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March 2024 (Volume 102)
Quarterly Article
Alan B. Cohen
September 2024
June 2024
Back to The Milbank Quarterly
After celebrating the centennial anniversary of the Milbank Quarterly in 2023, we begin the process of plotting the journal’s next century with an issue containing five Perspectives and six original scholarship articles on diverse topics, among them: transportation and justice; commercial determinants of health; the earned income tax credit and its effect on physical and mental health; cash support to improve the health of low-income families; the 40th anniversary of the Orphan Drug Act; state firearm law adoption; enforcement strategies for safe and accessible housing for people with disabilities; and patients’ creative ideas for innovation in health care.
As the health care sector increasingly invests in social conditions to improve health care use and outcomes, researchers and policymakers are shifting greater attention upstream to understand the mechanisms and potential interventions for addressing social risks that may improve health and well-being as well as ameliorate long-standing inequities. Transportation is a core social determinant, yet our understanding of transportation in health care has focused heavily on a limited view of transportation insecurity rather than the more inclusive approach of transportation justice. In “Transportation and Justice,” Kellia J. Hansmann and Na’amah Razon argue that incorporating a transportation justice framework enables us to address transportation and mobility needs more comprehensively and equitably within health care research, delivery, and policy. Using two case examples, they suggest ways to advance the impact of transportation interventions so that no person or group is disadvantaged by a lack of access to the opportunities they need to lead a meaningful and dignified life.
The rise of noncommunicable diseases is thought to reflect a global economic system that prioritizes wealth creation over health creation, with commercial actors contributing to poor health through the production and marketing of harmful or unhealthy products such as calorie-dense, nutrient-poor foods. Commercial actors also have been perceived as seeking to shape the science used to question the need for interventions to counter the harmful effects of their products through lobbying and other means that influence government regulation and policymaking. In “The Pitfalls of Ascribing Moral Agency to Corporations: Public Obligation and Political and Social Contexts in the Commercial Determinants of Health,” Eduardo J. Gómez, Nason Maani, and Sandro Galea contend that government and civil society should be held more accountable for creating food and beverage regulatory policies rather than assigning moral agency to the food and beverage industry. They also recommend that nutrition policymaking institutions should ensure civil society’s ability to formulate regulatory policy, and that government policymakers should be insulated from industry interference.
Low-wage work can pose a serious health threat for single adults without children in the United States because these individuals often are ineligible for welfare income supplements. Although they are eligible for the Earned Income Tax Credit (EITC), single adults without children are eligible only for one-quarter of the amount provided to single parents with one child. In “The Effect of the Earned Income Tax Credit on Physical and Mental Health—Results from the Atlanta Paycheck Plus Experiment,” Peter Muennig and colleagues report on a randomized controlled trial that tested a four-fold increase in the EITC for single adults without dependent children over three years of age in New York and Atlanta. The authors found mixed results—in New York, the intervention improved economic, mental, and physical health outcomes but, in Atlanta, it had no economic benefit or impact on physical health and may have worsened mental health. Because the tax filing and bonus receipt were lower in the Atlanta arm of the trial than in the New York arm, the authors surmise that this may explain the observed lack of economic benefits. They also believe that lower mental health scores in the treatment group may have been driven disproportionately by disadvantaged men. Nevertheless, the findings from the New York arm of the study offer promise for future policy.
Pregnancy and childhood are periods of heightened economic vulnerability, but current policies for addressing health-related social needs may be insufficient to assure positive maternal and child health outcomes, especially in economically disadvantaged families. To overcome weaknesses in the social safety net, direct provision of cash transfers to low-income families experiencing health challenges during pregnancy, infancy, and early childhood could provide them with much needed support in caregiving, increased access to health care, and improved health outcomes. In “Prescription for Cash? Cash Support to Low-income Families in Maternal and Pediatric Health Care Settings,” Margaret McConnell and colleagues discuss the interplay between health and economic vulnerability during pregnancy and childhood, and how these overlapping challenges are addressed by current policies. The authors discuss the rationale for providing cash transfers to low-income families in health care settings, including examples of research from ongoing trials.
Congress enacted the Orphan Drug Act of 1983 (ODA) to stimulate global life science innovation intended to treat rare diseases or conditions affecting fewer than 200,000 Americans or for which there was no reasonable expectation that the costs of development would be recoverable in the United States. The ODA, by many measures, has been strikingly successful. However, approximately 95% of the more than 7,000 known rare diseases still have no US Food and Drug Administration–approved treatment. In “The Orphan Drug Act at 40: Legislative Triumph and the Price of Success,” Peter Saltonstall, Heidi Ross, and Paul T. Kim recount the ODA’s success and the sustained public criticism of high drug prices, often for products that have orphan drug indications. They note that patients and their families will continue to defend the purpose and integrity of the ODA and will voice support for driving investments into rare disease research and clinical development.
US states are largely responsible for the regulation of firearms within their borders, and each state has a different legal environment regarding firearms, based on different values and beliefs of citizens, legislators, governors, and other stakeholders. In “Modeling State Firearm Law Adoption Using Temporal Network Models,” James Macinko, Duncan Clark, and Maurizio Porfiri propose a model for providing credible predictions of state firearm law adoption in the future. They employed a Temporal Exponential-family Random Graph Model, using data on all state firearm laws over the period 1979–2020 to estimate model parameters while controlling for factors associated with firearm law adoption. They found that a set of internal state factors are important predictors of firearm law adoption, but that the actions of neighboring states may be just as important. Analysis of scenarios provided insights into the mechanics of how adoption of laws by specific states (or groups of states) may perturb the rest of the network structure and alter the likelihood that new laws would become more (or less) likely to continue to diffuse to other states. The authors believe that this model approach outperforms standard approaches for policy diffusion studies, affording predictions superior to those of many machine learning tools, and offering applications for the study of policy diffusion in other domains.
The question of whether income inequality and health are causally related or only associated with one another has long been debated. In “Causal Assessment of Income Inequality on Self-Rated Health and All-Cause Mortality,” Michal Shimonovich and colleagues aimed to understand the association between income inequality and self-rated health (SRH) and all-cause mortality (mortality), and to assess whether these relationships are likely to be causal. They performed a meta-analysis involving 38 cross-sectional studies assessing SRH and 14 cohort studies of mortality, calculating pooled odds ratios for poor SRH and relative risks for mortality. They critically appraised the studies using established tools and frameworks. More than 60% of SRH studies and more than half of mortality studies were at serious risk of bias. From their analysis, they concluded that increased income inequality is only marginally associated with SRH and mortality, but that the current evidence base is too methodologically limited to support a causal relationship. They recommend that future research focus on income inequality measured at the national level and address confounding with natural experiment approaches.
People with disabilities experience a vicious cycle of poverty, poor health, and marginalization partly because of the inequitable implementation and enforcement of civil rights, housing, and criminal laws. Equitable enforcement, by contrast, ensures compliance with the law while considering and minimizing harms to marginalized people, thereby promoting health and disability justice through increased access to safe, stable, and accessible housing. In “Stopping the Vicious Cycle: Equitable Enforcement Strategies to Achieve Safe, Stable, and Accessible Housing for People with Disabilities,” Katie Hannon Michel and colleagues examine how people with both physical and mental health disabilities suffer negative health outcomes through underenforcement, in which they are disproportionately underserved by laws designed to promote their health, safety, and access to opportunity, and through overenforcement, in which they are disproportionately affected by punitive enforcement approaches. Although acknowledging that many major structural reforms are needed to fully realize access to safe, stable, accessible, and affordable housing for all people, especially those with disabilities, the authors focus on how equitable enforcement of existing laws can help to shift power to and protect the housing rights of people with disabilities.
Large-scale transformative initiatives have potential to improve the quality, efficiency, and safety of health care. However, such initiatives also tend to be complex, expensive, and challenging to implement and sustain. In “Four System Enablers of Large System Transformation in Health Care: A Mixed Methods Realist Evaluation,” Emilie Francis-Auton and colleagues describe a study of the implementation of a value-based health care program between 2017 and 2021 in every public hospital (n = 221) in New South Wales, Australia. The authors conducted literature reviews, program document reviews, and semi-structured interviews with stakeholders to elucidate their understanding of change theories. Their findings were validated with three health care quality expert panels (n = 51), and data were synthesized to distill overarching system enablers. Four system enablers were identified: (1) building an authorizing environment; (2) providing relevant, authentic, timely, and meaningful data; (3) designating and distributing leadership and decision making; and (4) supporting the emergence of a learning culture. The authors concluded that these enablers offer nuanced guidance for the implementation of large-scale health care interventions and can pave the way to contributing to higher quality, higher value, and safer care.
Commercial lobbying is often a barrier to the development and implementation of public health policies. Yet, little is known about the similarities and differences in the lobbying practices of different industry sectors or types of commercial actors. In “Mapping the Lobbying Footprint of Harmful Industries: 23 Years of Data from OpenSecrets,” Holly Chung, Katherine Cullerton, and Jennifer Lacy-Nichols compared the lobbying practices of four industry sectors that have been the focus of much public health research and advocacy: tobacco, alcohol, gambling, and ultraprocessed foods. The authors analyzed lobbying expenditure data from 1998–2020 from the OpenSecrets database and classified commercial actors as companies or trade associations. Their findings revealed that the ultra-processed food industry spent the most on lobbying ($1.15 billion), followed by the gambling ($817 million), tobacco ($755 million), and alcohol ($541 million) industries. Overall, companies were more active than trade associations, and spending often was highly concentrated, with two organizations accounting for almost 60% of tobacco spending and four organizations accounting for more than half of alcohol spending. The authors state that comparing the lobbying practices of different industry sectors offers a deeper appreciation of the diversity and similarities of commercial actors, and that understanding these patterns can help public health actors to develop effective counterstrategies.
Learning health systems have been promoted for a decade to achieve high-quality, patient-centered health care. Knowledge generated through day-to-day health care delivery, including patient insights, is critical to these systems, but the pace of translating patient insights into innovation has been slow and ineffective. In “Leveraging Patients’ Creative Ideas for Innovation in Health Care,” Yuna S. H. Lee and colleagues evaluated a method for systematically eliciting patients’ creative ideas, assessing the value of such ideas, and examining how patients’ creative ideas could be used to improve care within the context of their own health systems. The authors first developed a survey and tested strategies for elicitation of patients’ creative ideas with 600 patients from New York State. They then deployed the survey with a generative open-ended question sequence within a health care system and analyzed 1,892 patients’ responses, including 2,948 creative ideas. They discovered that patients generate more actionable and creative ideas when explicitly invited to share such ideas, especially patients with negative health care experiences, those from minority racial/ethnic backgrounds, and those with chronic illness. The most frequently elicited creative ideas focused on solving challenges, proposing interventions, amplifying exceptional practices, and conveying hopes for the future. This study highlights the benefits of engaging patients for quality improvement, offers a rigorously tested method for cultivating innovation using patient-generated knowledge, and outlines how creative ideas can enable organizational learning and innovation.
In closing, we invite readers to visit the Quarterly’s website for timely opinion pieces on important policy issues (https://www.milbank.org/quarterly/the-milbankquarterly-opinions/). Recent contributions include:
Alan B. Cohen became editor of The Milbank Quarterly in August 2018. He currently is a research professor in the Markets, Public Policy, and Law Department at the Boston University Questrom School of Business, and professor of health law, policy and management at the Boston University School of Public Health. He previously directed the Scholars in Health Policy Research Program and the Investigator Awards in Health Policy Research for the Robert Wood Johnson Foundation. Earlier in his career, he held faculty positions at Johns Hopkins University and Brandeis University, and spent 8 years at the Robert Wood Johnson Foundation. He is a member of the National Academy of Social Insurance. He received his BA in psychology from the University of Rochester, and his MS and ScD in health policy and management from the Harvard School of Public Health.
