Journal of Health Politics Policy and Law最新文献

The No Surprises Act, passed by Congress at the end of 2020, offers significant protections to most Americans with private health insurance. Insured Americans are vulnerable to receiving surprise medical bills when they receive services from out-of-network providers. Protections for consumers against such bills initially emerged in several states that passed laws. The varying approaches taken in different state laws ultimately offered a foundation for federal legislation. Although there was always a broad consensus among stakeholders for protecting consumers during both state and federal deliberations, it was a challenge to identify a means of determining the amount that an insurer should pay to the out-of-network provider. But Congress eventually reached a compromise that became law, and that law goes into effect in January 2022.

Context: The United States is the only high-income country that relies on employer-sponsored health coverage to insure a majority of its population. Millions of Americans lost employer-sponsored health insurance during the COVID-19-induced economic downturn. We examine public opinion toward universal health coverage policies in this context.

Methods: Through a survey of 1,211 Americans in June 2020, we examine the influence of health insurance loss on support for Medicare for All (M4A) and the Affordable Care Act (ACA) in two ways. First, we examine associations between pandemic-related health insurance loss and M4A support. Second, we experimentally prime some respondents with a vignette of a sympathetic person who lost employer-sponsored coverage during COVID-19.

Findings: We find that directly experiencing recent health insurance loss is strongly associated (10 pp, p < 0.01) with greater M4A support and with more favorable views of extending the ACA (19.3 pp, p < 0.01). Experimental exposure to the vignette increases M4A support by 6 pp (p = 0.05).

Conclusions: In the context of the COVID-19 pandemic, situational framings can induce modest change in support for M4A. However, real-world health insurance losses are associated with larger differences in support for M4A and with greater support for existing safety net policies such as the ACA.

Context: Regional international organizations (RIOs), from the South African Development Community (SADC) to the European Union (EU), are organizations that promote cooperation among countries in a specific region of the world. Asking what RIOs do to health and health policy by looking only at their formal health policies can understate their effects (e.g., a free trade agreement with no stated health goals can affect health policy) and overstate their effects (as with agreements full of ambition that did not deliver much).

Methods: We adopt a "three-faces" framework that identifies RIOs' direct health policies, the effects of their trade and market policies, and their effects on health via fiscal governance of their member states to better capture their health impact. We tested the usefulness of the framework by examining the Association of Southeast Asian Nations, EU, North American Free Trade Agreement, SADC, and the Union of South American Nations.

Findings: All RIOs had some impact on health systems and policies, and, in many cases, the principal policies were not identified as health policy.

Conclusions: Such a framework will be useful in understanding the effects of RIOs on health systems and policies because it captures indirect and even unintended health effects in a way that permits development of explanatory theories.

Context: Reductions in population mobility can mitigate COVID-19 virus transmission and disease-related mortality. But do social distancing policies actually change population behavior and, if so, what factors condition policy effects?

Methods: We leverage subnational variation in the stringency and timing of state-issued social distancing policies to test their effects on mobility across 109 states in Brazil, Mexico, and the United States. We also explore how conventional predictors of compliance, including political trust, socioeconomic resources, health risks, and partisanship, modify these policy effects.

Findings: In Brazil and the United States, stay-at-home orders and workplace closures reduced mobility, especially early in the pandemic. In Mexico, where federal intervention created greater policy uniformity, workplace closures produced the most consistent mobility reductions. Conventional explanations of compliance perform well in the United States but not in Brazil or Mexico, apart from those emphasizing socioeconomic resources.

Conclusions: In addition to new directions for research on the politics of compliance, the article offers insights for policy makers on which measures are likely to elicit compliance. Our finding that workplace closure effectiveness increases with socioeconomic development suggests that cash transfers, stimulus packages, and other policies that mitigate the financial burdens of the pandemic may help reduce population mobility.

Context: While the World Health Organization (WHO) has established guidance on COVID-19 surveillance, little is known about implementation of these guidelines in federations, which fragment authority across multiple levels of government. This study examines how subnational governments in federal democracies collect and report data on COVID-19 cases and mortality associated with COVID-19.

Methods: We collected data from subnational government websites in 15 federal democracies to construct indices of COVID-19 data quality. Using bivariate and multivariate regression, we analyzed the relationship between these indices and indicators of state capacity, the decentralization of resources and authority, and the quality of democratic institutions. We supplement these quantitative analyses with qualitative case studies of subnational COVID-19 data in Brazil, Spain, and the United States.

Findings: Subnational governments in federations vary in their collection of data on COVID-19 mortality, testing, hospitalization, and demographics. There are statistically significant associations (p < 0.05) between subnational data quality and key indicators of public health system capacity, fiscal decentralization, and the quality of democratic institutions. Case studies illustrate the importance of both governmental and civil-society institutions that foster accountability.

Conclusions: The quality of subnational COVID-19 surveillance data in federations depends in part on public health system capacity, fiscal decentralization, and the quality of democracy.

Context: Homeless policy advocates viewed Medicaid expansion as an opportunity to enhance health care access for this vulnerable population. We studied Medicaid expansion implementation to assess the extent to which broadening insurance eligibility affected the functioning of municipal homelessness programs targeting chronic homelessness in the context of two separate governance systems.

Methods: We employed a comparative case study of San Francisco, California, and Shreveport, Louisiana, which were selected as exemplar cases from a national sample of cities across the United States. We conducted elite interviews with a range of local-level stakeholders and combined this data with primary-source documentation.

Findings: Medicaid expansion did not substantially enhance the functioning of homelessness programs and policies because of Medicaid access challenges and governance conflicts. Administrative burden and funding limitations contributed to limited provider networks, inadequate service coverage, and lack of linkages between Medicaid enrollment and homelessness programming. Governance conflicts reinforced these functional challenges, with homelessness under the administration of local municipalities and nongovernmental organizations while states administer Medicaid.

Conclusions: Improving access to health care services for persons experiencing homelessness cannot occur without intentional coordination between sectors and levels of government and thus necessitates the development of targeted policies and programs to overcome these challenges.

Throughout his four years in office, President Trump made prescription drug pricing a focus of his policy agenda. President Trump not only used strong language to criticize the pharmaceutical industry and its practices but also introduced ambitious reform policies that had previously lacked acceptance among Republican policy makers. President Trump appears to have been successful in developing a new populist form of rhetoric that Republicans can use in support of novel drug pricing reforms such as the ones his administration considered. From a policy perspective, however, the Trump administration failed to implement any of their more ambitious reform ideas. This article considers three of the Trump administration's signature policies-state-sponsored prescription drug importation, Medicare Part B international reference pricing, and reforms to the Medicare Part D rebate system-and explores how they represent both the political ambitions and policy failures of the Trump administration. The fate of the Trump administration's prescription drug proposals also reveals lessons about innovation and access, which will be important to ongoing drug pricing reform efforts.

Context: This article aims to highlight challenges and adaptations made by local health officials in Tanzania in working to contain and manage COVID-19.

Methods: The study takes an inductive approach, drawing on the reported experiences of 40 officials at different levels of government across four purposefully selected regions in July 2020. Interviewees were asked about the guidance they received to contain COVID-19, the source of that guidance, their challenges and successes in implementing the guidance, and if and how they adapted the guidance to their particular setting.

Findings: The interviews depict considerable challenges, including a lack of supplies and resources for implementing infection control, surveillance, and mitigation practices and dealing with fear and stigma. At the same time, they also provide evidence of innovation and adaptation among street-level bureaucrats. Respondents overwhelmingly praised the president, whose limited national response is seen as helpful for reducing fear and stigma.

Conclusions: Other scholars have highlighted the potential dangers of street-level discretion if local officials "make policy" in ways that contradict their agencies' stated goals. In contrast, our study suggests benefits of autonomy at the street level-particularly in contexts where the central state was relatively weak and/or acting against the public interest.

Context: The CARES Act of 2020 allocated provider relief funds to hospitals and other providers. We investigate whether these funds were distributed in a way that responded fairly to COVID-19-related medical and financial need. The US health care system is bifurcated into the "haves" and "have nots." The health care safety net hospitals, which were already financially weak, cared for the bulk of COVID-19 cases. In contrast, the "have" hospitals suffered financially because their most profitable procedures are elective and were postponed during the COVID-19 outbreak.

Methods: To obtain relief fund data for each hospital in the United States, we started with data from the HHS website. We use the RAND Hospital Data tool to analyze how fund distributions are associated with hospital characteristics.

Findings: Our analysis reveals that the "have" hospitals with the most days of cash on hand received more funding per bed than hospitals with fewer than 50 days of cash on hand (the "have nots").

Conclusions: Despite extreme racial inequities, which COVID-19 exposed early in the pandemic, the federal government rewards those hospitals that cater to the most privileged in the United States, leaving hospitals that predominantly serve low-income people of color with less.