Milbank Quarterly最新文献

Policy Points One form of power that is required for advancing health and racial equity is narrative power: the ability to shift the stories we use to make sense of the world. Building this form of power requires the field of public health to strategically work to connect institutions and organizations to align in complementary ways to create, build, and sustain new narratives-what we refer to as narrative infrastructure. We illustrate these ideas using real-world examples drawn from work in tobacco control and emerging work in addressing structural racism in public health.

Policy Points Community health centers (CHCs) are mandated to simultaneously maintain collaborative relationships with all other health care providers in their service area while consistently expanding their footprint to serve more patients, creating a contradictory policy environment. This study suggests that CHCs may respond to competitive shocks by engaging in a turf war with encroaching rivals at the expense of their financial solvency and social mission. Compounded in part by mounting fiscal austerity that may exacerbate competitive pressures, new approaches are needed that strengthen guardrails against patient selection and create incentives for CHCs to move into persistently underserved communities.

Context: Community health centers (CHCs) are a critical and growing part of the health care safety net, doubling over the past 15 years to expand access to essential health care services to over 31 million patients in traditionally underserved communities. However, increasingly, CHCs have opened care delivery locations in communities already served by another CHC, potentially creating competitive markets with unknown implications for how this safety net operates.

Methods: This retrospective cohort study was performed in 810 CHCs that operated between 2009 and 2023. A difference-in-differences design was used with staggered implementation to examine the impacts of competitive shocks on clinic performance and, consequently, whether this changes the types of patients served and how clinics operate.

Findings: When a rival CHCs' growth results in a competitive shock, 95% of new sites are located no more than ten miles away from their existing service area. After a competitive shock, incumbent CHCs on average experienced significant decreases in financial stability and shifts in their patient mix toward those with Medicaid and away from patients who are uninsured and have more chronic conditions. Clinics also reallocated 11% of their resources closer to the encroaching rival, recentering and concentrating their organizations. Strikingly, multiple competitive shocks increased the annual probability of a closure, acquisition, or loss of CHC status from 0% to 1.67%.

Conclusions: Despite explicit policy guardrails, this pattern of rapid, recent, and localized growth has distorted incentives for individual clinics, weakening this critical safety net. Clinics may respond to such mounting pressures by engaging in a turf war, reallocating and concentrating resources closer toward the encroaching rival at the expense of their social mission and financial solvency. Both state and federal policymakers must incentivize CHCs to disperse into communities without established clinics and introduce new protections against underservice by stabilizing clinic budgets.

Policy Points The spillover effects of jail and prison incarceration extend to acute psychiatric emergencies in Black communities. State-level drug reform policies and policies that reduce labor market and housing discrimination for former inmates may have salutary mental health benefits for the broader community.

Context: The justice system incarcerates nearly 2.3 million individuals in the United States. Black Americans comprise 40% of those incarcerated despite representing less than 15% of the population. Theoretical work posits that mass incarceration can erode social capital by straining social and family networks as well as inducing carceral churn and coercive mobility within Black communities. Scholars report that greater incarceration may influence population-level health, specifically in communities of color. However, previous work does not address whether incarceration, as well as the racial disparity in incarceration, corresponds with psychiatric help seeking in the Black community.

Methods: We examine the relation between incarceration and psychiatric emergency department (ED) visits among Black Americans from 2006 to 2015. As the exposure, we use 1) jail and prison incarceration among Black Americans (per 100,000 population), and 2) the ratio of non-Hispanic Black to non-Hispanic White American incarcerated populations as a measure of racial inequity in the criminal legal system. We examine, as the outcome, annual psychiatric ED visits (per 100,000 population) among Black Americans in 404 counties from ten US states between 2006 and 2015 (2,360 county-years). Linear fixed effects analyses control for time-invariant county factors as well as percentage below the federal poverty line, percentage unemployed, number of hospitals, and arrests for violent crime.

Findings: One additional individual incarcerated (per 100,000 population) corresponds with a 1.4% increase in psychiatric ED visits in Black communities (p < 0.001). An increase in racial inequity in incarceration (non-Hispanic Black to non-Hispanic White American ratio) also coincides with a 2.2% increase in psychiatric emergencies among Black Americans (p < 0.001).

Conclusions: The long arm of incarceration may extend to psychiatric emergencies among Black Americans in the broader community. Researchers and policymakers may consider measures, such as drug reform or other social policies, to reduce the influence of mass incarceration on acute and adverse mental health in the Black community.

Policy Points Nonprofit hospitals should be required to provide adequate documentation that allows the Internal Revenue Service (IRS) to evaluate whether their reported activities genuinely qualify as community benefits. To enhance the current system, rigorous data reporting requirements must be established, including mandates for hospitals to report community benefits individually on Schedule H of Form 990, clearly demonstrating how these expenditures benefit each community. The IRS, the Centers for Medicare and Medicaid Services, and public health authorities should work with hospitals to standardize definitions to improve accountability CONTEXT: The American Hospital Association determined that in 2022 nonprofit hospitals spent $129 billion on community benefits. This is more than the entire budget for the US public health service. Different organizations estimate different amounts of community benefit spending depending on their definition of community benefit.

Methods: We used Schedule H from Internal Revenue Service (IRS) Form 990 data between 2019 and 2022 to determine the value of 17 components of community benefit and bad debt in nonprofit organizations. Using the descriptive analysis, this paper discusses the pros and cons of including certain categories of community benefit and suggests modifications to the definitions.

Findings: In 2022, nonprofit hospitals spent $94 billion on all 17 categories of community benefit. This expenditure included $21 billion in services that benefited the patient directly, $33 billion on services that benefited the community, and $41 billion on Medicaid shortfall. Hospitals also spent $26 billion on bad debt.

Conclusions: The value of community benefits varies significantly based on the definition used, even when the same data set is analyzed. Greater agreement on what community benefit means is necessary to ensure compliance with regulations regarding community benefit spending. This approach could involve coordination among the IRS, Centers for Medicare and Medicaid Services, and public health authorities to enhance accountability when working with hospital associations.

Policy Points A total of 21 states have passed drug price transparency laws with the goals of creating accountability around drug pricing and facilitating the development of policy solutions to address high prices. These laws vary in design but often require manufacturers to report the wholesale acquisition cost of drugs above a certain threshold for new drugs or of drugs that undergo a price increase above a certain margin, along with other data such as the manufacturer's costs. Initial findings suggest these laws may have contributed toward informing policymaking based on newly available public information but do not appear to have affected drug prices.

Policy Points Our research provides a starting point to benchmark government transparency measures to improve the quality and accessibility of information about lobbying. Policymakers and regulators can use our framework to develop or strengthen their own lobbying registers. Countries like Canada are a good example of how to design an accessible database about lobbying, and Chile, Ireland, and Scotland provide examples of comprehensive contact logs.

Context: Information about lobbying is crucial to alert the public about undue influence in government decision making. Yet, government disclosures of lobbying activities are rare internationally and vary considerably in their completeness and accessibility. Building on a framework to measure lobbying transparency, this study benchmarked national government disclosures to understand what information was shared and to develop recommendations to strengthen political transparency.

Methods: To identify lobbyist registers, we reviewed four international surveys that assessed lobbying transparency in 128 countries. For each country with an online register, we assessed the 50 indicators in the Framework for Comprehensive and Accessible Lobbying (FOCAL), generating an overall score for each government. To highlight the importance of transparency for public health, we compared the visibility of tobacco industry lobbying across all registers by documenting the information provided about two prominent tobacco companies: Philip Morris International and British American Tobacco.

Findings: We identified 28 countries with online lobbyist registers, all from upper or upper-middle income countries. No country fulfilled all 50 indicators in the FOCAL. The category of "scope" had the highest scores across countries, whereas the "revolving door" and "financial" categories had the lowest scores. We found evidence of lobbying by Philip Morris International, British American Tobacco, or one of their subsidiaries in 14 of the 28 countries with online lobbyist registers.

Conclusions: Our study empirically demonstrates the hidden nature of lobbying internationally. In the case of industries whose interests conflict with public health, poor lobbying transparency presents a risk that vested interests may undermine public health policymaking without anyone knowing. To ensure that health harming industry interests cannot escape scrutiny, public health advocates should support efforts to strengthen political transparency measures. Open access publishing facilitated by The University of Melbourne, as part of the Wiley - The University of Melbourne agreement via the Council of Australian University Librarians.

Policy Points Twenty-four states and the District of Columbia offer public insurance to pregnant undocumented immigrants who are income eligible for Medicaid. We found that residing in a state with public coverage of pregnant undocumented immigrants was associated with increased prenatal Medicaid coverage among immigrants and was not associated with corresponding reductions in private or other insurance coverage. Offering state public insurance to pregnant undocumented immigrants could increase immigrants' access to insurance coverage and recommended care during pregnancy.

Context: Health insurance coverage increases access to recommended pregnancy care, but undocumented immigrants are not eligible for pregnancy Medicaid coverage without state uptake of alternative policy options. Twenty-four states and the District of Columbia (DC) offer public insurance to undocumented immigrants who are income eligible for pregnancy Medicaid through the Children's Health Insurance Program From-Conception-to-End-of-Pregnancy option or state funds. Our objective was to examine the association between residing in a state with public insurance coverage for pregnant undocumented immigrants and prenatal insurance coverage among low-income immigrants.

Methods: We used 2016 to 2021 Pregnancy Risk Assessment Monitoring System responses linked to maternal nativity from birth certificate records from 19 states and DC. We compared the prevalence of any insurance, Medicaid insurance, and private or other insurance coverage of prenatal care between Medicaid income-eligible immigrants and nonimmigrants. We then estimated the association between state public coverage policy and prenatal insurance coverage among immigrants using linear regression models.

Findings: The study included 47,370 adults (13,271 immigrants and 34,099 nonimmigrants) who were income eligible for pregnancy Medicaid. In the ten included states with public coverage of pregnant undocumented immigrants, the proportion of immigrants with any insurance for prenatal care was 16.9 percentage points higher (95% CI, 14.9-18.9) compared with the proportion of immigrants in states without such coverage. In policy-adopting states, the proportion of immigrants with Medicaid for prenatal care was also 16.9 percentage points higher (95% CI, 14.1-19.7) compared with immigrants in nonpolicy-adopting states. We did not find differences by state coverage policy in having had private insurance coverage for prenatal care.

Conclusions: Providing state public insurance coverage to undocumented immigrants during pregnancy may increase overall prenatal insurance coverage by expanding access to Medicaid. We did not find evidence that extending public coverage to this population crowds out other insurance options.

Policy Points Since 2004, beneficiaries in government-administered traditional Medicare decreased by about 3 million (8%), whereas enrollment in Medicare Advantage (MA) plans run by private insurance companies increased by approximately 30 million (500%). MA's growth has exceeded the adequate evolution and refinement of the program's regulatory apparatus. MA now annually costs at least 20% (around $84 billion) more than what Medicare would have spent if all MA enrollees were in traditional Medicare (TM). This differential in payments has advantaged MA relative to TM and transformed the Medicare program in part by corporatizing it for tens of millions of beneficiaries. Most MA revenue now flows to large, increasingly vertically integrated, multinational, for-profit companies that are reshaping the US health care landscape for all patients, providers, and payers. Overpayments have strengthened the political position of the largest MA plan providers such that the program is at risk of interest group capture because of their powerful lobbying and political influence. Reforming MA should include the following: (a) ongoing improvements to the program's risk adjustment system and benchmark policy for rate setting, (b) replacing the quality bonus program with a value incentive program that is budget-neutral, and (c) standardizing MA plans into a small number of basic plan categories and having private health companies make competitive bids in each of them to compete on price instead of on benefit offerings. Savings from any MA payment reforms could shore up Medicare's Hospital Trust Fund or improve TM for a "Medicare 2.0" that competes on a more level playing field with MA.

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.