In this issue of the Quarterly, readers will find an eclectic mix of articles that cut across all four principal areas of the Journal's editorial interest, covering such diverse topics as Louisiana's experience with Medicaid program expansion, Washington State's experience with its “public option” Cascade Care Program, compulsory licensing of pharmaceuticals in high‐income countries, the development of a United States Aging Society Index, state‐level policies affecting perinatal and infant outcomes, and population health capabilities for strengthening the public health infrastructure.
Twelve states have yet to expand their Medicaid programs under the Affordable Care Act (ACA). In a Perspective titled “A Playbook for Implementing Medicaid Expansion: Louisiana's Experience,” Will Boles and colleagues discuss how Louisiana offers a model that other states and counties could use to enroll eligible persons while balancing eligibility integrity and limited administrative resources. The authors contend that, in the current COVID‐19 health care environment, Medicaid expansion can improve and protect population health and boost state economies, even in the face of budget shortfalls. They believe that Louisiana's experience with Medicaid expansion compares favorably with other states in terms of eligibility and enrollment efforts, but that future expansions may need to include other social support programs as part of states’ implementation strategies.
Rates of low birth weight (LBW) and infant mortality vary considerably among counties and racial groups in the United States, with economic resources being a likely contributor to observed disparities. In “Does a Rising Median Income Lift All Birth Weights? County Median Income Changes and Low Birth Weight Rates Among Births to Black and White Mothers,” David S. Curtis and colleagues analyzed county median income as a predictor of LBW rates and Black‐White LBW disparities. Using national birth records for 1992‐2014 from the National Center for Health Statistics, they found that a $10,000 increase in county median income was associated with 0.34 fewer LBW cases per 100 live births and smaller Black‐White LBW disparities of 0.58 per 100 births. County rates of maternal sociodemographic and health risks mediated the association between median income and LBW, but racial disparities in risk factors did not mediate the income association with Black‐White LBW disparities. They argue that efforts to increase income levels, such as through investing in human capital, enacting labor union protections, and attracting well‐paying employment, may have potential to reduce LBW rates and to achieve more equitable outcomes between Black and White mothers.
Although evidence demonstrates that immigration policy is a determinant of health, examination of the mechanisms by which such policy influences health processes has been limited. News coverage has served as a central platform for debates over restrictive and inclusive immigration policies, shaping policy agendas and framing policy issues. In “Coverage and Framing of Immigration Policy in US Newspapers,” Maria‐Elena De Trinidad Young and colleagues examined news coverage of exclusionary and inclusive immigration policy at federal and state levels and the variations in messages about immigrants during two periods of extensive policymaking: 2010‐2013 and 2017‐2019. In both periods, the majority of coverage focused on exclusionary policies at the federal level, despite a significant increase in integration policies between 2017 and 2019. Significant shifts also occurred in both the negative and positive framing of immigrants, with the dominant negative messages portraying immigrants as an economic drain or as criminals, and the dominant positive messages stressing immigrants’ economic contributions to immigrant families. The authors discuss the health implications of news coverage in influencing the immigration policy and social contexts that have been linked to health outcomes.
Currently, there is no reliable and comprehensive measure of contexts that best support successful aging at a state level. In “A US State Index of Successful Aging: Differences Between States and Over Time,” David H. Rehkopf and colleagues adapted a multidimensional index previously used to assess adaptation to successful aging in developed countries, and applied it to the 50 US states and the District of Columbia. Using data from multiple sources, they constructed an index measuring five distinct domains that define successful population aging: (1) productivity and engagement, (2) security, (3) equity, (4) cohesion, and (5) well‐being. They also created a ranking of states for the year 2017 based on these domains. The level of adaptation to successful aging varied substantially between states and over time. The authors assert that the US State Index of Successful Aging can be used to monitor US state progress in promoting the well‐being and health of aging populations.
The use of electronic health records (EHRs) has become commonplace in the United States, exerting considerable influence over providers, patients, and organizations. In “Electronic Health Records as Biased Tools or Tools Against Bias: A Conceptual Model,” Michael D. Rozier and colleagues propose a conceptual model showing how the design and subsequent use of EHRs can be subject to bias and can either encode and perpetuate systemic racism or be used to challenge it. The model illustrates how the implicit bias of individuals, both developers and end‐user clinical providers, influences the platform and its associated information. Biased information subsequently can lead to inequitable outcomes in clinical care, organizational decisions, and public policy. Relying on Donabedian's classic paradigm of structure, process, and outcome, the model can be used to evaluate where bias may become embedded in the system itself, and also to identify opportunities to resist and actively challenge bias. Its potential value lies in redefining and improving the value of technology to health by modifying EHRs to support more equitable data that can be used for better patient care and public policy.
Integrated health care is a complex enterprise requiring insightful evaluation of what works, how, for whom, and in what circumstances. Using a theory‐driven realist evaluation (RE) approach, Rowan G. M. Smeets and colleagues report on an evaluation of the TARGET program, a Dutch primary care initiative to facilitate greater integrated care for chronically ill patients. In “First Things First: How to Elicit the Initial Program Theory for a Realist Evaluation of Complex Integrated Care Programs,” the authors identified separate but related theories for primary care professionals (PCPs) and patients that illustrate how TARGET was hypothesized to enhance PCPs’ person‐centered conversational skills, increase patients’ active engagement in TARGET, and build mutual trust between PCPs and patients as well as between PCPs and their network partners. Although the evaluation approach is time‐intensive and requires a shift in mindset, the authors maintain that it facilitates deeper insight into program functioning than accommodated by prevailing experimental designs in integrated care.
Washington State established the nation's first public option plan, with coverage beginning in January 2021, when such plans were offered voluntarily by private insurers through the Washington Health Benefit Exchange and were subject to state‐mandated plan design and payment requirements. In “Participation, Pricing, and Enrollment in a Health Insurance ‘Public Option’: Evidence From Washington State's Cascade Care Program,” Aditi P. Sen and colleagues compared geographic availability and premiums of, and enrollment in, public option and non–public option plans, as well as characteristics of counties where the public option was available and counties where the public option was the lowest‐premium plan. The authors found that at least one public option plan was available in 19 of 39 counties and was the lowest‐premium option in 9 of the 19 counties where it was available. In the first year, only 1% of enrollees selected the public option, in part due to automatic reenrollment of the majority of returning enrollees in their 2020 plan. Although public option plans offered a low‐premium choice in counties that otherwise had fewer affordable plans, voluntary participation of insurers and providers and accompanying uncertainty about participation hindered widespread and substantial premium reductions. The authors recommend that states consider tying public option participation by insurers and providers to other state programs and using decision support tools to promote active enrollment.
Rates of preterm birth and infant mortality are alarmingly high in the United States. In “State‐Level Social and Economic Policies and Their Association With Perinatal and Infant Outcomes,” Jessica L. Webster and colleagues conducted a narrative review of the associations between perinatal and infant outcomes and four state‐level policies (tax credits, paid parental leave, minimum wages, and tobacco taxes) and created a social and economic policy profile for each state based on the observed policy indicators. All but 3 of 27 studies reviewed by the authors found these policies to be associated with an improvement in perinatal or infant outcomes. The authors conclude that state‐level social and economic policies have the potential to reduce adverse perinatal and infant health outcomes, and they suggest that states with the least expansive policies should consider enacting these evidence‐based policies.
The COVID‐19 pandemic exposed weaknesses in the public health infrastructure of the United States that stem from chronic underfunding and fragmentation in public health delivery systems. In “Identifying Value‐Added Population Health Capabilities to Strengthen Public Health Infrastructure,” Rachel Hogg‐Graham and colleagues used data from the National Longitudinal Survey of Public Health Systems to examine longitudinal and geographic trends in the delivery of population health capabilities and their impact on system strength across communities in the United States. The analysis revealed that communities with the strongest classification of public health system structure in both urban and rural areas implement the largest set of population health capabilities. Key activities include allocating resources based on a community health plan, surveying the community for behavioral risk factors, analyzing data on preventive services use, and engaging community stakeholders in health improvement planning. The study results suggest that public health systems can be strengthened through targeted implementation of high‐value population health capabilities.
Compulsory licensing of pharmaceutical products is a practice in which national authorities can license a third party to produce a patented drug, effectively enabling the production of a generic before the original patent has expired. Although the policy was designed and has been used to improve access to essential medicines in low‐income countries and during public health crises, there has been recent discussion that the threat of compulsory licensing contributes to lower drug prices in high‐income countries outside the United States. Lindor Qunaj and colleagues explored the plausibility of this assertion in “Compulsory Licensing of Pharmaceuticals in High‐Income Countries: A Systematic Review.” They examined 45 unique compulsory licensing episodes in the United States and 17 comparator nations over a 20‐year period following the 2001 Doha Declaration, recording the motivation and outcome of each instance. They found that a minority of episodes were motivated by high price and only three cases were clearly associated with a price discount. The study found no evidence to suggest that compulsory licensing is either frequently threatened or successfully implemented by countries outside the United States to secure price discounts on the most expensive pharmaceuticals—that is, those that are newly patented and just entering the market.
In closing, we invite readers to explore the Quarterly’s website for timely opinion pieces (https://www.milbank.org/quarterly/the‐milbank‐quarterly‐opinions/). Recent policy opinions include contributions by:
Heidi Allen, Ezra Golberstein, and Zinzi Bailey on how higher payments to Medicaid providers can help to eliminate health disparities;
John E. McDonough on how tying housing with social determinants of health through preventing tenant evictions can improve health; and
Richard Scheffler and Olivia Shane on California's approach to health equity.