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June 2024
Quarterly Article
Alan B. Cohen
Jun 26, 2024
Jun 24, 2024
Back to The Milbank Quarterly
In this issue of the Quarterly, readers will find eight Perspectives and three original scholarship articles on an assortment of topics, including: the potential of social democracy for addressing social determinants of health; policy strategies for a climate-ready health care system; a proposed logic model to inform future social care programs; a policy framework to enhance care for people with obesity; a means of defining structural determinants of health; a new regulatory pathway for integrated medical devices; new strategies for knowledge translation in population health; a framework for promoting health data equity for a multiracial population; a roadmap for assessing the impact of the 340B drug pricing program; changes in public support for public health data uses; and the relationship between White evangelical antistructural theology and health outcomes.
Multisector collaboration among health care insurers, health care systems, and social services organizations has long been the dominant approach for responding to health harms created by adverse social conditions. However, such collaboration may not achieve its goals, not only because of the difficulty involved but also because it often seeks only to mitigate the harms of social conditions rather than transforming the conditions. In “Multi-Sector Collaboration vs. Social Democracy for Addressing Social Determinants of Health,” Seth Berkowitz describes how social democracy may be a reasonable alternative approach that uses government policy to shape the civil, political, and economic institutions that produce health. Although social democracy requires political contestation, he argues that it may have greater potential to improve population health and health equity.
The need for a climate-ready health care system in the United States that minimizes greenhouse gas emissions and is prepared for the impacts of climate change on facilities and patients is undeniable. As pressure mounts to reduce greenhouse gas emissions, the health care system must respond by motivating institutions and engaging health care workers to adapt to climate change. In “Toward a Climate-Ready Health Care System: Institutional Motivators and Workforce Engagement,” Caleb Dresser and colleagues call for policies that address institutional barriers to change and create incentives aligned with climate readiness goals. The authors also recommend that content on the health care implications of climate change be integrated into educational curricula for health care professionals and organizations.
Over the past decade, there has been growing recognition that patients’ social conditions may influence health and health use outcomes. Consequently, policies related to social drivers of health have moved from being innovative practices to accepted norms and expectations. In “Revising the Logic Model Behind Health Care’s Social Care Investments,” Laura Gottlieb and colleagues summarize how increased awareness of patients’ social conditions has led to the emergence of various federal and state health care standards, regulations, and quality measures based on strong evidence linking social adversity with poor health outcomes. Using this evidence, the authors propose a more expansive logic model to explain the impacts of social care programs and to inform future social care program investments and evaluations.
The high prevalence of obesity in the United States and the condition’s impacts on the health and wellbeing of affected individuals are well known. In “Policy Interventions to Enhance Medical Care for People with Obesity in the United States – Challenges, Opportunities, and Future Directions,” James Jolin and colleagues contend that U.S. policymakers have insufficiently addressed care for people with obesity (body mass index ≥ 30 kg/m2). They propose a novel policy framework to increase access to effective obesity therapeutics and care, recognizing that, though prevention is critical, the epidemic proportions of obesity in the nation warrant immediate interventions to augment care. They also argue in favor of reducing barriers to and improving the quality of existing anti-obesity medications, as well as intensive behavioral therapy, weight management nutrition and dietary counseling, and bariatric surgery. In addition, they stress the importance of combating physician and broader stigma of obesity as part of a viable care agenda.
In the lexicon of population health, the World Health Organization includes in its definition of the social determinants of health the dual concepts of “the conditions in which people are born, grow, live, and age” and “the wider set of forces and systems shaping the conditions of daily life.” However, there has been a tendency to simplify the concept to include only the conditions of daily life. In “Keeping it Political and Powerful: Defining the Structural Determinants of Health,” Jonathan Heller and colleagues define the structural determinants of health as the written and unwritten rules that govern patterns of advantage among socially constructed groups in the conditions that affect health. They maintain that people and groups with more power based on current social structures work, both implicitly and explicitly, to retain their advantage by reinforcing or modifying these rules. They also assert that shifting the balance of power relations between socially constructed groups differentiates public health interventions in the structural determinants of health from those in the social determinants of health.
Most modern medical devices today contain embedded software that, in some cases, may include artificial intelligence (AI) or machine learning (ML). Yet, the Food and Drug Administration is using a regulatory framework developed 50 years ago to evaluate these increasingly complex devices. As these integrated devices become increasingly more sophisticated and widespread, Ted Cho and colleagues state in “Integrated Devices: A New Regulatory Pathway to Promote Revolutionary Innovation” that new regulatory systems are needed to keep pace with the evolution of the medical devices. They propose an alternative pathway for integrated devices that would utilize a two-stage review process with individual component review followed by holistic review. They believe that this novel pathway would provide regulators with new tools to address a changing medical device marketplace.
Scholars have long debated whether academic researchers should go beyond their traditional roles as “honest brokers” disseminating their research findings to become “issue advocates” who seek to shape public policy with evidence from their research. As interest in knowledge translation surges and as scholars engage more actively in policy work, concerns also have been raised about the field’s shortcomings. In “Overcoming Common Anxieties in Knowledge Translation: Advice for Scholarly Issue Advocates,” Paul Kershaw and Verena Rossa-Roccor offer useful advice on how to advance impact at a policy level. They suggest that knowledge from fields such as political science, moral psychology, and marketing should be integrated by scholars thinking and acting like marketers, lobbyists, movements, and political scientists, which would help to bridge the chasm between evidence and policy.
Health equity work generally has centered on monoracial populations. However, the rapid growth of the Multiracial population and the health disparities affecting people in that population complicate our understanding of racial health equity. Limited resources exist for health researchers and professionals grappling with this complexity. In “Asking MultiCrit Questions: A Reflexive and Critical Framework to Promote Health Data Equity for the Multiracial Population,” Tracy Lam-Hine and colleagues introduce a question-based framework built on core principles from Critical Multiracial Theory and Critical Race Public Health Praxis. The framework is designed to help researchers, practitioners, and policymakers navigate the complexities of racial definitions and to encourage health data equity for the Multiracial population.
The 340B Drug Pricing Program accounts for roughly 1% of the $4.3 trillion spent on health care in the United States. Despite the fact that decisions affecting the program have far-reaching consequences throughout the US health care safety net, relatively little analysis of the program’s impact has appeared in the academic research literature. In “Assessing the Impact of the 340B Drug Pricing Program: A Scoping Review of the Empirical, Peer-Reviewed Literature,” Timothy Levengood and colleagues examine 44 peer-reviewed, empirical studies published between 2003 and 2023. Their analysis of the literature provides a roadmap of the questions being asked about the 340B program and an initial synthesis of the answers. The highest-quality evidence suggests that nonprofit, disproportionate share hospitals may be using the 340B program in margin-motivated ways, with inconsistent evidence for increased safety net engagement. The authors recommend that future research examine heterogeneity by covered entity types (i.e., hospitals vs. public health clinics), their characteristics, and the time period of 340B enrollment.
Several global events in 2020, including a pandemic, raised awareness and concern about data privacy and the use of personal data for public health purposes. In “Changing US Support for Public Health Data Uses through Pandemic and Political Turmoil,” Cason Schmit and colleagues explore whether 2020’s events affected privacy preferences on secondary uses of identifiable data, focusing on public health and research uses. Based on two online surveys in February and November 2020 that asked respondents about their data privacy attitudes and their preferences using a choice-based conjoint analysis, the investigators found no statistically significant difference in the population’s data preferences between the two periods. Respondents reported the highest comfort with population health and research data activities and the lowest comfort with profit-driven activities. Most subgroups’ data preferences were comparable with those of the full population, except African Americans, who showed significant decreases in comfort with population health and research. The authors conclude that, despite world-changing events, the surveys revealed bipartisan public support for using identifiable data for public health and research, and that lower support among African Americans could reflect increased awareness of systemic racism, its harms, and persistent disparities.
Structural factors are important determinants of health. Because antistructuralism has been identified as a tenet of White evangelical theology in the United States, David Kindig and colleagues explored whether there exists an association between the percentage of White evangelicals in a US county and such county-wide health outcomes as premature mortality and percentage of persons reporting fair/poor health. In “Is White Evangelical Antistructural Theology Related to Poor Health Outcomes?” the authors analyze data from the 2022 County Health Rankings and the American Value Atlas of the Public Religion Research Institute. They find that every percent of evangelicals in a county is associated with 4.01 more premature deaths per 100,000 population and 0.13% reports of fair/poor health. After controlling for income, education, political ideology, and county school funding adequacy (a proxy for antistructuralism), the associations remain positive and significant. The authors hope that these findings will inform dialogue and critical analysis among individuals of evangelical faith, particularly fundamental and Pentecostal subsets, regarding a belief system that is inclusive and health-promoting. Study findings also demonstrate the importance of considering cultural factors such as religion and political ideology in population health outcomes research.
In closing, we invite readers to visit the Quarterly’s Opinion page for timely opinion pieces on important policy issues. 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.
