Journal of Health Politics Policy and Law最新文献

Context: Despite early skepticism about Medicaid's ability to withstand retrenchment as a program of "welfare medicine," it has proved remarkably durable. Existing analyses explain durability from a policy feedbacks perspective-how program provisions affect the subsequent political environment and policy-making options. This article updates earlier feedback accounts to the Affordable Care Act (ACA) era.

Methods: The article examines extant findings on policy feedbacks in Medicaid at the elite and mass levels since the 2010 passage of the ACA.

Findings: Mass feedbacks have been modest. Medicaid expansion under the ACA only slightly increased beneficiary political participation, if at all. Medicaid attitudes among beneficiaries and the larger public have become somewhat more supportive. Elite-level feedbacks are the most powerful, with the federal contribution-increased for expansion populations under the ACA-inexorably shaping state incentives. However, continued rejection of Medicaid expansion and attempts to add conditions to Medicaid eligibility in Republican-led states with large shares of Black residents demonstrate that federalism, race, and the program's welfare medicine image continue to threaten the program.

Conclusion: Medicaid survives as the nation's largest health insurance program by enrollment, and it is deeply woven into the health care system. However, it remains chronically vulnerable and variable across states despite robust aggregate enrollment and spending.

Context: As inequality grows, politically powerful health care institutions-namely Medicaid and health systems-are increasingly assuming social policy roles, particularly related to solutions to homelessness. Medicaid and health systems regularly interact with persons experiencing homelessness who are high users of emergency health services and who experience frequent loss of or inability to access Medicaid services because of homelessness. This research examines Medicaid and health system responses to homelessness, why they may work to address homelessness, and the mechanisms by which this occurs.

Methods: The authors collected primary data from Medicaid policies and the 100 largest health systems, along with national survey data from local homelessness policy systems, to assess scope and to measure mechanisms and factors influencing decision-making.

Findings: Nearly one third of states have Medicaid waivers targeting homelessness, and more than half of the 100 largest health systems have homelessness mitigation programs. Most Medicaid waivers use local homelessness policy structures as implementing entities. A plurality of health systems rationalizes program existence based on the failure of existing structures.

Conclusions: Entrenched health care institutions may bolster local homelessness policy governance mechanisms and policy efficacy. Reliance on health systems as alternative structures, and implementing entities in Medicaid waivers, may risk shifting homelessness policy governance and retrenchment of existing systems.

Context: In 2012, California instituted a new requirement for parents to consult with a clinician before receiving a personal belief exemption (PBE) to its school entry vaccine mandate. In 2015, the state removed this exemption altogether. In 2019, legislators cracked down on medical exemptions to address their misuse by vaccine refusers and supportive clinicians. This article uses "policy feedback theory" to explore these political conflicts, arguing that PBEs informed the emergence and approaches of two coalitions whose conflict reshaped California's vaccination policies.

Methods: The authors analyzed legal, policy, academic, and media documents; interviewed 10 key informants; and deductively analyzed transcripts using NVivo 20 transcription software.

Findings: California's long-standing vaccination policy inadvertently disseminated two fundamentally incompatible social norms: vaccination is a choice, and vaccination is not a choice. Over time, the culture and number of vaccine refusers grew, at least in part because the state's policy sanctioned the norm of vaccine refusal.

Conclusions: The long-term consequences of California's "mandate + PBE" policy-visible, public, and socially sanctioned vaccine refusal-undermined support for it over time, generating well-defined losses for a large group of people (the vaccinating public) and specifically for the provaccine parent activists whose experiences of personal grievance drove their mobilization for change.

Context: The role of political identities in determining attitudes to vaccines has attracted a lot of attention in the last decade. Explanations have tended to focus on the influence of party representatives on their sympathizers (partisan cues).

Methods: Four representative samples of the French adult population completed online questionnaires between July 2021 and May 2022 (N = 9,177). Bivariate and multivariate analyses were performed to test whether partisan differences in attitudes to vaccines are best explained by partisan cues or by parties' differences in propensity to attract people who distrust the actors involved in vaccination policies.

Findings: People who feel close to parties on the far left, parties on the far right, and green parties are more vaccine hesitant. The authors found a small effect of partisan cues and a much stronger effect of trust. More importantly, they show that the more politically sophisticated are less vaccine hesitant and that the nonpartisan are the biggest and most vaccine hesitant group.

Conclusions: The literature on vaccine attitudes has focused on the case of the United States, but turning attention toward countries where disenchantment with politics is more marked helps researchers better understand the different ways trust, partisanship, and political sophistication can affect attitudes to vaccines.

Context: Recent studies have highlighted Medicaid enrollment among middle- and higher-income populations and questioned whether the program is reaching those for whom it is intended.

Methods: The authors use administrative tax data to measure Medicaid enrollment and income in 2017, they use survey data to measure monthly income, and they use administrative data to identify Medicaid enrollment pathways.

Findings: Among 38.8 million nonelderly adults in Medicaid at any point in 2017, 24.4 million had annual income below their state's typical eligibility threshold, and 14.4 million (37%) had income above the threshold. Among those above the threshold, 3.5 million enrolled through a pathway allowing higher income (pregnant women, the "medically needy," and others). The authors also estimate that more than 12 million had at least one month with income below the threshold, and roughly 4 million had at least five months with income below the eligibility threshold.

Conclusions: Pathways allowing higher income account for one quarter of enrollees with annual incomes above typical thresholds. Among low-income adults, month-to-month variation in income is common and can account for most or all of the remaining enrollees with annual incomes above typical thresholds. A complete accounting of eligibility status would require merged data on income, Medicaid enrollment, and family structure.

Context: The organization of primary care in France has long remained a secondary issue on the political agenda. The government began to address the difficulties of care access and coordination in the 2000s, when a seemingly viable solution emerged from the field: the maisons de santé pluriprofessionnelles (MSPs). In a corporatist system and a predominantly private sector, the government chose an incentive-based contractual policy to encourage providers to join these structures. This article analyzes the implementation of this policy, which depends on private providers' commitment.

Methods: The article offers a comparative case study of six MSPs. Data were collected through semistructured interviews, observation sessions, and document analysis.

Findings: First, the article shows that the emergence of MSPs has only been possible thanks to an unprecedented alliance between general practitioners, the state, and the health insurance fund. Second, it argues that MSP policy implementation relies on a complex bargaining process between private providers and public authorities that enables the former to shape it to their local needs.

Conclusions: MSP implementation experiences raise questions both about the understanding of medical corporatism in France and the assimilation of policy changes and local variation through policy implementation.

Context: This study examines whether autocratic governments are more likely than democratic governments to manipulate health data. The COVID-19 pandemic presents a unique opportunity for examining this question because of its global impact.

Methods: Three distinct indicators of COVID-19 data manipulation were constructed for nearly all sovereign states. Each indicator was then regressed on democracy and controls for unintended misreporting. A machine learning approach was then used to determine whether any of the specific features of democracy are more predictive of manipulation.

Findings: Democracy was found to be negatively associated with all three measures of manipulation, even after running a battery of robustness checks. Absence of opposition party autonomy and free and fair elections were found to be the most important predictors of deliberate undercounting.

Conclusions: The manipulation of data in autocracies denies citizens the opportunity to protect themselves against health risks, hinders the ability of international organizations and donors to identify effective policies, and makes it difficult for scholars to assess the impact of political institutions on population health. These findings suggest that health advocates and scholars should use alternative methods to estimate health outcomes in countries where opposition parties lack autonomy or must participate in uncompetitive elections.

Context: The United States is deeply entangled in an opioid crisis that began with the overuse of prescription painkillers. At the height of the prescription opioid crisis (2006-2012), Mallinckrodt Pharmaceuticals was the nation's largest opioid manufacturer. This study explores Mallinckrodt's strategies for expanding its market share by promoting a new opioid.

Methods: The authors used the Opioid Industry Document Archive to analyze the incentive structures, sales contests, and rhetorical strategy behind Mallinckrodt's "Operation Change Agent," a campaign to switch patients from OxyContin to Mallinckrodt-manufactured painkillers. A structured search of the archive in October 2022 retrieved 464 documents dated between 2010 and 2020.

Findings: The authors identified a range of Mallinckrodt's sales force motivational techniques, including hypertargeting high-decile prescribers, providing free trial kits, using emotion-based language to connect with prescribers, and strategies for opposing prescriber resistance. Throughout, managers used specific incentivization metaphors to frame strategies in terms of sport and ultramarathons.

Conclusions: This research on internal corporate strategy joins the growing challenges to industry claims that opioid sales teams simply educated providers and helped fill existing demand for their products. It has important implications for regulatory policy and consumer protections that can better protect health in the face of competitive market forces.

There have been two waves of equity-based investment in physician practices. Both used a combination of public and private sources but in different mixes. The first investment wave, in the 1990s, was led by public equity and physician practice management companies, with less involvement by private equity (PE). The second investment wave followed the Affordable Care Act and was led by PE firms. It has generated concerns of wasteful spending, less cost-effective care, and initiatives harmful to patient welfare. This article compares the two waves and asks if they are parallel in important ways. It describes the similarities in the players, driving forces, acquisition dynamics, spurs to consolidation, types of equity involved, models to organize physicians, and levels of market penetration achieved. The article then tackles three unresolved issues: Does PE investment differ from other investment vehicles in concerning ways? Does PE possess capabilities that other investment vehicles lack and confer competitive advantage? Does physician practice investment offer opportunities for supernormal profits? It then discusses ongoing trends that may disrupt PE and curtail its practice investment. It concludes that past may be prologue, that is, what happened during the 1990s may well repeat, suggesting the PE threat is overblown.

Context: How do health coverage denials keep care out of reach for American patients by imposing unevenly distributed administrative burdens? This article argues that the process of appealing insurers' denials imposes administrative burdens on patients inequitably, deepening the divide between those with meaningful access to health coverage and those for whom benefits are out of reach.

Methods: The author conducted a nationwide survey of 1,340 US adults on their experiences with coverage denials; this was supplemented with 110 semistructured interviews with patients, physicians, and former health insurance executives.

Findings: Those who were less affluent were significantly less likely than their wealthier counterparts to appeal denials of coverage. Patients who underestimated the rate at which patients prevail in insurance appeals were less likely to appeal their own denials. Black Medicaid patients and those who were in worse health were significantly less likely to prevail in the appeals they pursued. Many unappealed denials were attributable to the significant administrative burdens associated with appeal, including learning and psychological costs.

Conclusions: Administrative burdens associated with appealing denials of coverage can deepen health inequities along class and race lines, suggesting a need for policy interventions to make it easier to navigate the health insurance bureaucracy.