Journal of Health Politics Policy and Law最新文献

American public health is in crisis. The second Trump administration has imposed sweeping budget cuts and staff layoffs on federal health agencies, eroded the nation's public health infrastructure, and pursued myriad policies that imperil population health both in the US and across the world. Why is public health under siege and what does this tumultuous moment reveal about the politics of public health? This article chronicles the damage to public health from the Trump administration, analyzes the sources of public health's current predicament, including rising partisan polarization, the COVID backlash, and a shifting political environment, and explores the challenges that lie ahead if public health is to surmount the turmoil that now engulfs it.

Health data linkage systems are essential for understanding and addressing health inequalities, yet the United States' system-already constrained by legal and institutional limitations-has been further eroded by the second Trump administration's policies. These include defunding data collection, politicizing inequality-related research, and breaching privacy rules that protect personal data. This article draws on documentary analysis, secondary data, and comparative institutional review to document recent changes to US health data infrastructure and evaluate alternative models from France, Sweden, and England. We find that the Trump administration's actions have severely undermined the US health data linkage system, disrupting the production of data and undermining public trust. A centralized system like Sweden's offers broad data linkage capacity but may not be feasible in the US due to privacy concerns. France's tight controls on access limit usability to elite analysts, undermining inequality. England's still nascent system offers a model for equitable access to data on social, economic and political determinants of health. Rebuilding the US health data linkage infrastructure post-Trump will require restoring public trust, restoring collection of key sociodemographic indicators, and ensuring equity in access. International examples provide guidance for a more politically sustainable, inclusive system.

How unprecedented is the current backlash against the public health enterprise? In this article, I explore prior attacks against public health practice in three exemplary domains: mass vaccination programs; air pollution control; and occupational safety. In all three domains, I argue that public health has been remarkably durable throughout the 20th century, and that most controversies over its powers - or even direct onslaughts from hostile elected officials - have failed to overturn long-standing practices or institutions, even if implementation may be altered for the worse. Once public health traditions - and the infrastructure that erects them - become entrenched, they have remained difficult to fully eliminate. There are signs, however, that the second Trump Administration's onslaught is different, both in the ferocity and velocity of its actions, and in a new 21st-century context that it inhabits, with different legal precedents, cultural beliefs, communication practices, and political norms. Throughout, I also identify historical seeds of its current path in the late-20thand early-21st century.

This article examines the implications of recent and proposed reductions in federal public health funding, with a focus on how these cuts disproportionately impact rural and low-resource communities. Drawing insight from national datasets, the authors document the increasing reliance of state and local public health systems on federal funds, particularly in the aftermath of COVID-19. Scenario modeling reveals that a rollback to pre-COVID federal funding levels would likely leave many local jurisdictions unable to sustain core public health services, especially where local fiscal capacity is limited. The authors argue that, while some communities may be able to partially offset federal losses with local revenues, most lack the means to do so at scale-particularly rural areas already strained by limited infrastructure. This paper offers empirical estimates of federal support, evaluates the plausibility of local revenue substitution, and analyzes the consequences of federal disinvestment on the Foundational Public Health Services. These findings underscore a key tension in federalism in which calls for local autonomy amid shrinking federal support risk exacerbating health inequities and eroding core protections, both of which lead to critical questions about the federal government's role and responsibility in ensuring a resilient and equitable public health system.

The Trump administration is restructuring federal health agencies to implement a new policy agenda. Central to this agenda is the Make America Healthy Again (MAHA) movement, which prioritizes individual solutions to broader public health problems, disregards science and scientific institutions, and aligns closely with the "wellness" industry. While it is normal for each administration to establish its own public health priorities, previous administrations did not dismantle existing institutions to do so. In contrast, this administration is consolidating power and actively politicizing the federal health bureaucracy-undermining scientific expertise and agency independence in the process. These changes are likely to have lasting impacts on both federal health agencies and public health, which extend well beyond the current administration.

Context: Despite major expansions in public health insurance under Medicaid and the Children's Health Insurance Program over the last 60 years, many immigrants remain ineligible for coverage.

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

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

Conclusions: A complicated patchwork of federal and state 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 health care and health.

Context: Notwithstanding an impressive corpus charting the politics of Medicaid, there is still 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 article 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.

Conclusions: Grassroots actors-those who are part of, represent, organize, or mobilize the people most affected by Medicaid policy-can play pivotal roles within Medicaid politics. Although 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: Medicaid expansion under the Affordable Care Act (ACA) 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 absolute and relative changes in uninsurance from 2010 to 2021 by race and ethnicity, stratified by Medicaid expansion status.

Methods: The sample included all respondents younger than age 65 (N = 30,339,104) from the American Community Survey, 2010-21. Absolute and relative differences in uninsurance, compared to white Non-Hispanic individuals, were calculated for individuals who were Hispanic; Black; Asian American, Pacific Islander, and Native Hawaiian (AANHPI); American Indian and Alaska Native (AIAN); and multiracial. States were stratified into ever-expanded versus nonexpansion 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 nonexpansion states. For AANHPI individuals, disparities were eliminated entirely in both expansion and nonexpansion states. For AIAN individuals, disparities declined in absolute terms but grew in relative terms, particularly in expansion states.

Conclusions: All groups experienced coverage gains after the ACA, but changes in disparities were heterogeneous. 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, the authors analyze waiver programs and document state administrative procedures that indirectly and directly ration access.

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

Conclusions: Administrative burdens impede disabled people's efforts to exercise their right to live in the community as afforded to them under the American with Disabilities Act. The opaqueness and associated burdens with waiver programs are a way to conceal these burdens, thereby demonstrating how burdens "neatly carry out the 'how' in the production of inequality, while concealing . . . the why" (Ray, Herd, and Moynihan 2023: 139).

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 today 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.