Journal of Health Politics Policy and Law最新文献

Context: Deaths of despair, a term used to capture rising mortality rates among Americans who appear to be suffering from growing mental and physical distress, have received added attention from those seeking to understand this disturbing trend. Yet it is unclear how, if at all, despair influences the political behavior of the people and communities where it is most prominent. The authors contribute to the health and politics literature by examining whether personal and community-level despair shapes political participation.

Methods: The authors examine the relationship between despair and voter turnout using novel data at both the aggregate and individual levels. First, a custom survey is used to test whether despair is associated with individual-level voter participation in several recent elections. Second, a new measure of community despair is developed at the county level that spans nearly 20 years to assess whether there is a relationship between despair and voter turnout in U.S counties.

Findings: The results suggest that higher levels of despair lead to lower turnout rates at both the individual and community levels.

Conclusions: This study suggests that the effects of experiencing despair are far reaching and shape political behavior among individuals and within communities.

Context: Policy feedback research has demonstrated that a highly tangible policy that shapes public attitudes through direct and day-to-day experiences often reshapes public opinion, with the effect of generating supportive or skeptical constituencies that determine the sustainability of future programs. This paper examines the impact of mass vaccination efforts on attitudes towards vaccines in a context of high vaccine hesitancy in the U.S.

Methods: We analyzed 73,092 survey responses from 9,229 participants in the longitudinal data from the Understanding America Study project, covering December 2020 to July 2023. Using two-way fixed-effects ordinary least squares regression and ordinal logistic regression, we estimated the changes in attitudes towards vaccines, including trust in vaccine manufacturing and approval processes, following COVID-19 vaccinations.

Findings: COVID-19 vaccination was associated with improved perceptions of vaccine effectiveness and social benefits and reduced mistrust in vaccine-related processes. However, it did not significantly alleviate concerns regarding vaccine side effects and illness. The strongest effects were observed among respondents initially hesitant but who eventually vaccinated.

Conclusions: The experience of COVID-19 vaccination generally improved attitudes and confidence in COVID-19 vaccines among the U.S. public, particularly among vaccine-hesitant people. These effects could have positive impacts on future immunization programs by mitigating vaccine hesitancy.

This article reviews the role of Medicaid Waivers in homeless policy, and their emerging role as a mechanism to address homelessness. We evaluate the political development of Waivers in housing and homeless policy over the past thirty years, and investigate the status of current and approved Waivers targeting homelessness. We then consider how Waivers may shape homeless policy governance going forward, including the success of existing systems, and ethical questions related to the role of healthcare payers in solutions to homelessness. We find that the scope of Medicaid Waivers to address homelessness has always been present, but significantly expanded post Affordable Care Act (ACA) and more notably following the COVID-19 pandemic. These expansions brought new opportunities for states to fund responses to homelessness through Medicaid social determinants of health (SDoH) provisions providing wrap-around medical services for populations at-risk of or experiencing homelessness, and now through time-limited direct housing costs paired with essential medical services. Over one third of states have an 1115 Waiver specifically targeting homelessness, with nearly one in five states including provisions that cover direct housing costs (e.g., rent). Going forward, Medicaid's involvement in homeless policy has the potential to reshape state and local responses to homelessness.

Addressing criticism that the agency's Covid-19 response was lacking, the US Centers for Disease Control and Prevention (CDC) has proposed internal agency reforms intended to improve its performance during the next pandemic. They are aimed at improving surveillance and analytic capacity and agency communications. This essay, via a counterfactual analysis of the CDC's proposed reforms, asks how, if completed in advance of Covid-19, they might have changed outcomes in four cases of guidance controversy during the pandemic. CDC planned reforms, though they have merit, are predicated on the ability to come to "scientific closure" in a highly charged political environment. To improve outcomes in a future pandemic, the agency should consider how it plans to communicate with the public when recovering from error and when addressing controversy spurred by criticism from credible experts. However, the ability of future presidents to limit CDC performance and communications in the next pandemic and the lack of political consensus around the value of independent public health expertise threaten the agency's reform goals.

Context: Vaccine hesitancy is associated with political and institutional distrust, but there is little research on how people's trust responds to political events. We revisit the fall of 2020 when evaluation of new COVID-19 vaccines collided with an impending national election. Drawing on a political Bayesian perspective, we assess abrupt changes in attention to political events and test hypotheses on subpopulation response: (1) partisan, (2) educational, and (3) ethnic and racial.

Methods: Analysis of daily changes in news reporting and social media use in 2020, combined with detailed analysis of two-large scale surveys fielded at the time, focusing on questions of COVID-19 vaccine hesitancy and safety concerns about COVID-19 vaccines.

Findings: Vaccine hesitancy in the US spiked from late August to early October 2020. We identify several plausible triggers for this spike, all pertaining to the FDA and electoral politics. Heightened vaccine hesitancy occurred among Democrats, Asian and Black citizens, as well as college-educated respondents. Turbulence mainly affected those who were initially most trusting in government and vaccines. Asian-American vaccine confidence recovered; that of Black Americans did not.

Conclusions: Electoral politics may destabilize citizen assumptions about vaccine authorization and boost uncertainty, thereby undermining public willingness to take approved vaccines.

Context: Despite major expansions in public health insurance under Medicaid and CHIP over the last 60 years, many immigrants remain ineligible for coverage.

Methods: We discuss the existing federal and state policies that extend public health eligibility to low-income pregnant immigrants, children, and nonelderly adults. We also conduct a literature review and summarize quasi-experimental evidence examining the impact of public health insurance eligibility expansions on insurance coverage, healthcare use, and health outcomes among immigrants.

Findings: Public health insurance eligibility for immigrants varies widely across states due to the implementation of different federal and state policy options. Previous studies on expanded eligibility identified positive effects on insurance coverage and healthcare utilization among pregnant and child immigrants, as well as some evidence indicating improved health outcomes. Further research is required to understand the longer-term impacts of expanded coverage, as well as to examine impacts of recent state expansions for adults.

Conclusions: A complicated patchwork of federal and states policies leads to major differences in immigrant access to publicly-funded insurance coverage across states and population groups. These policies likely have important implications for immigrant access to healthcare and health.

Context: Notwithstanding an impressive corpus charting the politics of Medicaid, we have much to learn about the contemporary politics of sustaining, expanding, and protecting the program. There is especially scant scholarly evidence on the significance and function of grassroots political actors (i.e.,the communities and groups most directly affected by health policy). This paper explores the role such groups play in the politics of Medicaid.

Methods: This research is based on qualitative interviews with organizers and advocates working in the domain of health policy.

Findings: The power of grassroots actors in Medicaid politics is constrained by political and structural forces including philanthropic funding practices, racism, and partisan polarization. Nevertheless, when bottom-up actors effectively exercise power, their involvement in Medicaid politics can transform policy processes and outcomes.

Conclusion: Grassroots actors-those who are part of, represent, organize, or mobilize people most affected by Medicaid policy-can play pivotal roles within Medicaid politics. While they do not yet have sufficient political wherewithal to consistently advance transformational policy change, ongoing political processes suggest that they hold promise for being an increasingly important political force.

Context: The Affordable Care Act's (ACA) Medicaid expansion produced major gains in coverage. However, findings on racial and ethnic disparities are mixed and may depend on how disparities are measured. This study examines both absolute and relative changes in uninsurance from 2010-2021 by race and ethnicity, stratified by Medicaid expansion status.

Methods: The sample contained all respondents under age 65 (N = 30,339,104) from the American Community Survey, 2010-2021. Absolute and relative differences in uninsurance, compared to White Non-Hispanic individuals, were calculated for Hispanic; Black; Asian-American, Pacific Islander and Native Hawaiian (AANHPI); American Indian and Alaska Native (AIAN); and multiracial individuals. States were stratified into ever-expanded vs. non-expansion status.

Findings: After the ACA, three patterns of coverage disparities emerge. For Hispanic and Black individuals, relative to White individuals, absolute disparities in uninsurance declined but relative disparities were largely unchanged, in both expansion and non-expansion states. For AANHPI individuals, disparities were eliminated entirely in both expansion and non-expansion states. For AIAN individuals, disparities declined in absolute terms but grew in relative terms, particularly in expansion states.

Conclusions: All groups experienced coverage gains post-ACA, but with heterogeneity in changes in disparities. Focused interventions are needed to improve coverage rates for Black, Hispanic, and AIAN individuals.

Context: States use Medicaid waivers to provide supports for disabled people in communities, rather than in institutions. Because waivers are not entitlements, those deemed eligible are not guaranteed these supports. How do states, in practice, use bureaucratic procedures to ration this 'conditional' right?

Methods: Drawing on primary and secondary data, we analyze waiver programs, and document state administrative procedures to indirectly and directly ration access.

Findings: Burdens indirectly limit disabled peoples' access to Medicaid home and community-based services, via a complex array of waiver programs that exacerbate costs associated with gaining eligibility, and directly limit access, via waitlists and prioritization among the eligible. There is also evidence that states strategically deploy opaqueness to provide political cover for unpopular waitlists. The overall process is opaque, confusing, and time intensive, with burdens falling hardest on marginalized groups.

Conclusions: Administrative burdens impede the right to live in the community afforded to people with disabilities under the American with Disabilities Act. The opaqueness and associated burdens with waiver programs are a way to conceal these costs, thereby demonstrating how burdens "neatly carry out the 'how' in the production of inequality, while concealing . . . the why."

The Medicaid program has changed enormously over the past 60 years from a very restrictive program primarily attached to recipients on public assistance in 1965 to a much more expansive program allowing coverage for persons regardless of marital, parental or employment status. Incorporating the 'medically needy'-an ambiguous concept from the start-allowed states to include many different groups in Medicaid who are not traditionally thought of as poor. In addition, three structural features illuminate why the program has expanded and changed dramatically over time: federalism and intergovernmental financing, the dominance of the private sector, and fragmentation. Unequal treatment among Medicaid covered groups alongside partisan politics create a political discourse that often reveals Medicaid as a public subsidy for stigmatized groups, while hiding Medicaid's reach into the middle-class. This central political ideological tension collides with programmatic realities such that Medicaid strangely often suffers from a residual, retrenchment politics while at the same time benefiting from embeddedness making it extremely difficult to truly turn back the clock on Medicaid's expansion.