In the September 2026 Issue of the Quarterly

In this issue of the Quarterly, readers will find three Perspectives on such topics as: racial equity impact assessments as tools for advancing population health and equity; firearms as a market-driven epidemic; and chronic absence as a public health priority. Following these Perspectives are eight original scholarship articles that include: a legislative history of the 340B drug discount program; a study of how SNAP access prior to pregnancy affects maternal and infant health outcomes; the association of Medicaid estate recovery with homeownership, home equity, and Medicaid enrollment; Medicaid policies related to telehealth; the effects of recent polarized elections on self-reported mental health; an experiment on how health care experiences shape system trust; the use of participatory research to build narrative power; and the impacts of global cannabis policy changes on substance use.

Racial equity impact assessments (REIAs) are used by local governments to integrate equity considerations into policymaking by evaluating potential impacts of proposed legislation before enactment. At present, there is limited empirical evidence regarding how REIA findings are characterized or how equity-focused evidence is taken up within legislative processes. In “Racial Equity Impact Assessments as Tools for Advancing Population Health and Equity in Local Policy,” Kellee White Whilby, Makeda Walelo, and Heron Bondoc examined all REIAs conducted in the District of Columbia between 2021 and 2024 across eight policy domains (e.g., health and human services, criminal justice and public safety, budget and fiscal policy), and analyzed legislative outcomes for bills with adverse ratings that were classified as enacted with modification, enacted without modification, or not enacted. They found that 46.4% of REIA ratings indicated positive equity impacts, while 9.0% identified potential adverse effects, and 34% were either inconclusive or negligible. They concluded that REIAs offer a mechanism for identifying potential policy equity impacts prior to enactment, but that adverse findings alone do not guarantee legislative action. They recommend strengthening institutional accountability structures and integrating equity evidence into decision-making processes in order to ensure that identified harms lead to meaningful policy change and increased population health equity.

The United States has among the highest firearm-related deaths in the world. In 2023, suicides accounted for 58% of firearm-related deaths and 38% of homicides. Firearms have become the leading cause of death among those under age 19, and are a consumer product that fits the definition of a market-driven epidemic (MDE). Evidence from other MDEs, such as tobacco and prescription opioids, demonstrates that large-scale, long-term reductions in harmful use can be achieved through a combination of focused, effective interventions by engaged governments, nongovernmental organizations, academia, media outlets, and even companies, at times. In “Firearms as a Market-Driven Epidemic: Potential Pathways to Reduce Preventable FirearmRelated Harm in the United States,” Eszter Rimányi and colleagues analyzed the peer-reviewed literature, government documents, and media reports relevant to the firearms epidemic according to the market-driven epidemics (MDE) definition and framework of five often overlapping phases: (1) market development; (2) evidence of harm; (3) corporate resistance; (4) mitigation; and (5) market adaptation. The authors found that the epidemic of firearm harm is progressing through the five stages of an MDE, but they contend that high rates of firearm-related deaths and injuries are not inevitable. By treating the firearm harm epidemic as a market-driven problem and drawing on insights from other MDE strategies, substantial reductions in violence may be achievable across the United States. States and cities have significantly reduced gun violence without infringing Second Amendment rights. They believe that the greatest unmet challenge now is generating increased engagement in gun safety among states and communities still experiencing high levels of preventable firearm deaths and related harms.

Chronic absence (i.e., missing more than 10% of time in school) rose sharply in the United States following the COVID-19 pandemic and now affects more than one in four students. It reflects unmet health and social needs and is patterned by deep structural inequalities. Both short- and long-term consequences include adverse impacts on educational attainment, health, and social outcomes. Because chronic absence remains largely framed and addressed as an education-sector problem, the scope and effectiveness of current responses are limited. In “Chronic Absence as a Public Health Priority: A Framework for Coordinated Action,” Catherine Falconer and colleagues synthesized interdisciplinary evidence from education, public health, and child development literature, and reconceptualized chronic absence as a public health issue. Their model integrates multilevel determinants of attendance across individual, family, school, community, and structural domains, and identifies implications for policy and cross-sector action. By viewing chronic absence through a public health lens, the authors reframe it from a purely educational outcome to a signal of unmet need and a multidimensional indicator of system performance. They advocate a prevention oriented public health approach that focuses on root causes that schools cannot address alone, such as poor health, housing instability, and unreliable transportation. Without this shift, efforts to reduce chronic absence are likely to remain fragmented and insufficient to achieve equitable improvements in child health and educational outcomes.

The 340B Drug Pricing Program (“340B”) began in 1992 as a narrowly focused program aimed at Public Health Service Act–funded clinics and public hospitals. Today, the program includes two-thirds of all nonprofit hospitals in the United States and accounts for more than $80 billion in discounted drug purchases. Past attempts to strengthen or cut the program have been stymied by the lack of clarity regarding Congress’s intentions in the original legislation. In “Stretching Scarce Enabling Legislation as Far as Possible: A Legislative History of the 340B Drug Discount Program,” Sayeh Nikpay, Mikayla Reinke, and Nicole Quinones sought to clarify Congress’s original intentions for 340B by analyzing internal primary source documents and conducting structured interviews with key informants regarding the creation of 340B. The authors found that, in establishing 340B, Congress had two intentions: (1) address an unintended consequence of the Medicaid Drug Rebate Program (MDRP) that had raised costs on safety-net clinics receiving significant discounts on drugs prior to the rebate program, and (2) establish minimum discounts for drug prices for core safety-net providers. Thus, they assert that Congress’s original intention for 340B was to enable core safety-net providers to continue to provide drugs to patients regardless of costs in the face of historic drug price increases set off by the MDRP. However, their analysis also concluded that the current scope of the program exceeds Congress’s original intent.

Able-bodied adults without dependents (ABAWDs) are eligible for Supplemental Nutrition Assistance Program (SNAP) benefits for only 3 months in any 36-month period, after which they are subject to a work requirement to continue receiving benefits. Because ABAWDs may later have children, this work requirement for childless adults may affect the health of pregnant women and their infants through the mother’s nutritional well-being prior to pregnancy. In “How Does SNAP Access Prior to Pregnancy Affect Maternal and Infant Health Outcomes?,” Sarah Hamersma and Mitchell McFarlane examined whether temporary county-level waivers of these work requirements improved health outcomes for mothers and their infants. Using restricted National Vital Statistics System natality data from 2004 to 2018, with virtually every birth in the United States in that period, linked at the county-month level to a dataset of ABAWD work-requirement waivers in the year prior to pregnancy, the authors analyzed binary maternal and infant health outcomes, controlling for economic conditions upon which waiver eligibility is determined. Their findings revealed statistically significant increases in adverse birth outcomes for first-time mothers exposed to work requirements just before pregnancy, including a 14% increase in very low birth weight infants and a 10% increase in very preterm births relative to baseline rates. In contrast, the introduction of a waiver was associated with little change in birth outcomes. For maternal outcomes, the removal of a waiver was unexpectedly associated with a significant reduction in eclampsia and a decline in labor inductions. The authors maintain that work requirements for food benefits may harm infant health, particularly when waivers are terminated, and recommend that policymakers weigh the costs and benefits of modifications to ABAWD work requirements.

In response to the high cost of state-run Medicaid programs, the 1993 Medicaid estate recovery policy was established to enable states to recover assets from the estates of beneficiaries after death. However, estate recovery may elicit behavioral responses from older adults who may no longer view real estate as an attractive asset, may borrow money from home equity to cover the cost of increasing care needs, or may avoid enrolling in Medicaid altogether. In “The Association of Medicaid Estate Recovery with Homeownership, Home Equity, and Medicaid Enrollment,” Amanda SpishakThomas investigated whether the implementation of Medicaid estate recovery is associated with homeownership, home equity, and Medicaid enrollment among lowincome adults. Using data from the Health and Retirement Study for 1992 – 2008, the author found that estate recovery significantly decreased home equity in the overall sample and among Black and White subgroups as well as those over age 74. In addition, estate recovery implementation was associated with a significant decrease in Medicaid enrollment among unmarried, low-income individuals aged 65 and older. These findings suggest that those most at risk for Medicaid estate recovery, namely low-income older adults, may behave exactly the way policymakers intended – avoiding enrollment in Medicaid and extracting housing wealth to cover the cost of their care. Still, the author argues, it is worth reconsidering a policy that recoups less than 1% of the long-term services and supports budget from Medicaid estate recovery to the detriment of low-income families who already have few assets.

During the COVID-19 pandemic, US states rapidly expanded policies enabling telehealth care delivery that increased access to care for patients, including those in rural and underserved communities. However, little is known about the impact of telehealth care expansion on health outcomes for underserved individuals. In “Expansion of State Medicaid Policies Related to Telehealth, 2018 – 2023: A National Legal Mapping Study,” Lucinda B. Leung and colleagues conducted a 50-state survey of telehealth policies to identify state policies addressing Medicaid telehealth care delivery and to explore explanatory state factors associated with telehealth adoption. Legal mapping methods were used to identify US state laws and policies addressing telehealth for Medicaid populations in effect up to December 31, 2023. Multivariable regressions were used to examine the data for associations between policy counts and several potential explanatory state factors from 2018 to 2023. While most telehealth policy adoption occurred during 2020 and 2021, with an audio-only reimbursement policy being the most rapidly adopted, state adoption of telehealth policies appeared to be independent of rurality, health professional shortage, Medicaid expansion, broadband internet availability, and other state factors, such as demographics, income, unemployment, COVID-19 cases, and deaths. The authors argue that the rapid enactment of Medicaid telehealth policies was not driven by any singular state factor, including rurality, and that policy can play an important role in the implementation of evidence-based health care tools.

Politics in the United States has become increasingly polarized, and little is known about how this phenomenon affects Americans’ mental health. In “The Effects of Recent Polarized Elections on Mental Health,” Michael Shepherd and Bethany Albertson evaluated how recent polarized elections have influenced Americans’ mental health, especially among political- and policy-based election losers. To investigate this question, the authors compared online search interest in politically related mental health issues and self-reported mental health data. Their analyses explored changes before and after election days in 2020 and 2024, using a question from the Behavioral Risk Factor Surveillance System (BRFSS) to compare differential changes for likely Democrats and Republicans. Overall, they found that the 2020 and 2024 presidential elections substantially increased interest in politics-related mental health issues online, and that likely partisan election losers and those who had the most to lose in terms of health policy were even more likely to have their mental health affected by the results of elections. The authors conclude that stakes of elections in this polarized era of American politics are worsening the mental health of Americans, and that additional resources may be necessary to allow therapists and clinicians to navigate additional care-seeking surrounding and following elections.

Trust in the US health care system has declined substantially in recent years. While prior research confirms that direct personal experiences with providers shape trust, questions remain about the influence of vicarious experiences, namely the health care stories shared by family members, friends, and community networks. In “Trust Through Others’ Eyes: An Experiment on How Vicarious Health Care Experiences Shape System Trust,” Silvia Cannas and Maria Cucciniello conducted a 2×2 between-subjects online survey experiment with 1,042 US adults. The sample was demographically representative by age, education, and gender, and was evenly divided between non-Hispanic White and non-Hispanic Black participants. Respondents were randomly assigned to 8 brief vignettes that varied by: (1) emotional valence (predominantly positive vs. predominantly negative) and (2) narrators’ racial identity (majority in-group vs. majority out-group). The authors found that vicarious experiences significantly affected trust in the US health care system, but not uniformly. Non-Hispanic White participants were not affected by in-group experiences and responded to out-group accounts, while the contrary held for non-Hispanic Blacks. Trust in one’s own doctor moderated these effects, with strong patient–provider relationships buffering individuals from the impact of systemic stories, and low provider trust heightening susceptibility to narrative influence. The authors recommend that health systems invest in creating structured opportunities for patients to share their positive care experiences, ensuring that these voices reach community networks where trust has been hardest to build and where authentic accounts of respectful, equitable care are currently underrepresented.

Narrative power is a foundational strategy used in community organizing. It involves dismantling dominant narratives that uphold inequity and constructing counternarratives that advance health equity and racial justice. Yet, the mechanisms through which narrative power can influence public opinion and subsequent policy are seldom evaluated with research. In “Participatory Research to Build Narrative Power: Results From Survey Research to Support Community Organizing for Health Justice and Equity,” Yusra Murad and colleagues, in research partnership with a power-building organization, developed and tested counternarratives that challenged dominant framings of the US health care system by (1) conducting interviews with community organizers to explore their motivations and health care experiences, (2) iteratively developing two counternarratives reflecting the system’s complexity and unaffordability, and (3) testing the counternarratives in a randomized experiment (N = 1,587) against a constructed dominant narrative and a no-message control. The experiment demonstrated that the dominant narrative effectively individualizes blame for poor health and dampens motivation for civic engagement, but that counternarratives rooted in the lived experiences and language of those most harmed by the system have potential to shift public beliefs, increase attribution for poor health to external factors vs. internal factors, and motivate some types of collective action. They assert that the study underscores the value of research partnerships between grassroots organizers and academic researchers in developing narrative power strategies.

Substantial changes in cannabis policies are occurring globally, but the impacts of these reforms on cannabis use, as well as downstream effects on other substance use, remain unclear. In “Impacts of Global Cannabis Policy Changes on Substance Use: A Systematic Review of Quasi-Experimental Studies,” Sarah B. Windle and colleagues conducted a systematic review to identify studies examining the impact of a cannabis policy change on substance use. Searching well-established databases as well as grey literature sources, the authors analyzed 176 reports published between 1993 and 2024, with approximately two-thirds published after 2019. Most were peer-reviewed publications (n = 148) applying a difference-in-differences (n = 129) or interrupted time series (n = 42) approach to data from the United States (n = 141). Key findings included: (1) medical and recreational cannabis legalization may increase cannabis initiation across age groups, with increased cannabis use among young adults; (2) differential impacts on alcohol use by policy and age group, with potential decreases following medical legalization, and potential increases following recreational legalization among young adults; and (3) evidence from a limited number of studies suggesting potential decreases in tobacco use among all age groups. Most studies found no change or a decrease in opioid-related outcomes, although evidence was less consistent for opioid-related mortality.

A March 2026 article, “From Tobacco to Ultra-Processed Food: How Industry Engineering Fuels the Epidemic of Preventable Disease,” by Ashley Gearhardt, Kelly Brownell, and Allan Brandt generated considerable reader interest. In this issue of the Quarterly, we are pleased to present two related commentaries that discuss policy strategies for addressing the harmful effects of ultra-processed foods. In the first commentary, William J. McCarthy, Darren Lov, and Frederick Ferguson argue that food industry engineering is less important than access to gut microbiota-accessible foods for preventing chronic disease. They contend that government agricultural and educational policies aimed toward increasing consumer access to healthier foods may be a more effective long-term approach to reducing nutrition-related chronic diseases. In a companion commentary, Gearhardt, Brownell, and Brandt agree that healthier eating habits are needed but that educational efforts alone are unlikely to succeed if individuals must navigate a food environment dominated by products specifically engineered to stimulate compulsive intake. They stress that meaningful progress requires complementary policies that promote nourishing foods while also critically addressing the commercial systems and product designs that undermine them.

Over the past year, the Quarterly editorial team has worked 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 already have been released in early view form as they became 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 a variety of policy issues. Recent contributions include:

• Lawrence O. Gostin on the Ebola and Hantavirus emergencies exposing our vulnerabilities;
• John E. McDonough on the public policy cornerstones of America’s financialized health care system;
• Paula M. Lantz on the targeted assaults by the Trump administration on notable public health achievements;
• Harold A. Pollack and colleagues on the challenges of so many individuals with intellectual and developmental disabilities living with caregivers over the age of 60;
• Andrew Anderson on the challenges of measuring whether behavioral health crisis systems are reaching people in need;
• Christopher Koller on what we talk about when we talk about health care affordability;
• Iliya Gutin on GLP-1s and the political economy of population health;
• Pauline J. Lapin and Laurie McWright sharing their insights on guiding principles for cultivating a sustainable culture for policy innovation;
• Michele Ver Ploeg, Joanne Guthrie, and Colleen Heflin on the inadequacy of existing data sources for evaluating the impacts of SNAP restrictions imposed by states; and
• Mona Hanna and H. Luke Shaefer on rethinking population health through place-based targeted universalism.

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