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Health policy is undergoing a period of rapid transformation, driven by major health reforms, changing market structures, pharmaceutical policy developments, technological innovation, and evolving models of care delivery. These changes have profound implications for health care access, affordability, quality, and health system sustainability. In this editorial, we identify 10 priority areas for health services and policy research that we believe will shape policy debates and evidence needs in the coming years. These priorities are organized across 5 domains: health care access, coverage, quality and delivery system reform; corporatization and financialization of health care systems; pharmaceutical policy and health services research; international comparisons and cross-national learning; and innovation, technological advancements, and resiliency of health systems. Specific areas we discuss include the effects of the H.R.1 on Medicaid coverage and economic security; the future of Medicare Advantage; the impact of immigration policies on access; the consequences of increasing corporatization of health care; reforms to pharmaceutical pricing; the role of international comparative research; and the implications of precision nutrition, climate-related disruptions, and artificial intelligence for health policy and health system performance. Across these topics, we emphasize the need for rigorous, policy-relevant research that moves beyond descriptive analyses to evaluate mechanisms, implementation, and real-world impacts.
Cardiovascular disease (CVD) is the leading cause of death in the United States, and women Veterans (WVs) face elevated risk due to traditional factors (hypertension (HTN), hyperlipidemia (HLD), obesity, diabetes, and smoking) and nontraditional factors (depression and post-traumatic stress disorder [PTSD]). Racial and ethnic disparities further affect their cardiovascular health. This study describes CVD prevalence, risk factors, and health behaviors among WVs to inform interventions. A cross-sectional survey was sent to 1,909 WVs receiving care at a VA Medical Center in California. Participants self-reported health behaviors, CVD diagnoses, and risk factors. The study was approved by the university and VA IRBs (IRB #24-42014). Among 380 respondents (20% response rate; mean age 53), 58% were non-Hispanic White, 20% non-Hispanic Black, and 14% Hispanic. Common CVD risk factors were HLD (38%), obesity (36%), HTN (33%), smoking (13%), and diabetes (10%). Physical activity was low (vigorous activity 1.9 days/week) and diet suboptimal (score 6.1). Hazardous alcohol use was reported by 45.5%. Mean Patient Health Questionnaire 8-Item Scale and PC-PTSD-5 scores indicated moderate depression (8.7) and mild PTSD (2.9). Risk factors and mental health conditions were higher among WVs aged 18-44; nearly 70% reported ≥1 CVD risk factor. CVD prevalence peaked among those aged 65+. WVs in this sample demonstrated concerning CVD risk profiles, alongside a high prevalence of mental health conditions and hazardous alcohol use. Future research should examine social and environmental determinants and link survey data with clinical records to clarify behavior-disease relationships. Addressing both mental health and lifestyle factors is essential to reduce CVD risk and improve long-term health outcomes in WVs.
Understanding how Americans think about public health and the role of government institutions is crucial for informing effective health communication in a polarized political climate. We deployed an open-ended national survey of 1004 adults in October 2025 to assess public perceptions of these topics. Respondents associated the term "public health" with health for everyone (44%) and health of everyone (23%), alongside healthcare (20%) and other themes. The most common perceived government benefit was facilitating access to healthcare (39%)-particularly by addressing cost (16%). Among perceived government harms, more Republicans than Democrats cited overregulation (16% vs 8%, P < 0.01), limiting personal freedoms (16% vs 6%, P < 0.001), and inefficiency (10% vs 4%, P < 0.01); more Democrats than Republicans mentioned dismissing science (7% vs 2%, P < 0.01) and defunding (7% vs 2%, P = 0.02). Weighted analyses yielded minimal substantive differences from unweighted findings. Findings reveal both cross-partisan common ground in term associations and divergent concerns regarding government action. Public health messaging should leverage shared priorities and acknowledge partisan concerns about government roles.
Patients are confronted with an overwhelming number of choices when enrolling in health insurance plans, with marketplace enrollees often having over 100 plan options and Medicare Advantage enrollees having on average 42 plan options. This can fuel confusion, administrative burden, and suboptimal plan selection, which in turn can be costly to the patient, who may face greater cost sharing and thus reduce even necessary health care utilization. This is particularly troubling because most Americans experience low levels of health insurance literacy as well as limited numeracy, making it especially challenging to adjudicate among plan options in this setting of health insurance complexity. Accurately discerning optimal plan choice is especially critical given America's notably high health care costs. While there are a growing number of navigator tools, including through the use of artificial intelligence, they tend to suffer from poor take-up and/or efficacy. Existing funding streams prioritize the assessment of the performance of existing interventions, but patients' challenges navigating health plan selection highlight the need to support research to both design and test new interventions to promote health insurance literacy and, in turn, access to necessary medical care.
Since January 2025, the Centers for Disease Control and Prevention (CDC) has shed more than one-quarter of its workforce through layoffs, contract cancellations, and fellowship terminations, raising urgent questions about the consequences for affected individuals and for national public health capacity. We surveyed 430 former CDC employees, contractors, and fellows to examine the economic, health, and psychological impacts of these separations. Among respondents representing over 7300 combined years of public health experience, nearly 80% experienced involuntary separations, and more than half remained unemployed at the time of the survey. Three-quarters faced financial barriers to health care, nearly 80% reported moderate or severe sleep problems, and half experienced moderate or severe psychological distress. Mid-career and early-career professionals and parents with 2 or more children faced the greatest vulnerabilities; retirement, reemployment, and personal financial reserves were protective. These findings document the profound human costs of federal workforce instability and point to the need for targeted transition support, restoration of affected programs, and sustained investment in public health workforce infrastructure to prevent future disruptions.
Despite targeted health reforms, differences in healthcare access, utilization, and mortality have persisted between American Indian and Alaska Native (AI/AN) and non-AI/AN people and within the AI/AN population. Using the 2015-2019 Medical Expenditure Panel Survey Household Component (MEPS-HC), we examined healthcare access, utilization, and care experiences for AI/AN people relative to non-AI/AN people and disaggregate the AI/AN population by race (ie, single race and one or more races) and ethnicity (ie, Hispanic and non-Hispanic). We found that AI/AN people had a lower probability of at least one dental and ambulatory visit annually than non-Hispanic White people. Conversely, non-Hispanic AI/AN people were more likely than non-Hispanic White people to have at least one emergency-department (ED) visit. Non-Hispanic AI/AN people who reported multiple races had higher rates of delayed or unmet needs due to cost than non-Hispanic White people. People solely identifying as AI/AN reported worse care experiences, and non-Hispanic AI/AN people rated their healthcare lower than non-Hispanic White people. Our findings highlight the importance of efforts to improve healthcare access and care experiences of AI/AN people and shed light on how decisions about disaggregating race and ethnicity may affect study results.
Health systems are partnering with social service organizations (SSOs) to establish health-related social needs (HRSN) programs, yet best practices have not been established. This study assessed the implementation of a partnership between one accountable care organization (ACO) and SSOs in Massachusetts' Medicaid Flexible Services Program (FSP) from 2020 to 2023 to address food and housing insecurity. To be FSP-eligible, individuals needed to be in the ACO, have food or housing insecurity, and meet specific health criteria. Quantitative measures of reach, enrollment, and services were integrated with findings from interviews with ACO (n = 12) and SSO (n = 11) staff. Overall, 15.1% of 16 289 FSP-eligible adults and 11.8% of 5476 FSP-eligible children were enrolled. Nutrition enrollments increased over time, but housing enrollments remained low. ACO and SSO staff described positive impacts, including tailored support for patients' needs, SSO organizational growth, and understanding of how SSOs can partner with health care. Implementation challenges included complex contracts, administrative burden, and housing shortages. State funding for SSO infrastructure, cross-sector data sharing, workflow simplification, and ACO-SSO communication improved efficiency and reduced burden. The ACO-SSO partnerships expanded resources to address beneficiaries' HRSN. Understanding factors that contribute to success on both sides of the partnership can inform future HRSN programs.
Because existing data are limited, we conducted a nationally representative survey to better understand American pediatricians' views on caring for children with disabilities. The American Academy of Pediatrics (AAP) 2023 Periodic Survey asked members about their attitudes and perceptions in the care of children with disabilities (33.0% response rate, data weighted to account for nonresponse bias). Descriptive and bivariate statistics were performed; multivariable logistic regressions examined responses adjusting for demographic characteristics. Among 463 pediatrician-respondents, 98% strongly/somewhat agreed their practice welcomed patients with disability, but 81% strongly/somewhat agreed that the health care system often treats patients with disability unfairly. While 86% of pediatricians strongly agreed that understanding the needs of patients with disability was valuable to them, only 27% were very confident in their ability to provide the same quality of care to patients with disability as those without disability. Pediatricians who were the most confident in their ability to provide the same quality of care to patients with disability were more than twice as likely to welcome them into their practice. Results indicate needed improvements in pediatric training and the health care system to reduce bias against disability and improve pediatricians' confidence in caring for children with disability.
Generative AI (genAI) is rapidly entering healthcare, but public comfort may vary in ways that could undermine equitable adoption. Using two independent cross-sectional survey waves of US adults conducted in May 2023 (N = 3130) and November 2025 (N = 3088) on the Outbreaks Near Me participatory surveillance platform, we assessed changes in awareness of genAI and four comfort and perception measures. The percentage of respondents reporting they had heard "a lot" about genAI rose from 26.5% (95% confidence interval [CI]: 24.5, 28.5) to 42.9% (95% CI: 40.6, 45.3), yet overall comfort with AI-led primary care and AI-led therapy changed minimally (-1.0 and -0.7% points, respectively). Subgroup trends diverged sharply by political identity, age, and race. Notably, Republicans trended more favorably from 2023 to 2025 while Democrats declined (interaction odds ratios across the four measures ranging from 1.69 [95% CI: 1.19, 2.39] to 2.11 [95% CI: 1.54, 2.90]). Emerging divides suggest receptivity to genAI in healthcare may become increasingly shaped by political identity rather than clinical evidence or personal experience, complicating equitable deployment.
The United States alcohol-regulatory system classifies beverages by base ingredient-spirits, malt, or wine-rather than alcohol content. As a result, a canned vodka soda and a malt seltzer with the same alcohol content can be taxed, distributed, and sold under different rules. An industry-led alcohol-equivalency movement is pressing states to classify low-alcohol spirit-based ready-to-drink cocktails by alcohol content, producing tax reductions, expanded retail access, and federal container modernization. Drawing on state statutes, fiscal notes, Alcohol and Tobacco Tax and Trade Bureau rulemaking, and public health evidence, this Policy Inquiry argues that alcohol-content-based classification is defensible but should not become deregulation without safeguards. Among the measures identified, none pairs spirit-based ready-to-drink tax or retail-access liberalization with minimum unit pricing, dedicated harm-reduction revenue, modernized warning mechanisms, and alcohol-availability controls. The article proposes a framework combining standard-drink-based access limits, minimum unit pricing, dedicated revenue, point-of-sale alcohol information, retail-marketing guardrails, and combined state and local licensing authority.
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To address the systemic financial and equity burdens of preventable diabetes-related lower-extremity amputations, this perspective evaluates current structural failures in US healthcare financing and proposes a scalable, prevention-oriented framework. Current fee-for-service models consistently reimburse expensive disease deterioration while neglecting early surveillance. Meanwhile, omitting preventive foot metrics from federal quality frameworks renders early intervention organizationally invisible. In response, this analysis incorporates data from a peer-reviewed, 5-year implementation study within a medically complex population using low-overhead, multilingual, digital patient education and risk-stratified surveillance. This low-friction intervention model achieved a diabetic foot ulcer rate of 2.8% and a major amputation rate of 0.43%, significantly outperforming the federal Healthy People 2030 benchmark of 0.55%. To replicate these results nationally, public payers must integrate risk-stratified podiatric surveillance into core quality reporting frameworks, expand reimbursement codes for asynchronous digital education, and formally classify patient-centered education as vital health infrastructure. Such policy prioritization will mitigate profound health disparities, reduce avoidable public spending, and preserve patient mobility.
Policymakers and health systems increasingly rely on area-based socioeconomic disadvantage indices to inform health policy and resource allocation. However, the extent to which indices score the same areas differently across the rural-urban continuum remains poorly understood. We compared 5 nationwide US indices (2022 versions) at the census tract level across 4 rural-urban designations using correlations, reliability testing, and decile score distributions. For the most discordant pair, the Neighborhood Atlas Area Deprivation Index (NA-ADI) and the Social Vulnerability Index (SVI), we used ridge regression and dominance analysis to identify specific items driving index disagreement. Disadvantage indices are not interchangeable. The NA-ADI's unstandardized items demonstrated rural-urban and demographic biases. In metropolitan areas, NA-ADI's overweighted housing cost and income items masked vulnerability among housing cost-burdened, predominantly urban minority populations, classifying these tracts as low deprivation. Conversely, in nonurban areas, NA-ADI inflated deprivation scores in predominantly White tracts, with relatively lower proportions of disadvantage indicators, due to inherently lower housing costs. The NA-ADI's lack of item standardization risks exacerbating disparities that disadvantage indices aim to alleviate. Transitioning to more methodologically rigorous, transparent indices and developing context-specific rural metrics are urgent imperatives for effective, efficient resource allocation and to address health disparities.
Respiratory infections, including pneumococcal disease (PD), respiratory syncytial virus (RSV), influenza, and COVID-19, impose substantial health and economic burdens on adults in the United States. Although vaccines are available, coverage remains suboptimal. We conducted a societal-perspective benefit-cost analysis of adult PD, RSV, influenza, and COVID-19 vaccination programs. Four disease models estimated averted morbidity, mortality, and productivity losses. We evaluated current CDC recommendations and scenarios of varying eligibility and coverage. A complementary analysis estimated the net present value of 1 year's vaccination activity. Under current age-based recommendations, vaccination prevents over 182 000 deaths and 2.5 million hospitalizations within 15 years. Society values these outcomes at 5-12 times the cost of delivering the programs. Including at-risk adults averts an additional 13 600 deaths. Restricting eligibility or coverage could increase vaccine-preventable hospitalizations by over 1 million, increasing healthcare costs by almost $50 billion; expanding eligibility and increasing coverage to 75% substantially improves societal welfare and could additionally avert over 100 000 deaths. One year's vaccination activity prevents ∼300 000 hospitalizations, and ∼18 500 deaths, generating $6-$12 in societal value per $1 spent. Adult respiratory vaccination programs generate considerable societal returns. Increasing coverage and sustaining clear, evidence-based recommendations can unlock further health and economic gains.
Medical debt is persistent among adults in the United States, challenging an individual's ability to meet other financial obligations. However, less is known about financial wellbeing impacts beyond the traditional banking system. We conducted a prospective longitudinal study to investigate the association between medical debt and subsequent use of alternative financial services, including buy now, pay later loans, payday loans, and cash advance products, using a nationally representative sample of 2021 adults from the Cumulative Life Stressors Impact on Mental Health and Well Being Study 2023-2025. Of the analytic sample, 451 (22.3% weighted) had ever reported medical debt, and 477 individuals (23.9% weighted) reported subsequent alternative financial service use. Having any medical debt in the baseline year was associated with a 11.9% point [95% CI: 7.3, 16.6] increase in the probability of subsequent alternative financial service use. This finding was significant for those with $500 to $999, $1000 to $2,499, and more than $5000 in medical debt at baseline. Individuals with medical debt are more likely to report using alternative financial services, reflecting a broader cycle in which health challenges and costly medical care are associated with financial precarity and poorer health.
Brucellosis remains a critical zoonotic threat to public health and livestock economies globally, particularly constraining small ruminant productivity in Africa, yet continental data remain scarce. The objectives of this review are to provide apparent small ruminant brucellosis prevalence/positivity estimates across Africa by country, region, continent, and diagnostic modality. A systematic search was conducted on PubMed, ScienceDirect, and Google Scholar for articles published from 2000 to 2025. Data from 151 eligible studies representing 28 countries were extracted and meta-analyzed. Due to extreme heterogeneity (I2 > 97%), a single continental pooled estimate is not epidemiologically meaningful. For descriptive reference, Africa's apparent pooled seroprevalence was 4.9% (95% CI: 3.0-7.5%; prediction interval: 0.1-32.1%), and pooled PCR positivity was 12.7% (95% CI: 6.0-21.9%; prediction interval: 0.8-38.9%). Descriptive regional seroprevalence ranged from 3.3% (95% CI: 1.2-7.4%) (West Africa) to 6.2% (95% CI: 3.8-9.4%) (East Africa). Country-level crude seroprevalence ranged from 0.18% (Morocco) to 19.53% (Libya), with diagnostic method prevalence ranging from 3.37% (2-Mercaptoethanol (2-ME)) to 21.54% (Whole Genome Sequencing (WGS)). Both B. abortus and B. melitensis are reported with significant variations. Data absence from several African countries highlights a critical knowledge gap. We propose multi-level prevention and control strategies.
Antimicrobial resistance (AMR) poses a critical global health threat, necessitating the discovery of novel antimicrobial agents. Traditional medicinal plants have long been used for managing infectious diseases, yet scientific validation of their efficacy remains limited for many species. This systematic review synthesizes existing evidence on the antimicrobial activities of nine medicinal plants traditionally used: Lepidium sativum, Saussurea costus, Rhus tripartita, Chenopodium murale, Pyrus communis, Argemone ochroleuca, Trigonella hamosa, Galium odoratum, and Erucaria hispanica. Following PRISMA guidelines, a comprehensive search was conducted in Google Scholar for studies published between 1 January 2000-1 August 2025. Search terms combined each plant's scientific name with antimicrobial-related keywords ("antimicrobial," "antibacterial," "antifungal") and study type filters ("in vitro," "in vivo"). Only English-language studies investigating the antibacterial or antifungal activity of extracts or isolated metabolites from the target species were included. Clinical trials, reviews, case reports, and non-English publications were excluded. Data extraction captured microorganism type and strain, plant part studied, extraction method, antimicrobial assay, and reported activity (MIC, MBC, or inhibition zone). A total of fifty-six eligible studies were included in the review. The evidence indicated that antibacterial and antifungal activities varied among the studied species. L. sativum, S. costus, R. tripartita, and C. murale were relatively well investigated, with findings showing broad-spectrum activity against both Gram-positive and Gram-negative bacteria. In contrast, P. communis, A. ochroleuca, and T. hamosa demonstrated antibacterial effects on both bacterial groups; however, they require further research. Several plants displayed notable antifungal effects, particularly against Candida spp., though results varied depending on extraction method, plant part, and microbial strain. Notably, studies employing advanced extraction techniques such as supercritical fluid extraction and green synthesis of nanoparticles, particularly silver nanoparticles, frequently reported enhanced antimicrobial efficacy compared to conventional solvent extracts. These nanoparticle formulations often exhibited larger inhibition zones and lower MIC values, highlighting their potential to potentiate the bioactivity of plant extracts. This review highlights the antimicrobial potential of the selected medicinal plants and supports their traditional use in managing infectious diseases. Standardized methodologies and bioactive compound isolation are recommended to facilitate their future development as candidates for combating AMR pathogens. https://www.crd.york.ac.uk/PROSPERO/view/CRD420251047619.
In 2020, Alzheimer's disease and related dementias (ADRD) diagnoses were reintroduced into the Medicare Advantage (MA) risk-adjustment model creating financial incentives that may increase diagnostic coding and plan payments. This effect may vary across plans depending on provider integration, administrative capacity, and geographic context, with implications for payments and potential "upcoding." Using 100% Medicare data from 2016-2021, we estimated event study and difference-in-differences models comparing adjusted trends in incident ADRD diagnoses in MA relative to traditional Medicare before and after the policy change. Incident dementia diagnoses increased in MA relative to traditional Medicare, despite an overall downward trend in diagnosis rates. Increases were larger among enrollees in MA health maintenance organization plans (20.8%) than in preferred provider organization plans (7.6%) and varied across insurers, ranging from 7.2% (United Healthcare) to 21.6% (Kaiser Permanente). Increases were more pronounced in urban than in rural areas. Reintroducing ADRD into the MA risk-adjustment model was associated with increased diagnostic coding, with substantial variation across plan types, insurers, and geographic contexts. Because ADRD diagnoses increase risk-adjusted payments, larger increases across some plans may reflect coding practices rather than true disease prevalence, highlighting the need for closer monitoring.
Reference-based pricing has shown promise in reducing hospital prices and spending for state employee health plans. However, its impact among other commercially insured populations is not well understood. We examined price and spending differences under an alternative health plan's reference pricing program for self-funded employers relative to prices paid by employers and commercial payers from Round 5.1 of the Employer Hospital Price Transparency Study. The program we studied paid hospitals at approximately 140% of Medicare payments. We found that the prices paid to hospitals were significantly lower than prices paid by other commercial payers. As a percentage of Medicare, the reference pricing program paid, on average, 118% points less for inpatient services and 162% points less for outpatient services. Relative to the prices paid by other commercial payers, we estimated that employers saved $417 million under the reference-based pricing program. These savings represent 56.5% of what they would have spent on hospital care had they paid similar rates as other commercial payers.