Milbank Quarterly最新文献

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 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 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.

Policy Points After the repeal of National Prohibition in 1933, the federal government gave states the bulk of the regulatory power over alcohol. Although states used this power early on, particularly since the 1970s state action on alcohol has largely liberalized alcohol control structures, allowed taxes' real value to decline with inflation, expanded physical availability, and failed to limit alcohol marketing. With declining federal funds for public health and health care, states have the power today to use alcohol taxes to raise much-needed revenues, and reduce alcohol problems while funding a range of needed programs and services.

Policy Points The government has a key role in ensuring equitable and just health care access for all constituents, including those involved with the criminal legal system. Multi-agency collaboration is a critical and effective path to ensure equitable health care access. Incarceration events can cause delays and disruptions in substance use disorder treatment, and treatment in carceral settings can prevent these adverse outcomes. Multi-agency collaborations can be strengthened by legislation, leadership support, the identification of shared goals, methods to share data, and subsequent accountability.

Policy Points Laws on drug use during pregnancy are enforced more harshly against structurally marginalized people. Despite this pattern, these laws' impacts on health and health care inequities are understudied. We offer recommendations for novel, robust research to generate evidence on this essential topic.

Policy Points There have been significant advancements in expanding care for opioid use disorder and suicide in general medical settings in the first quarter of the 21st century. Incessant barriers in the US health system continue to hinder progress in sufficiently scaling up evidence-based behavioral health interventions and getting them to those at highest risk. State policymakers have multiple levers available to make significant improvements to address ongoing challenges and improve access to evidence-based behavioral health services in emergency and primary care settings.

Policy Points There has been a pronounced shift from injecting to smoking drugs in the United States. This shift has the potential to reduce many health harms associated with illicit drug use. State laws are structural barriers to the provision of safer smoking supplies, cause preventable harm, and should be repealed.