In the March 2021 Issue of the Quarterly

Since the launch of the Quarterly’s Building Back Better series of policy opinion posts in November 2020, the United States has experienced one of the most tumultuous and traumatic periods in its history. In fact, the entire year of 2020 will be remembered as a “perfect storm” of global pandemic, tragically avoidable death, reduced life expectancy, economic depression, racial injustice, and civil unrest. Fortunately, the violent insurrection at the US Capitol on January 6, 2021 failed, and the inauguration of President Biden occurred two weeks later without incident. Since taking office, the Biden administration has initiated a host of federal policy changes affecting not only health but other areas of policy that relate to health, most notably environmental protection and climate change. Some of these policy shifts reverse Trump-era policies harmful to health, while others aim to improve or strengthen existing programs. Not surprisingly, many have aligned closely with ideas and recommendations contained in the 13 pieces posted thus far in the Building Back Better series. Because the administration continues to face formidable challenges that require timely, practical, evidence-based policy advice, we will continue the series for the foreseeable future and invite readers to visit our website (https://www.milbank.org/quarterly/building-back-better/).

The four Perspectives in this issue of the Quarterly all embrace the spirit of “building back better.” In “Population Health Science: Fulfilling the Mission of Public Health,” Frederick Zimmerman argues that public health has been distracted from its historical mission of ensuring the conditions in which people can be healthy. He attributes this to a heavy reliance on randomized controlled trials, a dearth of formal theoretical models, and a reluctance to engage in politics. However, he believes that the field of population health is bringing needed scientific tools to the aid of public health in fulfilling its core mission.

Persistent communication inequities have limited the access of racial and ethnic minorities to life-saving health information, making them more vulnerable to the harmful effects of misinformation. In “The Communication Infrastructure as a Social Determinant of Health: Implications for Health Policymaking and Practice,” Taylor Goulbourne and Itzhak Yanovitzky stress the need for greater public investment and support for minority-serving media and community outlets in order to close the gaps in access to credible health information for these population groups.

Progressives in the United States have long championed universal coverage in the form of “Medicare for All.” Although proposals have varied in design, many generally have built upon the existing structure of “original” or traditional Medicare. Jon Kingsdale takes a decidedly different approach in “Medicare Advantage for Most,” advocating for coverage expansion through Medicare Advantage, the Part C managed care alternative to traditional Medicare. He asserts that private plans under Medicare Advantage are “uniquely empowered to control costs and deliver good care” and, therefore, should serve as the public option in the ACA Marketplaces.

The United States lacks a well-organized system of primary mental health services for children and adolescents. In “Developing a Structure of Essential Services for a Child and Adolescent Mental Health System,” Edward Schor outlines an ambitious plan for such a system that will require coordination among multiple disciplines and agencies. A necessary first step will be to reach consensus on the essential structures and processes of mental health services.

In the sixth installment of our Milbank Classics series, Stephen Shortell offers “Reflections on the Five Laws of Integrating Medical and Social Services—21 Years Later.” His examination of Walter Leutz’s 1999 landmark article finds that research on integrated care models over time generally has supported as well as extended the original five laws, but that new opportunities involving digital health technologies, artificial intelligence, and the recognition that patients can play significant roles in integrating their own care may advance our understanding of how to promote greater integrated care.

Over the past decade, state Medicaid programs have grown in size and complexity, posing challenges for state agencies in designing and implementing new policies, and raising legitimate questions as to whether agencies are adequately seeking input from consumers. In “Engaging Consumers in Medicaid Program Design: Strategies from the States,” Jane Zhu and colleagues report on interviews with Medicaid leaders in 14 states in which they found significant variation among states in consumer engagement approaches. They encourage state leaders to share best practices in order to help strengthen their engagement efforts with Medicaid beneficiaries and to identify opportunities for program improvement reflecting community needs.

The high prevalence of obesity has challenged policymakers around the globe for many years. In “Is Obesity Policy in England Fit for Purpose? Analysis of Government Strategies and Policies, 1992-2020,” Dolly Theis and Martin White analyzed obesity policies in England, finding that 30 years of proposed government obesity policies have not led to successful reductions in obesity prevalence and health inequities. They contend that such policies have largely been proposed in ways that do not readily lead to implementation, that governments rarely commission evaluations of previous strategies or learn from policy failures, and that governments have tended to adopt less interventionist policy approaches. They warn that the COVID-19 pandemic has created greater urgency for policymakers to address the shortcomings identified in their analysis in order to tackle population obesity successfully.

Health care providers are collaborating increasingly with community‐based organizations (CBOs), such as food pantries and homeless shelters, to address patients’ social determinants of health. In “Money Moves the Mare: The Response of Community-Based Organizations to Health Care’s Embrace of Social Determinants,” Lauren Taylor and Elena Byhoff interviewed leaders of CBOs regarding their perceptions of these collaborative relationships. They found that CBOs perceive health care organizations as potential sources of revenue, and that this perception may be driving CBOs to appear more like health care organizations. They caution policymakers to consider balancing the benefits of professionalizing CBOs against the risks of medicalizing them.

As governments around the world increasingly adopt well-being indicators in addition to traditional economic indicators when making important policy decisions, there is a need to evaluate the outcomes that may be observed from policies aimed at improving well-being. In “Life Satisfaction and Subsequent Physical, Behavioral, and Psychosocial Health in Older Adults,” Eric Kim and colleagues evaluated whether positive change in life satisfaction over time was associated with better outcomes on 35 indicators of physical, behavioral, and psychosocial health and well-being. They found that individuals with the highest (versus lowest) life satisfaction had better subsequent outcomes on some physical health indicators and health behaviors and on nearly all psychosocial indicators. They concluded that life satisfaction is a valuable target for policies aiming to enhance several indicators of psychosocial well-being, health behaviors, and physical health outcomes.

Prescription drug spending per capita in the United States is twice that in France. In “Why France Spends Less than the United States on Drugs: A Comparative Study of Drug Pricing and Pricing Regulation,” Veronique Raimond and colleagues examined six brand-name drugs with the highest gross expenditures in Medicare Part D in 2017, and compared the price dynamics in France and the United States between 2010 and 2018. They analyzed associations between price changes in each country and key regulatory events related to drug pricing. In France, regulations that limit drug prices based on value when products are launched and that prohibit substantial price increases after launch appear to be key to controlling spending. They posit that if Medicare in 2018 had paid French prices for the six brand-name drugs, the agency would have saved $4.9 billion.

The relative performance of teaching hospitals has been debated for decades, with empirical evidence on dimensions of quality other than survival somewhat mixed. In “Quality and Cost of Care by Hospital Teaching Status: What are the Differences?” Frank Sloan reviewed the evidence base, finding that quality of care as measured in process of care studies and in longitudinal studies of long-term survival of cancer patients tends to be higher at major teaching hospitals, and that there is reason for patients to be willing to pay more for inclusion of major teaching hospitals in private insurer networks at least for some services. He concluded that payment differences between major teaching and non-teaching hospitals for hospital stays, especially for complex cases, potentially increase prices paid by other insurers for hospital care.

In closing, we invite readers to explore recent opinions by contributing writers John McDonough and Dalton Conley, as well as guest opinions by David Jones and Sherry Glied on assorted topics of interest (https://www.milbank.org/quarterly/the-milbank-quarterly-opinions/).

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