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From the Editor
Alan B. Cohen
Back to The Milbank Quarterly
As this issue of the Quarterly goes to press, the world is experiencing another surge of COVID‐19 cases, and the United States is setting new daily records for infections. The number of American lives lost to the virus is approaching 270,000, but the Trump administration still refuses to acknowledge the seriousness of the pandemic. Although the situation remains dire, there are some signs of hope. The election of Joe Biden as the next president augurs well for the nation. He has wasted little time in announcing a new coronavirus task force populated by leading scientists and physicians. His transition team also is poised to reverse or nullify legions of Trump administration policies and executive orders that have harmed or posed threats to population health. And now comes word that several COVID vaccines are nearing completion of Phase 3 trials, with at least one showing early evidence of effectiveness as high as 90%.
Of course, there remains much uncertainty regarding the transfer of power between now and January 20, 2021. Will President Trump relinquish control of the federal government or continue to contest the outcome of the election? Will his administration cooperate with the Biden team to achieve a relatively smooth transition? Will the two Georgia Senatorial runoff elections provide the Democrats with the seats they need to accomplish their legislative goals in the next session of Congress? These are momentous questions.
This issue of the Quarterly opens with a provocative Perspective by Jennifer Karas Montez that examines “US State Polarization, Policymaking Power, and Population Health.” As a follow‐up to her research article in the September 2020 issue of the journal, she argues that efforts to reverse both the downward trend in US life expectancy and the widening disparities among states in life expectancy must address the deep structural roots of polarized policies and political landscapes at the state level. Her research found that the adoption of more “liberal” policies by “conservative” leaning states could increase US life expectancy by more than 2 years, regardless of gender, thereby placing it on par with other high‐income countries.
The fifth installment in our Milbank Classics series reexamines the seminal article by John and Sonja McKinlay titled “The Questionable Contribution of Medical Measures to the Decline of Mortality in the United States in the Twentieth Century.” David Kindig writes in “The (Still) Limited Contribution of Medical Measures in Declines in Mortality” that the McKinlays’ assertion in 1977 that medical measures were not primarily responsible for the observed decline in all‐cause mortality from 1900 to 1973 remains fundamental to our understanding of population health today. He expresses both surprise and dismay that we still have not adequately answered the key question posed by the classic article regarding the role of medicine in mortality reduction.
In recent months, much has been written about the failure of the COVID‐19 supply chain, particularly as it relates to personal protective equipment (PPE). But COVID‐19 has impacted the supply chain in ways not previously seen—across all supply categories, regions, and borders. In “A Commons for a Supply Chain in the Post‐COVID‐19 Era: The Case for a Reformed Strategic National Stockpile,” Robert Handfield and colleagues analyzed several proposals for augmenting the current system, which failed to deliver the needed response to COVID‐19. They concluded that the proposals do not address the key attributes for pandemic plan renewal: flexibility, traceability and transparency, persistence and responsiveness, global independence, and equitable access. Instead, they call for a “commons‐based strategy” composed of a network of repositories, fluid inventories, and analytic monitoring governed by experts in order to achieve the nation’s strategic goals while also minimizing global supply chain risk.
Midwifery care, particularly when offered through birth centers, has shown promise in both improving pregnancy outcomes and containing costs. In “Midwifery and Birth Centers Under State Medicaid Programs: Current Limits to Beneficiary Access to a High‐Value Model of Care,” Brigette Courtot and colleagues found that Medicaid beneficiaries chose birth center care because they preferred midwife providers, wanted a more natural birth experience, and in some cases sought certain pain relief methods or birth procedures not available at hospitals. However, Medicaid beneficiaries do not have the same access to maternity care providers and birth settings as their privately insured counterparts, and Medicaid policy barriers prevent some birth centers from serving more Medicaid patients. They argue that, by addressing these barriers, policymakers could enable more Medicaid beneficiaries to access care associated with positive birth outcomes for mothers and newborns while simultaneously allowing the Medicaid program to reap significant savings. This article also is the subject of a Milbank Quarterly in Conversation podcast (https://www.milbank.org/quarterly/milbank-quarterly-podcast/).
Value‐based payment has the potential to spur innovation in upstream prevention, including attention to social needs that lead to poor health. However, there is uncertainty regarding the conditions under which value‐based payment will encourage health care providers to innovate to address these social risks. In “The Role of Value‐Based Payment in Promoting Innovation to Address Social Risks: A Cross‐Sectional Study of Social Risk Screening by US Physicians,” Amanda Brewster and colleagues analyzed data from the 2017‐2018 National Survey of Healthcare Organizations and Systems (a nationally representative sample of 2,178 physician practices) to ascertain the number of social risks systematically screened, the extent of practices’ participation in value‐based payment models, and measures of practices’ capacity for innovation. The authors found that social risk screening—an initial step in addressing social needs in health care—was not associated with overall exposure to value‐based payment for physician practices. They suggest that expanding social risk screening by physician practices may require standardized approaches and implementation assistance to reduce the level of innovative capacity required.
As US policymakers consider proposals to expand health insurance coverage as a means of reducing inequalities in health care access and use, the experiences of nations where well‐funded universal health care systems are in place may prove instructive. In “Educational Inequalities in Hospital Use Among Older Adults in England, 2004‐2015,” George Stoye and colleagues studied the variation in use of hospital care among education‐level‐defined groups of older adults in England, controlling for differences in health status, using data from six waves (2004‐2015) of the English Longitudinal Study of Ageing linked with participants’ hospital records for 7,713 older adults aged 65 years and older. They found no evidence of inequality in elective and emergency inpatient admissions among the education groups. However, there was a period of financial budget tightening for the NHS after 2010 that was associated with the emergence of education gradients in other forms of hospital care, with respondents in the high‐education group using more outpatient care and less emergency care than peers in the low‐education group. They caution that, while these estimates point to rising inequalities in the use of hospital care in England that could exacerbate existing health inequalities, adoption of a universal health care system in the United States still might likely reduce inequality in health care use.
Population health inequity remains entrenched in the United States, despite efforts to eliminate it. Public health researchers increasingly have called for moving from risk factor epidemiology toward consideration of dynamic local variations in the physiological impacts of structured lived experience. In “Weathering in Detroit: Place, Race, Ethnicity and Poverty as Conceptually Fluctuating Social Constructs Shaping Variation in Allostatic Load,” Arline Geronimus and colleagues employed a community‐based participatory research approach, based on a unique data set of 239 black, white, and Mexican adults from a stratified, multi‐stage probability sample of three Detroit neighborhoods, to measure participants’ allostatic load (a stress‐related physiologic measure) linked to their survey responses. The authors also examined the relationship between these measures and the Poverty‐Income‐Ratio among different racial/ethnic participant groups. Their analysis suggests that one‐size‐fits‐all analytic or policy models developed from the perspective of the dominant social group insufficiently address the experiences of diverse populations in specific settings and historical moments.
Regulatory agencies increasingly are being required to make market approval decisions for new drugs on the basis of limited clinical evidence, a situation that often has been encountered in cancer care. In “Approval of Cancer Drugs With Uncertain Therapeutic Value: A Comparison of Regulatory Decisions in Europe and the United States,” Maximilian Salcher‐Konrad and colleagues investigated how regulators manage uncertainty in the benefit‐risk profiles of new cancer drugs by comparing decisions made by the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) over a 5‐year period. They found that regulators in both agencies often deemed early and less complete evidence on the benefit‐risk profiles of cancer drugs sufficient to grant premarket approval, raising questions regarding the regulatory standards for the approval of new medicines. Even when regulators imposed requirements for postmarketing confirmatory studies for drugs approved through special approval pathways, meaningful evidence did not always materialize owing to shortcomings in study design and delays in conducting the required studies.
The rapid growth of life‐sustaining implantable devices that collect and relay massive amounts of digital health data to clinicians via smartphone applications has raised questions regarding health data privacy. Using pacemakers and implantable cardioverter‐defibrillators (ICDs) as a clinical model, I. Glenn Cohen and colleagues considered the legal implications of US and European privacy regulations for patient access to either summary or raw device data in “Ethical and Legal Implications of Remote Monitoring of Medical Devices.” Their analysis of applicable health privacy laws indicated that US patients may have surprisingly little access to their raw data collected and held by device manufacturers. They advocate for consistently granting patients access to the raw data collected by their implantable devices.
In behavioral economics, “nudges” steer people toward certain options but also allow them “to go their own way.” “Dark nudges” aim to change consumer behavior against their best interests, and “sludge” uses cognitive biases to make behavior change more difficult. In “Dark Nudges and Sludge in Big Alcohol: Behavioral Economics, Cognitive Biases, and Alcohol Industry Corporate Social Responsibility,” Mark Petticrew and colleagues studied whether dark nudges and sludge were being used by alcohol industry‐funded corporate social responsibility (CSR) organizations. Their analysis of these organizations’ websites and materials raises questions regarding whether alcohol industry CSR bodies use dark nudges and sludge to promote mixed messages about alcohol harms and to undermine scientific evidence. They point to the need for policymakers, practitioners, and the public to be aware of how such techniques are used to nudge consumers toward industry misinformation.
In closing, we wish to make readers aware of a new feature on the Quarterly’s website. “Building Back Better” is a collection of opinions written by members of our Editorial Advisory Board with the aim of offering policy ideas to the new Biden administration on a broad range of topics related to population health, the US public health infrastructure, and the US health care system. Opinion pieces will be posted on a regular basis throughout the transition period. We invite you to visit (https://www.milbank.org/quarterly/building‐back‐better/).
We also invite readers to explore recent opinions by contributing writers Sandro Galea, Heidi Allen, Sara Rosenbaum, and Joshua Sharfstein, as well as guest opinions by Richard Scheffler and Taylor Wang, and others on various topics of interest (https://www.milbank.org/quarterly/the‐milbank‐quarterly‐opinions/).
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.
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