Milbank Quarterly最新文献

Policy Points Social indicators of young peoples' conditions and circumstances, such as high school graduation, food insecurity, and smoking, are improving even as subjective indicators of mental health and well-being have been worsening. This divergence suggests policies targeting the social indicators may not have improved overall mental health and well-being. There are several plausible reasons for this seeming contradiction. Available data suggest the culpability of one or several common exposures poorly captured by existing social indicators. Resolving this disconnect requires significant investments in population-level data systems to support a more holistic, child-centric, and up-to-date understanding of young people's lives.

Policy Points Many studies have explored the impact of message strategies to build support for policies that advance racial equity, but few studies examine the effects of richer stories of lived experience and detailed accounts of the ways racism is embedded in policy design and implementation. Longer messages framed to emphasize social and structural causes of racial inequity hold significant potential to enhance support for policies to advance racial equity. There is an urgent need to develop, test, and disseminate communication interventions that center perspectives from historically marginalized people and promote policy advocacy, community mobilization, and collective action to advance racial equity.

Context: Long-standing racial inequities in health and well-being are shaped by racialized public policies that perpetuate disadvantage among Black, Brown, Indigenous, and people of color. Strategic messaging can accelerate public and policymaker support for public policies that advance population health. We lack a comprehensive understanding of lessons learned from work on policy messaging to advance racial equity and the gaps in knowledge it reveals.

Methods: A scoping review of peer-reviewed studies from communication, psychology, political science, sociology, public health, and health policy that have tested how various message strategies influence support and mobilization for racial equity policy domains across a wide variety of social systems. We used keyword database searches, author bibliographic searches, and reviews of reference lists from relevant sources to compile 55 peer-reviewed papers with 80 studies that used experiments to test the effects of one or more message strategies in shaping support for racial equity-related policies, as well as the cognitive/emotional factors that predict their support.

Findings: Most studies report on the short-term effects of very short message manipulations. Although many of these studies find evidence that reference to race or use of racial cues tend to undermine support for racial equity-related policies, the accumulated body of evidence has generally not explored the effects of richer, more nuanced stories of lived experience and/or detailed historical and contemporary accounts of the ways racism is embedded in public policy design and implementation. A few well-designed studies offer evidence that longer-form messages framed to emphasize social and structural causes of racial inequity can enhance support for policies to advance racial equity, though many questions require further research.

Conclusions: We conclude by laying out a research agenda to fill numerous wide gaps in the evidentiary base related to building support for racial equity policy across sectors.

Policy Points Local governments are increasingly adopting policies that earmark taxes for mental health services, and approximately 30% of the US population lives in a jurisdiction with such a policy. Policies earmarking taxes for mental health services are heterogenous in their design, spending requirements, and oversight. In many jurisdictions, the annual per capita revenue generated by these taxes exceeds that of some major federal funding sources for mental health.

Context: State and local governments have been adopting taxes that earmark (i.e., dedicate) revenue for mental health. However, this emergent financing model has not been systematically assessed. We sought to identify all jurisdictions in the United States with policies earmarking taxes for mental health services and characterize attributes of these taxes.

Methods: A legal mapping study was conducted. Literature reviews and 11 key informant interviews informed search strings. We then searched legal databases (HeinOnline, Cheetah tax repository) and municipal data sources. We collected information on the year the tax went into effect, passage by ballot initiative (yes/no), tax base, tax rate, and revenue generated annually (gross and per capita).

Findings: We identified 207 policies earmarking taxes for mental health services (95.7% local, 4.3% state, 95.7% passed via ballot initiative). Property taxes (73.9%) and sales taxes/fees (25.1%) were most common. There was substantial heterogeneity in tax design, spending requirements, and oversight. Approximately 30% of the US population lives in a jurisdiction with a tax earmarked for mental health, and these taxes generate over $3.57 billion annually. The median per capita annual revenue generated by these taxes was $18.59 (range = $0.04-$197.09). Per capita annual revenue exceeded $25.00 in 63 jurisdictions (about five times annual per capita spending for mental health provided by the US Substance Abuse and Mental Health Services Administration).

Conclusions: Policies earmarking taxes for mental health services are diverse in design and are an increasingly common local financing strategy. The revenue generated by these taxes is substantial in many jurisdictions.

Policy Points A large body of scientific work examines the mechanisms through which social determinants of health (SDOH) shape health inequities. However, the nuances described in the literature are infrequently reflected in the applied frameworks that inform health policy and programming. We synthesize extant SDOH research into a heuristic framework that provides policymakers, practitioners, and researchers with a customizable template for conceptualizing and operationalizing key mechanisms that represent intervention opportunities for mitigating the impact of harmful SDOH. In light of scarce existing SDOH mitigation strategies, the framework addresses an important research-to-practice translation gap and missed opportunity for advancing health equity.

Context: The reduction of health inequities is a broad and interdisciplinary endeavor with implications for policy, research, and practice. Health inequities are most often understood as associated with the social determinants of health (SDOH). However, policy and programmatic frameworks for mitigation often rely on broad SDOH domains, without sufficient attention to the operating mechanisms, and effective SDOH mitigation strategies remain scarce. To expand the cadre of effective SDOH mitigation strategies, a practical, heuristic framework for policymakers, practitioners, and researchers is needed that serves as a roadmap for conceptualizing and targeting the key mechanisms of SDOH influence.

Methods: We conduct a critical review of the extant conceptual and empirical SDOH literature to identify unifying principles of SDOH mechanisms and to synthesize an integrated framework for conceptualizing such mechanisms.

Findings: We highlight eight unifying principles of SDOH mechanisms that emerge from landmark SDOH research. Building on these principles, we introduce and apply a conceptual model that synthesizes key SDOH mechanisms into one organizing, heuristic framework that provides policymakers, practitioners, and researchers with a customizable template for conceptualizing and operationalizing the key SDOH mechanisms that represent intervention opportunities to maximize potential impact for mitigating a given health inequity.

Conclusions: Our synthesis of the extant SDOH research into a heuristic framework addresses a scarcity of peer-reviewed organizing frameworks of SDOH mechanisms designed to inform practice. The framework represents a practical tool to facilitate the translation of scholarly SDOH work into evidence-based and targeted policy and programming. Such tools designed to close the research-to-practice translation gap for effective SDOH mitigation are sorely needed, given that health inequities in the United States and in many other parts of the world have widened over the past two decades.

Policy Points Obesity has emerged as a main threat to future improvements in population health, and there is little evidence that the epidemic is retreating. The traditional model of "calories in, calories out," which has guided public health policy for decades, is increasingly viewed as far too simple a framing to explain the evolution of the epidemic or guide public policy. Advances in the science of obesity, coming from many fields, highlight the structural nature of the risk, which has provided an evidence base to justify and guide policies toward addressing the social and environmental drivers of obesity. Societies and researchers need to play the long game in that widespread reductions in obesity in the short run are unlikely. Nonetheless, there are opportunities. Policies specifically targeting the food environment such as taxing high-calorie beverages and foods, restricting the marketing of junk foods to children, enhancing food labeling, and improving the dietary environment at schools may yield long-run benefits.

Policy Points Administrative burdens, which are the onerous experiences people have when trying to access government benefits and services, reduce older adult's access to health promoting policies. Although considerable attention has been focused on threats to the old-age welfare state, ranging from long-term financing problems to attempts to roll back benefits, administrative barriers to these programs already threaten their effectiveness. Reducing administrative burden is a viable way to improve population health among older adults going forward over the next decade.

Policy Points Since its founding, the Supreme Court has played a major role in defining the parameters of governments' public health powers and the scope of individual health-related rights. Although conservative courts have been less favorable to public health objectives, federal courts have, for the most part, advanced public health interests through consensus and adherence to the rule of law. In establishing the current six-three conservative supermajority, the Trump administration and the Senate shifted the Supreme Court dramatically. A majority of Justices, led by Chief Justice Roberts, did shift the Court in a decidedly conservative direction. It did so incrementally, guided by the Chief's intuition that the Institution itself should be preserved, mindful of maintaining public trust and appearing outside the political fray. That has all changed because Roberts' voice no longer holds sway. Five members of the Court have displayed a willingness to overturn even long-held precedent and dismantle public health policy in favor of the Justices' core ideological tenants-notably the extensive reach of the First and Second Amendments and a parsimonious view of executive and administrative action. Public health is vulnerable to judicial rulings in this new conservative era. This includes classic public health powers in infectious disease control as well as reproductive rights; lesbian, gay, bisexual, trans, queer or questioning, and others (LGBTQ+) rights; firearm safety; immigration; and climate change. Congress has the power to curb the most extreme actions of the Court while still adhering to the vital ideal of a nonpolitical branch. That does not require Congress itself to overreach (such as by "packing" the Supreme Court, as Franklin Delaeno Roosevelt once proposed). Congress could, however, 1) disempower lower federal judges from issuing injunctions that apply nationwide, 2) limit the Supreme Court's so-called shadow docket, 3) alter the way that presidents appoint federal judges, and 4) set reasonable term limits for federal judges and Supreme Court Justices.

Policy Points Global health institutions and instruments should be reformed to fully incorporate the principles of good health governance: the right to health, equity, inclusive participation, transparency, accountability, and global solidarity. New legal instruments, like International Health Regulations amendments and the pandemic treaty, should be grounded in these principles of sound governance. Equity should be embedded into the prevention of, preparedness for, response to, and recovery from catastrophic health threats, within and across nations and sectors. This includes the extant model of charitable contributions for access to medical resources giving way to a new model that empowers low- and middle-income countries to create and produce their own diagnostics, vaccines, and therapeutics-such as through regional messenger RNA vaccine manufacturing hubs. Robust and sustainable funding of key institutions, national health systems, and civil society will ensure more effective and just responses to health emergencies, including the daily toll of avoidable death and disease disproportionately experienced by poorer and more marginalized populations.

Policy Points Racism is an upstream determinant of health that influences health through many midstream and downstream factors. This Perspective traces multiple plausible causal pathways from racism to preterm birth. Although the article focuses on the Black-White disparity in preterm birth, a key population health indicator, it has implications for many other health outcomes. It is erroneous to assume by default that underlying biological differences explain racial disparities in health. Appropriate science-based policies are needed to address racial disparities in health; this will require addressing racism.