In the September 2020 Issue of the Quarterly

The COVID-19 pandemic remains in full swing across the globe, with the death toll mounting steadily while the search continues for effective vaccines and therapeutics to combat it. Few have been untouched by the epidemic’s rampage—whether having survived its deadly grip, suffered the loss of a loved one, lost one’s source of income, or simply had one’s life turned upside down by the restrictions put in place to stem its spread. COVID-19 pervasively rules the daily news cycle, dominates our thoughts and conversations, and dictates new norms of behavior that challenge and perhaps, at times, rankle our sensibilities. How long it will last is anyone’s guess.

Recently, we issued a call for papers about health beyond COVID in three broad areas: improving population health; improving public health infrastructure; and improving health care. Thus far, we have been pleased to receive several thoughtful commentaries and original research articles in all three areas that will directly inform policymakers and policymaking in health and social sectors. The call for papers (https://www.milbank.org/quarterly/call-for-papers/) remains open through December 31, 2020.

This issue of the Quarterly opens with two insightful Perspectives related to population health. In “Population Health in the Time of COVID-19: Confirmations and Revelations,” Ana Diez Roux reflects upon the clinical, epidemiologic, and social factors that drive the many visible manifestations of the pandemic in the population. She observes that the pandemic has revealed how we as a society have acted (or have failed to act) to protect our health, and she discusses the challenges and implications for the future, including how the pandemic may yield unanticipated opportunities for population health. She offers several suggestions for how we can change the way we live and how we may create systems and environments that promote health and health equity.

In “Well-Being in the Nation: A Living Library of Measures to Drive Multisector Population Health Improvement and Address Social Determinants,” Somava Saha and colleagues describe how the 100 Million Healthier Lives framework facilitated a multisector collaboration to develop community-level measures to improve population health, well-being, and equity. The Well-Being in the Nation measures are the first set of vetted measures from multiple sources that align well with population health initiatives, such as Public Health 3.0 and Healthy People 2030. The measures also offer an opportunity for a collaborative learning measurement system to drive a learning health and well-being system across sectors at the community, state, and national levels.

The fourth installment in our Milbank Classics series focuses on the landmark 1990 article by James House, Ronald Kessler, and Regula Herzog titled “Age, Socioeconomic Status, and Health.” In her commentary, “Revisiting Compression of Morbidity and Health Disparities in the 21^st Century,” Paula Lantz applauds the article for having contributed importantly to population health research in two key ways: first, by presenting an early empirical test of the construct of compression of morbidity in the United States, and, second, by shifting focus from early positive predictions regarding compression of morbidity on population health and social well‐being to a clear warning that significant social disparities may likely interfere with attainment of the ideal for the disadvantaged. She argues that “the ultimate goal of population health should be for all people—not just the socially advantaged—to live long lives, with aging‐related declines in physical and cognitive health compressed into a short time period before death.” Citing the recent alarming declines in US life expectancy, she recommends that future compression of morbidity research and action take into account the impact of these observed declines as well as the impact of other causes of death that have strong social drivers and patterns.

The decline in US life expectancy and the fact that it has become more unequal across US states is also the subject of an original research article and a Milbank Quarterly in Conversation podcast (https://www.milbank.org/quarterly/milbank-quarterly-podcast/). In “US State Policies, Politics, and Life Expectancy,” Jennifer Karas Montez and colleagues analyze changes in 18 state-level policy domains from 1970 to 2014 and their role in the stagnation and recent decline in US life expectancy. They find that some policies appear to be critical levers for improving life expectancy, such as policies on tobacco, labor, immigration, civil rights, and the environment. The authors differentiate between “liberal” and “conservative” state policies, and estimate that US life expectancy would be 2.8 years longer among women and 2.1 years longer among men if all US states enjoyed the health advantages of states with more liberal policies. Adoption of these policies would place US life expectancy on par with other high-income nations.

Drug overdose is the leading cause of injury-related death in the United States. Synthetic opioids, principally illicit fentanyl, have been the leading culprits in associated mortality rates. Ju Nyeong Park and colleagues reconceptualize the opioid epidemic in “Situating the Continuum of Overdose Risk in the Social Determinants of Health: A New Conceptual Framework.” In this scoping review, the authors propose a novel “continuum of overdose risk” framework to place social determinants more directly into our understanding of this national emergency. In addition, they propose six strategies to address the epidemic’s social roots, including developing partnerships with people who use drugs, incorporating harm reduction interventions, and reversing decades of drug criminalization policies in order to successfully reduce drug-related mortality over the long term.

Surprise medical bills increasingly have plagued consumers and generated outrage among some members of Congress. Out-of-network air ambulance bills, in particular, represent a growing problem. In “Out-of-Network Air Ambulance Bills: Prevalence, Magnitude, and Policy Solutions,” Erin Fuse Brown and colleagues estimate the prevalence and magnitude of privately insured persons’ out-of-network air ambulance bills and analyze the legal barriers to curtailing surprise bills. Using the Health Care Cost Institute’s 2014-2017 data from three large national insurers, the authors find that less than 25% of air ambulance transports of commercially insured patients are in-network, and that 40% of transports result in a potential balance bill, averaging $19,851, which is more than three times greater than the Medicare rate for the same service. Because the Airline Deregulation Act has preempted states’ efforts to control air ambulance balance billing, they conclude that a federal solution is needed, and owing to the failure of market forces to discipline either prices or supply, they maintain that out-of-network air ambulance rates should be benchmarked to some multiple of Medicare rates or, alternatively, services could be delivered and financed through a combined competitive bidding and public utility regulation approach.

Fruit and vegetables are part of a healthy diet, and suboptimal intake of these nutrients is associated with increased risk of diet-related diseases, but no national retail-based fruit and vegetable subsidy program currently exists to benefit the health of the entire population. In “Legal Feasibility and Implementation of Federal Strategies for a National Retail-Based Fruit and Vegetable Subsidy Program in the United States,” Jennifer Pomeranz and colleagues examine existing federal, state, local, and nongovernmental organization (NGO) policies and programs that subsidize fruits and vegetables, and also evaluate Congress’s power to implement a national retail-based fruit and vegetable subsidy program. Their legal and policy analysis suggests that a national subsidy program could be created if Congress would use its Commerce Clause powers to tax or spend through direct regulation, licensing, taxation, tax incentives, and conditional funding. They believe that a voluntary conditional funding program may be best, but that a mandatory federal-state cooperative program combining regulation and licensing would be a reasonable alternative.

In the past decade, the number of federal, state, and local transgender-specific policies increased, with some policies advancing protections for transgender and other gender-diverse people, while other policies were restrictive. Little was known about the relationships between these policies and use of medical gender affirmation services (such as hormone treatment and therapy/counseling) or about how these associations may vary among different racial and ethnic groups. In “State-Level Transgender-Specific Policies, Race/Ethnicity, and Use of Medical Gender Affirmation Services among Transgender and Other Gender-Diverse People in the United States,” Tamar Goldenberg and colleagues use multilevel modeling to examine these relationships, finding that protective policies are associated with increased care, and that broad religious exemption laws and Medicaid policies that exclude transgender-specific care are both associated with less use of therapy/counseling. The relationship between race/ethnicity and medical gender affirmation services varies across states, with state-level policies seeming to affect medical gender affirmation service use by non-Hispanic white transgender people and transgender people of color differently.

Concerns have been raised about risk selection in the Medicare Shared Savings Program (MSSP). Specifically, turnover in accountable care organization (ACO) physicians and patient panels has raised questions regarding whether ACOs may be earning shared-savings bonuses by selecting lower-risk patients or providers with lower-risk panels. In “Savings or Selection? Initial Spending Reductions in the Medicare Shared Savings Program and Considerations for Reform,” J. Michael McWilliams and colleagues perform three sets of analyses of Medicare claims data to determine whether there was risk selection among the early cohorts of the MSSP. The authors find no evidence of ACO manipulation of provider composition or billing to inflate savings. Participation in the original MSSP was associated with modest savings and not with favorable risk selection. They contend that the findings suggest opportunities to build on early progress in guiding future program reforms in the revamped MSSP.

Bundled payments have been promoted as an alternative to fee-for-service payments that can mitigate the latter’s incentives for increased service volume. Over the past decade, the Medicare program has expanded its use of bundled payments, but there have been few reviews of the impact of these payment programs on cost, resource use, utilization, and quality. In “Medicare’s Bundled Payment Initiatives for Hospital-Initiated Episodes: Evidence and Evolution,” Christine Yee and colleagues examine the history and features of 16 Medicare bundled payment programs involving hospital-initiated episodes of care. The authors evaluate the methodological quality and quantitative findings from 37 studies that used higher-quality research designs. Their principal finding is that bundled payments for hospital-initiated episodes may be a good alternative to fee-for-service payments by helping to slow the growth of payer spending, but that they do not necessarily reduce absolute spending. They also find no overwhelming evidence of compromised quality. Nevertheless, designing a bundled payment contract that is attractive to both providers and payers remains a challenging task.

Strategic purchasing of health care has been a popular policy idea around the world for decades, but several factors have hindered its effective implementation. In “Power and Purchasing: Why ‘Strategic Purchasing’ Fails,” Scott Greer and colleagues report on in-depth case studies of strategic purchasing in England, the Netherlands, and the United States. In each country, they review definitions of “strategic” purchasing to distinguish it from the mere use of contracts to regulate inter-organizational relationships. Their analysis suggests that none of these health care systems has achieved effective strategic purchasing because of asymmetries in market power, information, financial power, and political power. They question whether further investment in strategic purchasing policies is worthwhile, and recommend that policymakers focus instead on the real sources of power in a health care system, taking into account the asymmetries, ways to work with them, and the constraints that they create.

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