In the December 2023 Issue of the Quarterly

With this issue of the Milbank Quarterly, we complete a year-long celebration of the journal’s centennial anniversary. In April, we released a special issue containing 36 forward-looking articles on “The Future of Population Health: Challenges and Opportunities.” Also, that month, we co-sponsored three webinars with the Boston University School of Public Health as part of its Public Health Conversations series that highlighted selected articles from the special issue. This past October, at the annual meeting of the Interdisciplinary Association for Population Health Science, Magdalena Cerda, Mark Hayward, and Jennifer Karas Montez presented their special issue papers in a panel session moderated by Sandro Galea.

As 2023 draws to a close, we are pleased to present in this issue two Perspectives and nine original scholarship articles on such topics as: access to care for uninsured immigrant children; improved coordination between key federal agencies regarding drugs receiving accelerated approval; the role of place in long-term services and supports; the association between partisan affiliations of state governments and state mortality rates; an assessment of primary care systems in Canada; community health center perspectives on financial payment and social risk screening; and local implementation of immigration policies.

In “Moving Towards Inclusion: Access to Care Models for Uninsured Immigrant Children,” Katelyn Girtain and colleagues examine the challenges faced by uninsured immigrant children in obtaining access to health care. The authors argue that, although health coverage for all children regardless of immigration status or date of United States entry would be ideal, incremental policy change may be a more realistic and efficient way to achieve equitable access to high-quality health care for uninsured immigrant children. They call for efforts that prioritize achievable goals grounded in data, are attentive to the sociopolitical environment, and are inclusive of diverse perspectives.

Programs that include molecular HIV surveillance and cluster detection and response have been a core public health activity in the United States since 2018 and represent the “fourth pillar” of the Ending the HIV Epidemic initiative launched in 2019. However, these programs have been controversial, with networks of people living with HIV calling for a moratorium. In “Advancing Dialogue About Consent and Molecular HIV Surveillance in the United States,” Stephen Molldrem and colleagues analyze the policy landscape and present four proposals to federal stakeholders intended to advance major reforms in the HIV surveillance and detection programs.

Increased use of the Food and Drug Administration (FDA)’s accelerated-approval pathway has posed challenges for the Medicare program, which often pays for expensive therapies despite substantial uncertainty about benefits and risks to Medicare beneficiaries. In “Improving FDA-CMS Coordination for Drugs Granted Accelerated Approval,” Peter J. Neumann and colleagues argue that policymakers have focused on expedited pathways at the FDA without sufficient attention to complementary policies at the Centers for Medicare and Medicaid Services (CMS). To inform policy options and recommendations, they report on semi-structured interviews with stakeholders to capture diverse perspectives on the topic, and recommend 10 areas for consideration: clarifying the FDA’s evidentiary standards; strengthening FDA authorities; promoting earlier discussions among the FDA, the CMS, and drug companies; improving Medicare’s coverage with evidence development program; tying Medicare payment for accelerated-approval drugs to evidence generation milestones; issuing CMS guidance on real-world evidence; clarifying Medicare’s “reasonable and necessary” criteria; adopting lessons from international regulatory-reimbursement harmonization efforts; ensuring that the CMS has adequate staffing and expertise; and emphasizing equity. They contend that improved coordination will require reforms at both the FDA and CMS, including administrative and legislative actions, new resources, and strong leadership at both agencies.

Long-term services and supports (LTSS) in the United States have been characterized by their patchwork nature and by a lack of generalizable person-reported information on LTSS care experiences connected to place of community residence, which has obscured our understanding of inequities that exist. In “The Role of Place and Person- and Family-Oriented Long-Term Services and Supports,” Chanee D. Fabius and colleagues articulate a conceptual framework of LTSS-relevant environmental domains, drawing on newly available data linkages from the 2015 National Health and Aging Trends Study to connect person-reported care experiences with public use spatial data. The authors assess relationships between LTSS-relevant environmental characteristic domains and person-reported care adverse consequences due to unmet need, participation restrictions, and subjective well-being for 2,411 older adults with disabilities and for key population subgroups by race, dementia, and Medicaid enrollment status. They find that the LTSS environment is highly associated with person-reported care experiences, but the direction of the relationship varies by domain. Measures of neighborhood social and economic deprivation (e.g., poverty, public assistance, social cohesion) are highly associated with experiencing adverse consequences due to unmet care needs. They recommend that greater attention be devoted to strengthening state- and community-based policies and practices that support aging in place.

Despite having made significant investments to transform primary care, Canada lags behind peer nations in providing timely access to physicians and places of care, in developing interprofessional teams, and in communicating across health care settings. In “Building High-Performing Primary Care Systems: After A Decade of Policy Change, Is Canada Walking the Talk?,” Monica Aggarwal and colleagues employ a multiple comparative case study approach to explore changes in primary care delivery across 13 Canadian jurisdictions over the period 2012 – 2021. The authors find that the most significant changes included adopting electronic medical records, investments in quality improvement training and support, and developing interprofessional teams. Progress was more limited in implementing primary care governance mechanisms, system coordination, patient enrollment, and payment models. They believe that Canada’s experience can inform innovation internationally by demonstrating how preexisting policy legacies constrain the possibilities for widespread primary care reform. To accelerate primary care transformation in Canada and abroad, they argue that a national strategy and performance measurement framework is needed based on meaningful engagement of patients and other stakeholders.

Increasing political polarization of states reached a high point during the COVID-19 pandemic, when the party affiliation of elected officials often predicted their policy response. However, the health consequences of these divisions have been unclear. In “Association Between Partisan Affiliations of State Governments and State Mortality Rates Before and During the COVID-19 Pandemic,” Steven H. Woolf and colleagues examine whether the partisan orientation of governors or legislatures was associated with mortality outcomes during the COVID-19 pandemic. Using data on deaths and the partisan orientation of governors and legislators from the Centers for Disease Control and Prevention and the National Conference of State Legislatures, respectively, the authors measure the association between Republican representation (percentage of seats held) in legislatures and (1) age-adjusted, all-cause mortality rates in 2015 – 2021 and (2) excess death rates during three phases of the COVID-19 pandemic, controlling for median household income, the prevalence of four risk factors (obesity, chronic obstructive pulmonary disease, heart attack, and stroke), and state policy orientation. They find that states with Republican governors or greater Republican representation in legislatures experienced higher all-cause mortality during 2015 – 2021, but that most associations lost statistical significance after adjustment for control variables. Although mortality was higher in states with Republican governors and greater Republican legislative representation before and during much of the pandemic, the authors posit that observed associations could be explained by the adverse effects of policy choices, reverse causality (e.g., popularity of Republican candidates in states with lower socioeconomic and health status), or unmeasured factors that predominate in states with Republican leaders.

Employment is recognized as a key social determinant of health, and the high rates of unemployment, underemployment, and poverty observed across the rapidly growing autistic population in the United States are of growing concern. Although a web of publicly funded services exists to support the employment, and associated health and well-being, of citizens with autism and other intellectual and developmental disabilities, there is a lack of overarching surveillance of employment services for these individuals. In “Unrealized Cross-system Opportunities to Improve Health through Employment among People with Developmental Disabilities,” Anne M. Roux and colleagues analyze the distribution of employment services among autistic people compared with those with intellectual disability using 2008 – 2016 data from the Centers for Medicare and Medicaid Services and the Rehabilitation Services Administration. The authors note that the number of autistic people served through Vocational Rehabilitation (VR) tripled during the study years, whereas those served through Medicaid only increased slightly. VR spending increased by 384% over the study years, whereas Medicaid spending decreased by 29%. The authors conclude that, while VR appears to have absorbed short-term employment needs of autistic individuals, Medicaid was severely lacking in serving those who needed longer-term employment services. They estimate that 1.98 million autistic adults did not receive employment services that could be critical to improving their health and well-being.

The protection of intellectual property (IP) rights has long been a contentious issue. In recent years, the debate over IP rights as a barrier to access of affordable medicines has been heightened by the global vaccine inequity occurring during the COVID-19 pandemic. The Trade-Related Aspects of IP Rights (TRIPS) Agreement of the World Trade Organization allows for the mechanism of compulsory licensing, whereby patent licenses may be granted without consent of the patent holder in certain circumstances, and has been employed for the export of pharmaceutical products to countries with insufficient manufacturing capacity. In “Trade-Related Aspects of Intellectual Property Rights Flexibilities and Public Health: Implementation of Compulsory Licensing Provisions into National Patent Legislation,” Lauren McGivern investigates domestic patent legislation for 195 countries (193 UN members and two observers) and three customs territories, looking specifically for provisions on compulsory licenses. Of the 187 countries with domestic or regional patent laws, 176 (94.1%) have provisions on compulsory licensing and 72 (38.5%) have provisions implementing TRIPS Article 31bis. The author asserts that the study highlights the gap in the implementation of TRIPS flexibilities in countries’ national patent legislation, especially in least-developed countries. Though it will not fully solve patent barriers to the access of medicines, implementation of compulsory licensing (and specifically those for the import and export of pharmaceutical products) may provide governments with another tool to safeguard their population’s public health.

Health care delivery systems increasingly are attempting to address patients’ social risks (e.g., food, housing, and transportation insecurity) in care delivery contexts. In “Community Health Center Staff Perspectives on Financial Payments for Social Risk Screening – A Qualitative Study,” Justin M. Lopez and colleagues interviewed clinicians, frontline staff, and administrative leaders from 12 Oregon community health centers (CHCs) about their social care initiatives. The authors examined participants’ awareness of existing or anticipated financial incentives, uses for incentive dollars, and perceived impact of financial incentives on social care activities in clinical practices. Frontline staff reported that the strongest motivator for clinic social care practices was the ability to provide responsive social services, while clinic managers noted that, for financial incentives to substantively change CHC practices, payments sizable enough to expand the social care workforce would be needed. The authors concluded that small fee-for-service payments to CHCs for social risk screening and navigation services may be unlikely to markedly influence CHC social care practices.

As the number of hospital maternity unit closures has increased nationwide, the need for telehealth services for the supervision, evaluation, and management of prenatal and postpartum care has grown. However, challenges in digital access persist. In “Dual Barriers: Examining Digital Access and Travel Burdens to Hospital Maternity Care Access in the United States, 2020,” Peiyin Hung and colleagues examined associations between driving time to hospital maternity units and digital access to understand whether augmenting digital access and telehealth services might help mitigate travel burdens to maternity care. Analyzing data from the 2020 American Hospital Association Annual Survey and the 2020 American Community Survey, the authors found that communities farther away from a maternity unit had disproportionally lower broadband and device accessibility, and though urban communities had greater digital access to technology and broadband subscriptions compared to rural communities, disparities in the percentage of households with access to digital devices were more pronounced within urban areas. The authors concluded that socioeconomically disadvantaged communities face significant barriers to maternity care access, both with substantial travel burdens and inadequate digital access. To optimize maternity care access, they stress that ongoing efforts (such as the Affordable Connectivity Program introduced in the 2021 Infrastructure Act) will be needed to bridge the gaps in digital access and to target communities with substantial travel burdens to care and limited digital access.

In the United States, state-level policies can advance immigrant health and health care access by extending noncitizens’ access to public benefits, workplace rights, and protections from immigration enforcement. However, there has been little examination of their implementation at the local level. In “Caught Between a Well-Intentioned State and a Hostile Federal System: Local Implementation of Immigrant Policies,” Maria-Elena de Trinidad Young and colleagues assessed the local implementation of state immigrant policies, using a purposive sample of California counties with large immigrant populations and distinct social and political dynamics to conduct and analyze in-depth interviews with community-based organizations that provided health, safety net, and other services. Their analysis revealed tensions among the inclusionary goals of state immigrant policies, local anti-immigrant climates, and federal policy changes. These tensions were manifested between state policy goals and resistance from local law enforcement agencies and policymakers. In addition, because of ongoing threats from federal immigration policies, there was a mismatch between the services and resources provided by state policies and local community needs. They concluded that the observed tensions among state immigrant policies, local immigration climates, and federal policy changes indicated unequal implementation of state immigrant policies across state communities, resulting in challenges and limited benefits from policies for many immigrant communities.

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-milbank-quarterly-opinions/). Recent contributions include:

• Harold Pollack, Nate Glasser, and Selwyn Rogers on the “iron cage” of violence prevention;
• Ashley Meehan and Joshua Sharfstein on screening for housing needs;
• Paula Lantz on the sharp decline in COVID-19 mortality; and
• John McDonough on what a second Trump Administration might mean for US health policy.

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