In the June 2023 Issue of the Quarterly

In April, we celebrated the Quarterly’s centennial anniversary with the release of a special issue on “The Future of Population Health: Challenges and Opportunities.” With contributions from 72 authors, the issue contains 36 articles in six cross-cutting thematic areas that, collectively, explore the most important challenges facing population health over the next 10 years, and offer practical policy prescriptions and strategies for meeting those challenges. Available through July 25th via open access, we invite you to read at: https://onlinelibrary.wiley.com/toc/14680009/2023/101/S1

Leading off the June 2023 issue of the Milbank Quarterly is a Perspective by Nathaniel Anderson and colleagues on “Mixed Signals in Child and Adolescent Mental Health and Well-Being Indicators in the United States: A Call for Improvements to Population Health Monitoring.” The authors note that social indicators of young peoples’ conditions and circumstances, such as high school graduation, food insecurity, and smoking, have been improving but that subjective indicators of mental health and well-being have been worsening. They argue that, although this divergence may suggest that policies targeting the social indicators may have been ineffective in improving overall mental health and well-being, an alternative explanation may be that one or more common exposures may have been poorly captured by existing social indicators. To resolve this question, they recommend greater investment in population-level data systems to support a more holistic, child-centric, and up-to-date understanding of young people’s lives.

Two original scholarship articles address issues central to the fabric of the American health care system. In “Big Med’s Spread,” Lawton Robert Burns and Mark Pauly examine the growing trend in cross-market hospital system mergers and the supposed benefits—as expressed by the systems’ executives as well as by industry consultants—of these new systems in increasing efficiencies, adding new capabilities, creating operating synergies, and addressing health inequities. The authors evaluate the presumed benefits against existing evidence regarding hospital system outcomes and conclude that these benefits are non-existent and that other motives may be at play in the formation of cross-market mergers that have nothing to do with efficiencies, synergies, or community benefits. Instead, they argue that these cross-market mergers may be self-serving efforts by system chief executive officers (CEOs) to boost their compensation. They urge the boards of hospital systems that engage in cross-market mergers to exercise greater diligence over the actions of their CEOs.

In “Century-Long Trends in the Financing and Ownership of American Health Care,” Adam Gaffney and colleagues analyze trends in health care ownership and financing over a century. Using multiple historical and current data sources to classify health care provider ownership and physicians’ employers, the authors examine the public versus private share of health care spending since 1923. They calculate a “comprehensive” public share metric that accounts for public subsidization of private health expenditures through either the tax exemption for employer-sponsored insurance plans or government purchase of such plans for public employees. They find that for-profit ownership of most health care subsectors has risen in recent decades and now dominates in several sectors, including nursing facilities, ambulatory surgical facilities, dialysis facilities, hospices, and home health agencies. However, most community hospitals remain not-for-profit. They also find that a growing share of physicians now identify as employees and that the taxpayer-financed share of health care spending has increased dramatically from 9% in 1923 to 69% in 2020, with taxpayer-financed subsidies to private expenditures accounting for much of the recent growth. They conclude that American health care has become increasingly publicly financed yet investor-owned, and that this trend has been accompanied by rising costs and, recently, worsening population health. They contend that a reassessment of the US model of health care financing and ownership appears warranted.

Long-standing racial inequities in health and well-being have been shaped by racialized public policies that perpetuate disadvantage among people of color. Strategic messaging may be able to counter these disadvantages by stimulating public and policymaker support for policies that advance population health. In “Strategic Messaging to Promote Policies that Advance Racial Equity: What Do We Know, and What Do We Need to Learn?” Jeff Niederdeppe and colleagues describe a scoping review of peer-reviewed studies from communication, psychology, political science, sociology, public health, and health policy that tested how various message strategies influence support and mobilization for racial equity policy domains across a wide variety of social systems. They report that studies tend to focus on the short-term effects of very short message manipulations, and that the body of evidence generally has not explored the effects of richer, more nuanced stories of lived experience and detailed accounts of the ways racism is embedded in public policy design and implementation. They offer a research agenda to fill numerous gaps in the evidentiary base related to building support for racial equity policy across sectors.

Many nations have adopted different approaches to support older adults through policies, programs, and social environments, all of which may affect population health. In “Societal Adaptation to Aging and Prevalence of Depression Among Older Adults: Evidence From 20 Countries,” Robin Richardson and colleagues linked the Aging Society Index (ASI), a new theory-based measure of societal adaptation to aging, to harmonized individual-level data from older adults in 20 countries. Using multi-level models that account for differences in the population composition across countries, they estimated the association between country-level ASI scores and depression prevalence. They also tested whether associations were stronger among the old-old and among sociodemographic groups that experience greater disadvantage. The authors found that countries with higher ASI scores (indicating more comprehensive approaches to supporting older adults) had lower depression prevalence overall, with strong reductions in prevalence among the oldest adults in the sample. They assert that country-level strategies to support older adults may become increasingly important as adults grow older and that improvements in societal adaptation to aging may be one avenue for improving population mental health.

State and local governments have been adopting taxes that earmark revenue for mental health. However, this financing model has not been systematically assessed. In “Earmarked Taxes for Mental Health Services in the United States: A Local and State Legal Mapping Study,” Jonathan Purtle and colleagues outline a legal mapping study that used literature reviews and key informant interviews, coupled with searches of legal databases and municipal data sources, to identify the year the tax went into effect, passage by ballot initiative (yes/no), tax base, tax rate, and revenue generated annually (gross and per capita). The study identified 207 policies earmarking taxes for mental health services (95.7% local, 4.3% state, 95.7% passed via ballot initiative). Property taxes (73.9%) and sales taxes/fees (25.1%) were most often used. They also found substantial heterogeneity in tax design, spending requirements, and oversight. A large proportion of the US population (about 30%) lives in a jurisdiction with a tax earmarked for mental health, and these taxes generate over $3.57 billion annually. As the prevalence of mental health problems increases, policymakers need to explore this increasingly common local financing strategy because the revenue generated by such taxes can be substantial in many jurisdictions.

Health inequities are most often understood as associated with the social determinants of health (SDOH). However, policy and programmatic frameworks for mitigation often rely on broad SDOH domains, without sufficient attention to the operating mechanisms. In “Conceptualizing the Mechanisms of Social Determinants of Health: A Heuristic Framework to Inform Future Directions for Mitigation,” Marco Thimm-Kaiser and colleagues conducted a critical review of the extant conceptual and empirical SDOH literature to identify unifying principles of SDOH mechanisms. Eight unifying principles of SDOH mechanisms emerged from their analysis. Building on these principles, they developed a conceptual model that synthesizes key SDOH mechanisms into a single organizing, heuristic framework. The framework provides policymakers, practitioners, and researchers with a practical tool to facilitate the translation of scholarly SDOH work into evidence-based and targeted policy and programming.

Public reporting of quality measures may have the unintended consequence of exacerbating disparities in access to high-quality, long-term care for older adults. In “Potentially More Out of Reach: Public Reporting Exacerbates Inequities in Home Health Access,” Shekinah A. Fashaw-Walters and colleagues used data from multiple databases to estimate differential access to high-quality home health agencies between July 2014 and June 2017. They found that, after the introduction of the home health five-star ratings in 2016, adjusted rates of high-quality home health agency use increased for all home health patients, except for Hispanic/Latine and Asian American/Pacific Islander patients. Additionally, they found that the disparity in high-quality home health agency use between low-income and higher-income home health patients was exacerbated after the introduction of the five-star quality ratings. Patients within predominantly Hispanic/Latine neighborhoods had a significant decrease in their use of high-quality home health agencies, while patients in predominantly White and integrated neighborhoods had a significant increase in high-quality home health agency use. The authors recommend that policymakers be aware of the potential unintended consequences of implementing home health public reporting, specifically for Hispanic/Latine, Asian American/Pacific Islander, and low-income home health patients, as well as patients residing in predominantly Hispanic/Latine neighborhoods.

It is well known that “junk food” consumption contributes substantially to weight gain, cardiometabolic diseases, and certain cancers. Taxes targeted to these products can raise the prices of the products to reduce consumption and the tax revenue can be used to invest in low-resource communities. While such taxes are administratively and legally feasible, no definition of “junk food” has been established. In “US Policies That Define Foods for Junk Food Taxes, 1991–2021,” Jennifer L. Pomeranz and colleagues reviewed federal, state, territorial, and Washington DC statutes, regulations, and bills defining and characterizing food for tax and related policies for the period 1991 through 2021. Their research identified and evaluated 47 unique laws and bills that defined food through one or more criteria such as product category, processing, place, nutrients, and serving size. Of these 47 policies, 26 used more than one criterion to define food categories, especially those with nutrition-related goals. They found that, to specifically identify unhealthy food, policies commonly included a combination of product category, processing, and/or nutrient criteria. An excise tax assessed on manufacturers or distributors of junk food may be an effective method to reduce consumption of unhealthy food.

Despite growing interest in identifying patients’ social needs, relatively little is known about the extent of hospitals’ provision of services to address them. In “Provision of Social Care Services by US Hospitals,” Bradley Iott and Denise Anthony assembled data from various secondary sources regarding hospital characteristics, types of social care services, and community benefits spending. The authors estimated associations between hospital characteristics and types of services offered and, among tax-exempt hospitals, estimated associations between social care services and community benefits spending and policies. They also modeled associations between community benefits spending/policies and each type of social care services. The authors found that tax-exempt hospitals offered about 36% more social care services than for-profit hospitals, and that larger bed size, health system affiliation, and having community partnerships were associated with more social care services, whereas rural hospitals and those managed under contract offered fewer social care services. They also found that hospitals in states with minimum community benefits spending requirements offered significantly fewer social care services. Overall, they conclude that, although tax-exempt status and increased community benefits spending were associated with increased social care services provision, the observation that certain hospital characteristics and state minimum community benefits spending requirements were associated with fewer social care services suggests opportunities for policy reform to increase social care services implementation.

In closing, we invite readers to visit the Quarterly’s website for timely opinion pieces on important policy issues (https://www.milbank.org/quarterly/the-milbank-quarterly-opinions/). Recent contributions include:

• Sandro Galea on reimagining prevention
• John McDonough on building a movement at the 2023 US Anti-Monopoly Summit
• Paula Lantz on the end of the COVID-19 public health emergency orders
• Joshua Auerbach and Joshua Sharfstein on recent federal court decisions affecting public health
• Harold Pollack and colleagues on ethical study designs in the opioid epidemic
• Dalton Conley on new developments in the science of slowing the aging process

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