The Fund supports networks of state health policy decision makers to help identify, inspire, and inform policy leaders.
The Milbank Memorial Fund supports two state leadership programs for legislative and executive branch state government officials committed to improving population health.
The Fund identifies and shares policy ideas and analysis to advance state health leadership, strong primary care, and sustainable health care costs.
Keep up with news and updates from the Milbank Memorial Fund. And read the latest posts from our staff and guest authors.
The Fund publishes The Milbank Quarterly, as well as reports, issues briefs, and case studies on topics important to health policy leaders.
The Milbank Memorial Fund is is a foundation that works to improve population health and health equity.
June 2026 (Volume 104)
Quarterly Article
Alan B. Cohen
Jun 12, 2026
Back to The Milbank Quarterly
In this issue of the Quarterly, readers will find four Perspectives on varied topics, such as spending on primary care, coverage contractions under the “One Big Beautiful Bill Act,” the political economy of wellness, and problems associated with the commodification of health care. Following these Perspectives are six original scholarship articles that include a new, industry-standard measure of state policy contexts, the association between state policy contexts and working-age adults’ mental health, the association between extended postpartum Medicaid coverage and Medicaid-paid care, the alignment (or non-alignment) of Medicaid managed care plans with state requirements to cover substance use disorder treatment medications, changes in health care use and outcomes among groups maintaining versus losing Medicaid coverage upon enrollment in Medicare, and state preemption of local policymaking on social determinants of health that may exacerbate existing racial disparities in health and economic outcomes.
Although primary care is acknowledged to be foundational in most health systems, it is undervalued and under-funded in many countries, leading to shrinking workforces, decreased access, disrupted continuity of care, and reduced comprehensiveness. In “Sufficient and Efficient Spending on Primary Care Benefits National Health and Health Systems,” Robert L. Phillips and colleagues explore the steps that nations must take to devise and promote sustainable models of care. They argue that high-quality, accessible primary care requires sustained and strategic investment that must be implemented with measurement and accountability. Policies that impose unfunded mandates or devalue core functions, such as continuity and comprehensiveness, erode system performance and make it impossible for primary care to deliver on its promise for cost, utilization, satisfaction, and health outcomes. They conclude that sufficient and efficient funding in team-based, person-centered primary care must be a political and policy priority.
The “One Big Beautiful Bill Act” (OBBBA) or HR 1 is expected to impose the largest coverage losses in United States history through cuts to federal funding for Medicaid. In “What Happens When Coverage is Cut? Looking Backwards and Forward from the ‘One Big Beautiful Bill’,” Adam Gaffney and colleagues review four prior coverage contractions—Reagan-era Medicaid cuts, the 2005 TennCare disenrollment, the 2019 Arkansas work requirements, and the recent Medicaid unwinding—to shed light on the OBBBA’s potential impacts. Their analysis suggests that most individuals who lose Medicaid may not find alternative coverage, and that states are unlikely to compensate for federal funding cuts, findings that run counter to some assumptions adopted by the Congressional Budget Office in predicting the impacts of Medicaid cuts. They also find that studies of coverage contractions complement data from coverage expansions in predicting worse health care access, declining household finances, and poorer health for needy individuals owing to the OBBBA.
Wellness has grown into a multi-trillion-dollar industry encompassing a multitude of products and practices that affect health and wellbeing. The growth of the wellness industry has been fueled in part by the global digital revolution, which also has spread health misinformation that poses substantial regulatory, social, and political challenges. In “The Political Economy of Wellness: Commercial Determinants of a Burgeoning Industry,” Nancy Karreman and colleagues apply a commercial determinants of health lens to wellness as a useful means to examine its intersection with systems of capital production, corporate interests, and neoliberal norms of personal responsibility. The authors contend that, as wellness movements gain prominence in American and global policymaking, attention to these intersections will be crucial to understanding the consequences for health policy.
A quarter-century after bioethicist Edmund Pellegrino warned about the commodification of health and health care, the problem appears to have worsened, with increasing commodification objectifying and dehumanizing people while also undermining core concepts of holistic person-centered health. In “Decommodifying and Humanizing Health Care: Visiting Pellegrino’s Ethical Imperative,” Kevin Fiscella, Alejandro Vera, and Ashley Jenkins scrutinize the ethical perils of commodification and how they threaten human rights, the fulfillment of human potential, and the delivery of comprehensive health care. The authors maintain that multilevel sustained strategies are required to decommodify and humanize health and health care based on mental models, national and state policies, practices, resource flow, power dynamics, and relationships and connections.
Recent studies have linked the rising rates and growing disparities in working-age (ages 25–64) mortality in the United States partly to changes in states’ policy contexts since the 1980s. Yet, such studies have relied largely on measures of states’ policy contexts that were created for other purposes and use complex methods that can be difficult to interpret. Thus, a policy index designed for population health analyses with a clearer understanding of the utility of such indices would be a valuable contribution to the field. In “US State Policy Index for Population Health Analyses,” Jennifer Karas Montez, Iliya Gutin, and Shannon Monnat introduce a valid, transparent, replicable, and easily updated measure that is useful for understanding how the general orientation of state policies predicts mortality. Drawing on the World Health Organization’s Social Determinants of Health Framework and existing studies of the impact of specific state policies, the authors developed and validated the State Policies and Politics Data (SPPD) Index. Based on 11 state policies, with a range from 0 to 1 on a conservative-to-liberal continuum, higher scores on the index from 1980 to 2023 (reflecting an adoption of policies that strengthen economic security, expand safety nets, and discourage risky behaviors) were strongly associated with lower working-age mortality rates. Exhibiting predictive validity, the index is strongly associated with all-cause and cause-specific working-age mortality rates, and provides researchers with a straightforward, annual, and timely tool.
Mental health among working-age adults in the United States notably worsened during the COVID-19 pandemic, following a steady decades-long decline. Although the impact of states’ COVID-19 policies on mental health has received much attention, less is known about the impact of a broader set of long-standing state policy contexts. In “US State Policy Contexts and Mental Health Among Working-Age Adults,” Iliya Gutin and colleagues investigated how working-age adults’ mental health was associated with states’ policy contexts over 30 years, and assessed whether the pandemic disrupted the association. The authors used nationally representative data on adults ages 25-64 in the 1993-2022 waves of the Behavioral Risk Factor Surveillance System, merged with measures of three state policy indices, one of which was an index summarizing states’ policy contexts on a liberal-to-conservative continuum annually from 1993 to 2020. During the study period, each unit increase toward state policy conservatism was associated with 0.26 additional days of poor mental health and a 7% higher probability of extreme distress. The pandemic did not disrupt these associations. State policy contexts were a stronger predictor of poor mental health among adults without a college degree than adults with a degree, underscoring that state policy contexts may exacerbate existing educational disparities in mental health.
Prior to the COVID-19 pandemic, persons with pregnancy Medicaid coverage were typically disenrolled after 60 days postpartum, at which point they could retain Medicaid only if they qualified through another eligibility category (most commonly as a parent). The March 2020 Families First Coronavirus Response Act (FFCRA) extended postpartum Medicaid coverage by requiring states to pause disenrollment in exchange for enhanced federal funding. In “Extended Pregnancy Medicaid During COVID-19 and Enrollment and Health Care Use in the Postpartum Year,” Erica L. Eliason, Maria W. Steenland, and Rebecca A. Gourevitch analyzed 2019-2022 Medicaid claims data from 15 states to determine the association between extended postpartum Medicaid coverage and Medicaid-paid care. Using a continuous difference-in-difference design that leveraged variations in FFCRA-associated eligibility changes (state-level differences in pre-FFCRA pregnancy and parental Medicaid eligibility as a percentage of the federal poverty level [FPL]), the authors found that a 100 percentage-point FPL increase in postpartum Medicaid eligibility under the FFCRA was associated with 2.9 additional months of enrollment, a 27.3 percentage-point increase in 12-month continuous Medicaid, 107.2 more emergency department visits per 1,000 beneficiaries, and a 3.2 percentage-point increase in services with mental and behavioral health diagnoses. Overall, they concluded that continuous Medicaid coverage during the FFCRA was associated with longer postpartum enrollment and increases in some health care utilization, but that no increases in Medicaid-paid outpatient care or care for pregnancy-related conditions were found. They believe that improved communication around extended postpartum Medicaid coverage may improve the translation of coverage into health care access.
States contract with Medicaid managed care plans to administer benefits for roughly 70 million Medicaid enrollees, yet little is known about how plan benefit policies for substance use disorder (SUD) treatment medications align with state requirements. In “Medicaid Managed Care Plan Alignment with State Substance Use Disorder Treatment Coverage Requirements,” Sage R. Feltus and colleagues linked a national survey of state Medicaid officials regarding state requirements for SUD medication benefits in 2021 with data on SUD medication coverage and management from all 167 Medicaid managed care plans in 2021, and assessed the extent to which plans aligned with state requirements. The authors found that many of the 167 Medicaid managed care plans responsible for SUD pharmacy benefits did not align with state requirements to cover SUD treatment medications and that many plans imposed prior authorization requirements on these medications. Democratic-leaning states were more likely to require coverage of alcohol and opioid use disorder medications. Plans located in Republican-leaning states were less likely to be subject to state requirements governing coverage and prior authorization of substance use disorder treatment medications, with the exception of methadone, and were also less likely to align with requirements when imposed by states.
Each year, about 280,000 older adults experience the “Medicare Cliff,” becoming eligible for Medicare and losing Medicaid coverage when they turn age 65 owing to discontinuities in financial eligibility criteria. However, little is known about the long-term associations between a loss in Medicaid coverage and health status, health care utilization, and economic status in later life. In “Long-Term Changes in Health Care Use and Outcomes Among Groups Maintaining Versus Losing Medicaid Upon Medicare Enrollment,” Maryssa Pallis and colleagues used longitudinal data from the Health and Retirement Study for the period 1998-2020 to track individuals over a 10-year follow-up period from when they first became eligible for Medicare. Their analysis indicated that, even though respondents with Medicaid prior to Medicare eligibility started with better health overall, permanent loss of Medicaid was associated with poorer health outcomes and higher mortality relative to those who kept Medicaid or had a temporary disruption. Permanent loss of Medicaid was also negatively associated with appropriate health care utilization and positively associated with higher out-of-pocket health care spending relative to those who kept Medicaid or had a temporary disruption. The authors recommend that policymakers consider increasing eligibility criteria for Medicaid at age 65 from 100% of the federal poverty level (FPL) to 138% FPL, and that eligibility and outreach efforts for Medicare Savings Plans or introducing state-level Medicaid income disregards from 100% FPL to 138% FPL could mitigate the Medicare Cliff in the absence of federal eligibility reform. Addressing the Medicare Cliff issue would therefore lead to improved health outcomes and reduced health care costs.
Racial disparities persist in the United States, particularly with respect to health and economic outcomes. In recent years, there has been increased focus on the ways in which upstream determinants of health contribute to these disparities, but how forced inaction on these upstream determinants affects health and economic outcomes is not well understood. The prevalence of state preemption (i.e., when state lawmakers restrict policy actions among local decision makers) is increasing, and it is essential to understand how restricting local policymaking affects racial disparities in health and economic outcomes. In “Preemption and Generational Health Equity: The Role of Forced Inaction in Shaping Outcomes,” Margaret H. Swenson and colleagues examined the associations of state preemption with childhood poverty levels and low birthweight. They found that state preemption is significantly associated with higher rates of low birthweight among Black residents, with each additional preemptive policy associated with a 0.5 percentage-point increase in the low birthweight rate. State preemption also was significantly associated with higher rates of childhood poverty among both Black and White residents. Specifically, each additional preemptive policy was associated with a 5 percentage-point and a 1.4 percentage-point higher rate of childhood poverty among Black residents and White residents, respectively. The study revealed that state preemption of local policymaking on social determinants of health may exacerbate racial disparities in health and economic outcomes. To minimize these disparities and increase health equity, the authors advise state policymakers to consider these findings when deliberating on preemptive policies that would restrict local policymaking.
Over the past year, the Quarterly editorial team has been working with co-editors Paula M. Lantz of the University of Michigan and Steven H. Woolf of Virginia Commonwealth University to produce a special issue devoted to “Disease Burden, Mortality, and Life Expectancy in the United States: What Can State Policymakers Do to Meet the Challenges?” A collection of 25 articles, the special issue examines epidemiologic trends and challenges, social determinants of health and associated policies, state-level innovations, and public health infrastructure and governmental issues. The special issue will be available in its entirety later this year, but individual articles are being released in early view form as they become available.
In closing, we invite readers to visit the Quarterly’s website (https://www.milbank.org/quarterly/the-milbank-quarterly-opinions/) for insightful commentaries on an array of policy issues. Recent contributions include:
Alan B. Cohen became editor of The Milbank Quarterly in August 2018. He formerly was 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.
