Milbank Quarterly最新文献

{"title":"Moving Toward Inclusion: Access to Care Models for Uninsured Immigrant Children.","authors":"Katelyn Girtain, Sural Shah, Ana C Monterrey, J Raul Gutierrez, Mark Kuczewski, Julie M Linton","doi":"10.1111/1468-0009.12665","DOIUrl":"10.1111/1468-0009.12665","url":null,"abstract":"<p><p>Policy Points Models for access to care for uninsured immigrant children that mitigate structural and sociopolitical barriers to inclusive health care include funding structures (e.g., state-sponsored coverage) and care delivery systems (e.g., federally qualified health centers,). Although the quintessential model of access to care necessitates health coverage for all children regardless of immigration status or date of United States entry, incremental policy change may more realistically and efficiently advance equitable access to high-quality health care. Intentional advocacy efforts should prioritize achievable goals that are grounded in data, are attentive to the sociopolitical milieu, are inclusive of diverse perspectives, and would meaningfully impact health care access and outcomes.</p>","PeriodicalId":49810,"journal":{"name":"Milbank Quarterly","volume":" ","pages":"1009-1032"},"PeriodicalIF":4.8,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10726766/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9878702","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":"The Role of Place in Person- and Family-Oriented Long-Term Services and Supports.","authors":"Chanee D Fabius, Safiyyah M Okoye, Mingche M J Wu, Andrew D Jopson, Linda C Chyr, Julia G Burgdorf, Jeromie Ballreich, Danny Scerpella, Jennifer L Wolff","doi":"10.1111/1468-0009.12664","DOIUrl":"10.1111/1468-0009.12664","url":null,"abstract":"&lt;p&gt;&lt;p&gt;Policy Points Little attention to date has been directed at examining how the long-term services and supports (LTSS) environmental context affects the health and well-being of older adults with disabilities. We develop a conceptual framework identifying environmental domains that contribute to LTSS use, care quality, and care experiences. We find the LTSS environment is highly associated with person-reported care experiences, but the direction of the relationship varies by domain; increased neighborhood social and economic deprivation are highly associated with experiencing adverse consequences due to unmet need, whereas availability and generosity of the health care and social services delivery environment are inversely associated with participation restrictions in valued activities. Policies targeting local and state-level LTSS-relevant environmental characteristics stand to improve the health and well-being of older adults with disabilities, particularly as it relates to adverse consequences due to unmet need and participation restrictions.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Context: &lt;/strong&gt;Long-term services and supports (LTSS) in the United States are characterized by their patchwork and unequal nature. The lack of generalizable person-reported information on LTSS care experiences connected to place of community residence has obscured our understanding of inequities and factors that may attenuate them.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;We advance a conceptual framework of LTSS-relevant environmental domains, drawing on newly available data linkages from the 2015 National Health and Aging Trends Study to connect person-reported care experiences with public use spatial data. We assess relationships between LTSS-relevant environmental characteristic domains and person-reported care adverse consequences due to unmet need, participation restrictions, and subjective well-being for 2,411 older adults with disabilities and for key population subgroups by race, dementia, and Medicaid enrollment status.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Findings: &lt;/strong&gt;We find the LTSS environment is highly associated with person-reported care experiences, but the direction of the relationship varies by domain. Measures of neighborhood social and economic deprivation (e.g., poverty, public assistance, social cohesion) are highly associated with experiencing adverse consequences due to unmet care needs. Measures of the health care and social services delivery environment (e.g., Medicaid Home and Community-Based Service Generosity, managed LTSS [MLTSS] presence, average direct care worker wage, availability of paid family leave) are inversely associated with experiencing participation restrictions in valued activities. Select measures of the built and natural environment (e.g., housing affordability) are associated with participation restrictions and lower subjective well-being. Observed relationships between measures of LTSS-relevant environmental characteristics and care experiences were generally h","PeriodicalId":49810,"journal":{"name":"Milbank Quarterly","volume":" ","pages":"1076-1138"},"PeriodicalIF":4.8,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10726875/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9938235","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":"Community Health Center Staff Perspectives on Financial Payments for Social Care.","authors":"Justin M Lopez, Holly Wing, Sara L Ackerman, Danielle Hessler, Laura M Gottlieb","doi":"10.1111/1468-0009.12667","DOIUrl":"10.1111/1468-0009.12667","url":null,"abstract":"<p><p>Policy Points State and federal payers are actively considering strategies to increase the adoption of social risk screening and interventions in health care settings, including through the use of financial incentives. Activities related to social care in Oregon community health centers (CHCs) provided a unique opportunity to explore whether and how fee-for-service payments for social risk screening and navigation influence CHC activities. CHC staff, clinicians, and administrative leaders were often unaware of existing financial payments for social risk screening and navigation services. As currently designed, fee-for-service payments are unlikely to strongly influence CHC social care practices.</p><p><strong>Context: </strong>A growing crop of national policies has emerged to encourage health care delivery systems to ask about and try to address patients' social risks, e.g., food, housing, and transportation insecurity, in care delivery contexts. In this study, we explored how community health center (CHC) staff perceive the current and potential influence of fee-for-service payments on clinical teams' engagement in these activities.</p><p><strong>Methods: </strong>We interviewed 42 clinicians, frontline staff, and administrative leaders from 12 Oregon CHC clinical sites about their social care initiatives, including about the role of existing or anticipated financial payments intended to promote social risk screening and referrals to social services. Data were analyzed using both inductive and deductive thematic analysis approaches.</p><p><strong>Findings: </strong>We grouped findings into three categories: participants' awareness of existing or anticipated financial incentives, uses for incentive dollars, and perceived impact of financial incentives on social care activities in clinical practices. Lack of awareness of existing incentives meant these incentives were not perceived to influence the behaviors of staff responsible for conducting screening and providing referrals. Current or anticipated meaningful uses for incentive dollars included paying for social care staff, providing social services, and supporting additional fundraising efforts. Frontline staff reported that the strongest motivator for clinic social care practices was the ability to provide responsive social services. Clinic leaders/managers noted that for financial incentives to substantively change CHC practices would require payments sizable enough to expand the social care workforce as well.</p><p><strong>Conclusions: </strong>Small fee-for-service payments to CHCs for social risk screening and navigation services are unlikely to markedly influence CHC social care practices. Refining the design of financial incentives-e.g., by increasing clinical teams' awareness of incentives, linking screening to well-funded social services, and changing incentive amounts to support social care staffing needs-may increase the uptake of social care practices in CHCs.</p>","PeriodicalId":49810,"journal":{"name":"Milbank Quarterly","volume":" ","pages":"1304-1326"},"PeriodicalIF":4.8,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10726824/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10019189","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":"Dual Barriers: Examining Digital Access and Travel Burdens to Hospital Maternity Care Access in the United States, 2020.","authors":"Peiyin Hung, Marion Granger, Nansi Boghossian, Jiani Yu, Sayward Harrison, Jihong Liu, Berry A Campbell, B O Cai, Chen Liang, Xiaoming Li","doi":"10.1111/1468-0009.12668","DOIUrl":"10.1111/1468-0009.12668","url":null,"abstract":"&lt;p&gt;&lt;p&gt;Policy Points The White House Blueprint for Addressing the Maternal Health Crisis report released in June 2022 highlighted the need to enhance equitable access to maternity care. Nationwide hospital maternity unit closures have worsened the maternal health crisis in underserved communities, leaving many birthing people with few options and with long travel times to reach essential care. Ensuring equitable access to maternity care requires addressing travel burdens to care and inadequate digital access. Our findings reveal socioeconomically disadvantaged communities in the United States face dual barriers to maternity care access, as communities located farthest away from care facilities had the least digital access.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Context: &lt;/strong&gt;With the increases in nationwide hospital maternity unit closures, there is a greater need for telehealth services for the supervision, evaluation, and management of prenatal and postpartum care. However, challenges in digital access persist. We examined associations between driving time to hospital maternity units and digital access to understand whether augmenting digital access and telehealth services might help mitigate travel burdens to maternity care.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;This cross-sectional study used 2020 American Hospital Association Annual Survey data for hospital maternity unit locations and 2020 American Community Survey five-year ZIP Code Tabulation Area (ZCTA)-level estimates of household digital access to telecommunication technology and broadband. We calculated driving times of the fastest route from population-weighted ZCTA centroids to the nearest hospital maternity unit. Rural-urban stratified generalized median regression models were conducted to examine differences in ZCTA-level proportions of household lacking digital access equipment (any digital device, smartphones, tablet), and lacking broadband subscriptions by spatial accessibility to maternity units.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Findings: &lt;/strong&gt;In 2020, 2,905 (16.6%) urban and 3,394 (39.5%) rural ZCTAs in the United States were located &gt;30 minutes from the nearest hospital maternity units. Regardless of rurality, these communities farther away from a maternity unit had disproportionally lower broadband and device accessibility. Although urban communities have greater digital access to technology and broadband subscriptions compared to rural communities, disparities in the percentage of households with access to digital devices were more pronounced within urban areas, particularly between those with and without close proximity to a hospital maternity unit. Communities where nearest hospital maternity units were &gt;30 minutes away had higher poverty and uninsurance rates than those with &lt;15-minute access.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;Socioeconomically disadvantaged communities face significant barriers to maternity care access, both with substantial travel burdens and inadequate digital access. To optimize maternity ","PeriodicalId":49810,"journal":{"name":"Milbank Quarterly","volume":" ","pages":"1327-1347"},"PeriodicalIF":4.8,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10726888/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10415514","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":"Unrealized Cross-System Opportunities to Improve Employment and Employment-Related Services Among Autistic Individuals.","authors":"Anne M Roux, Kaitlin K Miller, Sha Tao, Jessica E Rast, Jonas Ventimiglia, Paul T Shattuck, Lindsay L Shea","doi":"10.1111/1468-0009.12666","DOIUrl":"10.1111/1468-0009.12666","url":null,"abstract":"&lt;p&gt;&lt;p&gt;Policy Points Employment is a key social determinant of health and well-being for the estimated 5.4 million autistic adults in the United States-just as it is for citizens without disabilities. Evaluation and monitoring of publicly funded employment services is paramount given the dramatic increases in adults with autism who need job supports. Vocational Rehabilitation agencies appeared to be absorbing short-term employment needs of autistic people, but Medicaid was severely lacking-and losing ground-in serving those who need longer-term employment services. Across both Vocational Rehabilitation and Medicaid, we estimated that only 1.1% of working-age autistic adults who potentially need employment services are actually receiving them-leaving an estimated 1.98 million autistic individuals without the employment services that are associated with achievement of well-being.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Context: &lt;/strong&gt;Employment is a key social determinant of health. As such, high rates of unemployment, underemployment, and poverty across the rapidly growing autistic population are concerning. A web of publicly funded services exists to support the employment, and associated health and well-being, of United States citizens with autism and other intellectual and developmental disabilities, namely through Vocational Rehabilitation (VR) and Medicaid home- and community-based services (HCBS) waivers. Given an absence of overarching surveillance of employment services, this study aimed to characterize the distribution of autistic service users across Medicaid versus VR, understand the types of employment services utilized within these programs and expenditures, and assess overall capacity to provide employment services as needs continue to increase.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;This study examined the distribution of employment services among autistic people compared with those with intellectual disability using 2008-2016 data from the Centers for Medicare & Medicaid Services and the Rehabilitation Services Administration. Estimated need for employment services among autistic individuals was compared with capacity derived from VR service counts and a review of HCBS waivers.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Findings: &lt;/strong&gt;The number of autistic people served through VR tripled during the study years, whereas those served through Medicaid only increased slightly. VR spending increased by 384% over the study years, whereas Medicaid costs decreased by 29%. Across VR and Medicaid, we estimated that only 1.1% of working-age autistic adults who needed employment services received them.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;Although VR appeared to be absorbing short-term employment needs of autistic individuals, Medicaid was severely lacking-and losing ground-in serving those who needed longer-term employment services. VR far outpaced Medicaid in both the number of autistic people served and total expenditures across the study years. However, an estimated 1.98 million autistic adult","PeriodicalId":49810,"journal":{"name":"Milbank Quarterly","volume":" ","pages":"1223-1279"},"PeriodicalIF":4.8,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10726849/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9879637","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":"Trade-Related Aspects of Intellectual Property Rights Flexibilities and Public Health: Implementation of Compulsory Licensing Provisions into National Patent Legislation.","authors":"Lauren McGIVERN","doi":"10.1111/1468-0009.12669","DOIUrl":"10.1111/1468-0009.12669","url":null,"abstract":"<p><p>Policy Points Given the challenges associated with negotiating the COVID-19 Trade-Related Aspects of Intellectual Property Rights (TRIPS) Waiver, there are questions as to whether the World Trade Organization is able to effectively address pandemics and global crises under the current architecture. Although the framework set out by the TRIPS Agreement does not view intellectual property (IP) rights as a means to foster public health and development, IP rights should nonetheless be interpreted through a public health lens. Countries should implement compulsory licensing provisions into their patent legislation, which increase access to medicines and allow governments (especially in developing and least-developed countries) to better protect public health.</p><p><strong>Context: </strong>The protection of intellectual property (IP) rights, given international legal effect through the World Trade Organization (WTO) Trade-Related Aspects of IP Rights (TRIPS) Agreement, has long been a contentious issue. In recent years, the long-standing debate on IP rights as a barrier to the access of affordable medicines has been heightened by the global vaccine inequity evidenced during the COVID-19 pandemic. The TRIPS Agreement contains a number of flexibilities that WTO members can exploit in order to accommodate their policy needs. Among these is the mechanism of compulsory licensing, whereby patent licenses may be granted without consent of the patent holder in certain circumstances. TRIPS Article 31bis created a special mechanism for compulsory licenses specifically for the export of pharmaceutical products to countries with insufficient manufacturing capacity.</p><p><strong>Methods: </strong>We analyzed domestic patent legislation for 195 countries (193 UN members and two observers) and three customs territories. We analyzed patent legislation for provisions on compulsory licenses, including those defined in Article 31bis of the TRIPS Agreement.</p><p><strong>Findings: </strong>We identified 11 countries with no patent legislation. Of the 187 countries with domestic or regional patent laws, 176 (94.1%) had provisions on compulsory licensing and 72 (38.5%) had provisions implementing TRIPS Article 31bis.</p><p><strong>Conclusions: </strong>The results of this study have highlighted the gap in the implementation of TRIPS flexibilities in countries' national patent legislation, especially in least-developed countries. Although it will not fully solve patent barriers to the access of medicines, implementation of compulsory licensing (and specifically those for the import and export of pharmaceutical products) will provide governments with another tool to safeguard their population's public health. Further discussions are needed to determine whether the WTO can provide effective responses to future pandemics or global crises.</p>","PeriodicalId":49810,"journal":{"name":"Milbank Quarterly","volume":" ","pages":"1280-1303"},"PeriodicalIF":4.8,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10726804/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10468767","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":"Advancing Dialogue About Consent and Molecular HIV Surveillance in the United States: Four Proposals Following a Federal Advisory Panel's Call for Major Reforms.","authors":"Stephen Molldrem, Anthony K J Smith, Alexander McCLELLAND","doi":"10.1111/1468-0009.12663","DOIUrl":"10.1111/1468-0009.12663","url":null,"abstract":"<p><p>Policy Points Molecular HIV surveillance and cluster detection and response (MHS/CDR) programs have been a core public health activity in the United States since 2018 and are the \"fourth pillar\" of the Ending the HIV Epidemic initiative launched in 2019. MHS/CDR has caused controversy, including calls for a moratorium from networks of people living with HIV. In October 2022, the Presidential Advisory Council on HIV/AIDS (PACHA) adopted a resolution calling for major reforms. We analyze the policy landscape and present four proposals to federal stakeholders pertaining to PACHA's recommendations about incorporating opt-outs and plain-language notifications into MHS/CDR programs.</p>","PeriodicalId":49810,"journal":{"name":"Milbank Quarterly","volume":" ","pages":"1033-1046"},"PeriodicalIF":4.8,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10726778/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9693284","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":"Improving Food and Drug Administration-Centers for Medicare and Medicaid Services Coordination for Drugs Granted Accelerated Approval.","authors":"Peter J Neumann, Elliott Crummer, James D Chambers, Sean R Tunis","doi":"10.1111/1468-0009.12670","DOIUrl":"10.1111/1468-0009.12670","url":null,"abstract":"&lt;p&gt;&lt;p&gt;Policy Points The increasing number of drugs granted accelerated approval by the Food and Drug Administration (FDA) has challenged the Medicare program, which often pays for expensive therapies despite substantial uncertainty about benefits and risks to Medicare beneficiaries. We recommend several administrative and legislative approaches for improving FDA-Centers for Medicare and Medicaid Services (CMS) coordination around accelerated-approval drugs, including promoting earlier discussions among the FDA, the CMS, and drug companies; strengthening Medicare's coverage with evidence development program; linking Medicare payment to evidence generation milestones; and ensuring that the CMS has adequate staffing and resources to evaluate new therapies. These activities can help improve the integrity; transparency; and efficiency of approval, coverage, and payment processes for drugs granted accelerated approval.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Context: &lt;/strong&gt;The Food and Drug Administration (FDA)'s accelerated-approval pathway expedites patient access to promising treatments. However, increasing use of this pathway has challenged the Medicare program, which often pays for expensive therapies despite substantial uncertainty about benefits and risks to Medicare beneficiaries. We examined approaches to improve coordination between the FDA and Centers for Medicare and Medicaid Services (CMS) for drugs granted accelerated approval.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;We argue that policymakers have focused on expedited pathways at the FDA without sufficient attention to complementary policies at the CMS. Although differences between the FDA and CMS decisions are to be expected given the agencies' different missions and statutory obligations, procedural improvements can ensure that Medicare beneficiaries have timely access to novel therapies that are likely to improve health outcomes. To inform policy options and recommendations, we conducted semistructured interviews with stakeholders to capture diverse perspectives on the topic.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Findings: &lt;/strong&gt;We recommend ten areas for consideration: clarifying the FDA's evidentiary standards; strengthening FDA authorities; promoting earlier discussions among the FDA, the CMS, and drug companies; improving Medicare's coverage with evidence development program; tying Medicare payment for accelerated-approval drugs to evidence generation milestones; issuing CMS guidance on real-world evidence; clarifying Medicare's \"reasonable and necessary\" criteria; adopting lessons from international regulatory-reimbursement harmonization efforts; ensuring that the CMS has adequate staffing and expertise; and emphasizing equity.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;Better coordination between the FDA and CMS could improve the transparency and predictability of drug approval and coverage around accelerated-approval drugs, with important implications for patient outcomes, health spending, and evidence generation processes. Improved co","PeriodicalId":49810,"journal":{"name":"Milbank Quarterly","volume":" ","pages":"1047-1075"},"PeriodicalIF":4.8,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10726896/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10167654","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":"Caught Between a Well-Intentioned State and a Hostile Federal System: Local Implementation of Inclusive Immigrant Policies.","authors":"Maria-Elena DE Trinidad Young, Sharon Tafolla, Fabiola M Perez-Lua","doi":"10.1111/1468-0009.12671","DOIUrl":"10.1111/1468-0009.12671","url":null,"abstract":"<p><p>Policy Points Inclusive state immigrant policies that expand rights and resources for immigrants may improve population health, but little is known about their local-level implementation. Local actors that have anti-immigrant attitudes can hinder the implementation of state policies, whereas the persistent influence of anti-immigrant federal policies reinforces barriers to accessing health and other resources granted by state policies. Local actors that serve immigrants and support state policy implementation lack the resources to counter anti-immigrant climates and federal policy threats.</p><p><strong>Context: </strong>In the United States, inclusive state-level policies can advance immigrant health and health care access by extending noncitizens' access to public benefits, workplace rights, and protections from immigration enforcement. Although state policies carry promise as structural population health interventions, there has been little examination of their implementation at the local level. Local jurisdictions play multiple roles in state policy implementation and possess distinct immigration climates. Examining the local implementation of state immigrant policy can address challenges and opportunities to ensure the health benefits of inclusive policies are realized equitably across states' regions.</p><p><strong>Methods: </strong>To examine the local implementation of state immigrant policies, we selected a purposive sample of California counties with large immigrant populations and distinct social and political dynamics and conducted and analyzed in-depth interviews with 20 community-based organizations that provided health, safety net, and other services.</p><p><strong>Findings: </strong>We found that there were tensions between the inclusionary goals of state immigrant policies and local anti-immigrant climates and federal policy changes. First, there were tensions between state policy goals and resistance from local law enforcement agencies and policymakers (e.g., Board of Supervisors). Second, because of the ongoing threats from federal immigration policies, there was a mismatch between the services and resources provided by state policies and local community needs. Finally, organizations that served immigrants were responsible for contributing to policy implementation but lacked resources to meet community needs while countering local resistance and federal policy threats.</p><p><strong>Conclusions: </strong>This study contributes knowledge regarding the challenges that emerge after state immigrant policies are enacted. The tensions among state immigrant policies, local immigration climates, and federal policy changes indicate that state immigrant policies are not implemented equally across state communities, resulting in challenges and limited benefits from policies for many immigrant communities.</p>","PeriodicalId":49810,"journal":{"name":"Milbank Quarterly","volume":" ","pages":"1348-1374"},"PeriodicalIF":4.8,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10726814/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10236094","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":"Building High-Performing Primary Care Systems: After a Decade of Policy Change, Is Canada \"Walking the Talk?\"","authors":"Monica Aggarwal, Brian Hutchison, Reham Abdelhalim, G Ross Baker","doi":"10.1111/1468-0009.12674","DOIUrl":"10.1111/1468-0009.12674","url":null,"abstract":"&lt;p&gt;&lt;p&gt;Policy Points Considerable investments have been made to build high-performing primary care systems in Canada. However, little is known about the extent to which change has occurred over the last decade with implementing programs and policies across all 13 provincial and territorial jurisdictions. There is significant variation in the degree of implementation of structural features of high-performing primary care systems across Canada. This study provides evidence on the state of primary care reform in Canada and offers insights into the opportunities based on changes that governments elsewhere have made to advance primary care transformation.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Context: &lt;/strong&gt;Despite significant investments to transform primary care, Canada lags behind its peers in providing timely access to regular doctors or places of care, timely access to care, developing interprofessional teams, and communication across health care settings. This study examines changes over the last decade (2012 to 2021) in policies across 13 provincial and territorial jurisdictions that address the structural features of high-performing primary care systems.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;A multiple comparative case study approach was used to explore changes in primary care delivery across 13 Canadian jurisdictions. Each case consisted of (1) qualitative interviews with academics, provincial health care leaders, and health care professionals and (2) a literature review of policies and innovations. Data for each case were thematically analyzed within and across cases, using 12 structural features of high-performing primary care systems to describe each case and assess changes over time.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Findings: &lt;/strong&gt;The most significant changes include adopting electronic medical records, investments in quality improvement training and support, and developing interprofessional teams. Progress was more limited in implementing primary care governance mechanisms, system coordination, patient enrollment, and payment models. The rate of change was slowest for patient engagement, leadership development, performance measurement, research capacity, and systematic evaluation of innovation.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;Progress toward building high-performing primary care systems in Canada has been slow and variable, with limited change in the organization and delivery of primary care. Canada's experience can inform innovation internationally by demonstrating how preexisting policy legacies constrain the possibilities for widespread primary care reform, with progress less pronounced in the attributes that impact physician autonomy. To accelerate primary care transformation in Canada and abroad, a national strategy and performance measurement framework is needed based on meaningful engagement of patients and other stakeholders. This must be accompanied by targeted funding investments and building strong data infrastructure for performance measurement to support rigorous","PeriodicalId":49810,"journal":{"name":"Milbank Quarterly","volume":" ","pages":"1139-1190"},"PeriodicalIF":4.8,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10726918/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41160124","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}