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Policy Points For half a century, firearm-related deaths and injuries have been endemic in the United States, with COVID-19 contributing to a record high of 48,830 deaths in 2021, an epidemic rate increase. By 2023, national trends masked a significant 10-fold difference in firearm-related death rates among states. Over decades, some states have experienced large, sustained reductions in firearm-related death rates, while others have experienced increases. Firearms are a consumer product that fit the definition of a market-driven epidemic (MDE), with the firearms industry having successfully marketed gun ownership through strategies that include fear, predatory tactics, and emphasis on lethality; stalling public health research for decades; and employing strategies used in other industries to promote potentially harmful products. Evidence from classic MDEs, such as tobacco and prescription opioids, demonstrates that large-scale, long-term reductions in harmful use can be achieved through a combination of focused, effective interventions and engaged governments, nongovernmental organizations, academia, media outlets, and, at times, companies themselves. The United States has developed a robust array of evidence-based mitigation strategies to reduce firearm-related harm, including gun safety laws, focused hospital and mental health programs, community and environmental programs, and social and economic policies. Applying insights from classic MDEs, building on what has worked, and increased active engagement among stakeholders are needed to reduce preventable firearm harm. The United States has among the highest firearm-related deaths in the world. In 2023, suicides accounted for 58% of firearm-related deaths and 38% of homicides. Firearms have become the leading cause of death among those under age 19. Nonfatal injuries, outnumbering deaths over two-to-one, often lead to lifelong physical and mental health sequelae. The firearms market, valued at around $40 billion per year, is one-tenth the estimated $500 billion cost of the epidemic due to medical costs, work loss, and quality-adjusted life years lost. Peer-reviewed literature, government documents, and media reports were used to analyze the firearms epidemic according to the market-driven epidemics (MDE) definition and framework of five often overlapping phases: (1) market development; (2) evidence of harm; (3) corporate resistance; (4) mitigation; and (5) market adaptation. The MDE framework emerged from the analysis of efforts that reduced cigarette, sugar, and prescription opioid use. The central question for mitigating the firearm MDE is: What combination of interventions and actors will achieve large-scale, long-term reductions in firearm-related deaths and other harm? The epidemic of firearm harm fits the MDE definition and is progressing through the five stages of an MDE. Phase 1. Firearms marketing accelerated rapidly when the focus shifted from marksmanship, sportsmanship, and hunting to themes of self-defense, home protection, patriotism, and masculinity. Phase 2. Evidence of harm at the population level has linked firearm ownership or possession to significant increases in suicide deaths, homicide, femicide, and gun-related injuries. Phase 3. Firearms industry resistance has used "corporate playbook" strategies to downplay the evidence of preventable harm, discredit public health, and influence the passage of favorable legislation. Phase 4. Decades of action by government, academia, and civil society have produced an array of mitigation interventions shown to reduce firearm-related suicides, homicides, and other harm. Jurisdictions that have implemented these measures have been able to achieve significant, sustained decreases in firearm-related deaths, while some high-burden areas that have declined to implement such measures and have enacted permission policies have experienced notable increases in firearm-related deaths. Phase 5. The firearms market has evolved through consumer demand for "non-lethal" alternatives (i.e., TASERs, rubber bullets) and through company expansion of overseas sales and pursuit of new technologies (i.e., "smart guns," magazine safeties). High rates of firearm-related deaths and injuries are not inevitable. By treating the firearm harm epidemic as the market-driven problem it is, drawing on insights from other MDEs strategies, substantial reductions in violence may be achievable across the United States. States and cities have significantly reduced gun violence without infringing Second Amendment rights. The greatest unmet challenge now is generating increased engagement in gun safety among states and communities still experiencing high levels of preventable firearm deaths and related harms.
Policy Points The original purpose of the 340B program was to exempt Public Health Service Act funded clinics and state and local public hospitals from the inflationary best-price component of the recently enacted Medicaid drug rebate program. The secondary purpose was to reduce drug prices for these clinics and hospitals in order to preserve and expand access to free and discounted care. The cutoff for the disproportionate share hospital-based eligibility criteria was selected as part of political compromises to qualify specific nonprofit hospitals. The 1992 340B Drug Pricing Program ("340B") started as a narrowly focused program aimed at Public Health Service Act-funded clinics and public hospitals. Today 340B includes two-thirds of all nonprofit hospitals in the United States and accounts for more than $80 billion in discounted drug purchases. Statutory language authorizing 340B is sparse, and attempts to strengthen or cut the program have been stymied by lack of clarity on Congress's original intentions. The object of this study was to clarify Congress's original intentions for 340B. Our qualitative analysis was informed by the collection and analysis of two sources: (1) 175 internal primary source documents and (2) 19 structured interviews conducted with 18 key informants with respect to the creation of 340B. Congress had two intentions in establishing 340B in 1992. The first was to address an unintended consequence of the Medicaid Drug Rebate Program (MDRP), which raised costs on safety-net clinics that received significant discounts on drugs prior to the rebate program. Such core safety-net clinics operate on fixed budgets heavily dependent on federal grants, which also require them to provide free and discounted care to patients regardless of their ability to pay. The purpose of 340B was to exempt these clinics from the best price provision of the MDRP. The second was to establish minimum discounts for drug prices for core safety-net providers. While public hospitals were added because of their safety-net mission, the disproportionate share hospital eligibility criterion were included to qualify two specific hospitals to secure bipartisan support. Congress's original intention for 340B was to enable core safety-net providers to continue to provide drugs to patients regardless of costs in the face of historic drug price increases set off by the MDRP. The current scope of the program exceeds Congress's original intent.
Policy Points The One Big Beautiful Bill Act (OBBBA) may impose the largest coverage losses in US history, causing the number uninsured to rise by 55% in the coming decade. We examined four prior coverage contractions-Reagan-era Medicaid cuts, the 2005 TennCare disenrollment, 2019 Arkansas work requirements, and the Medicaid Unwinding-to shed light on the OBBBA's impacts. These suggest that most who lose Medicaid do not find alternative coverage, and that states are unlikely to compensate for federal cuts, findings that run counter to some assumptions adopted by the Congressional Budget Office in predicting the impacts of Medicaid cuts. Studies of coverage contractions complement data from coverage expansions in predicting worse health care access, household finances, and health for needy individuals due to the OBBBA. Studies also suggest that the magnitude of harms from contractions may exceed that suggested by expansions. The so-called One Big Beautiful Bill Act signed into law by President Trump on July 4, 2025 will cut $1 trillion from federal health care programs over the coming decade and cause 10 million individuals to become uninsured according to the Congressional Budget Office. Most analyses of the bill's impacts have assumed they would be the inverse of those documented from previous coverage expansions. An examination of past coverage cuts might yield additional insights into the probable impacts of this legislation on the medical care and health of the needy. We reviewed studies of four prior large scale coverage contractions: Reagan-era Medicaid cuts, the 2005 Tenncare Disenrollment, the 2019 implementation of work requirements in Arkansas, and the postpandemic "Unwinding" of Medicaid. The experience of these prior coverage contractions complements evidence from analyses of coverage expansions in predicting that widespread insurance loss will lead to a reduction in care utilization, an increase in household financial strain, and worsened physical and mental health for low-income individuals. These coverage contractions additionally suggest that most who lose Medicaid coverage will not find alternative coverage; that work requirements will impose burdensome administrative costs on states; that states are unlikely to offset reductions in federal Medicaid funding with internal funds; and that the second-order effects of coverage losses may, in some instances, be greater (in magnitude) than the benefits seen after coverage expansions. Cuts to federal health care programs will produce sharp contractions in public coverage that will worsen existing problems in US health care such as insurance churn, degrading care, and worsening health inequality. While states may take some steps to mitigate harmful impacts, better protection of the medically needy would require repeal of the legislation, while full protection would require universal, seamless coverage.
Policy Points State policies and programs play an outsized role in shaping availability and access to sexual and reproductive health services across the nation. This has a major impact on women's access to contraception, abortion, and maternity services. In particular, state decisions about health care Medicaid coverage and payment, professional credentialing, reproductive rights, and regulatory policy all affect whether access to sexual and reproductive health services is broadened or constrained and ultimately whether low-income women will be able to access the broad range of services they need. Beyond coverage and payment, examples of recent state policies impacting reproductive health care include telehealth provision of abortion, pharmacists' prescribing authority, and efforts related to maternal health care quality improvement and oversight. Access to sexual and reproductive health care varies widely by geography, and state-level policies play a major role in establishing the contours that govern the coverage, provision, availability, and costs of services. The role of state-level policies has been amplified in the wake of the 2022 Supreme Court ruling in Dobbs v. Jackson Women's Health Organization, which eliminated the federal right to abortion care allowing states to set their own policies to ban or protect abortion. Additionally, states play a major role in shaping Medicaid policies that affect access to contraception and maternity care. This Perspective examines the many ways that state policy choices affects access to three interrelated areas of reproductive health care: contraception, abortion, and maternity care. State policy actions and decisions are at the core of reproductive health coverage and access. They are shaped by funding decisions, eligibility, and coverage polices established by the legislative and administrative bodies. This includes state policies related to contraceptive coverage and rights, Medicaid eligibility, telehealth and pharmacy access, scope of Medicaid and private insurance coverage, and efforts related to quality improvement and oversight. Affordability, availability, and coverage are still barriers to sexual and reproductive health services in many parts of the nation. Several states have intentionally erected barriers to abortion care, but structural challenges also affect contraception and maternity care access. Financing and regulatory policies treat contraception, abortion, and maternity care as distinct domains, but they are inextricably linked and many women often seek these services from the same clinicians. State level policies related to health coverage, reimbursement levels, workforce supply, and quality of care all overlap and affect the care that women receive and their experiences with the health care system. State policymakers play an outsize role in developing and implementing approaches to address their resident's reproductive health needs. The implementation of Medicaid work requirements and other federal cuts to health spending in the next several years is expected to lead to a major increase in people becoming uninsured at the same time that the reproductive health care safety-net faces financial uncertainty. States that take a coordinated, systems-level approach to health care can strengthen access, improve care delivery, and better meet patients' reproductive health care needs.
Policy Points When shaping policies on the upstream determinants of health, such as economic and housing policies, state lawmakers should evaluate the potential consequences of state preemption-i.e., restricting policymaking among other levels of government. State preemption is associated with higher rates of childhood poverty among Black residents and White residents as well as low birthweight among Black residents. For both outcomes, the associations are stronger among Black residents. When deliberating on preemptive policies, state decision-makers should consider whether these policies are likely to exacerbate racial disparities, thereby indicating the need to develop policy alternatives. Racial disparities-unequal outcomes between racial groups-persist in the United States, particularly with respect to health and economic outcomes. There has been increased focus on the ways in which upstream determinants of health contribute to these disparities; however, little is known about how forced inaction on these upstream determinants affects health and economic outcomes. The prevalence of state preemption-when state lawmakers restrict policy actions among local decision-makers-is increasing. Therefore, it is essential to understand how restricting local policymaking affects racial disparities in health and economic outcomes. This study examines the associations of state preemption with childhood poverty levels and low birthweight. The data for low birthweight were collected from 1,377 counties, and the data for childhood poverty were collected from 1,607 counties. We used ordinary least squares regression and spatial regression to analyze racial disparities in these two outcomes. Furthermore, we used seemingly unrelated estimation to determine whether the effects of state preemption differed significantly between Black and White models for each outcome. The results indicated that state preemption is significantly associated with higher rates of low birthweight among Black residents. Specifically, each additional preemptive policy was associated with a .5 percentage-point increase in the low birthweight rate among Black residents. State preemption was also significantly associated with higher rates of childhood poverty among both Black and White residents. Specifically, each additional preemptive policy was associated with a 5 percentage-point and a 1.4 percentage-point higher rate of childhood poverty among Black residents and White residents, respectively. Additional testing of childhood poverty models confirms that the association was stronger in the Black model than the White model. This study reveals that state preemption of local policymaking on social determinants of health may exacerbate racial disparities in health and economic outcomes. To minimize these disparities and increase health equity, state policymakers should consider the current findings before restricting local policymaking.
Policy Points The United States is an outlier in its permissive regulatory landscape for direct-to-consumer (DTC) advertising of prescription drugs. The First Amendment is a barrier to banning DTC prescription drug promotion, but it is not a barrier to addressing false, deceptive, or unfair advertising, which may include forms of influencer and social media promotion. The learned intermediary doctrine shields drug manufacturers from liability in most states, even when they engage in pervasive DTC advertising that leads to consumer misunderstanding. State courts and legislatures should reconsider this doctrine to ensure that consumers are adequately protected. The US Food and Drug Administration needs increased resources and additional authority over the promotion of compounded drugs. The United States is an outlier worldwide in its permissive regulatory landscape for direct-to-consumer (DTC) prescription drug promotion. Recent proposals to restrict DTC prescription drug advertising raise questions about potential challenges under the First Amendment of the U.S. Constitution which protects commercial speech. Prescription drugs are unique in that they require a healthcare provider (HCP) to prescribe the product; the HCP serves as a "learned intermediary" between the pharmaceutical company and the consumer of the product. Under the learned intermediary doctrine, pharmaceutical companies satisfy their duty to warn consumers about drug risks by warning HCPs, and are thereby shielded from tort liability even if consumers rely on their advertisements and are harmed. Using government websites and Lexis+, we researched statutes, regulations and case law related to the First Amendment's protection of commercial speech, the statutory and regulatory framework for DTC prescription and compounded drug promotion, and the learned intermediary doctrine. The Food and Drug Administration (FDA) oversees DTC prescription drug promotion but lacks comparable authority over compounded drug promotion. Certain forms of DTC advertising may be particularly misleading and warrant increased FDA oversight. Although commercial speech is broadly protected under the First Amendment, false, deceptive and misleading commercial speech can be regulated or restricted. FDA issued guidance to industry for traditional media promotion, but lacks guidance on social media, online telehealth, and influencer-generated content. The learned intermediary doctrine was created by state courts before the advent of DTC advertising and now provides perverse incentives to companies to aggressively market their drugs without consequence. Congress should provide FDA with equal authority over compounded drug promotion as it has for prescription drug promotion. FDA should issue regulations or guidance on modern forms of DTC advertising. The learned intermediary is based on outdated concepts and should be reconsidered by state legislatures and courts.
Policy Points Wellness has grown into a multi-trillion-dollar industry encompassing a multitude of products and practices that affect health and well-being. Applying a lens of commercial determinants of health to wellness is useful to examine its intersection with systems of capital production, corporate interests, and neoliberal norms of personal responsibility. The global digital revolution has fueled both the growth of the wellness industry and the spread of health misinformation, posing regulatory, social, and political challenges. As wellness movements gain prominence in American and global policymaking, attention to these intersections is crucial to understanding consequences for health policy. The global wellness industry has multifaceted impacts on health and well-being, including through the sale and consumption of wellness products, the provision of health information to consumers, and the promotion of specific norms and values. Despite its growing prominence, the wellness industry and its impacts on health and policymaking remain understudied. This article examines how the wellness industry operates as a commercial, social, and political determinant of health. We draw on commercial determinants of health and corporate political activity frameworks to analyze the strategies, structures, and discourses of the wellness industry. We examine existing academic literature, regulatory documents, industry data, and media and policy sources to map the wellness industry's characteristics, regulatory environment, and political dimensions, including its role in shaping US public health policy through the Make America Healthy Again (MAHA) movement. The wellness industry deploys political strategies closely resembling those of other harmful commodities industries, including undermining scientists and policymakers, promoting personal empowerment, and lobbying against regulation. While wellness products and practices are often framed as responding to the erosion of institutional trust and health care systems' failure to address persistent health inequities, their promotion may deepen, rather than alleviate, these crises. The MAHA movement illustrates how wellness logics have become embedded in policymaking, platforming individualized wellness while falling short of addressing the systemic drivers of ill health and inequity. Applying a commercial determinants of health lens to wellness highlights the need for stronger regulatory oversight of health claims, demonetization of harmful online health misinformation, and structural investment in equitable health care systems. This is particularly urgent given the MAHA movement's alignment of wellness with populist politics. Further research is merited to systematically document wellness industry practices across diverse national contexts and investigate links between wellness discourse, health inequalities, and political polarization.
Policy Points This study examines the association between the implementation of Medicaid estate recovery and homeownership, home equity, and Medicaid enrollment among low-income adults. Estate recovery is associated with a decrease in Medicaid enrollment among unmarried, low-income older adults and a decrease in home equity overall and among Black respondents, White respondents, and adults over 74 years of age. These findings suggest that low-income adults may behave as intended, avoiding Medicaid and extracting housing wealth to cover care costs; still, it is worth reconsidering a policy that recoups less than 1% of the Medicaid budget to the detriment of low-income families with few assets. In response to the high cost of state-run Medicaid programs, the 1993 Medicaid estate recovery policy was established to enable states to recover assets from the estates of beneficiaries after death. Estate recovery may trigger behavioral responses from older adults who may no longer view real estate as an attractive asset, may borrow money from home equity to cover the cost of increasing care needs, or may avoid enrolling in Medicaid altogether. Using 1992-2008 data from the Health and Retirement Study, this study exploits the time variation in state adoption of estate recovery to determine the association of recovery policies with homeownership decisions, home equity, and Medicaid enrollment among low-income older adults using a difference-in-difference fixed-effects model. The implementation of estate recovery significantly decreased home equity in the overall sample and among Black and White subgroups as well as those over age 74 years. Additionally, estate recovery implementation was associated with a significant decrease in Medicaid enrollment among unmarried, low-income individuals aged 65 years and older. No significant association was found between homeownership and estate recovery overall or among subgroups. These findings suggest that those most at risk for Medicaid estate recovery, namely, low-income older adults, may behave exactly the way policymakers intended, avoiding enrollment in Medicaid and extracting housing wealth to cover the cost of their care. Still, it is worth reconsidering a policy that recoups less than 1% of the long-term services and supports budget from Medicaid estate recovery to the detriment of low-income families who already had few assets. These findings reflect the limited choices that older adults and their families have in making long-term care decisions, filling a gap in the extant literature, which has not adequately explored the impacts of estate recovery.
Policy Points In 2021, young adults without children became (temporarily) newly eligible for the earned income tax credit, the largest US poverty alleviation program. This 2021 expansion was associated with fewer poor mental health days and modest improvements in physical health. This study suggests the importance of providing economic support for young adults at this critical juncture of the life course, when they are ineligible for many other social safety net benefits. In 2021, Congress expanded the earned income tax credit (EITC)-the largest US poverty alleviation program-to young adults without children who had previously been ineligible. The EITC improves health by targeting poverty as a social determinant of health, but no studies have examined health effects of the 2021 expansion on this newly eligible population during this critical period of their life span. This study addresses this gap in the literature. We used 2021-2023 serial cross-sectional data from the Behavioral Risk Factor Surveillance System (N = 11,137), restricting the analysis to low-income young adults without children. We used quasi-experimental difference-in-differences and event study models to evaluate the impact of the EITC expansion on self-reported health and health behaviors. We considered (newly eligible) young adults aged 18 to 24 years without children to be exposed and those aged 25 to 34 years (already eligible) to be unexposed. We compared those interviewed during the EITC expansion to those interviewed before the expansion and after its expiration. Outcomes included mental and physical health in the past 30 days and binge drinking. Models were adjusted for self-reported demographic covariates and month and state fixed effects. We carried out numerous sensitivity analyses. In difference-in-differences models, the 2021 EITC expansion was associated with fewer poor mental health days (-1.08; 95% CI -1.94 to -0.23). Event study models confirmed this and also demonstrated modest improvements in physical health. There were no effects on binge drinking. Effects were similar among various subgroups (i.e., sex, race/ethnicity). Results were robust to sensitivity analyses. Expanding the EITC improved the health and well-being of young adults without children, a group often left out of US safety net programs during this key juncture of the life course. This study informs ongoing decisions regarding EITC policy design at the state and federal levels.
Policy Points Negative vicarious health care experiences circulating within communities can significantly erode systemic trust, while positive experiences can help rebuild it. Health systems should actively monitor the narratives circulating within distinct community networks, treating patterns of negative shared experiences as early signals of eroding institutional trust that warrant a proactive organizational response. Investing in the quality of patient-provider relationships could be a concrete lever for institutional trust resilience: strong provider relationships buffer individuals-including those in historically marginalized communities-against the corrosive effects of negative systemic narratives circulating in their networks. Health systems should invest in creating structured opportunities for patients to share their positive care experiences, ensuring that these voices reach community networks where trust has been hardest to build and where authentic accounts of respectful, equitable care are currently underrepresented. Trust in the US health care system has declined substantially in recent years, threatening patient engagement, care outcomes, and health policy effectiveness. While prior research confirms that direct personal experiences with providers shape trust, questions remain about the influence of vicarious experiences-the health care stories shared by family members, friends, and community networks. This gap is particularly consequential in the United States, where structural inequalities have created distinct collective memories and expectations that circulate within racial and ethnic communities. This study addresses this gap by examining how the emotional valence (positive or negative) and racial identity of the narrators influence trust in the US health care system, with attention to variation by respondents' race and baseline trust in their own provider. We conducted a 2×2 between-subjects online survey experiment with 1,042 US adults. The sample was demographically representative by age, education, and gender, and evenly divided between non-Hispanic White and non-Hispanic Black participants. Respondents were randomly assigned to eight brief vignettes that varied in two dimensions: (1) emotional valence (predominantly positive vs. predominantly negative) and (2) narrators' racial identity (majority in-group vs. majority out-group). We find that vicarious experiences significantly affect trust in the US health care system-but not uniformly. Non-Hispanic White participants were not affected by in-group experiences and responded to out-group accounts, while the contrary held for non-Hispanic Blacks. Trust in one's own doctor moderated these effects: strong patient-provider relationships buffered individuals from the impact of systemic stories, whereas low provider trust heightened susceptibility to narrative influence. These findings underscore the role of collective narratives in shaping systemic trust and highlight new avenues for its strengthening among diverse populations.
Policy Points Reimposing work requirements for the Supplemental Nutrition Assistance Program-by removing temporary, location-based waivers-causes a decline in food assistance participation among childless women. This loss of nutritional support prior to pregnancy is linked to tangible, negative health outcomes for their infants. Analyses show that, when work requirements are reimposed, there are statistically significant increases in very low birth weight and very preterm births. These adverse effects are found among first-time mothers, the group most likely to have been subject to these work requirements as "able-bodied adults without dependents" just prior to their pregnancy. Able-bodied adults without dependents (ABAWDs) are eligible for Supplemental Nutrition Assistance Program benefits for only 3 months in any 36-month period, after which they are subject to a work requirement to continue receiving benefits. Because ABAWDs may later have children, this work requirement for childless adults may affect the health of pregnant women and their infants through the mother's nutritional well-being prior to pregnancy. The objective of this study was to examine whether temporary county-level waivers of these work requirements improved health outcomes for mothers and their infants. This study used restricted National Vital Statistics System natality data from 2004 to 2018, with virtually every birth in the United States in that period, linked at the county-month level to a dataset of ABAWD work-requirement waivers in the year prior to pregnancy. Several binary maternal and infant health outcomes were examined in intent-to-treat analyses using two-way fixed-effects regressions and event studies with application of an estimator robust to heterogeneous treatment effects. The analysis also controlled for economic conditions upon which waiver eligibility is determined. Statistically significant increases in adverse birth outcomes were found for first-time mothers exposed to (re-introduced) work requirements just before pregnancy, including a 14% increase in very low birth weight infants and a 10% increase in very preterm births relative to baseline rates. In contrast, the introduction of a waiver was associated with little change in birth outcomes. For maternal outcomes, the removal of a waiver was unexpectedly associated with a significant reduction in eclampsia and a decline in labor inductions. The study found little to no effect of waiver status on other maternal outcomes, such as diabetes or cesarean section rates. This study found evidence that work requirements for food benefits may harm infant health, particularly when waivers are terminated. These results provide evidence that may inform policymakers weighing the costs and benefits of modifications to ABAWD work requirements.
Policy Points Evidence suggests the 2021 temporary Child Tax Credit expansion reduced material hardship and improved parental mental health, but less is known about its effects on child well-being. Compared with the preexpansion period, advanced monthly payments were associated with short-term improvements in child behavioral health. However, these gains did not persist after payments ended, even with the lump-sum payment, likely reflecting stress and hardship tied to the policy's temporary nature, especially among lower-income and Black children. Policymakers may need to consider program design features, such as more frequent distribution of unconditional cash benefits, to better support child well-being. In July 2021, to alleviate material hardship, Congress temporarily expanded the Child Tax Credit (CTC), one of the largest income transfer programs in the United States. Prior research has linked the expansion to improvements in material hardship, food insecurity, and parental mental health. This study is among the first to examine its association with child well-being. We analyzed data from 1,028 children in the 2020-2021 waves of the Child Development Supplement of the Panel Study of Income Dynamics, a national longitudinal data set. CTC exposure was defined based on benefit size calculated using eligibility rules. Outcomes included caregiver/self-rated child health, behavioral problems, and food security. We used individual fixed-effects models to estimate within-person changes in outcomes, comparing pre- and postexpansion periods while adjusting for time-invariant confounders. The 2021 PSID wave (November 2021-June 2022) included three CTC phases: 1) advanced monthly payments (November-December 2021), 2) expired monthly payments (January-April 2022), and 3) following the distribution of remaining lump sum (May-June 2022). Analyses were stratified by these phases to capture potential disparate impacts. We also conducted subgroup analyses by income and race/ethnicity. During the monthly payment period, a $1,000 increase in CTC was associated with a 0.69-point reduction of behavioral problems in the overall sample (95% confidence interval [CI]: -1.31 to -0.067), corresponding to a 10% reduction from baseline. No associations were observed after monthly payments expired. Following the distribution of the lump sum, lower-income children had worse caregiver/self-rated health (-0.075, 95% CI: -0.14 to -0.010) and increased behavioral problems (0.95, 95% CI: 0.45-1.45) compared with higher-income children. Differences by race/ethnicity were also observed. More frequent distribution of unconditional cash benefits may improve child behavioral health. These findings inform ongoing state and federal poverty policymaking and contribute to theoretical knowledge on income and child health.
Policy Points Housing is a fundamental social determinant of health and is particularly amenable to policy intervention. Policies that seek to improve health should improve housing quality, affordability, and stability. The public housing program has improved health across the life course, but the structure of the program currently limits its applicability. Public housing can be adapted to foster policy innovation at the state level. A renewed public housing program should (1) serve a broader income spectrum; (2) integrate across levels of government; (3) capitalize on the social support benefits of project-based housing; (4) emphasize effective administration; and (5) develop funding sources less vulnerable to political shifts. Housing is a fundamental social determinant of health and is particularly amenable to policy intervention. However, the nationwide housing affordability crisis presents significant challenges for leveraging housing policy to improve population health in the United States. The US public housing program began during the New Deal, but has changed considerably since the mid-20th century. The program provides affordable and stable housing to nearly 1 million low-income families, and may offer lessons for a way forward in improving health through better and more stable housing. Comparing the health impacts of US housing programs, public housing stands out as an unexpected success. Children in public housing experience better mental health, fewer emergency room visits, and greater housing stability. Adults report better physical and mental health, reduced risk of diabetes, and improved food security. However, recent federal housing policy has emphasized the tenant-centered housing voucher program at the expense of public housing. While the contemporary public housing program improves health and well-being across the life course, the early public housing program may offer lessons to improve outcomes in the 21st century. Specifically, a renewed public housing could focus on high-quality construction, emphasize effective management, and serve a broader spectrum of income levels. I also outline how public housing could benefit from an increasing role for state policy and enable integration across levels of government. Housing is particularly responsive to public housing, but current housing policies have proven insufficient to guarantee stable housing for all. The public housing program offers a promising way forward to leverage housing to address the US population health crisis.
Policy Points Changes in states' policy contexts since the 1980s may help explain why mortality rates among working-age adults have risen and become more unequal across geographic areas. Investigating this pressing issue requires a new, industry-standard measure of those contexts. During 1980-2023, higher scores on the State Policies and Politics Database (SPPD) State Policy Index (reflecting an adoption of policies that strengthen economic security, expand safety nets, and discourage risky behaviors) were strongly associated with lower working-age mortality rates. The SPPD State Policy Index is a valid, transparent, replicable, and easily updated measure that is useful for understanding how the general orientation of state policies predicts mortality. Recent studies have linked the rising rates and growing disparities in working-age mortality partly to changes in US states' policy contexts since the 1980s. Yet, such studies largely rely on measures of states' policy contexts, or "policy indices," that were created for other purposes, are not regularly updated, and use complex methods that can be difficult to interpret and replicate. Further elucidating the mortality trends and disparities would benefit from a policy index that is designed for population health analyses and a clearer understanding of the utility of such indices. Drawing on the World Health Organization's Social Determinants of Health Framework and existing studies of the impact of specific state policies, we identified 11 policies to be included in an annual index from 1980-2023. It ranges from 0 to 1 on a conservative-to-liberal continuum. We evaluated the index on multiple dimensions of validity. The index demonstrates strong validity. Exhibiting convergent validity, the index has a 0.89 correlation with two existing validated and widely used holistic policy indices created for other purposes using more than 135 state policies and two different modeling approaches. Exhibiting predictive validity, the index is strongly associated with all-cause and cause-specific working-age (ages 25-64) mortality rates. The strength of the associations is similar to those using the two existing indices but have standard errors of about one-third to one-half the size. The index is also associated with mortality at younger and older ages. The State Policies and Politics Database (SPPD) State Policy Index is valid for investigating the links between the general orientation of states' policies and mortality rates. It provides researchers with a straightforward, transparent, annual, and timely index. We discuss the reasons for using policy indices, particularly in an era of policy co-occurrence, and address two criticisms of indices.
Policy Points The continuous coverage provision of the March 2020 Families First Coronavirus Response Act resulted in extended postpartum Medicaid for individuals with pregnancy Medicaid coverage, which increased postpartum Medicaid enrollment, improved continuity of coverage, and increased Medicaid-paid emergency department visits and mental and behavioral health diagnoses in the 3 to 12 months postpartum. These findings provide insight into the extent to which increased coverage translated into changes in postpartum Medicaid-paid care. Communication and outreach are likely needed to ensure that individuals are aware of and able to use their extended postpartum Medicaid coverage. Before the COVID-19 pandemic, persons with pregnancy Medicaid coverage were typically disenrolled after 60 days postpartum, at which point they could retain Medicaid only if they qualified through another eligibility category (most commonly as a parent). The March 2020 Families First Coronavirus Response Act (FFCRA) extended postpartum Medicaid coverage by requiring states to pause disenrollment in exchange for enhanced federal funding. This study examined 2019-2022 Medicaid claims data from 15 states to determine the association between extended postpartum Medicaid coverage and Medicaid-paid care. We employed a continuous difference-in-difference design, leveraging variations in FFCRA-associated eligibility changes (state-level differences in pre-FFCRA pregnancy and parental Medicaid eligibility as a percentage of the federal poverty level [FPL]). The study population included individuals with a birth between January 2019 and December 2021 that was paid for by pregnancy Medicaid coverage. The study population was followed for 12 months after childbirth. Outcomes included Medicaid enrollment, continuity of coverage, outpatient and emergency department visits, and pregnancy-related and mental-health-related diagnoses. Care outcomes were measured from 3 to 12 months postpartum. In adjusted models, we found that a 100 percentage-point FPL increase in postpartum Medicaid eligibility under the FFCRA was associated with 2.9 additional months of enrollment (95% CI: 0.9, 4.3), a 27.3 percentage-point increase in 12-month continuous Medicaid (95% CI: 2.3, 44.6), 107.2 more emergency department visits per 1,000 beneficiaries (95% CI: 18.7, 167.6), and a 3.2 percentage-point (95% CI: 1.7, 5.4) increase in services with mental and behavioral health diagnoses. Continuous Medicaid coverage during the FFCRA was associated with longer postpartum enrollment and increases in some health care utilization. However, no increases in Medicaid-paid outpatient care or care for pregnancy-related conditions were found, which may have been due to enrollees' limited awareness of their continued eligibility. Improved communication around extended postpartum Medicaid coverage may improve the translation of coverage into health care access.
Policy Points State "must-query" prescription drug monitoring programs (PDMPs) were associated with increased overdose deaths, suggesting these policies may have unintended consequences. Black and Hispanic populations experienced disproportionately higher increases in overdose deaths following must-query PDMP adoption, highlighting that these policies may contribute to health disparities. Addressing systemic inequities in health care access and substance use treatment may help supplement the effective components of PDMPs, ensuring that these policies reduce rather than exacerbate overdose deaths. Despite recent declines in national overdose deaths, these reductions have not been equitably experienced. Black and Hispanic communities continue to face rising rates of opioid-related mortality, even as overdose death rates among White individuals have begun to decline. One of the most widely implemented policy responses to the overdose crisis has been the adoption of prescription drug monitoring programs (PDMPs), particularly "must-query" mandates requiring prescribers to consult the PDMP before issuing controlled substances. However, limited research has examined whether the impact of these mandates varies by race and ethnicity. We used restricted-use National Vital Statistics System data from 2013 to 2020 to estimate county-level overdose mortality stratified by drug type and race and ethnicity. We categorized deaths as follows: (1) all drug overdoses, (2) all opioid overdoses, and (3) natural/semisynthetic opioid overdoses. Exposure to must-query mandates was modeled as the proportion of the prior year during which mandates were in effect. Using Bayesian spatiotemporal models with county random effects and spatial autocorrelation, we estimated relative rates (RRs) for each outcome overall and by race and ethnicity, adjusting for state policies and sociodemographic characteristics. Must-query mandates were associated with increases in overdose deaths across all groups, with the largest relative increases among Hispanic (RR = 1.32, 95% credible interval [CrI]: 1.21-1.44) and Black individuals (RR = 1.23, 95% CrI: 1.14-1.33) compared with White individuals (RR = 1.14, 95% CrI: 1.10-1.19). These increases were also observed among Black and Hispanic individuals for natural/semisynthetic opioid overdoses. PDMP must-query mandates are not uniformly protective across racial and ethnic groups. Increases in overdose mortality following adoption, particularly among Black and Hispanic populations, underscore the need to evaluate drug policies through an equity lens and consider broader structural determinants of health that shape their effectiveness.
Policy Points Researchers investigate how recent elections in the United States have influenced mental health, especially among political- and policy-based election losers. The previous two presidential elections worsened the self-reported mental health of Americans on average. Likely partisan election losers and those who had the most to lose in terms of health policy were even more likely to have their mental health affected by the results of elections. As American politics has become increasingly polarized and the perceived stakes of elections have loomed larger in recent years, elections have become a source of worsening mental health for Americans. Politics is increasingly important to many Americans. Yet little is known about how the increasing centrality of politics affects Americans' mental health. This work aimed to evaluate how recent polarized elections have influenced Americans' mental health. To investigate this question, we compared online search interest in politically related mental health issues and self-reported mental health data. Analyses explored changes before and after election days in 2020 and 2024. The two outcome variables were aggregate Google search interest in politics-related mental health issues and individual responses to the following item from the Behavioral Risk Factor Surveillance System (BRFSS): ''Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good? With BRFSS, we compared differential changes for likely Democrats and Republicans using multiple proxy measures and for those with health policy interest in the election. The 2020 and 2024 presidential elections substantially increased interest in politics-related mental health issues online. The 2020 election led to just under 0.2 additional days of poor mental health (P < .05), and the 2024 election led to just under 0.5 additional days of poorer mental health (P < .05). Likely losing partisans and those who stood to lose out from Trump's reelection in terms of health policy were found to drive most of this relationship, with just under 1 full additional day of poorer mental health for each group. The stakes of elections in this polarized era of American politics are worsening the mental health of Americans. Additional resources may be necessary to allow therapists and clinicians to navigate additional care-seeking surrounding and following elections.
Policy Points Funding that states' Long-Term Care Ombudsman Programs (LTCOPs) receive must cover all activities in that state related to the care of all individuals in nursing homes (NHs) and board and care (i.e., residential care communities, assisted living, and similar care homes); over time, duties and demands have expanded without similar increases in funding. States are contributing more to their federally mandated LTCOPs than they have historically. Evidence from this study suggests that increased spending on LTCOPs is associated with improved NH resident care, supporting the National Academies of Sciences, Engineering, and Medicine's recent call for increased funding to LTCOPs. Funded partially by the Older Americans Act, state Long-Term Care Ombudsman Programs (LTCOPs) provide a critical role in serving as advocates for older adults in long-term care (LTC) facilities. Ombudsmen regularly visit residents, resolve disputes, and assist with discharge planning. In 2022, the National Academies of Sciences, Engineering, and Medicine called for increased LTCOP funding to improve nursing home (NH) quality. However, it is unclear how changes in program funding are associated with the care provided to NH residents. Based on the functions that the LTC Ombudsmen are intended to provide, we hypothesized that increases in LTCOP spending would be associated with improved care in NHs. We examined 20-year trends in funding for the LTCOP (2000 to 2019). Using 2011-2019 data from the National Ombudsman Reporting System, LTCFocus.org, Centers for Medicare & Medicaid Services Care Compare, and the Area Health Resource File, we examined the relationship between LTCOP spending per LTC bed at the state level and NH outcomes, controlling for year, state, facility, and market characteristics. Overall, LTCOP funding increased over 20 years. However, the share of federal contributions to the LTCOP has decreased from 58.8% in 2000 to 46.9% of the total program's budget in 2019. The LTCOP spent an average of $37.30 per LTC bed in 2019, with wide state variation. In 2011, the average share of residents receiving antipsychotics was 25.4%, the share of those who were physically restrained was 2.9%, and the share of those with low-care needs was 13.5%. For every $100 annual increase in total spending per bed, there was a statistically significant 1.32, 1.13, and 2.95 percentage-point decrease in the share of residents receiving antipsychotics, those who were physically restrained, and those who with low-care needs, respectively. States that have increased funding for their LTCOP observe better NH resident care. These findings support calls to increase funding for LTCOPs.
Policy Points The pressing need for alignment across the US health system has the potential to amplify the reach and impact of the public health system by stretching available dollars and facilitating broader access to services. States should explicitly position themselves as system integrators of shared infrastructure, aligning public health with other systems through shared governance, service delivery, financing, and technology solutions. Particularly in rural communities that lack reliable access to essential health care and social services, states should prioritize regional and shared service models as scalable opportunities to address workforce shortages, achieve economies of scale, expand access, and sustain services. The US public health system is facing an inflection point characterized by chronic underinvestment, workforce and service delivery challenges, outdated data infrastructure, growing health inequities, and increasing instability within the broader health care safety net including projected Medicaid coverage changes and continued rural hospital closures. Fragmentation across public health, health care, social services, and financing systems limits the nation's ability to address complex population health challenges and invest in prevention. This paper examines opportunities for state-led alignment of the public health system through a systems-oriented framework. Drawing on current policy developments, emerging evidence, national frameworks, and state-based examples, we identify and analyze five strategies through which states can strengthen population health: (1) aligning Medicaid and public health around shared population health goals; (2) developing more sustainable and flexible financing mechanisms; (3) expanding regional service delivery and shared-service models; (4) strengthening public-private partnerships; and (5) aligning technology and data modernization efforts with critical infrastructure needs. The analysis highlights how state governments can serve as system integrators and stewards of shared infrastructure by aligning governance, financing, service delivery, partnerships, and technology across traditionally siloed sectors. Examples from multiple states demonstrate the potential for Medicaid-public health integration, blended and braided financing approaches, regional service delivery models, public-private collaborations, and interoperable data systems to improve efficiency, expand access to services, strengthen workforce capacity, support population health outcomes, and increase system sustainability. These approaches are particularly important in rural and underserved communities, where workforce shortages, hospital closures, and limited resources threaten access to essential services. Addressing today's public health challenges requires moving beyond fragmented, program-specific approaches toward a more integrated, prevention-focused health system. States are uniquely positioned to lead this transformation by aligning public health with innovations in Medicaid, financing, service delivery, private-sector partnerships, and technology infrastructure. Strategic state leadership can improve efficiency, sustainability, and responsiveness while strengthening foundational public health capacity. In an era of resource constraints and rising health threats, state-led systems alignment positions states as integrators of shared infrastructure and represents a critical opportunity to improve population health and build a more resilient public health system.
Policy Points The criminal justice system functions as a primary social determinant of health in the United States, generating disproportionate physical, psychological, and chronic health burdens on Black communities and other marginalized groups. Policing structural barriers-including qualified immunity, police union contracts, and municipal financing of misconduct settlements-systematically shield law enforcement from accountability and divert public resources from health-promoting investments. Evidence-based interventions-including coresponder programs, community violence interruption, diversion initiatives, and Medicaid prerelease enrollment-demonstrate measurable improvements in public safety and health equity outcomes. Policymakers must adopt a health-in-all-policies approach that reallocates resources from punitive criminal justice practices to upstream investments in housing, mental health care, youth employment, and community well-being. Transforming criminal justice into a health-promoting system requires cross-sectoral leadership, rigorous research, and training reform that centers racial equity, officer well-being, and community-driven public safety models. The United States incarcerates more people per capita than any peer nation, and its criminal justice system disproportionately impacts Black, Indigenous, and other communities of color. Police violence, mass incarceration, and carceral health crises each independently generate significant health burdens, while their intersection compounds longstanding racial health disparities. The COVID-19 pandemic amplified these structural failures, exposing the lethal consequences of overcrowded facilities, inadequate health care access, and systemic racism embedded across criminal justice institutions. This perspective piece synthesizes peer-reviewed literature, national surveillance data, and policy analyses to examine the criminal justice system as a social determinant of health. Drawing on the Public Health Critical Race Praxis framework, the authors identify mechanisms linking carceral practices to population health outcomes and evaluate both policy gains and persistent failures across policing, mass incarceration, and community health domains. Police violence, disproportionately directed at Black individuals-who are 3.5 times more likely than White individuals to be killed by police when unarmed-generates illness spillovers including elevated rates of chronic disease and mental health disorders in affected communities. Carceral settings function as breeding grounds for infectious disease, with COVID-19 infection rates in some US detention facilities reaching up to 14 times higher than surrounding general populations. Policing structural barriers including qualified immunity, police union contracts, and municipal financing of misconduct settlements insulate officers from accountability and redirect billions in public funds away from health-promoting services. Evidence-based alternatives-including coresponder programs, diversion initiatives, community violence interruption, and Medicaid prerelease enrollment-demonstrate measurable reductions in crime, use of force, and health disparities. The criminal justice system is not a neutral arbiter of public safety but a potent and often detrimental determinant of health, particularly for Black and other marginalized communities. Dismantling the carceral shadow requires policymakers to adopt a health-in-all-policies approach that reallocates resources upstream, holds law enforcement accountable, and centers rehabilitation over punishment. A fundamental reconception of public safety as public health is both a moral imperative and an evidence-based strategy for advancing health equity and reducing the chronic disease, mental health, and mortality burdens generated by current carceral practices.