In the December 2021 Issue of the Quarterly

The turbulent events of the past year have highlighted the health consequences of systemic racism in the United States and compelled our editorial team to reexamine the Quarterly’s guiding principles and values. We came to the inescapable conclusion that the Quarterly needs to embrace diversity and equity more centrally within its core values and activities to fulfill its mission of providing the best available evidence and experience to health policymakers, leaders, and researchers. We believe that policies and practices that promote diversity and foster equity among all populations and individuals represent the best way to improve the health of populations. We are committed to pursuing diversity and equity in all that we do. To that end, we have undertaken three specific actions.

Our Vision for the Future

First, we have incorporated diversity and equity explicitly into the core values of the Quarterly (https://www.milbank.org/quarterly/values). Equity-focused research and commentary is now a fourth area of editorial interest, along with the three areas of population health, state health policy, and lessons for the United States from other nations’ health care systems. We welcome manuscripts that propose and/or evaluate innovative strategies and policies for achieving health equity, including efforts to eliminate or mitigate systemic racism that adversely affects the health and well-being of marginalized populations.

Second, we are working to increase the racial, ethnic, geographic, and disciplinary diversity of our Editorial Advisory Board, as well as our contributing opinion writers and manuscript reviewers. We believe that a more diverse pool of advisors, writers, and reviewers will enhance the Quarterly’s ability to bring the best possible evidence and experience to our readers from a variety of perspectives and viewpoints. Thus, we are delighted to welcome five new distinguished members to the Board – Taeku Lee (University of California, Berkeley), John Lowe (University of Texas at Austin), Marcella Nunez-Smith (Yale University), Christopher Parker (University of Washington), and Leana Wen (George Washington University and the Brookings Institution). Their bios may be found here.

Third, we are striving to reach and encourage a more diverse set of scholars to submit their research to the Quarterly. We are committed to identifying authors whose perspectives and experiences reflect the concerns and health challenges of historically underrepresented and socially disadvantaged populations and communities. We expect this action to bring forth new authors whose research and commentary will broaden and enrich the discussion of population health and health policy issues featured in the journal.

In This Issue

It is well accepted that, to make informed decisions regarding strategies to improve health care delivery and population health, policymakers would benefit from evidence obtained from rigorously designed and executed studies, such as randomized controlled trials (RCTs). However, this is often difficult to achieve in practice because RCTs, which are known for their ability to produce credible causal impact estimates, are not easy to mount. In “Beyond Causality: Additional Benefits of Randomized Controlled Trials for Improving Health Care Delivery,” Marcella Alsan and Amy Finkelstein argue that RCTs offer policymakers and researchers multiple benefits beyond causality to answer key questions that they want to answer. Drawing upon examples of recent RCTs in health care, they illustrate how policymakers can use such trials to solve pressing challenges.

In 2000, the United States Surgeon General issued a report that identified the state of oral health in America as an issue of major concern, highlighting significant disparities among vulnerable populations and associations with overall health and social determinants. Since then, multiple stakeholder groups have advocated expanding access to oral health coverage, integrating medicine and dentistry, and improving the dental workforce. In “Oral Health Stakeholders: A Time for Alignment and Action,” Shenam Ticku and colleagues describe how stakeholder groups are shaping the oral health policy landscape in the 21st century. To achieve change, they believe that multiple movements must coalesce around common goals and messages and that a champion must emerge to lead the way. The authors cite the ongoing COVID-19 pandemic and political changes resulting from the 2020 elections as factors that can open a window of opportunity to unite stakeholders to achieve comprehensive policy change.

In the field of public health, the law and legal systems are poorly understood and substantially underutilized to address unfair or unjust societal conditions underpinning health inequities. In “Advancing Action on Health Equity Through a Sociolegal Model of Health,” Ashley Schram and colleagues propose a modified version of the social determinants of health equity framework (originally developed by the 2008 World Health Organization Commission on the Social Determinants of Health) that conceptually integrates the functions of the law as identified by the 2019 Lancet–O’Neill Institute Commission on Global Health and Law. They contend that health justice partnerships offer a means for implementing a sociolegal model of health to reduce health inequities through strengthened legal capacities among the health care workforce and patients, and that this in turn will enable them to resolve health issues with legal solutions.

Interventions to improve outcomes for patients with complex health and social needs are increasingly being implemented through cross-sector partnerships with nonmedical organizations. However, payment systems often constrain options to implement models of care that address social and medical needs in an integrated fashion. In “Population Health Innovations And Payment To Address Social Needs Among Patients And Communities With Diabetes,” Kathryn Gunter and colleagues examine the experiences of 8 organizations involved in the Bridging the Gap: Reducing Disparities in Diabetes Care initiative. Among the strategies being employed to address medical and social needs are augmented staffing models to support high-risk patients with diabetes, information technology innovations, and system-wide protocols to identify high-risk populations with gaps in care. Participating sites identify and address social needs (e.g., food insecurity, housing), invest in human capital to support social needs referrals and coordination (e.g., embedding social service employees in clinics), and work with organizations to connect to community resources. Key challenges include difficulty in accessing flexible upfront funding to support infrastructure for interventions, and the fact that value-based payment mechanisms usually reward clinical performance metrics rather than measures of population health or social needs. The authors recommend that population health strategies that address medical and social needs for populations living with diabetes be tailored to a range of health care organizations, geographies, populations, community partners, and market factors, and that payment models be designed to support these strategies for sustainability.

The 2018 Declaration of Astana reemphasized the importance of primary health care and its role in achieving universal health coverage, yet policymakers need guidance on how to allocate resources in a manner that maximizes its economic benefits. In “Economic Aspects of Delivering Primary Care Services: An Evidence Synthesis to Inform Policy and Research Priorities,” Lorcan Clarke and colleagues present a synthesis of 109 published systematic reviews regarding evidence on the economic aspects of different models of delivering primary care services, as they relate to coverage, financing, service delivery, and governance. Their analysis reveals a significant body of evidence suggesting that specific primary care arrangements, such as health workers’ task shifting and telemedicine, can have positive economic impacts, such as lower overall health care costs. However, reviews on the impact of increasing primary care funding or the overall supply of primary care services are notably absent in the literature, leading the authors to suggest that there is great opportunity for further research to systematically examine the broader economic impacts of investing in primary care services.

Choosing Wisely is an initiative of the ABIM Foundation that aims to reduce the use of unnecessary, low-value medical services through development of recommendations related to service utilization. However, despite the creation and dissemination of these recommendations, evidence shows that low-value services are still prevalent. In “The Impact of Choosing Wisely Interventions on Low-Value Medical Services: A Systematic Review,” Betsy Cliff and colleagues report on synthesized findings from 131 studies on interventions designed to reduce medical care identified as low value by Choosing Wisely. They find that active interventions, particularly those with multiple components, are more likely to generate intended effects than efforts involving dissemination of Choosing Wisely recommendations without interventions. They conclude that interventions built on the Choosing Wisely recommendations are more effective in reducing the use of low-value care when targeting clinicians and using more than one component.

In the fall of 2017, the termination of direct federal payment for cost-sharing reduction (CSR) subsidies to insurers participating in the Affordable Care Act (ACA) individual health insurance marketplaces led to a substantial change in the relative prices of silver and gold plans on the Covered California insurance marketplace. Prior to this change, all gold plans in California had been more expensive than comparable silver plans that were offered by the same insurer using the same network in the same county. However, for the 2018 plan year, some gold plans that had lower cost sharing also had lower premiums than did comparable silver plans, resulting in silver “dominated” plans being sold through Covered California. In “When All That Glitters is Gold: Dominated Plan Choice on Covered California for the 2018 Plan Year,” Petra Rasmussen and David Anderson use the Covered California enrollment and product files from 2014 to 2018 to examine individuals earning above 200% of the federal poverty level who purchased plans from insurers who sold dominated silver plans in 2018. Their analysis reveals that households actively enrolled in 2018 and previously enrolled in a silver plan in 2017 enrolled in a dominated plan at higher rates than did new enrollees and those who were enrolled in non-silver plans in 2017. In fact, more than 30% of households that had their coverage automatically renewed in 2018 enrolled in a dominated plan and spent, on average, an additional $38.87 per month in premiums. The authors urge health insurance marketplaces to improve decision supports and choice curation for consumers to eliminate the possibility of individuals choosing dominated plans.

Early childhood education (ECE) programs enhance the health and social well-being of children and families. Yet, in many states, these programs face opposition and underinvestment. Public support and strategies to counter such opposition are critical to the future political feasibility of enhancing early childhood policies and programs. In “Evidence-Based Message Strategies to Increase Public Support for State Investment in Early Childhood Education: Results from a Longitudinal Panel Experiment,” Jeff Niederdeppe and colleagues detail the results of a randomized controlled study that tested the effectiveness of four different communication strategies to increase public support for state investments in childcare policies. The four message strategies included: an argument-based message (“simple pro-policy”); a message preparing audiences for encountering and building resistance to opposing messages (“inoculation”); a story illustrating the structural nature of the problem and solution (“narrative”); and both inoculation and narrative messages (“combined”). The authors found that respondents who read the narrative message had higher support for state investment in childcare policies than those who read the inoculation message or those in the no-exposure control group. The findings offer guidance for policy advocates seeking to increase public support for early childhood policies and programs.

In 2012, Colorado and Washington were the first states to legalize recreational marijuana through voter-initiated ballots. In both, counties could restrict or ban local marijuana facilities through various regulatory methods, including ordinances and zoning. In “County-level Recreational Marijuana Policies and Local Policy Changes in Colorado and Washington States (2012-2019),” Denise Payán and colleagues use a mixed-methods approach to describe the types of county-level recreational marijuana policies enacted in both states. They report that, by April 1, 2019, Colorado counties were less likely than Washington counties to allow marijuana facilities, with 48.4% of Colorado counties prohibiting recreational marijuana facilities in their jurisdiction compared to 23.1% of Washington counties. The policy debates included a wide variety of stakeholders, and in their analysis, the authors identify key areas of policy and public health research needed to inform future local marijuana policy decisions, including the impact of legalization on public health outcomes (particularly for youth) and public safety.

Rising prescription drug costs are consuming a growing proportion of state and private insurance budgets. In response, some state legislatures have recently authorized prescription drug–pricing boards to address the high prices of brand-name prescription drugs and to assess the value of those drugs. In “Pursuing Value-Based Prices for Drugs: A Comprehensive Comparison of State Prescription Drug-Pricing Boards,” Liam Bendicksen and colleagues compare five state boards in terms of their design, jurisdiction, and responsibilities. They find that boards’ structure, scope, and statutory leverages to compel manufacturers to negotiate lower net costs are key factors that influence whether and to what extent they can achieve cost savings for states. The authors argue that these agencies can enable states to address rising prescription drug costs, in part by virtue of their very existence, and that other states seeking to implement similar policies can build on the experiences and designs of current boards.

In closing, we invite readers to explore the Quarterly’s website for timely opinion pieces. Recent policy opinions include contributions by:

• Paula Lantz on the social determinants of declining birth rates in the United States;
• Hahrie Han on collective action and the social determinants of health;
• John McDonough on the need for a national health care workforce commission; and
• Mark Pauly on the simultaneous pursuit of tax justice and health care cost containment.

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