In the December 2019 Issue of the Quarterly

From the Editor

As a multidisciplinary journal of population health and health policy, the Quarterly prides itself in publishing original research articles and opinions on a variety of topics from authors representing diverse disciplines, policy perspectives, and national settings. This diversity of topic, discipline, perspective, and setting is once again on display in the current issue.

In “Toward a Corporate Culture of Health: Results of a National Survey,” Michael Anne Kyle and colleagues report on a national survey of 1,017 private sector organizations intended to assess current levels of corporate engagement in promoting a culture of health (CoH), as measured by the extent to which businesses promote employee, environmental, consumer, and community health and wellbeing. They find substantial variation among businesses, with 38% taking health‐related actions, such as mentioning health and well‐being in the corporate mission, having a strategic plan for CoH, and perceiving a positive return on CoH investments. They conclude, however, that there is much opportunity for growth, even among those currently taking the most action, and that strengthening the business case for a corporate CoH may increase private sector investments in health and wellbeing.

Mandatory vaccination is not a unitary concept across the globe, and coercive childhood immunization policies are complex, with differing legal and moral features. In “Childhood Vaccination Mandates: Scope, Sanctions, Severity, Selectivity, and Salience,” Katie Attwell and Mark Navin introduce a taxonomy for classifying real world and theoretical mandatory childhood vaccination policies. They identify four key attributes of such policies: scope (which vaccines to require); sanctions and severity (which kind of penalty to impose on vaccine refusers, and how much of that penalty to impose); and selectivity (how to enforce or exempt people from vaccine mandates). A fifth attribute—salience—identifies the magnitude of the burdens imposed on the unvaccinated. The taxonomy provides policymakers a framework for making comparative judgments about current and potential mandatory vaccination policies.

The proposed implementation of block grants or per capita caps to reduce federal spending in the Medicaid program has been a highly controversial issue. Several states that expanded their Medicaid programs under the Affordable Care Act currently have pending applications for Section 1115 Medicaid waivers under review. To date, only Tennessee (a nonexpansion state) has received federal approval to experiment with this cost‐cutting approach. Policymakers and health practitioners are concerned that these changes to the program could have serious implications for health centers and their ability to fulfill their mission for Medicaid beneficiaries. Using a mixed‐methods approach in “Predicting the Impact of Transforming the Medicaid Program on Health Centers’ Revenues and Capacity to Serve Medically Underserved Communities,” Anne Rossier Markus and colleagues find that both block grants and per capita caps would adversely affect health centers’ total revenues and general service capacity. They recommend that states prioritize communicating changes to health centers in a timely way and be prepared to set aside dedicated funding to address anticipated shortfalls.

There has been little study of how politicians define and discuss issues relevant to population health in their electoral campaign advertisements. In “Issues Relevant to Population Health in Political Advertising in the United States, 2011‐2012 and 2015‐2016,” Erika Franklin Fowler and colleagues examine the prevalence of references to population health‐relevant issues conveyed in campaign advertising for political office at all levels of government in the United States in 2011‐2012 and 2015‐2016. The authors’ analysis uncovers substantial variation across years, by level of political office, by political party, and across geographic areas, indicating that where a person lives relates to her potential exposure to political communication about various health‐related topics. They conclude that, although political campaigns frequently reference population health‐relevant content in US political advertising for all levels of government, explicit connections to health are rare.

In France, private health insurance (PHI) has an exceptionally high level of coverage and accounts for only 13.7% of national health expenditures. French health insurance is a complementary and voluntary scheme that historically has been dominated by nonprofit, mutual benefit societies. However, over the past 20 years, the market share of for‐profit insurance companies has grown tremendously. In “Private Health Insurance in France: Between Europeanization and Collectivization,” Cyril Benoît and Gaël Coron examine this trend and conclude that PHI in France has been affected by European Union legislation favoring larger firms and for‐profit companies, and by complementary health coverage becoming gradually standardized and based at the corporate level. Together, these changes, they assert, are likely to reduce freedom of choice and individual welfare, an assumption supported by other recent studies.

First introduced in the early 1970s, Assertive Community Treatment (ACT) has become one of the most influential mental health programs ever developed. Today, however, ACT is associated with a rising tide of criticism challenging the program’s practices and philosophy while alternative service models are advancing. In “Innovation and Its Discontents: Pathways and Barriers in the Diffusion of Assertive Community Treatment,” David Rochefort traces the history of the ACT movement, using a diffusion‐of‐innovation framework to understand the factors that have shaped the program’s adoption. He believes that ACT will continue its presence in mental health treatment, but that a growing number of hybrid and competing versions of the program are likely to develop to serve specialized groups and to respond to consumer demands and the recovery paradigm in behavioral health care.

In another article related to behavioral health, Jonathan Purtle and colleagues explore “State Legislators’ Support for Behavioral Health Parity Laws: The Influence of Mutable and Fixed Factors at Multiple Levels.” The authors conducted a multi‐modal (post mail, email, telephone) survey of US state legislators in 2017 to assess how evidence about comprehensive state behavioral health parity legislation might be effectively disseminated to legislators and how characteristics of legislators might influence their support for such policies. Finding that 39% of legislators strongly support parity legislation and that the strongest predictors of support are beliefs that the legislation increases access to behavioral health treatment without increasing insurance premium costs, they conclude that these legislator characteristics and all state‐level contextual factors should be the focus of dissemination efforts.

In a new Milbank Quarterly Perspective, “Navigating the Shifting Terrain of US Health Care Reform—Medicare for All, Single Payer, and the Public Option,” Jonathan Oberlander tackles the confusion surrounding the use of such health care reform terms as Medicare for All, single payer, and public option. He adroitly dissects the meaning of these terms, noting that their various connotations reflect divergent political and philosophical assumptions about the preferred direction of health care reform, and that the current debate over their meaning mirrors persistent tensions in health policy between pragmatism and principle, incremental and systemic reform, and building on or tearing down the status quo. He questions whether Medicare will endure beyond 2020 as a prominent reform model that defines the health care debate or whether we are now witnessing a shift that presages US health policy moving in a different direction.

In this issue, we introduce a new feature, Policy Forum, a collection of opinions in which different perspectives are brought to bear on an important policy topic. The inaugural forum centers on New Zealand’s Wellbeing Budget, a first‐of‐its‐kind policy innovation intended to invest public funds in five priority areas: improving mental health; reducing child poverty; addressing inequalities faced by indigenous people; thriving in a digital age; and transitioning to a low‐emission, sustainable economy. Michael Mintrom first describes the new policy and its potential for improving population health. Ashley Bloomfield, director‐general of health in New Zealand, contributes additional policy context and discusses implementation challenges that New Zealand faces. Sandro Galea and Salma Abdalla examine the innovation through an American lens, addressing the extent to which the United States has (or has not) made similar investments in health and wellbeing for its citizens.

Finally, our contributing writers and some invited guest authors present opinions on a diverse array of topics:

  • In a guest opinion, Kara Odom Walker, Delaware’s health and human services secretary, outlines the steps she and other state leaders are taking to meet their state’s primary care needs, including establishing a health care spending growth benchmark, tracking measures of quality of care, increasing state investment in primary care, and communicating more effectively with providers and consumers.
  • Sara Rosenbaum examines a recent federal court decision allowing implementation of the Trump administration’s Title X “gag” rule, which blocks patients seen by health providers with Title X family planning funding from receiving information on or referrals for abortion. She discusses the legal challenge to the rule and explains why the decision was not sound, given strong legal arguments against the gag rule, as well as extensive evidence of harm to the millions of people who depend on Title X.
  • Using data from the Vietnam Draft Lottery of 50 years ago, Dalton Conley and Tim Johnson report on their analysis of the draft’s impact on drug use, violence, and employment, with particular emphasis on outcomes linked with “deaths of despair,” such as suicide and fatal drug overdoses. Finding that military service affects mortality from these causes, with the greatest threat occurring immediately after a veteran has returned home, they urge policymakers to embrace the lessons of Vietnam when considering the rise in deaths of despair and the health risks to our veterans from America’s wars in Iraq and Afghanistan.
  • John McDonough explores The Business Roundtable’s recent statement on the purpose of the corporation that places workers, customers, communities, and other stakeholders on equal footing with shareholders. He argues that, while this appears to be an encouraging step toward greater corporate social responsibility, the question remains whether we truly are embarking on a new national conversation concerning the role of the for‐profit corporation in American society.
  • With high drug prices currently dominating policy discussions in Congress and in various states, Brian Miller and Gail Wilensky put forward a proposal for containing the costs of high‐priced biologic drugs. They suggest using either a reference price based on a “standard‐of‐care therapy” or an abbreviated patent exclusivity period, until postmarket requirements are completed for drugs approved through the accelerated pathway of the Food and Drug Administration.
  • Joshua Sharfstein offers fresh perspective on the National Academies of Sciences, Engineering, and Medicine’s recent consensus study on adolescent development. Rather than seeing an adolescent’s condition as the result of a series of bad decisions, the study points out that differences in outcomes are related to differences in opportunity. He calls upon the field of population health to exploit this realization by embracing the importance of a healthy adolescence.
  • In a guest opinion, David Jones considers the question of whether states in the Deep South will ever expand their Medicaid programs and whether it would matter. Although Medicaid expansion would greatly increase coverage for many in these states, major access challenges would remain. He also contends that the election cycles in Kentucky, Louisiana, and Mississippi will likely shape the future of Medicaid in these and neighboring states for years to come.

In closing, we are pleased to welcome our newest contributing writer, Heidi Allen, whose first opinion piece is aptly titled “Medicaid’s Heavy Lift” and serves as a cogent reminder of the key roles that the Medicaid program plays in meeting the health care needs of more than 70 million Americans. She sifts through the contentious arguments for and against Medicaid expansion, and warns us not only to be mindful of our untested assumptions about the superiority of private insurance but also to acknowledge government’s role in making health insurance available to all citizens.



About the Author

Alan B. Cohen became editor of The Milbank Quarterly in August 2018. He currently is a research professor in the Markets, Public Policy, and Law Department at the Boston University Questrom School of Business, and professor of health law, policy and management at the Boston University School of Public Health. He previously directed the Scholars in Health Policy Research Program and the Investigator Awards in Health Policy Research for the Robert Wood Johnson Foundation. Earlier in his career, he held faculty positions at Johns Hopkins University and Brandeis University, and spent 8 years at the Robert Wood Johnson Foundation. He is a member of the National Academy of Social Insurance. He received his BA in psychology from the University of Rochester, and his MS and ScD in health policy and management from the Harvard School of Public Health.

See Full Bio