Milbank Quarterly最新文献

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.

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.