Benjamin D Sommers, Rebecca Brooks Smith, Jose F Figueroa
{"title":"Closing Gaps or Holding Steady? The Affordable Care Act, Medicaid Expansion, and Racial Disparities in Coverage, 2010-2021.","authors":"Benjamin D Sommers, Rebecca Brooks Smith, Jose F Figueroa","doi":"10.1215/03616878-11567660","DOIUrl":"10.1215/03616878-11567660","url":null,"abstract":"<p><strong>Context: </strong>Medicaid expansion under the Affordable Care Act (ACA) produced major gains in coverage. However, findings on racial and ethnic disparities are mixed and may depend on how disparities are measured. This study examines absolute and relative changes in uninsurance from 2010 to 2021 by race and ethnicity, stratified by Medicaid expansion status.</p><p><strong>Methods: </strong>The sample included all respondents younger than age 65 (N = 30,339,104) from the American Community Survey, 2010-21. Absolute and relative differences in uninsurance, compared to white Non-Hispanic individuals, were calculated for individuals who were Hispanic; Black; Asian American, Pacific Islander, and Native Hawaiian (AANHPI); American Indian and Alaska Native (AIAN); and multiracial. States were stratified into ever-expanded versus nonexpansion status.</p><p><strong>Findings: </strong>After the ACA, three patterns of coverage disparities emerge. For Hispanic and Black individuals, relative to white individuals, absolute disparities in uninsurance declined, but relative disparities were largely unchanged in both expansion and nonexpansion states. For AANHPI individuals, disparities were eliminated entirely in both expansion and nonexpansion states. For AIAN individuals, disparities declined in absolute terms but grew in relative terms, particularly in expansion states.</p><p><strong>Conclusions: </strong>All groups experienced coverage gains after the ACA, but changes in disparities were heterogeneous. Focused interventions are needed to improve coverage rates for Black, Hispanic, and AIAN individuals.</p>","PeriodicalId":54812,"journal":{"name":"Journal of Health Politics Policy and Law","volume":" ","pages":"253-281"},"PeriodicalIF":3.3,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142332624","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Rationing Rights: Administrative Burden in Medicaid Long-Term Care Programs.","authors":"Pamela Herd, Rebecca A Johnson","doi":"10.1215/03616878-11567708","DOIUrl":"10.1215/03616878-11567708","url":null,"abstract":"<p><strong>Context: </strong>States use Medicaid waivers to provide supports for disabled people in communities rather than in institutions. Because waivers are not entitlements, those deemed eligible are not guaranteed these supports. How do states, in practice, use bureaucratic procedures to ration this \"conditional\" right?</p><p><strong>Methods: </strong>Drawing on primary and secondary data, the authors analyze waiver programs and document state administrative procedures that indirectly and directly ration access.</p><p><strong>Findings: </strong>Burdens indirectly limit disabled people's access to Medicaid home- and community-based services via a complex array of waiver programs that exacerbate costs associated with gaining eligibility. In addition, burdens directly limit access via wait lists and prioritization among the eligible. There is also evidence that states strategically deploy opaqueness to provide political cover for unpopular wait lists. The overall process is opaque, confusing, and time intensive, with burdens falling hardest on marginalized groups.</p><p><strong>Conclusions: </strong>Administrative burdens impede disabled people's efforts to exercise their right to live in the community as afforded to them under the American with Disabilities Act. The opaqueness and associated burdens with waiver programs are a way to conceal these burdens, thereby demonstrating how burdens \"neatly carry out the 'how' in the production of inequality, while concealing . . . the why\" (Ray, Herd, and Moynihan 2023: 139).</p>","PeriodicalId":54812,"journal":{"name":"Journal of Health Politics Policy and Law","volume":" ","pages":"223-251"},"PeriodicalIF":3.3,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142332630","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Medicaid's Political Development since 1965: How a Fragmented and Unequal Program Has Expanded.","authors":"Colleen M Grogan","doi":"10.1215/03616878-11567692","DOIUrl":"10.1215/03616878-11567692","url":null,"abstract":"<p><p>The Medicaid program has changed enormously over the past 60 years from a very restrictive program primarily attached to recipients on public assistance in 1965 to a much more expansive program today allowing coverage for persons regardless of marital, parental, or employment status. Incorporating the \"medically needy\"-an ambiguous concept from the start-allowed states to include many different groups in Medicaid who are not traditionally thought of as poor. In addition, three structural features illuminate why the program has expanded and changed dramatically over time: federalism and intergovernmental financing, the dominance of the private sector, and fragmentation. Unequal treatment among Medicaid-covered groups alongside partisan politics create a political discourse that often reveals Medicaid as a public subsidy for stigmatized groups while hiding Medicaid's reach into the middle class. This central political ideological tension collides with programmatic realities such that Medicaid strangely often suffers from a residual retrenchment politics while at the same time benefiting from embeddedness, making it extremely difficult to truly turn back the clock on Medicaid's expansion.</p>","PeriodicalId":54812,"journal":{"name":"Journal of Health Politics Policy and Law","volume":" ","pages":"137-164"},"PeriodicalIF":3.3,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142332628","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Policy Feedbacks and Medicaid on Its 60th Anniversary.","authors":"Andrea Louise Campbell","doi":"10.1215/03616878-11567676","DOIUrl":"10.1215/03616878-11567676","url":null,"abstract":"<p><strong>Context: </strong>Despite early skepticism about Medicaid's ability to withstand retrenchment as a program of \"welfare medicine,\" it has proved remarkably durable. Existing analyses explain durability from a policy feedbacks perspective-how program provisions affect the subsequent political environment and policy-making options. This article updates earlier feedback accounts to the Affordable Care Act (ACA) era.</p><p><strong>Methods: </strong>The article examines extant findings on policy feedbacks in Medicaid at the elite and mass levels since the 2010 passage of the ACA.</p><p><strong>Findings: </strong>Mass feedbacks have been modest. Medicaid expansion under the ACA only slightly increased beneficiary political participation, if at all. Medicaid attitudes among beneficiaries and the larger public have become somewhat more supportive. Elite-level feedbacks are the most powerful, with the federal contribution-increased for expansion populations under the ACA-inexorably shaping state incentives. However, continued rejection of Medicaid expansion and attempts to add conditions to Medicaid eligibility in Republican-led states with large shares of Black residents demonstrate that federalism, race, and the program's welfare medicine image continue to threaten the program.</p><p><strong>Conclusion: </strong>Medicaid survives as the nation's largest health insurance program by enrollment, and it is deeply woven into the health care system. However, it remains chronically vulnerable and variable across states despite robust aggregate enrollment and spending.</p>","PeriodicalId":54812,"journal":{"name":"Journal of Health Politics Policy and Law","volume":" ","pages":"165-188"},"PeriodicalIF":3.3,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142332629","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Charley E Willison, Naquia A Unwala, Katarzyna Klasa
{"title":"Entrenched Opportunity: Medicaid, Health Systems, and Solutions to Homelessness.","authors":"Charley E Willison, Naquia A Unwala, Katarzyna Klasa","doi":"10.1215/03616878-11567700","DOIUrl":"10.1215/03616878-11567700","url":null,"abstract":"<p><strong>Context: </strong>As inequality grows, politically powerful health care institutions-namely Medicaid and health systems-are increasingly assuming social policy roles, particularly related to solutions to homelessness. Medicaid and health systems regularly interact with persons experiencing homelessness who are high users of emergency health services and who experience frequent loss of or inability to access Medicaid services because of homelessness. This research examines Medicaid and health system responses to homelessness, why they may work to address homelessness, and the mechanisms by which this occurs.</p><p><strong>Methods: </strong>The authors collected primary data from Medicaid policies and the 100 largest health systems, along with national survey data from local homelessness policy systems, to assess scope and to measure mechanisms and factors influencing decision-making.</p><p><strong>Findings: </strong>Nearly one third of states have Medicaid waivers targeting homelessness, and more than half of the 100 largest health systems have homelessness mitigation programs. Most Medicaid waivers use local homelessness policy structures as implementing entities. A plurality of health systems rationalizes program existence based on the failure of existing structures.</p><p><strong>Conclusions: </strong>Entrenched health care institutions may bolster local homelessness policy governance mechanisms and policy efficacy. Reliance on health systems as alternative structures, and implementing entities in Medicaid waivers, may risk shifting homelessness policy governance and retrenchment of existing systems.</p>","PeriodicalId":54812,"journal":{"name":"Journal of Health Politics Policy and Law","volume":" ","pages":"307-336"},"PeriodicalIF":3.3,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142332625","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Katie Attwell, Adam Hannah, Shevaun Drislane, Mark Christopher Navin
{"title":"Policy Feedback and the Politics of Childhood Vaccine Mandates: Conflict and Change in California, 2012-2019.","authors":"Katie Attwell, Adam Hannah, Shevaun Drislane, Mark Christopher Navin","doi":"10.1215/03616878-11377933","DOIUrl":"10.1215/03616878-11377933","url":null,"abstract":"<p><strong>Context: </strong>In 2012, California instituted a new requirement for parents to consult with a clinician before receiving a personal belief exemption (PBE) to its school entry vaccine mandate. In 2015, the state removed this exemption altogether. In 2019, legislators cracked down on medical exemptions to address their misuse by vaccine refusers and supportive clinicians. This article uses \"policy feedback theory\" to explore these political conflicts, arguing that PBEs informed the emergence and approaches of two coalitions whose conflict reshaped California's vaccination policies.</p><p><strong>Methods: </strong>The authors analyzed legal, policy, academic, and media documents; interviewed 10 key informants; and deductively analyzed transcripts using NVivo 20 transcription software.</p><p><strong>Findings: </strong>California's long-standing vaccination policy inadvertently disseminated two fundamentally incompatible social norms: vaccination is a choice, and vaccination is not a choice. Over time, the culture and number of vaccine refusers grew, at least in part because the state's policy sanctioned the norm of vaccine refusal.</p><p><strong>Conclusions: </strong>The long-term consequences of California's \"mandate + PBE\" policy-visible, public, and socially sanctioned vaccine refusal-undermined support for it over time, generating well-defined losses for a large group of people (the vaccinating public) and specifically for the provaccine parent activists whose experiences of personal grievance drove their mobilization for change.</p>","PeriodicalId":54812,"journal":{"name":"Journal of Health Politics Policy and Law","volume":" ","pages":"1075-1110"},"PeriodicalIF":3.3,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141249082","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jeremy K Ward, Sébastien Cortaredona, Hugo Touzet, Fatima Gauna, Patrick Peretti-Watel
{"title":"Explaining Political Differences in Attitudes to Vaccines in France: Partisan Cues, Disenchantment with Politics, and Political Sophistication.","authors":"Jeremy K Ward, Sébastien Cortaredona, Hugo Touzet, Fatima Gauna, Patrick Peretti-Watel","doi":"10.1215/03616878-11373758","DOIUrl":"10.1215/03616878-11373758","url":null,"abstract":"<p><strong>Context: </strong>The role of political identities in determining attitudes to vaccines has attracted a lot of attention in the last decade. Explanations have tended to focus on the influence of party representatives on their sympathizers (partisan cues).</p><p><strong>Methods: </strong>Four representative samples of the French adult population completed online questionnaires between July 2021 and May 2022 (N = 9,177). Bivariate and multivariate analyses were performed to test whether partisan differences in attitudes to vaccines are best explained by partisan cues or by parties' differences in propensity to attract people who distrust the actors involved in vaccination policies.</p><p><strong>Findings: </strong>People who feel close to parties on the far left, parties on the far right, and green parties are more vaccine hesitant. The authors found a small effect of partisan cues and a much stronger effect of trust. More importantly, they show that the more politically sophisticated are less vaccine hesitant and that the nonpartisan are the biggest and most vaccine hesitant group.</p><p><strong>Conclusions: </strong>The literature on vaccine attitudes has focused on the case of the United States, but turning attention toward countries where disenchantment with politics is more marked helps researchers better understand the different ways trust, partisanship, and political sophistication can affect attitudes to vaccines.</p>","PeriodicalId":54812,"journal":{"name":"Journal of Health Politics Policy and Law","volume":" ","pages":"961-988"},"PeriodicalIF":3.3,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141249079","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Why Some Nonelderly Adult Medicaid Enrollees Appear Ineligible Based on Their Annual Income.","authors":"Geena Kim, Alexandra Minicozzi, Chapin White","doi":"10.1215/03616878-11373728","DOIUrl":"10.1215/03616878-11373728","url":null,"abstract":"<p><strong>Context: </strong>Recent studies have highlighted Medicaid enrollment among middle- and higher-income populations and questioned whether the program is reaching those for whom it is intended.</p><p><strong>Methods: </strong>The authors use administrative tax data to measure Medicaid enrollment and income in 2017, they use survey data to measure monthly income, and they use administrative data to identify Medicaid enrollment pathways.</p><p><strong>Findings: </strong>Among 38.8 million nonelderly adults in Medicaid at any point in 2017, 24.4 million had annual income below their state's typical eligibility threshold, and 14.4 million (37%) had income above the threshold. Among those above the threshold, 3.5 million enrolled through a pathway allowing higher income (pregnant women, the \"medically needy,\" and others). The authors also estimate that more than 12 million had at least one month with income below the threshold, and roughly 4 million had at least five months with income below the eligibility threshold.</p><p><strong>Conclusions: </strong>Pathways allowing higher income account for one quarter of enrollees with annual incomes above typical thresholds. Among low-income adults, month-to-month variation in income is common and can account for most or all of the remaining enrollees with annual incomes above typical thresholds. A complete accounting of eligibility status would require merged data on income, Medicaid enrollment, and family structure.</p>","PeriodicalId":54812,"journal":{"name":"Journal of Health Politics Policy and Law","volume":" ","pages":"1051-1074"},"PeriodicalIF":3.3,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141249085","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Implementing Primary Care Reform in France: Bargaining, Policy Adaptation, and the Maisons de Santé Pluriprofessionnelles.","authors":"Anne Moyal","doi":"10.1215/03616878-11373736","DOIUrl":"10.1215/03616878-11373736","url":null,"abstract":"<p><strong>Context: </strong>The organization of primary care in France has long remained a secondary issue on the political agenda. The government began to address the difficulties of care access and coordination in the 2000s, when a seemingly viable solution emerged from the field: the maisons de santé pluriprofessionnelles (MSPs). In a corporatist system and a predominantly private sector, the government chose an incentive-based contractual policy to encourage providers to join these structures. This article analyzes the implementation of this policy, which depends on private providers' commitment.</p><p><strong>Methods: </strong>The article offers a comparative case study of six MSPs. Data were collected through semistructured interviews, observation sessions, and document analysis.</p><p><strong>Findings: </strong>First, the article shows that the emergence of MSPs has only been possible thanks to an unprecedented alliance between general practitioners, the state, and the health insurance fund. Second, it argues that MSP policy implementation relies on a complex bargaining process between private providers and public authorities that enables the former to shape it to their local needs.</p><p><strong>Conclusions: </strong>MSP implementation experiences raise questions both about the understanding of medical corporatism in France and the assimilation of policy changes and local variation through policy implementation.</p>","PeriodicalId":54812,"journal":{"name":"Journal of Health Politics Policy and Law","volume":" ","pages":"1015-1050"},"PeriodicalIF":3.3,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141249081","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Regime Type and Data Manipulation: Evidence from the COVID-19 Pandemic.","authors":"Simon Wigley","doi":"10.1215/03616878-11373750","DOIUrl":"10.1215/03616878-11373750","url":null,"abstract":"<p><strong>Context: </strong>This study examines whether autocratic governments are more likely than democratic governments to manipulate health data. The COVID-19 pandemic presents a unique opportunity for examining this question because of its global impact.</p><p><strong>Methods: </strong>Three distinct indicators of COVID-19 data manipulation were constructed for nearly all sovereign states. Each indicator was then regressed on democracy and controls for unintended misreporting. A machine learning approach was then used to determine whether any of the specific features of democracy are more predictive of manipulation.</p><p><strong>Findings: </strong>Democracy was found to be negatively associated with all three measures of manipulation, even after running a battery of robustness checks. Absence of opposition party autonomy and free and fair elections were found to be the most important predictors of deliberate undercounting.</p><p><strong>Conclusions: </strong>The manipulation of data in autocracies denies citizens the opportunity to protect themselves against health risks, hinders the ability of international organizations and donors to identify effective policies, and makes it difficult for scholars to assess the impact of political institutions on population health. These findings suggest that health advocates and scholars should use alternative methods to estimate health outcomes in countries where opposition parties lack autonomy or must participate in uncompetitive elections.</p>","PeriodicalId":54812,"journal":{"name":"Journal of Health Politics Policy and Law","volume":" ","pages":"989-1014"},"PeriodicalIF":3.3,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141249084","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}