Health affairs scholar最新文献

[This corrects the article DOI: 10.1093/haschl/qxaf026.].

Home care workers (HCWs), who provide paid in-home support for daily activities, are at the center of the care received by millions of Americans. However, HCWs are profoundly marginalized professionally and economically within our political-economic system, which devalues care work, public goods, and the labor of women, immigrants, and workers of color. This systemic marginalization has contributed to the impoverishment of millions of HCWs and massive workforce shortages, which prevent millions of Americans from accessing the consistent care they need. Home care cooperatives-businesses co-owned and controlled by HCWs-represent an alternative approach that places HCWs at the center. By providing greater compensation, training opportunities, and control over workplace decisions, home care cooperatives have achieved greater continuity of care and half the turnover rates compared with traditional agencies. They demonstrate what is possible when HCWs are centered at an organizational level and what could be achieved if HCWs were centered at a system level. This latter possibility requires the following: (1) reclaiming care work as a public good and investing in it accordingly; (2) structurally empowering HCWs within the care team and broader economy; and (3) new narratives about HCWs that recognize their skills, value, and centrality in providing quality care.

As new approaches of political economy gain ground in some sectors, American health care still reflects many aspects of neoliberalism. In this piece, we build on proposals to reorient health care policy around a new industrial policy for health. A core component of this strategy-and our focus here-is a revival of public provisioning of medical services and pharmaceuticals. Although less prevalent today, forms of public provisioning still exist in vital ways. These models demonstrate how public provisioning can not only address urgent capacity needs-it can promote local ownership, operate as a competitive public option that bolsters worker power, and assure societal return on public investments.

People need to consume goods and services that support health, such as nutritious food, medical care, and quality housing, throughout their lives. Many of these goods and services are allocated using markets, which means that people need income to provide purchasing power for these goods and services. However, everyone has times when supporting themselves through paid labor is not possible, so many individuals will not receive the income needed for a healthy life if income distribution is tied solely to economic production. Therefore, a key political economy of health goal is to put in place income-support policy that gets income to those unable to engage in paid labor. The 3 main forms of income-support policy-social assistance, social insurance, and guaranteed income-offer different strengths and limitations. I argue that social insurance, because of its focus on getting income to people in situations in which they cannot or should not engage in paid labor, is a fundamental part of a political economy that supports everyone's health.

Advocates of a political economy approach to US health policy center an analysis of power and the broad political, social, and economic landscape that enables or harms health. They must contend, however, with a dominant policy orientation focused on ensuring individual access to the existing healthcare system. This Policy Inquiry reviews the recent history of US antitrust and climate/industrial policy, both domains where policy movements taking a political economy approach have had significant and unexpected recent success, to draw lessons for health policy, in which a "care economy" movement aligned with political economy has had some momentum, but not produced major policy change. Advocates of a political economy approach to US health policy should continue to build on the momentum of the care economy movement while also looking for ways to tie healthcare market reform into the shifts in industrial policy and antitrust. Across both spaces, advocates should center the building of issue networks, make connections to historically resonant political themes, and, where possible, find ways to tap into the energy of youth organizers-all strategies shared across antitrust and climate policy.

Despite expectations that suicide rates would surge during the pandemic, the national suicide rate declined in the United States in 2020 before returning to pre-pandemic levels in 2021. Explanations of the decline in suicides at the national level include a "pulling-together effect" in the face of a crisis and a shorter than expected pandemic recession. However, suicide rates and the change over time in suicide rates vary substantially across US states. At various times during the pandemic states enacted physical-distancing and economic support policies that may have affected suicide rates. We examined the association between state-level physical-distancing and economic support policy contexts and suicide rates among US adults ages 25-64 years during the COVID-19 pandemic. We found that a 1-SD increase in the stringency of a state's physical-distancing policies was associated with a 5.3% reduction in male suicide rates but was not associated with female suicide rates. Economic support policies were not associated with suicide rates for the period as a whole. The results support the growing evidence that COVID-19 policies had indirect and unintended consequences beyond their direct effect on COVID-19 transmission and death, in this case to reduce suicides among working-age males.

LGB (lesbian, gay, and bisexual) individuals have higher rates of tobacco and alcohol use than the general population. While protective social policies have been found to reduce these disparities, their long-term impact remains largely unknown. In this study, we used data from waves 3 (2001-2002) and 4 (2008-2009) of the National Longitudinal Study of Adolescent to Adult Health to assess the impact of exposure to LGB state policy protections during emerging adulthood on substance use in young adulthood. Using multivariable Poisson models, we evaluated whether emerging adulthood was a critical period of exposure and quantified the relative reduction in substance use disparities between LGB and heterosexual individuals living in more protective states. Findings suggest that LGB individuals living in states with more policy protections during emerging adulthood had a significantly lower prevalence of tobacco use and binge drinking in young adulthood compared with those in less protective states. These findings were not observed among heterosexual individuals, indicating that policy effects were specific to LGB individuals. Furthermore, these protections appeared to reduce overall substance use disparities, especially among female participants. It is critical to continue evaluating policy protections to safeguard the health of the LGB community, especially considering the potential erosion of these vital protections.

Southern states face severe home care labor shortages due to low wages, poor working conditions, and limited career advancement opportunities, which are exacerbated by the region's historical labor policies and economic inequalities. This study analyzed workforce size in relation to the population of older adults likely to require paid home care services, subsequently contextualizing those results using a thematic analysis of state American Rescue Plan Act section 9817 spending plans to identify trends in proposed initiatives designed to strengthen the workforce across the region. Our findings highlight significant disparities in workforce availability, with more diverse areas with higher concentrations of Hispanic, immigrant, and low-income populations exhibiting higher workforce capacity compared with less diverse regions. We also found consensus across states on the inadequacy of direct care worker wages, demonstrated by the large number of proposed reimbursement rate increases included in the state spending plans.

Safety-net emergency departments (EDs) are a critical component of the US health care system, delivering emergency care for patients in need, including vulnerable populations. EDs provide unscheduled acute care for patients 24 hours a day, 7 days a week, regardless of a person's ability to pay. In addition, EDs have transformed beyond their traditional roles of providing emergency services and being the centers for regionalized trauma, cardiac, and stroke care, to also becoming stewards of public health by leading screening and treatment efforts for nonemergent conditions, such as HIV, hepatitis C, mental health, and opioid use disorder. Many safety-net hospitals and their EDs serve essential roles in urban and rural communities, making the impact of recent closures particularly concerning. In response, we convened clinical, operational, and administrative leaders of key safety-net EDs across the United States in order to develop expert consensus related to critical issues facing safety-net EDs. The goals were to help inform policymakers about current challenges and to offer timely recommendations so that together we can mend the safety net as the country works toward the goal of health equity for all.