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From the Editor
Alan B. Cohen
Oct 11, 2021
Oct 5, 2021
Back to The Milbank Quarterly
As this issue of the Quarterly goes to press, the global struggle with COVID-19 is midway through its second year. Infection rates are surging once again and the Delta variant of the virus has become the dominant strain in many parts of the world. In the United States, vaccine hesitancy persists despite the availability of effective vaccines, transforming COVID-19 into a pandemic of the unvaccinated. Access to vaccines remains a significant challenge for many nations, with inequities in supply and distribution precluding much of the world’s population from obtaining adequate protection.
Given the lethal effects and economic consequences of COVID, it is not surprising that the world is so preoccupied with this scourge. However, many other population health and health policy concerns deserve the attention of both policymakers and practitioners. In this issue of the Quarterly, readers will find Perspectives and Original Scholarship articles covering a wide range of important policy-relevant topics. In “Social Prescribing in NHS Primary Care: What Are The Ethical Considerations?” Rebecca Brown and colleagues examine how social prescribing in the United Kingdom’s National Health Service (NHS)strives to improve patients’ health and wellbeing by connecting them with community assets, such as voluntary or charitable organizations that provide social and personal support. Social prescribing not only attends to patients’ nonclinical needs, but also helps to reduce the use of NHS resources. While the authors acknowledge that social prescribing schemes hold promise, they argue that evidence of their effects and effectiveness is sparse, and that ethical issues affecting patients, clinicians, and community organizations must be addressed in future research. The increasing use of artificial intelligence (AI) and machine learning in medicine holds great promise, but concerns have been raised about algorithm inaccuracy that might lead to patient injury and medical liability. In “Artificial Intelligence in Medicine: Redistributing Liability Across the Ecosystem,” George Maliha and colleagues note that prior work has focused primarily on medical malpractice, and that the AI ecosystem consists of multiple stakeholders beyond clinicians. They contend that current medical liability frameworks are inadequate to encourage both safe clinical implementation and continued disruptive innovation of AI. They recommend several policy options for building a more balanced liability system, such as altering the standard of care, providing insurance and indemnification, instituting special no-fault adjudication systems, and imposing further regulation.
State-level policymaking in the United States has assumed growing importance in the COVID era, particularly with respect to expansion of Medicaid programs and the recognition that social determinants, such as homelessness, play a significant role in affecting people’s health and wellbeing. In “Medicaid Waivers and Tenancy Supports for Individuals Experiencing Homelessness: Implementation Challenges in Four States,” Frank Thompson and colleagues explore how California, Illinois, Maryland, and Washington used Medicaid’s Section 1115 demonstration waivers to test strategies to finance tenancy support services for persons experiencing or at risk of homelessness. The authors find that three of the states made significant progress in launching their initiatives, while the fourth had delayed implementation in order to consider alternative means for providing tenancy supports. The experiences of the four states offer lessons for Medicaid officials in other jurisdictions that are interested in pursuing tenancy support initiatives, but the authors cite limitations of tenancy supports that argue in favor of federal policy-makers allowing states more latitude to subsidize housing costs directly for those experiencing or at risk of homelessness as an optional Medicaid benefit.
Another area in which state policymaking can make a difference in people’s lives is that of publicly funded prenatal care for undocumented immigrants. Rachel Fabi and colleagues analyze the legislative histories of prenatal policies in California, New York, and Nebraska in “State Policymaking and Stated Reasons: Prenatal Care for Undocumented Immigrants in an Era of Abortion Restriction.” Their analysis identifies moral reasons (based on respect for autonomy and justice) as well as reasons relating to the health and economic benefits of prenatal care that underlie these policies. Much of the variation by state in reasons supporting prenatal policies seems related to the state’s position on protection of reproductive rights and to policymakers’ positions on access to abortion. Yet, despite these differences, the three states arrived at similar prenatal policies for immigrants. The authors conclude that there may be areas where policymakers with different political orientations can converge on health policies affecting access to care for undocumented immigrants, and that future research should explore the use of various message frames for expanding public health insurance coverage to immigrants in other contexts.
In the face of continuing physician shortages in many parts of the United States, the increased use of nurse practitioners (NPs) has been a bulwark against decreased access to care. However, restrictive scope-of-practice (SOP) laws in some states limit the ability of NPs to practice without physician supervision. In the midst of the COVID-19pandemic, calls for relaxing such restrictive laws and granting NPs greater independence have met with resistance from groups claiming that independent NPs overprescribe certain medications, particularly opioids. In “Nurse Practitioner Scope-of-Practice Laws and Opioid Prescribing,” Benjamin McMichael analyzed a data set of approximately1.5 billion individual opioid prescriptions between 2011 and 2018 to determine whether an association exists between laws allowing NPs to practice independently and opioid prescribing patterns among both physicians and NPs. He finds that relaxing NP scope-of-practice laws generally reduced opioid prescriptions in commercially insured, cash-paying, Medicare, government-assistance, and all patients, respectively, with Medicaid patients seeing no statistically significant change in opioid prescriptions. These findings do not support the contention that allowing NPs to practice independently increases opioid prescriptions.
Long a popular staple in the American diet, artificial trans fat was used widely in processed and restaurant foods. However, as studies in the early1990s linked the consumption of artificial trans fat with heart disease, a strategic combination of research, advocacy, communications, grass-roots mobilization, legislation, regulatory actions, and litigation against companies and government took shape to remove artificial trans fat from the United States food supply. In “The Demise of Artificial Trans Fat: A History of a Public Health Achievement,” Margo Wootan and colleagues document the history of trans fat and the insights gained regarding policy strategy and advocacy best practices that led to the demise of this harmful food substance. The authors believe that the lessons learned from the trans fat experience can inform efforts to address other public health challenges, such as the current threats posed by excessive exposure to sodium and added sugars, which persist in the US food system.
Serious mental illness (SMI) imposes a significant burden on healthcare systems and communities, but it is unclear what value community members place on relieving this burden. Treatment for mental illness also competes with many other publicly funded priorities. In “Who Would Pay Higher Taxes for Better Mental Health? Results of a Large-Sample National Choice Experiment,” F. Reed Johnson and colleagues present findings from a discrete-choice experiment survey that aimed to quantify people’s willingness to pay taxes for increased spending among several competing public programs, including a program for treating severe mental health conditions. The experiment found that respondents were willing to be taxed as much as $99 to $181 annually for public mental health programs, and would accept reductions of between 1.6 and 3.4 beneficiaries in other programs in return for 1 additional mental health program beneficiary. Even when including those who opposed any tax increase, the willingness of respondents to pay taxes for mental health program expansions suggests that public programs that provide mental health services are underfunded.
In “Linking Data on Constituent Health with Elected Officials’ Opinions: Associations between Urban Health Disparities and Mayor Beliefs about Disparities in Their Cities,” Jonathan Purtle and colleagues assess whether the magnitude of income-based life expectancy disparity within a city is associated with the opinions of that city’s mayoral official (i.e., mayor or deputy mayor) about health disparities in their city. The authors observe that, in cities in the highest quartile of income-based life expectancy disparity, 50% of mayoral officials “strongly agreed” that health disparities existed and 53% believed the disparities were “very unfair.” In contrast, in cities in the lowest disparity quartile, 34% of mayoral officials “strongly agreed” that health disparities existed and22% believed the disparities were “very unfair.” From their analysis, they conclude that mayoral officials’ opinions about health disparities in their jurisdictions generally align with, and are potentially influenced by, information about the magnitude of income-based life expectancy disparities among their constituents. They also find that associations between officials’ opinions about health disparities in their city and the magnitude of life expectancy disparity in their city are not moderated by their own social or fiscal ideology or by the ideology of their constituents.
Growing concern about generic drug markets has emerged in recent policy debates involving prescription drug prices. In “The Evolution of Supply and Demand in Markets for Generic Drugs,” Richard G. Frank, Thomas G. McGuire, and Ian Nason scrutinize data for 77 molecules that lost patent protection during the so-called “patent cliff” between 2010 and 2013. In particular, they examine recent changes in factors affecting the supply and demand for generic drugs, including price, competition, supply disruptions and recalls, changes to the supply chain, and buy-side concentration. They find that, for large-market oral solids, generic entry and price declines were consistent with past studies showing a significant number of market entrants and substantial reductions in the average price of a molecule. In smaller markets for oral solids and injectable products, however, they observe fewer entrants, higher rates of exit, smaller price reductions, and, in some cases, considerable price instability. Overall, competition in generic drug markets varies widely by market size and product form, and changes in demand-side market structure place more downward pressure on prices stemming from buy-side concentration. Although greater regulatory oversight by the US Food and Drug Administration exerts upward pressure on costs, they contend that demand and supply-side changes point to further market instabilities across all generic markets, owing to producers’ changing economic position.
In closing, we invite readers to explore the Quarterly’s website for timely opinion pieces as well as posts in our Building Back Better series. Recent policy opinions include contributions by:
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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