of MH and SUD services and in modeling the applied practice of cross-disciplinary work, but there is more work to be done to develop a comprehensive, community-based system of care for MH and SUD conditions. Medicaid's work in MH and SUD conditions is both standard bearing and an important work in progress.