Milbank Quarterly最新文献

Policy Points The role of Medicaid in financing, organizing, and delivering substance use disorder (SUD) treatment has grown tremendously over time owing to expansions of eligibility and a push toward more uniformity in benefits. Current innovations in SUD treatment focus on expanding the delivery system to create a comprehensive continuum of care, using more value-based payment to reward quality care, and integrating SUD treatment with other systems (e.g., housing, employment, and the criminal legal system). Many of the promising innovations in delivery have not yet been rigorously studied, and implementation of effective models is often stymied because of the lack of flexibility in program requirements and variation in needs and resources across communities. Although policymakers can justifiably laud the great strides Medicaid has made in raising the standards for SUD treatment, there is a huge remaining gap in access to services amidst an unprecedented overdose crisis and looming turmoil in the program.

Policy Points To address persistent gaps in behavioral health care access and availability, particularly for underresourced populations, state policymakers have implemented four core strategies to address the shortage of behavioral health providers serving the Medicaid population. In this paper, we describe each of these state policy strategies, discuss their potential workforce and service impacts, and highlight unanswered questions about their effectiveness and implementation. Altogether, our review of these policy strategies suggests that rigorous evaluation of these state policy strategies is needed along with broader transformations to the behavioral health system to sustainably grow and retain the workforce in the long term.

Policy Points The sources and adequacy of funding for crisis systems currently varies significantly among the US states and across services in the crisis continuum. Crisis services are funded by a wide range of sources, including 988 telecom fees and other state appropriations, community mental health services block grants and other federal funding sources, Medicaid, and commercial insurance. Priority areas for research related to financing crisis systems include evaluating the effects of 988 telecom fees, value-based payment models, and non-Medicaid payors.

Policy Points This perspective argues that state economic and social support policies are key determinants of population mental health. Key policy successes of the past decade include state expansion of Medicaid eligibility, increase in minimum wage, and implementation of paid sick leave. Key policy priorities include the prioritization of evidence-based policies that improve economic security and the expansion of social support policies that are not tied to employment.

Policy Points Menthol-flavored e-cigarettes are disproportionately used by youth who co-use other substances; allowing menthol sales may undermine efforts to reduce poly-tobacco and poly-substance use. Fruit/ice-fruit flavors are most common among lower-risk youth (those not engaged in other substance use), and banning these flavors could help prevent nicotine initiation. Because nearly all youth who vape use non-tobacco-flavored e-cigarettes, comprehensive policies that eliminate access to all non-tobacco-flavored e-cigarettes, including menthol, may be more effective than selective bans. Stronger enforcement and broader flavor restrictions could help prevent initiation and reduce sustained use, particularly among youth who co-use menthol-flavored e-cigarettes and other substances.

Context: The specific nontobacco e-cigarette flavors used by US youth who exclusively vape e-cigarettes compared with youth who engage in poly-tobacco or poly-substance use can help identify the populations most likely to be impacted by e-cigarette flavor policies. This study examines correlations between e-cigarette flavor use and past 30-day tobacco and substance use among US youth who vape.

Methods: We analyzed the Monitoring the Future survey data (2021-2023), a nationally representative annual study of US eighth, tenth, and 12th graders. Among 14,675 participants who vaped nicotine in the past year, we assessed their most frequently used e-cigarette flavor: fruit/ice-fruit, menthol, mint, sweet, tobacco, or unflavored. Log-binomial regression models estimated adjusted prevalence ratios (APRs) for correlations between e-cigarette flavor use and past 30-day tobacco and substance use, adjusting for sociodemographic characteristics and e-cigarette use.

Findings: Few youth predominately vaped tobacco-flavored (1.3%) or unflavored (3.6%) e-cigarettes, regardless of whether they did or did not use other tobacco products or nontobacco substances. Menthol-flavored (12.1%) e-cigarette use was correlated with past 30-day cigarette (APR 1.53, 95% CI 1.29-1.81), smokeless tobacco (APR 1.53, 95% CI 1.24-1.89), cigars/hookah tobacco products (APR 1.51, 95% CI 1.13-2.02), and alcohol (APR 1.16, 95% CI 1.02-1.32) use. In contrast, fruit/ice-fruit-flavored (72.3%) e-cigarettes were less commonly used among youth who smoked cigarettes (APR 0.83, 95% CI 0.76-0.90), used smokeless tobacco (APR 0.83, 95% CI 0.75-0.91), or reported noncannabis illicit drug use (APR 0.89, 95% CI 0.80-0.98).

Conclusions: Closing federal regulatory loopholes and implementing state and local bans on all non-tobacco-flavored e-cigarettes may support efforts to reduce youth nicotine uptake. Policies that limit access and sales to menthol-flavored e-cigarettes could be particularly relevant for youth at risk of poly-tobacco or poly-substance use.

Policy Points State "must-query" prescription drug monitoring programs (PDMPs) were associated with increased overdose deaths, suggesting these policies may have unintended consequences. Black and Hispanic populations experienced disproportionately higher increases in overdose deaths following must-query PDMP adoption, highlighting that these policies may contribute to health disparities. Addressing systemic inequities in health care access and substance use treatment may help supplement the effective components of PDMPs, ensuring that these policies reduce rather than exacerbate overdose deaths.

Context: Despite recent declines in national overdose deaths, these reductions have not been equitably experienced. Black and Hispanic communities continue to face rising rates of opioid-related mortality, even as overdose death rates among White individuals have begun to decline. One of the most widely implemented policy responses to the overdose crisis has been the adoption of prescription drug monitoring programs (PDMPs), particularly "must-query" mandates requiring prescribers to consult the PDMP before issuing controlled substances. However, limited research has examined whether the impact of these mandates varies by race and ethnicity.

Methods: We used restricted-use National Vital Statistics System data from 2013 to 2020 to estimate county-level overdose mortality stratified by drug type and race and ethnicity. We categorized deaths as follows: (1) all drug overdoses, (2) all opioid overdoses, and (3) natural/semisynthetic opioid overdoses. Exposure to must-query mandates was modeled as the proportion of the prior year during which mandates were in effect. Using Bayesian spatiotemporal models with county random effects and spatial autocorrelation, we estimated relative rates (RRs) for each outcome overall and by race and ethnicity, adjusting for state policies and sociodemographic characteristics.

Findings: Must-query mandates were associated with increases in overdose deaths across all groups, with the largest relative increases among Hispanic (RR = 1.32, 95% credible interval [CrI]: 1.21-1.44) and Black individuals (RR = 1.23, 95% CrI: 1.14-1.33) compared with White individuals (RR = 1.14, 95% CrI: 1.10-1.19). These increases were also observed among Black and Hispanic individuals for natural/semisynthetic opioid overdoses.

Conclusions: PDMP must-query mandates are not uniformly protective across racial and ethnic groups. Increases in overdose mortality following adoption, particularly among Black and Hispanic populations, underscore the need to evaluate drug policies through an equity lens and consider broader structural determinants of health that shape their effectiveness.

Policy Points Latine communities in the United States experience disproportionately high uninsurance rates because of systemic barriers, including limited language equity, lack of provider (clinical or nonclinical) concordance, discrimination, misinformation, and immigration-related fears. Data on individuals eligible for but not enrolled in insurance programs are lacking, which prevents the identification of barriers, population impacted, and tailored approaches to meet specific needs of vulnerable communities. We propose community-informed policy strategies, including culturally tailored outreach, involvement of trusted community health workers, and improved health equity data collection. Framing data in terms of eligible but not enrolled individuals shifts the focus to existing coverage gaps and the potential for improvement, encouraging states to take more proactive enrollment actions.

Policy Points Many have urged academic institutions to rethink conflict of interest policies governing leaders' outside activities, which pose not only individual conflicts for leaders themselves but institutional conflicts for their academic employers. Although the American Association of Medical Colleges and Association of American Universities have provided guidance on managing such conflicts, neither offer a structured approach for determining when and under what conditions it is appropriate for a leader to engage in specific outside activities. To address this gap, this article develops a decision-making framework that institutional oversight bodies can use to assess the permissibility of academic leaders' proposed outside activities.