In the March 2020 Issue of The Quarterly

This issue of the Quarterly features scholarly opinions on a range of important issues, including policy innovations in Washington State, infant mortality, the effects of climate change on health, and strategies for making maximum use of resources obtained from opioid settlements.

• Laurie Jinkins, Speaker-designate of Washington State’s House of Representatives, leads off by describing the state’s novel 2019 legislation creating a public long-term care insurance program. She asserts that, in the absence of a federal long-term care benefit, Washington’s Long-Term Care Trust Act demonstrates how states can lead the way on this issue for an aging population.
• James Capretta then explores Washington State’s effort to test a public option in the individual insurance market.He characterizes it as a “quasi-public option”—a privately administered plan with publicly influenced payment rates—that some view as a preferred alternative to a single payer plan, but which, he contends, also faces substantial political and practical challenges.
• David Kindig adopts an unconventional approach to analyzing infant mortality in the United States, noting that the current focus on unacceptably high mortality rates among African Americans and Native Americans may overlook the devastating effects reflected in the high absolute numbers of deaths among rural white infants. He argues that policymakers must examine both the infant mortality rate and absolute numbers of deaths when considering policy remedies and resource allocation decisions.
• David Rosner once again sounds the alarm concerning the impending dangers of global warming for population health. He points out that the United States’ retreat from the Paris Agreement on climate change poses great harm to all nations, and that our continuing inaction to transform from fossil fuels to clean energy sources is a product of our “willful ignorance and resistance to change.”
• Robert Pack,Cheryl Heaton, and Sandro Galea recount the history of the tobacco Master Settlement Agreement (MSA) between 46 State Attorneys General and the tobacco industry in 1999. To avoid making the same mistakes in any potential opioid MSA, they propose a model for distributing funds equitably to states, cities, and counties proportionate to their disease burden, and call for the creation of a national nonprofit organization to allocate the resources quickly and fairly to communities highly impacted by the opioid crisis.
• Paula Lantz discusses the findings that the Camden Coalition’s “hot spotting” approach to the highest-cost patients, or superutilizers, had no impact on hospitalizations or associated costs at six months and notes that red flags have been waving for many years, including evidence that fluctuations in high-cost populations makes them hard to study and that several evaluations have found mixed or modest results for cost-containment interventions.

In a new installment of Milbank Quarterly Classics, Sandro Galea celebrates Edgar Sydenstricker’s 1935 article on “The Changing Concept of Public Health.” He notes that its principal contribution to the field is the groundbreaking insight that achievement of better health in populations requires control of all environmental factors that affect physical and mental well-being. Calling this the basic criterion of public health, Galea contends that Sydenstricker’s paper presaged contemporary movements in population health science, and still resonates today with professionals and policymakers who embrace social determinants of health and a “health in all policies” approach to population health improvement.

In a new Milbank Quarterly Perspective, Gerald Oppenheimer and Ronald Bayer examine the evidence regarding whether moderate drinking is protective against heart disease, a debate that has raged among epidemiologists, social scientists, and alcohol policy experts for more than 40 years. The authors relate the history of previous research, including a large, multiyear randomized controlled trial, as well as the politics surrounding the interpretation and reporting of study findings. In the end, they conclude that definitive evidence regarding the risks and benefits of moderate alcohol consumption is still lacking, and that policymakers have a responsibility to inform the public of this evidentiary uncertainty when making recommendations.

Various states have implemented a mix of opioid misuse prevention policies, but little is known about the effectiveness of such policies. In “The Association of State Opioid Misuse Prevention Policies With Patient- and Provider-Related Outcomes: A Scoping Review,” Amanda Mauri and colleagues examined evaluations of legislative and administrative policy interventions that address opioid prescribing and dispensing, patient behavior, or patient health. They identified 71 articles that evaluated nine types of state policies targeting opioid misuse. Although the quality of available evidence appeared to be poor for the majority of policies, the authors found moderate evidence suggesting that drug supply management policies and robust prescription drug monitoring programs may reduce opioid prescribing. However, evidence regarding interventions targeting patient behavior and health outcomes, including naloxone access laws and Good Samaritan laws, was insufficient to draw conclusions. To learn more about the findings from this study, you may wish to listen to the first installment of our new podcast series, Milbank in Conversation, with authors Amanda Mauri and Rebecca Haffajee.

Because of the Affordable Care Act’s (ACA) Medicaid expansion, homeless persons have been enrolling in the program in greater numbers, and there is growing interest in some states to develop Medicaid-funded tenancy support services (TSS) to reduce avoidable health care spending for this population. In “Medicaid Utilization and Spending among Homeless Adults in New Jersey,” Joel Cantor and colleagues analyzed the characteristics of adults eligible for Medicaid TSS and compared their utilization and Medicaid spending patterns with those of matched non-homeless beneficiaries. They found that homeless adults suffer high burdens of mental health and substance use disorders, including opioid-related conditions, with health care spending levels 10% to 27% greater than those of non-homeless Medicaid beneficiaries. Extending TSS to this high-need population could potentially reduce avoidable Medicaid utilization and spending.

Among the various social determinants of health, where an individual lives is often a better predictor of her health than her genetic code, but communities that attempt to address health inequities based on place often find that preemption by state government limits what they can do. In “Equity-First: Conceptualizing A Normative Framework to Assess the Role of Preemption in Public Health,” Derek Carr and colleagues reviewed the role of law and policy in the genesis of health inequities and how preemption has both created and alleviated such inequities. They propose an equity-first preemption framework to establish evidence-based criteria for assessing when preemption will enhance or inhibit equity, and a research agenda for developing the evidence necessary to inform and operationalize the framework.

Maternal mortality rates in the United States exceed those of other developed countries, and are particularly acute for black mothers who are at 3 to 4 times greater risk compared to their white counterparts. In “Maternal Mortality and Public Health Programs: Evidence from Florida,” Patrick Bernet and colleagues analyzed administrative data on pregnancy-related public health expenditures, maternal mortality rates, and sociodemographic factors from all 67 Florida counties for 2001 to 2014. They found that a 10% increase in pregnancy-related public health spending led to a 13.5% decline in maternal mortality rates among black mothers and a 20% reduction in the black-white maternal mortality gap. Their analysis provides strong evidence that investment in public health programs can effectively reduce maternal mortality rates while also addressing racial disparities.

The prevention of type 2 diabetes is a key pillar of national public health policy. Using the Knowledge to Action framework in “Translating Knowledge into Action to Prevent Type 2 Diabetes: Medicare Expansion of the National Diabetes Prevention Program Lifestyle Intervention,” Carlye Burd and colleagues analyzed factors supporting the translation and national implementation of a lifestyle change intervention to lower the risk of type 2 diabetes in individuals with prediabetes. Key findings of their analysis centered on: the importance of collaboration among researchers, policymakers, and payers to encourage early adopters; development of evidence-based, national standards to support widespread adoption of the intervention; and community organization input to scale the intervention to the national level. Their analysis offers valuable lessons for bringing other evidence-based interventions to scale.

Bundled payment methods are becoming increasingly popular among payers. In “Unraveling the Complexity in the Design and Implementation of Bundled Payments: A Scoping Review of Key Elements From a Payer’s Perspective,” Sander Steenhuis and colleagues examined bundled payments in the context of the care procurement process. They found that, compared with traditional fee-for-service payment models, bundled payments tend to introduce an alternative set of financial incentives, intersect with most aspects of governance within organizations, and demand a different type of collaboration among organizations. They recommend that payers approach bundled payments as part of a broader transformation toward a more sustainable value-based health care system.

Published March 2020
DOI: 10.1111/1468-0009.12452

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