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Policy Points Community health workers (CHWs) recognize that health care and public health institutions and representatives value their roles, but these institutions are often unaware of the labor required to obtain the expertise that CHWs leverage. Despite a recognition of the value of the CHW role, CHWs feel their roles are not properly compensated or acknowledged, and they face other structural barriers that perpetuate the precarity of the role. As the CHW landscape for compensation and certification changes, these conditions need to be considered to better support and sustain this workforce. Community health workers (CHWs) are frontline public health workers who support the well-being and capacity building of residents disproportionately affected by health inequities. The purpose of this study is to examine diverse perspectives on the conditions for CHW success as CHWs were engaged in rapidly implemented, highly responsive education, vaccination, and recovery efforts during the COVID-19 pandemic in a large county in Southern California. The Community Activation to Transform Local Systems (CATALYST) study leveraged a community-based participatory research approach to conduct a case study of CHW COVID-19 responses in Orange County, California. From 2023 to 2024, we conducted 16 semistructured, in-depth interviews and eight focus group discussions with CHWs (n = 60). Interviews and focus group discussions were recorded, transcribed, and analyzed following an adapted flexible coding approach, including inductive and deductive codes. Findings highlight three key themes: 1) CHWs recognize that institutions value their expertise and capacity to build connections with community members, 2) CHWs' labor to build their expertise often goes unacknowledged, and 3) CHWs face financial and structural constraints that undermine the value ascribed to their contributions. Despite this, CHWs stress the importance of proper recognition and fair compensation to reflect the critical role CHWs serve in advancing community health. Institutions recognize CHWs' impact; however, CHWs feel that the aspects of their work that build their expertise often go unnoticed and undervalued. To sustain CHWs as integral members of the public health workforce, especially during crises and recovery, institutions need to recognize the full extent of CHW roles and provide adequate financial and structural support essential to preserve the model's viability and impact. Findings from this case study may inform policies and practices for governmental and health care systems that rely upon and contract with CHWs to mitigate health inequities. Such practices include evolving CHW accreditation and reimbursement policies and initiatives.

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 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 Our research provides a starting point to benchmark government transparency measures to improve the quality and accessibility of information about lobbying. Policymakers and regulators can use our framework to develop or strengthen their own lobbying registers. Countries like Canada are a good example of how to design an accessible database about lobbying, and Chile, Ireland, and Scotland provide examples of comprehensive contact logs. Information about lobbying is crucial to alert the public about undue influence in government decision making. Yet, government disclosures of lobbying activities are rare internationally and vary considerably in their completeness and accessibility. Building on a framework to measure lobbying transparency, this study benchmarked national government disclosures to understand what information was shared and to develop recommendations to strengthen political transparency. To identify lobbyist registers, we reviewed four international surveys that assessed lobbying transparency in 128 countries. For each country with an online register, we assessed the 50 indicators in the Framework for Comprehensive and Accessible Lobbying (FOCAL), generating an overall score for each government. To highlight the importance of transparency for public health, we compared the visibility of tobacco industry lobbying across all registers by documenting the information provided about two prominent tobacco companies: Philip Morris International and British American Tobacco. We identified 28 countries with online lobbyist registers, all from upper or upper-middle income countries. No country fulfilled all 50 indicators in the FOCAL. The category of "scope" had the highest scores across countries, whereas the "revolving door" and "financial" categories had the lowest scores. We found evidence of lobbying by Philip Morris International, British American Tobacco, or one of their subsidiaries in 14 of the 28 countries with online lobbyist registers. Our study empirically demonstrates the hidden nature of lobbying internationally. In the case of industries whose interests conflict with public health, poor lobbying transparency presents a risk that vested interests may undermine public health policymaking without anyone knowing. To ensure that health harming industry interests cannot escape scrutiny, public health advocates should support efforts to strengthen political transparency measures. Open access publishing facilitated by The University of Melbourne, as part of the Wiley - The University of Melbourne agreement via the Council of Australian University Librarians.

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 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 State policymakers have moved rapidly to regulate adolescent social media use, frequently stating concerns about mental health, harmful content exposure, and developmental impacts. The degree to which policymakers' arguments in favor of state social media regulations correspond to the state of the current scientific evidence remains questionable. The evidence to substantiate policymakers' assertions has substantial limitations in the ability to answer causal questions, but some promising directions are emerging around targeted protections for highly susceptible youth. The potential adverse effects of social media use for adolescents have received substantial attention. In response, a growing number of state-level social media regulations are emerging in the United States. These policy interventions are being implemented in the context of mixed scientific evidence, forcing policymakers to weigh the need for proactive regulation against the limitations of extant research. We explore policymakers' publicly stated rationales for social media regulations and contextualize their claims within extant scientific literature. We conducted a media content analysis of elected government officials' statements about 69 state social media legislative initiatives that were adopted or enacted prior to September 2024 using Google News. Subsequently, we critically reviewed the strength of the evidence underlying common themes. We screened 637 documents, included 161, and extracted three main themes connected to claims about social media-related adolescent harms: (1) harm to adolescents' mental health (mentioned in 55 articles), including six subthemes (e.g., social media addiction, self-harm or suicide, anxiety and depression); (2) exposure to dangerous online content (73 mentions), including five subthemes (e.g., access to pornography, risks of sexual exploitation); and (3) harm to adolescent development (38 mentions), including three subthemes (i.e., negative impacts on learning, social relationships, and brain development). We identified some evidence to support associations between social media use and adverse outcomes, particularly for vulnerable youth, but, overall, the current research base has significant limitations and cannot definitively establish causal effects. State policymakers have moved rapidly to regulate adolescent social media use, often citing concerns about mental health, harmful content, and developmental impacts. The evidence to substantiate these assertions remains preliminary, but some promising directions are emerging around targeted protections for highly susceptible youth. We formulate a research agenda to inform evidence-based policy.

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 Nonprofit hospitals should be required to provide adequate documentation that allows the Internal Revenue Service (IRS) to evaluate whether their reported activities genuinely qualify as community benefits. To enhance the current system, rigorous data reporting requirements must be established, including mandates for hospitals to report community benefits individually on Schedule H of Form 990, clearly demonstrating how these expenditures benefit each community. The IRS, the Centers for Medicare and Medicaid Services, and public health authorities should work with hospitals to standardize definitions to improve accountability CONTEXT: The American Hospital Association determined that in 2022 nonprofit hospitals spent $129 billion on community benefits. This is more than the entire budget for the US public health service. Different organizations estimate different amounts of community benefit spending depending on their definition of community benefit. We used Schedule H from Internal Revenue Service (IRS) Form 990 data between 2019 and 2022 to determine the value of 17 components of community benefit and bad debt in nonprofit organizations. Using the descriptive analysis, this paper discusses the pros and cons of including certain categories of community benefit and suggests modifications to the definitions. In 2022, nonprofit hospitals spent $94 billion on all 17 categories of community benefit. This expenditure included $21 billion in services that benefited the patient directly, $33 billion on services that benefited the community, and $41 billion on Medicaid shortfall. Hospitals also spent $26 billion on bad debt. The value of community benefits varies significantly based on the definition used, even when the same data set is analyzed. Greater agreement on what community benefit means is necessary to ensure compliance with regulations regarding community benefit spending. This approach could involve coordination among the IRS, Centers for Medicare and Medicaid Services, and public health authorities to enhance accountability when working with hospital associations.

Policy Points Community health centers (CHCs) are mandated to simultaneously maintain collaborative relationships with all other health care providers in their service area while consistently expanding their footprint to serve more patients, creating a contradictory policy environment. This study suggests that CHCs may respond to competitive shocks by engaging in a turf war with encroaching rivals at the expense of their financial solvency and social mission. Compounded in part by mounting fiscal austerity that may exacerbate competitive pressures, new approaches are needed that strengthen guardrails against patient selection and create incentives for CHCs to move into persistently underserved communities. Community health centers (CHCs) are a critical and growing part of the health care safety net, doubling over the past 15 years to expand access to essential health care services to over 31 million patients in traditionally underserved communities. However, increasingly, CHCs have opened care delivery locations in communities already served by another CHC, potentially creating competitive markets with unknown implications for how this safety net operates. This retrospective cohort study was performed in 810 CHCs that operated between 2009 and 2023. A difference-in-differences design was used with staggered implementation to examine the impacts of competitive shocks on clinic performance and, consequently, whether this changes the types of patients served and how clinics operate. When a rival CHCs' growth results in a competitive shock, 95% of new sites are located no more than ten miles away from their existing service area. After a competitive shock, incumbent CHCs on average experienced significant decreases in financial stability and shifts in their patient mix toward those with Medicaid and away from patients who are uninsured and have more chronic conditions. Clinics also reallocated 11% of their resources closer to the encroaching rival, recentering and concentrating their organizations. Strikingly, multiple competitive shocks increased the annual probability of a closure, acquisition, or loss of CHC status from 0% to 1.67%. Despite explicit policy guardrails, this pattern of rapid, recent, and localized growth has distorted incentives for individual clinics, weakening this critical safety net. Clinics may respond to such mounting pressures by engaging in a turf war, reallocating and concentrating resources closer toward the encroaching rival at the expense of their social mission and financial solvency. Both state and federal policymakers must incentivize CHCs to disperse into communities without established clinics and introduce new protections against underservice by stabilizing clinic budgets.

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&#xa0;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&#xa0;<&#xa0;.05), and the 2024 election led to just under 0.5 additional days of poorer mental health (P&#xa0;<&#xa0;.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 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&#xa0;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&#xa0;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&#xa0;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&#xa0;months postpartum. In adjusted models, we found that a 100&#xa0;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&#xa0;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&#xa0;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 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 Certified nurse-midwife (CNM)/certified midwife (CM) care is associated with outcomes that are comparable or improved compared to physician care across multiple domains of health care quality, especially safety and effectiveness. CNM/CM care is consistently associated with lower rates of intrapartum interventions and improved birth outcomes and patient satisfaction. Integration of CNM/CM care remains limited across many US health systems due to scope of practice restrictions and institutional policies. Growing, diversifying, and integrating CNM/CM care offers a critical pathway to advancing health care quality, equity, and efficiency in the United States and addressing the alarming rise in adverse perinatal and sexual and reproductive health outcomes. The alarming rise in US maternal mortality and disparities in perinatal, sexual, and reproductive health outcomes underscores the urgent need for effective, equitable, and evidence-based models of care. Care provided by certified nurse-midwives (CNMs) and certified midwives (CMs) has played a critical role in addressing these disparities, yet a comprehensive synthesis of its impact across health care quality domains is lacking. A scoping review methodology following PRISMA-ScR guidelines was used to assess the association of CNM/CM care and perinatal, sexual, and reproductive health outcomes through the lens of the Institute of Medicine's six domains of health care quality: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. This review included United States-based studies published since 2012 identified via PubMed and CINAHL. Studies were screened for relevance to the six domains and CNM/CM care. Data were extracted into a spreadsheet, grouped by domains, and analyzed using narrative synthesis. A total of 66 studies met inclusion criteria. Within the safety, effectiveness, and patient-centeredness domains, CNM/CM care was associated with similar or improved perinatal, sexual, and reproductive health outcomes compared to physician care, including lower rates of cesarean birth, fewer interventions, improved neonatal outcomes, greater patient satisfaction, and reduced health care costs. CNM/CM care also demonstrated potential in mitigating racial and geographic maternal health disparities, though scope of practice restrictions and institutional policies limited CNM/CM integration. Despite this evidence, gaps remain in understanding the influence of CNM/CM care on health care quality as it relates to efficiency, timeliness, and equity. These findings highlight the importance of expanding CNM/CM integration within the United States' health care system to improve care delivery and associated health outcomes, reduce health disparities, and advance health equity. Future studies should incorporate standardized outcome measures and explore the role of CNM/CM care within collaborative models to enhance perinatal care quality and accessibility.

Policy Points Certified community behavioral health clinics (CCBHCs) commonly partner with emergency response systems in mobile crisis response through 911 referral arrangements, wherein behavioral health practitioner-only teams respond to 911 calls, and co-response partnerships, wherein a CCBHC clinician joins a police or emergency medical services team. Both the internal staff capacity of the CCBHC and external police capacity are associated with when CCBHCs partner with emergency response systems in mobile crisis response, although their effects differ by partnership: Co-response is more likely when CCBHCs have greater internal capacity, whereas 911 referral is more common in communities with lower police capacity. Stakeholders seeking to increase CCBHC-emergency response system partnerships may need to apply different strategies depending on the type of arrangement they aim to expand. Individuals with behavioral health disorders are more likely to experience substantial harm from a police encounter, prompting reforms to minimize encounters between police and people experiencing a behavioral health crisis. One strategy involves expanding partnerships between certified community behavioral health clinic (CCBHC) mobile crisis teams and emergency response systems, often through two models: 911 referral, wherein a CCBHC's behavioral health practitioner-only team responds to 911 calls, and co-response, wherein a CCBHC clinician joins a police or emergency medical services (EMS) team. We examine whether the internal capacity of the CCBHC and external police capacity influence when CCBHCs engage in these partnerships. Using data from the only national survey of CCBHCs, this study applies multivariable logistic regression to assess whether CCBHC staff capacity and police capacity are associated with CCBHC-emergency response system partnerships in mobile crisis, controlling for organizational characteristics of the CCBHC and demographic and socioeconomic features of its service area. One-third (33.0%, 95% confidence interval [CI], 26.0-40.0) of CCBHCs report a 911 referral partnership, and nearly half (48.5%, 95% CI 41.1-55.9) report a co-response arrangement. While police capacity is not significantly associated with co-response, a one standard deviation increase in police capacity corresponds to an 11.0-percentage-point (95% CI -19.5 to -2.5) decrease in the predicted probability of a 911 referral partnership. CCBHC capacity is not associated with 911 referral arrangements, but CCBHCs in the top tertile of CCBHC capacity are 19.2 (95% CI 4.3-34.2) percentage points more likely to report a co-response partnership. The internal capacity of CCBHCs and external police capacity are associated with when CCBHCs partner with emergency response systems in mobile crisis. Because a robust behavioral health crisis system likely requires multiple response models with varying police involvement, stakeholders may need different strategies depending on the type of partnership they aim to expand.

Policy Points States' overarching policy contexts are a meaningful yet overlooked predictor of adults' mental health, with more conservative contexts associated with worse mental health outcomes over a 30-year period. Counterfactual analyses suggest that widespread policy shifts could meaningfully alter the national prevalence of mental distress, positioning state policy contexts as important yet underutilized levers for improving population mental health. These associations are strongest among adults without a college degree, underscoring that state policy contexts may exacerbate existing educational disparities in mental health. Mental health among US working-age adults notably worsened during the COVID-19 pandemic, following a steady decades-long decline. The impact of states' COVID-19 policies on mental health has received much attention; however, less is known about the impact of a broader set of long-standing and overarching state policy contexts. This study examines how working-age adults' mental health was associated with states' policy contexts over 30 years. It also assesses whether the pandemic disrupted the association and whether the association is more pronounced among adults without a college degree. We use nationally representative data on adults ages 25-64 in the 1993-2022 waves of the Behavioral Risk Factor Surveillance System (N = 5,891,073), merged with measures of three state policy indices. The outcomes are self-rated poor mental health days in the last 30 days and extreme distress (poor mental health in all 30 days). The main independent variable is an index that summarizes states' overarching policy contexts, on a liberal-to-conservative continuum, annually from 1993-2020. Two additional indices summarize states' COVID-19 policies, one on in-person restrictions and a second on economic supports, monthly from March 2020 to December 2022. We estimate the association between states' overarching policy contexts and mental health, net of covariates, fixed differences between states, and COVID-19 policies. During the study period, each unit increase toward state policy conservatism was associated with 0.26 additional days of poor mental health and a 7% higher probability of extreme distress. The pandemic did not disrupt these associations. State policy contexts were a stronger predictor of poor mental health among adults without a college degree than adults with a degree. States' overarching policy contexts are an important yet understudied predictor of mental health. Current and proposed changes in state policies may have important consequences for mental health among working-age adults, their families, and communities.

Policy Points The economics and outcomes of modern primary care are substantially driven by investment in interprofessional clinical team members aimed at delivering complex, population health-oriented care. Neither interprofessional primary care team investment nor the work products expected in return are well represented in current commonly used productivity metrics. Stakeholder perspective-guided scoping review followed by expert panel input on measure development showed the feasibility of applying economic methods for assessing primary care productivity relative to multiple high-value products. Current primary care productivity measures do not account for investment in interprofessional primary care teams in relation to primary care goals and thus are insufficient for assessing and improving primary care efficiency and productivity. We explored alternative productivity measurement methods. We conducted a scoping review of English language literature between 2008 and 2023 to identify articles that assessed primary care practice productivity and efficiency. We reviewed the full texts of articles to assess their analytic models including inputs, outputs, and context measures. Using scoping review results to inform content, we conducted a modified Delphi expert panel to discuss potential use cases, analytic approaches, and data elements for new primary care productivity measures. Panelists anonymously voted on recommendations for guiding near-term measure development and testing. Evidence review identified 25 included studies. The majority (76%, 19/25) used an economic model-based productivity calculation, predominantly estimated using data envelopment analysis (DEA), with stochastic frontier analysis accounting for most of the remainder. Primary care staffing was the most common input, included in 84% of the 19 economic model studies. As outputs, over half (53%) of studies included measures of quality of care, whereas the same proportion included numbers of clinical activities. No studies used patient-reported experiences of care. Expert panelists recommended that initial measure development focus on primary care practice efficiency improvement, building the measure on routinely collected health system data, accounting for the clinical team's full-time equivalent staffing, and incorporating quality of care. Panelists endorsed DEA while also acknowledging that other approaches had potential. We identified measurement approaches that aligned with both economic and foundational primary care principles but none that were implemented for routine use. Opportunities exist to develop metrics that accurately reflect primary care structures, goals, and values.