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From the Editor
Alan B. Cohen
May 26, 2023
May 23, 2023
Back to The Milbank Quarterly
With this issue, the Milbank Quarterly enters its 101st year of publication. Few scholarly journals have enjoyed such longevity, and we are gratified to have reached this milestone. Throughout its history, the Quarterly has been dedicated to bringing the best available evidence to bear on the salient issues of the day in population health, public health, and health policy. This issue carries on that proud tradition with a range of articles that include the future of Medicare payment models, the political challenges faced by public option health insurance plans, strategies for testing and detecting lead poisoning in children, ways to optimize equity in hospital-based emergency care, 50 years of trust research in health care, strategies for improving the delivery of maternal and child health, inequities in home health care access, and state strategies to reduce childhood obesity.
The Affordable Care Act (ACA) set in motion a number of reform efforts aimed at improving Medicare payment policy, including the creation of the Center for Medicare and Medicaid Innovation (CMMI). In “Strengthening the Center for Medicare and Medicaid Innovation’s Approach to Constructing Alternative Payment Models,” Joseph Kannarkat and colleagues assess efforts by CMMI over the past decade to develop evidence-based alternative payment models (APM) for improving health care quality and reducing costs. The authors conclude that APM performance to date has been mixed, noting that CMMI released its Innovation Strategy Refresh in October 2021 to highlight challenges faced by payment models and to suggest new strategic approaches for the upcoming decade. They also point out that the Refresh leaves open key issues regarding how CMMI will address persistent issues, including how to transition away from the fee-for-service framework that underlies much of Medicare reimbursement. The authors suggest strategies for engaging beneficiaries in APM incentives, expanding operational flexibility to improve clinical behaviors (e.g., through waivers), rectifying conflicting model incentives, building voluntary short-term and mandatory long-term incentives to mitigate selection bias, and transitioning to an overriding population-based model to constrain net costs.
A decade after failing to make it into the Affordable Care Act, the so-called “public option” has reemerged as a reform goal at both the national and state levels, with polls reporting bipartisan support. In “Popular… to a Point: The Enduring Political Challenges of the Public Option,” Adrianna McIntyre and colleagues examine the popularity of the public option and its potential to compete with private health insurance products. They argue that the polls offer an incomplete picture, obscuring a complicated reality in which wide partisan attitude gaps exist under a surface of broad support. Though the health insurance marketplaces created by the ACA were intended to promote competition between public and private plans and expand insurance access for people without coverage through an employer or a public program, affordability and inadequate insurance have remained persistent concerns. The authors assert that, while the public option is not necessarily unattainable policy, its adoption will be challenging because of institutional hurdles and entrenched interests that may still oppose it, and because the broader national political terrain has not become substantially more hospitable toward reform since the failure of the public option in 2009.
Child lead poisoning is arguably the longest-standing child public health epidemic in United States history, but the challenge of removing lead from children’s environments is an arduous task preventing achievement of that goal. Until that goal can be realized, the protection of children’s health will depend on the adequacy of existing methods for testing and detecting lead. In “Improving Equitability and Inclusion for Testing and Detection of Lead Poisoning in US Children,” Christina Sobin and colleagues review current testing practices and discuss the feasibility of a three-pronged revision of those practices that potentially could bring child blood lead level testing into homes and communities. The authors contend that such modifications of current practices would immediately increase the nation’s capacity for inclusive and equitable detection and monitoring of dangerous lower-range blood lead levels in American children.
Current pay-for-performance payment policies ignore hospital transfers for emergency conditions, which may exacerbate disparities. No conceptual framework currently exists that offers a patient-centered, population-based perspective for hospital transfer networks. In “NET-EQUITY, A Conceptual Framework for Optimizing the Equity of Hospital-Based Emergency Care: The Structure of Hospital Transfer Networks,” Charleen Hsuan and colleagues propose a conceptual framework for understanding hospital transfer networks through an equity lens. The NET-EQUITY framework spotlights the external and internal factors that determine the structure of hospital transfer networks, including structural inequity and racism, and may help optimize population outcomes, decrease disparities, and enhance planning. In developing the framework, the authors synthesized work on health systems and quality of health care by Avedis Donabedian, the Institute of Medicine, Stephen Shortell, and the research framework of the National Institute on Minority Health and Health Disparities.
Trust plays a critical role in facilitating health care delivery and calls for rebuilding trust in health care have become increasingly common in recent years. In “Fifty Years of Trust Research in Health Care: A Synthetic Review,” Lauren Taylor and colleagues report on a synthetic review of the health services and health policy literatures that identified 725 articles since 1970 for analysis. Most articles focused on patients’ trust in clinicians, but others explored clinicians’ trust in patients, clinicians’ trust in other clinicians, and clinician/patient trust in health care organizations and systems. The authors found a lack of consensus regarding definitions, dimensions, and key attributes of trust. They also noted that researchers leaned heavily on cross-sectional survey designs, with limited methodological attention to the relational or contextual realities of trust. Moreover, trust was most commonly treated as an independent variable related to attitudinal and behavioral outcomes. Overall, the authors conclude that, while conceptual murkiness in terminology and limited observability of the phenomena have hampered efforts to advance both the theoretical and empirical study of health-related trust, the essential role of trust in population health necessitates continued study and grappling with the topic.
The improvement of maternal and child health (MCH) care in the United States requires solutions that address care access and the social determinants that contribute to health disparities. Direct service provision of MCH services by local health departments (LHDs) may substitute or complement public health services provided by other community organizations. In “Who Delivers Maternal and Child Health Services? The Contributions of Public Health and Other Community Partners,” Taryn Quinlan and colleagues analyzed the 2018 National Longitudinal Survey of Public Health Systems and 2016 National Association of County and City Health Officials Profile data to measure LHD provision of MCH services and its association with patterns of social service collaboration among community partners. They discovered that 85% of LHDs provided at least one of seven observed MCH services, with the most common service being supplemental nutrition assistance (71%) and the least common being obstetric care (15%). LHDs with MCH service provision were significantly more likely to collaborate with all types of social service organizations. However, over half of MCH-service-providing LHDs were found to be low collaborators, suggesting unrealized opportunities for social service engagement in these communities.
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 Fashaw-Walters and colleagues evaluated the impact of the Centers for Medicare and Medicaid Services (CMS) home health 5-star rating system on changes in high-quality home health agency use, by race, ethnicity, income status, and place-based factors. Using a difference-in-differences framework, with data from multiple CMS datasets for the period July 2014 to June 2017, the authors found that adjusted rates of high-quality home health agency use increased for all home health patients, except for Hispanic/Latino and Asian American/Pacific Islander patients. In addition, 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 5-star quality ratings. The authors urge policymakers to be aware of the potential unintended consequences of implementing home health public reporting, specifically for Hispanic/Latino, Asian American/Pacific Islander, and low-income home health patients, as well as for patients residing in predominantly Hispanic/Latino neighborhoods.
To reduce childhood obesity, leading medical organizations have recommended increasing the time that children spend in physical education (PE) and other school-based physical activity (PA). Yet, it is unknown how many states have passed laws that follow these recommendations, and whether these changes in state laws have had effects on obesity rates or the time that children actually spend in PE and PA. In “Have States Reduced Obesity by Legislating More Physical Activity in Elementary School?” Paul von Hippel and David Frisvold analyzed state laws in relation to national samples of 13,920 children from two different cohorts of elementary school students. One cohort attended kindergarten in 1998, while the other attended kindergarten in 2010. Both cohorts were followed from kindergarten through fifth grade. The authors estimated the effects of changes in state laws on obesity and physical activity, finding that 24 states and the District of Columbia had increased the time that children were recommended or required to spend in PE or PA, but that these changes in state policies had not increased actual time spent in PE or recess, had not affected average body mass index scores, and had not affected the prevalence of overweight or obesity. They concluded that increasing the PE or PA time required or recommended by state laws has not slowed the obesity epidemic and, in view of the failure of many schools to comply with state laws, it is not clear that better compliance would reduce obesity prevalence.
As we celebrate the Quarterly’s centennial anniversary this month, we wish to remind readers that a special issue of the journal is scheduled for publication next month (https://onlinelibrary.wiley.com/doi/10.1111/1468-0009.12601). It contains insightful articles in six broad 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. We are grateful to the many contributors to the issue: Paris Adkins-Jackson, Philip Alberti, Georges Benjamin, Paula Braveman, Tyson Brown, Patrick Carter, Magdalena Cerda, Dave Chokshi, Rebecca Cunningham, Daniel Dawes, Karen DeSalvo, Johnathon Ehsani, Michael Esposito, Rebecca Etz, Mateo Farina, Alexandra Finch, Tiffany Ford, Nicholas Freudenberg, Eric Friedman, Bianca Frogner, Sandro Galea, Daniel Goldberg, Sarah Gollust, Suhas Gondi, Juan Gonzalez, Lawrence Gostin, Jacob Grumbach, Mark Hayward, Pamela Herd, Patricia Homan, David Jernigan, Kushal Kadakia, Katherine Keyes, Nolan Kline, Noa Krawczyk, Paula Lantz, Savannah Larimore, Alana LeBrón, Hedwig Lee, William D. Lopez, Nicole Lurie, Ellen Mackenzie, Beth McGinty, Roshanak Mehdipanah, Neil Mehta, Jeffrey Michael, Katherine Michelmore, Jamila Michener, William Miller, Michelle Moniz, Jennifer Karas Montez, Peter Muennig, Amruta Nori-Sarma, Nicole Novak, Anaeze Offodile, Davis Patterson, Heather Pierce, Natasha Pilkauskas, Ninez Ponce, Rashawn Ray, Jessica Roche, Joshua Sharfstein, Riti Shimkhada, Susan Skillman, Kayte Spector-Bagdady, Kurt Stange, Ivy Torres, Gregory Wellenius, David Williams, Maria-Elena de Trinidad Young, and Marc Zimmerman.
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:
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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