Milbank Quarterly最新文献

{"title":"A Scoping Review of Certified Nurse-Midwife and Certified Midwife Care in the United States: Assessing Outcomes Across Six Patient Care Domains.","authors":"Emma Virginia Clark, Robyn Schafer, Rachel Lane Walden, Julie Blumenfeld, Carrie E Neerland, Katie Page, Mavis N Schorn, Sanjana Chimata, Heather M Bradford","doi":"10.1111/1468-0009.70069","DOIUrl":"10.1111/1468-0009.70069","url":null,"abstract":"<p><p>Policy Points Certified nurse-midwife (CNM)/certified midwife (CM) care is associated with outcomes that are comparable or improved compared to physician care across multiple domains of health care quality, especially safety and effectiveness. CNM/CM care is consistently associated with lower rates of intrapartum interventions and improved birth outcomes and patient satisfaction. Integration of CNM/CM care remains limited across many US health systems due to scope of practice restrictions and institutional policies. Growing, diversifying, and integrating CNM/CM care offers a critical pathway to advancing health care quality, equity, and efficiency in the United States and addressing the alarming rise in adverse perinatal and sexual and reproductive health outcomes.</p><p><strong>Context: </strong>The alarming rise in US maternal mortality and disparities in perinatal, sexual, and reproductive health outcomes underscores the urgent need for effective, equitable, and evidence-based models of care. Care provided by certified nurse-midwives (CNMs) and certified midwives (CMs) has played a critical role in addressing these disparities, yet a comprehensive synthesis of its impact across health care quality domains is lacking.</p><p><strong>Methods: </strong>A scoping review methodology following PRISMA-ScR guidelines was used to assess the association of CNM/CM care and perinatal, sexual, and reproductive health outcomes through the lens of the Institute of Medicine's six domains of health care quality: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. This review included United States-based studies published since 2012 identified via PubMed and CINAHL. Studies were screened for relevance to the six domains and CNM/CM care. Data were extracted into a spreadsheet, grouped by domains, and analyzed using narrative synthesis.</p><p><strong>Findings: </strong>A total of 66 studies met inclusion criteria. Within the safety, effectiveness, and patient-centeredness domains, CNM/CM care was associated with similar or improved perinatal, sexual, and reproductive health outcomes compared to physician care, including lower rates of cesarean birth, fewer interventions, improved neonatal outcomes, greater patient satisfaction, and reduced health care costs. CNM/CM care also demonstrated potential in mitigating racial and geographic maternal health disparities, though scope of practice restrictions and institutional policies limited CNM/CM integration. Despite this evidence, gaps remain in understanding the influence of CNM/CM care on health care quality as it relates to efficiency, timeliness, and equity.</p><p><strong>Conclusions: </strong>These findings highlight the importance of expanding CNM/CM integration within the United States' health care system to improve care delivery and associated health outcomes, reduce health disparities, and advance health equity. Future studies should incorporate standardized outcome measures a","PeriodicalId":49810,"journal":{"name":"Milbank Quarterly","volume":" ","pages":"220-291"},"PeriodicalIF":4.1,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13139960/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147366922","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Regulating Direct-to-Consumer Prescription Drug Advertising in the United States.","authors":"Jennifer L Pomeranz, Erika Hanson, Dariush Mozaffarian","doi":"10.1111/1468-0009.70071","DOIUrl":"10.1111/1468-0009.70071","url":null,"abstract":"<p><p>Policy Points The United States is an outlier in its permissive regulatory landscape for direct-to-consumer (DTC) advertising of prescription drugs. The First Amendment is a barrier to banning DTC prescription drug promotion, but it is not a barrier to addressing false, deceptive, or unfair advertising, which may include forms of influencer and social media promotion. The learned intermediary doctrine shields drug manufacturers from liability in most states, even when they engage in pervasive DTC advertising that leads to consumer misunderstanding. State courts and legislatures should reconsider this doctrine to ensure that consumers are adequately protected. The US Food and Drug Administration needs increased resources and additional authority over the promotion of compounded drugs.</p><p><strong>Context: </strong>The United States is an outlier worldwide in its permissive regulatory landscape for direct-to-consumer (DTC) prescription drug promotion. Recent proposals to restrict DTC prescription drug advertising raise questions about potential challenges under the First Amendment of the U.S. Constitution which protects commercial speech. Prescription drugs are unique in that they require a healthcare provider (HCP) to prescribe the product; the HCP serves as a \"learned intermediary\" between the pharmaceutical company and the consumer of the product. Under the learned intermediary doctrine, pharmaceutical companies satisfy their duty to warn consumers about drug risks by warning HCPs, and are thereby shielded from tort liability even if consumers rely on their advertisements and are harmed.</p><p><strong>Methods: </strong>Using government websites and Lexis+, we researched statutes, regulations and case law related to the First Amendment's protection of commercial speech, the statutory and regulatory framework for DTC prescription and compounded drug promotion, and the learned intermediary doctrine.</p><p><strong>Findings: </strong>The Food and Drug Administration (FDA) oversees DTC prescription drug promotion but lacks comparable authority over compounded drug promotion. Certain forms of DTC advertising may be particularly misleading and warrant increased FDA oversight. Although commercial speech is broadly protected under the First Amendment, false, deceptive and misleading commercial speech can be regulated or restricted. FDA issued guidance to industry for traditional media promotion, but lacks guidance on social media, online telehealth, and influencer-generated content. The learned intermediary doctrine was created by state courts before the advent of DTC advertising and now provides perverse incentives to companies to aggressively market their drugs without consequence.</p><p><strong>Conclusions: </strong>Congress should provide FDA with equal authority over compounded drug promotion as it has for prescription drug promotion. FDA should issue regulations or guidance on modern forms of DTC advertising. The learned intermediary is base","PeriodicalId":49810,"journal":{"name":"Milbank Quarterly","volume":" ","pages":"13-47"},"PeriodicalIF":4.1,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13042421/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146182970","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Multidimensional Approaches to Ranking State-Level Rurality to Enhance Comparisons Across States.","authors":"Daniel Baslock, Nari Yoo","doi":"10.1111/1468-0009.70067","DOIUrl":"10.1111/1468-0009.70067","url":null,"abstract":"<p><p>Policy Points Single indicators such as rural population percentage can misrepresent a state's rural character, leading to flawed policy comparisons and resource allocation. This study introduces a multidimensional rurality index that combines population share, land area, and population density to create a more comprehensive ranking of US states. Policymakers and researchers can use this index to better identify and compare states with similar rural profiles (e.g., Mountain West vs. Northeast), enabling more targeted and effective rural health policies and research.</p><p><strong>Context: </strong>Inadequate descriptions of rurality limit comparisons across rural areas and can lead to overgeneralizations in health policy research. Single indicators of state-level rurality, such as rural population percentage or population density, are often used in isolation and fail to capture the multidimensional nature of rural character, obscuring important differences among states. A more holistic measure is needed to inform research on health care access, quality, and health disparities.</p><p><strong>Methods: </strong>This study developed a composite state-level rurality index for the 50 US states for three indicators: rural population percentage, rural land area percentage, and rural population density. We used Borda count and dominance count ranking methods to integrate these indicators into a final ranking. Principal component analysis (PCA) was then used to visualize the data and identify states with similar profiles.</p><p><strong>Findings: </strong>Mountain West states, including Alaska, Montana, and Wyoming, ranked highest in multidimensional rurality. States traditionally considered highly rural based on a single indicator, such as Vermont and Maine (owing to high rural population share), exhibited rural profiles more similar to states such as Mississippi and Arkansas. The PCA visually distinguished between states with land-based rurality (e.g., vast, sparsely populated areas) and those with population-based rurality (e.g., high proportion of residents in rural towns).</p><p><strong>Conclusions: </strong>This multidimensional index provides a tool for health policy research, facilitating more targeted and meaningful comparisons among rural states. It can help guide the study of health care infrastructure, workforce challenges, and health equity by moving beyond less nuanced classifications and highlighting the diverse forms of rurality across the United States.</p>","PeriodicalId":49810,"journal":{"name":"Milbank Quarterly","volume":" ","pages":"136-152"},"PeriodicalIF":4.1,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13042425/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145828898","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Preemption and Generational Health Equity: The Role of Forced Inaction in Shaping Outcomes.","authors":"Margaret H Swenson, Lauren D Boczkowski, Brad Riley, K Noelle Broughton, Christopher J Koliba","doi":"10.1111/1468-0009.70078","DOIUrl":"https://doi.org/10.1111/1468-0009.70078","url":null,"abstract":"&lt;p&gt;&lt;p&gt;Policy Points When shaping policies on the upstream determinants of health, such as economic and housing policies, state lawmakers should evaluate the potential consequences of state preemption-i.e., restricting policymaking among other levels of government. State preemption is associated with higher rates of childhood poverty among Black residents and White residents as well as low birthweight among Black residents. For both outcomes, the associations are stronger among Black residents. When deliberating on preemptive policies, state decision-makers should consider whether these policies are likely to exacerbate racial disparities, thereby indicating the need to develop policy alternatives.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Context: &lt;/strong&gt;Racial disparities-unequal outcomes between racial groups-persist in the United States, particularly with respect to health and economic outcomes. There has been increased focus on the ways in which upstream determinants of health contribute to these disparities; however, little is known about how forced inaction on these upstream determinants affects health and economic outcomes. The prevalence of state preemption-when state lawmakers restrict policy actions among local decision-makers-is increasing. Therefore, it is essential to understand how restricting local policymaking affects racial disparities in health and economic outcomes.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;This study examines the associations of state preemption with childhood poverty levels and low birthweight. The data for low birthweight were collected from 1,377 counties, and the data for childhood poverty were collected from 1,607 counties. We used ordinary least squares regression and spatial regression to analyze racial disparities in these two outcomes. Furthermore, we used seemingly unrelated estimation to determine whether the effects of state preemption differed significantly between Black and White models for each outcome.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Findings: &lt;/strong&gt;The results indicated that state preemption is significantly associated with higher rates of low birthweight among Black residents. Specifically, each additional preemptive policy was associated with a .5 percentage-point increase in the low birthweight rate among Black residents. State preemption was also 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. Additional testing of childhood poverty models confirms that the association was stronger in the Black model than the White model.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;This study reveals 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, state poli","PeriodicalId":49810,"journal":{"name":"Milbank Quarterly","volume":" ","pages":""},"PeriodicalIF":4.1,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147321977","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The 2021 Child Tax Credit and Children's Health and Well-Being: Evidence From a National Longitudinal Study.","authors":"Guangyi Wang, Daniel F Collin, Deborah Karasek, Rita Hamad","doi":"10.1111/1468-0009.70064","DOIUrl":"10.1111/1468-0009.70064","url":null,"abstract":"<p><p>Policy Points Evidence suggests the 2021 temporary Child Tax Credit expansion reduced material hardship and improved parental mental health, but less is known about its effects on child well-being. Compared with the preexpansion period, advanced monthly payments were associated with short-term improvements in child behavioral health. However, these gains did not persist after payments ended, even with the lump-sum payment, likely reflecting stress and hardship tied to the policy's temporary nature, especially among lower-income and Black children. Policymakers may need to consider program design features, such as more frequent distribution of unconditional cash benefits, to better support child well-being.</p><p><strong>Context: </strong>In July 2021, to alleviate material hardship, Congress temporarily expanded the Child Tax Credit (CTC), one of the largest income transfer programs in the United States. Prior research has linked the expansion to improvements in material hardship, food insecurity, and parental mental health. This study is among the first to examine its association with child well-being.</p><p><strong>Methods: </strong>We analyzed data from 1,028 children in the 2020-2021 waves of the Child Development Supplement of the Panel Study of Income Dynamics, a national longitudinal data set. CTC exposure was defined based on benefit size calculated using eligibility rules. Outcomes included caregiver/self-rated child health, behavioral problems, and food security. We used individual fixed-effects models to estimate within-person changes in outcomes, comparing pre- and postexpansion periods while adjusting for time-invariant confounders. The 2021 PSID wave (November 2021-June 2022) included three CTC phases: 1) advanced monthly payments (November-December 2021), 2) expired monthly payments (January-April 2022), and 3) following the distribution of remaining lump sum (May-June 2022). Analyses were stratified by these phases to capture potential disparate impacts. We also conducted subgroup analyses by income and race/ethnicity.</p><p><strong>Findings: </strong>During the monthly payment period, a $1,000 increase in CTC was associated with a 0.69-point reduction of behavioral problems in the overall sample (95% confidence interval [CI]: -1.31 to -0.067), corresponding to a 10% reduction from baseline. No associations were observed after monthly payments expired. Following the distribution of the lump sum, lower-income children had worse caregiver/self-rated health (-0.075, 95% CI: -0.14 to -0.010) and increased behavioral problems (0.95, 95% CI: 0.45-1.45) compared with higher-income children. Differences by race/ethnicity were also observed.</p><p><strong>Conclusions: </strong>More frequent distribution of unconditional cash benefits may improve child behavioral health. These findings inform ongoing state and federal poverty policymaking and contribute to theoretical knowledge on income and child health.</p>","PeriodicalId":49810,"journal":{"name":"Milbank Quarterly","volume":" ","pages":"116-135"},"PeriodicalIF":4.1,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13042757/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145716432","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"From Tobacco to Ultraprocessed Food: How Industry Engineering Fuels the Epidemic of Preventable Disease.","authors":"Ashley N Gearhardt, Kelly D Brownell, Allan M Brandt","doi":"10.1111/1468-0009.70066","DOIUrl":"10.1111/1468-0009.70066","url":null,"abstract":"<p><p>Policy Points Ultraprocessed foods (UPFs) are engineered to heighten reward and accelerate delivery of reinforcing ingredients, driving compulsive consumption and disrupting appetite regulation. This is a growing challenge for health policy. UPFs share key engineering strategies adopted from the tobacco industry, such as dose optimization and hedonic manipulation. These parallels should inform how we classify and regulate UPFs. Policy tools that helped reduce tobacco-related harm, including restrictions on child-targeted marketing, taxes, improved labeling, limits on availability in schools and hospitals, and litigation, should be adapted to address the public-health threat posed by UPFs.</p><p><strong>Context: </strong>Ultraprocessed foods (UPFs) now dominate the global food supply and are strongly associated with risks for heart disease, cancers, metabolic disease, diabetes, and obesity. UPFs are likely associated with rates of neurologic issues such as dementia and Parkinson's disease and predict premature death. Drawing on the history of tobacco regulation, we examine how the design, marketing, and distribution of UPFs mirror those of industrial tobacco products. Such information speaks to the sophistication and aims of food product manipulation and its consequences.</p><p><strong>Methods: </strong>This review synthesizes findings from addiction science, nutrition, and public health history to identify structural and sensory features that increase the reinforcing potential of both cigarettes and UPFs. We focus on five key areas: dose optimization, delivery speed, hedonic engineering, environmental ubiquity, and deceptive reformulation.</p><p><strong>Findings: </strong>Cigarettes and UPFs are not simply natural products but highly engineered delivery systems designed specifically to maximize biological and psychological reinforcement and habitual overuse. Both industries have used similar strategies to increase product appeal, evade regulation, and shape public perception, including adding sensory additives, accelerating reward delivery, expanding contextual access, and deploying health-washing claims. These design features collectively hijack human biology, undermine individual agency, and contribute heavily to disease and health care costs.</p><p><strong>Conclusions: </strong>UPFs should be evaluated not only through a nutritional lens but also as addictive, industrially engineered substances. Lessons from tobacco regulation, including litigation, marketing restrictions, and structural interventions, offer a roadmap for reducing UPF-related harm. Public health efforts must shift from individual responsibility to food industry accountability, recognizing UPFs as potent drivers of preventable disease.</p>","PeriodicalId":49810,"journal":{"name":"Milbank Quarterly","volume":" ","pages":"76-115"},"PeriodicalIF":4.1,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13042894/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146108154","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Coming to Terms With MAHA.","authors":"Alan B Cohen","doi":"10.1111/1468-0009.70081","DOIUrl":"10.1111/1468-0009.70081","url":null,"abstract":"","PeriodicalId":49810,"journal":{"name":"Milbank Quarterly","volume":" ","pages":"5-12"},"PeriodicalIF":4.1,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13097477/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147445845","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Health and the Right to Universal Basic Neighborhoods.","authors":"Michael O Emerson, Lauren Anderson, Jecorey Arthur, Nancy Seay, Ted Smith","doi":"10.1111/1468-0009.70070","DOIUrl":"10.1111/1468-0009.70070","url":null,"abstract":"<p><p>Policy Points Health disparities are a symptom of population-level problems, and interventions to improve health equity should be at the neighborhood level. We argue that the most effective and pragmatic prescription for improving population health is what we call Universal Basic Neighborhoods (UBN). We offer a Model Legislation Template, which can help citizens and cities raise to legal status the right of neighborhoods to be UBN. Attaining UBN status can transform neighborhoods into healthier, more equitable, vibrant communities.</p><p><strong>Context: </strong>The United States lags far behind other comparable nations on health indicators. To promote population health in cities, we argue for the right to Universal Basic Neighborhoods (UBN).</p><p><strong>Methods: </strong>We define UBN as \"the minimally acceptable mix of neighborhood health assets for residents to flourish in quality and length of life.\" This article explores the foundational needs for such a concept and creates a specific set of domains, factors, and metrics for assessing UBN status. We apply this concept and its measurement to two neighborhoods in Louisville, Kentucky, assessing both health assets and liabilities. In doing so, we locate pathways for interventions.</p><p><strong>Findings: </strong>We found that the Crescent Hill neighborhood can be considered a UBN. The Russell neighborhood's extensive set of liabilities overwhelms its assets when we consider health outcomes.</p><p><strong>Conclusions: </strong>If we want to create UBN, we need a means. We thus outline a model legislation template for ensuring the right to UBN and improving urban neighborhood health.</p>","PeriodicalId":49810,"journal":{"name":"Milbank Quarterly","volume":" ","pages":"171-197"},"PeriodicalIF":4.1,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13042788/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146203582","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"How Health Departments Can Use Inside-Outside Strategies to Build Partnerships With Community Power-Building Organizations to Achieve Structural Change.","authors":"Anthony B Iton, Pritpal S Tamber, Gina Massuda Barnett, Rachel Rubin, Adam Kader, Christina R Welter, Elizabeth Fisher, Jennifer Ybarra, Pamela Agustin-Anguiano, Greg Bonett, Jeanne Ayers, Meredith Minkler","doi":"10.1111/1468-0009.70068","DOIUrl":"10.1111/1468-0009.70068","url":null,"abstract":"<p><p>Policy Points Changing structures, such as laws, policies, regulations, practices, and norms, in pursuit of health and racial equity is hard for any organization to do alone, including health departments. Health departments can advance health and racial equity by partnering with movements for fairer and more just social arrangements that often emanate from civil society through the work of community power-building organizations. This requires health departments to adopt an inside-outside strategy, which consists of practices needed internally to effectively participate in movements and practices needed externally to become allied in them.</p><p><strong>Context: </strong>Disparities in health often arise due to unfair or unjust social arrangements making them inequities. These social arrangements are codified through structures-laws, policies, regulations, practices, and norms. Changing structures is generally considered the work of professional entities, such as health departments. However, inequities persist, which suggests new, more focused approaches are needed.</p><p><strong>Methods: </strong>Health departments are not alone in pursuing fairer and more just social arrangements. There are also movements for social justice, which emanate from community power-building organizations (CPBOs). CPBOs benefit from being in relationship with organizations that know how to change structures, such as health departments.</p><p><strong>Findings: </strong>For health departments to be in relationship with CBPOs and movements requires them to adopt an inside-outside strategy. Inside refers to the work needed to be done internally to effectively participate in movements. Outside refers to the work needed to be done externally to become allied in them. We describe two such strategies, one from California and one from Illinois.</p><p><strong>Conclusions: </strong>Our examples illustrate how public health's careful participation in movements can advance health equity. Health departments need to think of themselves as part of an ecosystem of organizations pursuing fairer and more just social arrangements.</p>","PeriodicalId":49810,"journal":{"name":"Milbank Quarterly","volume":" ","pages":"58-75"},"PeriodicalIF":4.1,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13042465/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146259880","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Medicaid Work Requirements: Engaging Clinics and Pharmacies to Prevent Disenrollment.","authors":"T Joseph Mattingly, Madeline O'Neal","doi":"10.1111/1468-0009.70065","DOIUrl":"10.1111/1468-0009.70065","url":null,"abstract":"<p><p>Policy Points The One Big Beautiful Bill Act introduces the first nationwide Medicaid work requirement, replacing state-level variation with a uniform federal standard. Past state experiences show that poor reporting design drives most procedural disenrollments-highlighting the need for accessible, integrated verification systems. Leveraging primary care clinics and community pharmacies for work verification, supported by sustainable reimbursement models, could preserve coverage for eligible beneficiaries while meeting program integrity goals.</p><p><strong>Background/policy context: </strong>The One Big Beautiful Bill Act, enacted on July 4, 2025, established the first nationwide Medicaid work requirement, replacing prior state-specific Section 1115 demonstrations with a uniform federal standard. Historical evidence from welfare programs and Medicaid pilots, particularly in Arkansas, suggests that while work or community engagement requirements may have moderate public support, poorly designed reporting systems and administrative barriers can lead to substantial procedural disenrollment without measurable employment gains.</p><p><strong>Policy proposal: </strong>This perspective outlines a framework for leveraging high-touch health care settings-primary care clinics and community pharmacies-to facilitate verification of work or community engagement hours. These sites already maintain frequent contact with Medicaid beneficiaries, have established billing relationships with Medicaid, and can provide physical access points that mitigate digital-access disparities. Policy options for provider compensation include fee-for-service payments per verification or capitated per-member-per-month arrangements.</p><p><strong>Policy implications: </strong>By integrating verification into trusted, accessible care settings, states can reduce administrative burden, preserve coverage for eligible beneficiaries, and align One Big Beautiful Bill Act's implementation with program integrity goals.</p>","PeriodicalId":49810,"journal":{"name":"Milbank Quarterly","volume":" ","pages":"48-57"},"PeriodicalIF":4.1,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13042914/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146208442","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}