Most recent papers:

• The Effects of Recent Polarized Elections on Mental Health.
  Michael E. Shepherd, Bethany Albertson.
  Milbank Quarterly. 5 days ago
  ["The Milbank Quarterly, EarlyView. ", "\n\n\n\nPolicy Points\n\nResearchers investigate how recent elections in the United States have influenced mental health, especially among political‐ and policy‐based election losers.\nThe previous two presidential elections worsened the self‐reported mental health of Americans on average.\nLikely 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.\nAs American politics has become increasingly polarized and the perceived stakes of elections have loomed larger in recent years, elections have become a source of worsening mental health for Americans.\n\n\nContext\nPolitics is increasingly important to many Americans. Yet little is known about how the increasing centrality of politics affects Americans’ mental health. This work aimed to evaluate how recent polarized elections have influenced Americans’ mental health.\n\n\nMethods\nTo investigate this question, we compared online search interest in politically related mental health issues and self‐reported mental health data. Analyses explored changes before and after election days in 2020 and 2024. The two outcome variables were aggregate Google search interest in politics‐related mental health issues and individual responses to the following item from the Behavioral Risk Factor Surveillance System (BRFSS): ʻʻNow thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good? With BRFSS, we compared differential changes for likely Democrats and Republicans using multiple proxy measures and for those with health policy interest in the election.\n\n\nFindings\nThe 2020 and 2024 presidential elections substantially increased interest in politics‐related mental health issues online. The 2020 election led to just under 0.2 additional days of poor mental health (P < .05), and the 2024 election led to just under 0.5 additional days of poorer mental health (P < .05). Likely losing partisans and those who stood to lose out from Trump's reelection in terms of health policy were found to drive most of this relationship, with just under 1 full additional day of poorer mental health for each group.\n\n\nConclusions\nThe stakes of elections in this polarized era of American politics are worsening the mental health of Americans. Additional resources may be necessary to allow therapists and clinicians to navigate additional care‐seeking surrounding and following elections.\n\n"]

  May 01, 2026   doi: 10.1111/1468-0009.70086   open full text
• US State Policy Index for Population Health Analyses.
  Jennifer Karas Montez, Iliya Gutin, Shannon M. Monnat.
  Milbank Quarterly. 9 days ago
  ["The Milbank Quarterly, EarlyView. ", "\n\n\n\nPolicy Points\n\nChanges in states’ policy contexts since the 1980s may help explain why mortality rates among working‐age adults have risen and become more unequal across geographic areas. Investigating this pressing issue requires a new, industry‐standard measure of those contexts.\nDuring 1980‐2023, higher scores on the State Policies and Politics Database (SPPD) State Policy Index (reflecting an adoption of policies that strengthen economic security, expand safety nets, and discourage risky behaviors) were strongly associated with lower working‐age mortality rates.\nThe SPPD State Policy Index is a valid, transparent, replicable, and easily updated measure that is useful for understanding how the general orientation of state policies predicts mortality.\n\n\n\nContext\nRecent studies have linked the rising rates and growing disparities in working‐age mortality partly to changes in US states’ policy contexts since the 1980s. Yet, such studies largely rely on measures of states’ policy contexts, or “policy indices,” that were created for other purposes, are not regularly updated, and use complex methods that can be difficult to interpret and replicate. Further elucidating the mortality trends and disparities would benefit from a policy index that is designed for population health analyses and a clearer understanding of the utility of such indices.\n\n\nMethods\nDrawing on the World Health Organization's Social Determinants of Health Framework and existing studies of the impact of specific state policies, we identified 11 policies to be included in an annual index from 1980‐2023. It ranges from 0 to 1 on a conservative‐to‐liberal continuum. We evaluated the index on multiple dimensions of validity.\n\n\nFindings\nThe index demonstrates strong validity. Exhibiting convergent validity, the index has a 0.89 correlation with two existing validated and widely used holistic policy indices created for other purposes using more than 135 state policies and two different modeling approaches. Exhibiting predictive validity, the index is strongly associated with all‐cause and cause‐specific working‐age (ages 25‐64) mortality rates. The strength of the associations is similar to those using the two existing indices but have standard errors of about one‐third to one‐half the size. The index is also associated with mortality at younger and older ages.\n\n\nConclusions\nThe State Policies and Politics Database (SPPD) State Policy Index is valid for investigating the links between the general orientation of states’ policies and mortality rates. It provides researchers with a straightforward, transparent, annual, and timely index. We discuss the reasons for using policy indices, particularly in an era of policy co‐occurrence, and address two criticisms of indices.\n\n"]

  April 27, 2026   doi: 10.1111/1468-0009.70085   open full text
• Medicaid Managed Care Plan Alignment With State Substance Use Disorder Treatment Coverage Requirements.
  Sage R. Feltus, Christina M. Andrews, Lauren Peterson, Colleen M. Grogan, Amanda J. Abraham, Olivia M. Hinds, Maureen T. Stewart.
  Milbank Quarterly. 9 days ago
  ["The Milbank Quarterly, EarlyView. ", "\n\n\n\nPolicy Points\n\nStates contract with Medicaid managed care plans to administer benefits for roughly 70 million Medicaid enrollees, yet little is known about how plan benefit policies for substance use disorder (SUD) treatment medications align with state requirements.\nIn this study, we found that among the population of 167 Medicaid managed care plans responsible for SUD pharmacy benefits in 2021, many did not align with state requirements to cover SUD treatment medications.\nMany plans imposed prior authorization requirements on these medications, even when prohibited from doing so. Alignment between state requirements and reported plan policies was less common among plans operating in Republican‐leaning states.\n\n\n\nContext\nMedicaid is the largest payer of substance use disorder (SUD) treatment in the United States. Managed care plays an important role, administering benefits for more than 80% of Medicaid enrollees. While state governments have enacted coverage requirements for SUD treatment medications that managed care plans must follow, the extent to which managed care coverage policies align with these rules remains largely unknown.\n\n\nMethods\nWe linked a national survey of state Medicaid officials regarding state requirements for SUD medication benefits in 2021 with data on SUD medication coverage and management from all 167 Medicaid managed care plans in 2021. We assessed the extent to which plans aligned with state requirements—overall, and by the dominant voter political lean in the state in which the plans were embedded.\n\n\nFindings\nIn 2021, the proportion of Medicaid managed care plans aligned with state coverage requirements for alcohol use disorder treatment medications was slightly higher than that for opioid use disorder treatment medications. Alignment for coverage was more common than alignment with prior authorization prohibitions. Democratic‐leaning states were more likely to require coverage of alcohol and opioid use disorder medications, except in the case of methadone. In Republican‐leaning states, most managed care plans did not align with requirements to cover disulfiram and acamprosate and 45.4% did not align with methadone coverage requirements. Plans in Republican‐leaning states were less likely to align with prior authorization bans on every SUD treatment medication.\n\n\nConclusions\nMedicaid managed care plans located in Republican‐leaning states were less likely to be subject to state requirements governing coverage and prior authorization of SUD treatment medications, with the exception of methadone, and were also less likely to align with requirements when imposed by states.\n\n"]

  April 27, 2026   doi: 10.1111/1468-0009.70083   open full text
• The Association of Medicaid Estate Recovery with Homeownership, Home Equity, and Medicaid Enrollment.
  Amanda Spishak‐Thomas.
  Milbank Quarterly. 9 days ago
  ["The Milbank Quarterly, EarlyView. ", "\n\n\n\nPolicy Points\n\nThis study examines the association between the implementation of Medicaid estate recovery and homeownership, home equity, and Medicaid enrollment among low‐income adults.\nEstate recovery is associated with a decrease in Medicaid enrollment among unmarried, low‐income older adults and a decrease in home equity overall and among Black respondents, White respondents, and adults over 74 years of age.\nThese findings suggest that low‐income adults may behave as intended, avoiding Medicaid and extracting housing wealth to cover care costs; still, it is worth reconsidering a policy that recoups less than 1% of the Medicaid budget to the detriment of low‐income families with few assets.\n\n\n\nContext\nIn 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. Estate recovery may trigger 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.\n\n\nMethods\nUsing 1992‐2008 data from the Health and Retirement Study, this study exploits the time variation in state adoption of estate recovery to determine the association of recovery policies with homeownership decisions, home equity, and Medicaid enrollment among low‐income older adults using a difference‐in‐difference fixed‐effects model.\n\n\nFindings\nThe implementation of estate recovery significantly decreased home equity in the overall sample and among Black and White subgroups as well as those over age 74 years. Additionally, estate recovery implementation was associated with a significant decrease in Medicaid enrollment among unmarried, low‐income individuals aged 65 years and older. No significant association was found between homeownership and estate recovery overall or among subgroups.\n\n\nConclusions\nThese 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, 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 had few assets. These findings reflect the limited choices that older adults and their families have in making long‐term care decisions, filling a gap in the extant literature, which has not adequately explored the impacts of estate recovery.\n\n"]

  April 27, 2026   doi: 10.1111/1468-0009.70087   open full text
• From Tobacco to Ultraprocessed Food: How Industry Engineering Fuels the Epidemic of Preventable Disease.
  Ashley N. Gearhardt, Kelly D. Brownell, Allan M. Brandt.
  Milbank Quarterly. March 24, 2026
  ["The Milbank Quarterly, Volume 104, Issue 1, Page 76-115, March 2026. ", "\n\n\n\nPolicy Points\n\nUltraprocessed 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.\nUPFs 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.\nPolicy 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.\n\n\n\nContext\nUltraprocessed 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.\n\n\nMethods\nThis 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.\n\n\nFindings\nCigarettes 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.\n\n\nConclusions\nUPFs 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.\n\n"]

  March 24, 2026   doi: 10.1111/1468-0009.70066   open full text
• Multidimensional Approaches to Ranking State‐Level Rurality to Enhance Comparisons Across States.
  Daniel Baslock, Nari Yoo.
  Milbank Quarterly. March 24, 2026
  ["The Milbank Quarterly, Volume 104, Issue 1, Page 136-152, March 2026. ", "\n\n\n\nPolicy Points\n\nSingle indicators such as rural population percentage can misrepresent a state's rural character, leading to flawed policy comparisons and resource allocation.\nThis study introduces a multidimensional rurality index that combines population share, land area, and population density to create a more comprehensive ranking of US states.\nPolicymakers 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.\n\nContext\nInadequate 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.\n\n\nMethods\nThis 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.\n\n\nFindings\nMountain 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).\n\n\nConclusions\nThis 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.\n\n"]

  March 24, 2026   doi: 10.1111/1468-0009.70067   open full text
• Health and the Right to Universal Basic Neighborhoods.
  Michael O. Emerson, Lauren Anderson, Jecorey Arthur, Nancy Seay, Ted Smith.
  Milbank Quarterly. March 24, 2026
  ["The Milbank Quarterly, Volume 104, Issue 1, Page 171-197, March 2026. ", "\n\n\n\nPolicy Points\n\nHealth disparities are a symptom of population‐level problems, and interventions to improve health equity should be at the neighborhood level.\nWe argue that the most effective and pragmatic prescription for improving population health is what we call Universal Basic Neighborhoods (UBN).\nWe offer a Model Legislation Template, which can help citizens and cities raise to legal status the right of neighborhoods to be UBN.\nAttaining UBN status can transform neighborhoods into healthier, more equitable, vibrant communities.\n\n\n\nContext\nThe 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).\n\n\nMethods\nWe 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.\n\n\nFindings\nWe 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.\n\n\nConclusions\nIf 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.\n\n"]

  March 24, 2026   doi: 10.1111/1468-0009.70070   open full text
• Measuring Community Power as a Structural Determinant of Health for Latino Communities.
  Julianna Pacheco, Nicole Novak, Samantha Deragon, Stephanie Schmitt.
  Milbank Quarterly. March 24, 2026
  ["The Milbank Quarterly, Volume 104, Issue 1, Page 153-170, March 2026. ", "\n\n\n\nPolicy Points\n\nVoting rights are the most common measure of power when studying structural determinants of health. Voting is a narrow conceptualization of community power and irrelevant for noncitizen populations who are vitally affected by health policymaking despite not being able to vote.\nWe measure six factors related to community power, including laws, policies, and practices/norms at the county level that are applicable to counties with significant populations who identify as Latino. These measures act to either overcome or exacerbate historical power imbalances based on race, ethnicity, and citizenship status.\nThese findings contribute to our understanding of the structural determinants of health and highlight the important ways that community power can be conceptualized and measured for specific racial or ethnic groups.\n\n\nContext\nWe broaden our understanding of community power by going beyond traditional measures of voting and voting rights. Our objectives are to (1) create county‐level measures of community power that are more expansive than voting and (2) explore the descriptive and geographic patterns of community power.\n\n\nMethods\nSix novel measures of community power were developed at the county level. Three were indicators of power‐building activities that overcome historic power imbalances faced by Latino populations. These include measures on political representation, immigrant incorporation, and language accessibility for elections. We also measured three indicators related to immigration enforcement that act to exacerbate historical power disparities. Correlational and spatial analyses were conducted to better understand descriptive and geographic patterns.\n\n\nFindings\nWe found little evidence that our measures are correlated; spatial analyses largely confirmed this. There was evidence of regional spatial autocorrelation, but inferences depended largely on the measure used. We generally found that counties with more than 10% of residents who identify as Latino have higher values on our power‐building measures, suggesting that these areas are especially primed to amplify the voices of Latino residents. Interestingly, our measures related to immigration enforcement were largely unrelated to recent Latino population growth (e.g., “new destination counties”).\n\n\nConclusions\nPower is a fundamental driver of the conditions that produce or mitigate health disparities, but the process by which communities influence decision making may be difficult to measure. This work provides a blueprint for future scholars studying the link between community power and health equity across different races, ethnicities, and citizenship statuses.\n\n"]

  March 24, 2026   doi: 10.1111/1468-0009.70072   open full text
• How Corruption Influences Population Health.
  Ilias Kyriopoulos, Dimitrios Minos, Sotiris Vandoros, Elias Mossialos.
  Milbank Quarterly. March 24, 2026
  ["The Milbank Quarterly, Volume 104, Issue 1, Page 198-219, March 2026. ", "\n\n\n\nPolicy Points\n\nThis study examines the link between corruption and mortality.\nWe find that corruption is associated with higher mortality, particularly in low‐income countries. It is also linked to lower government revenue and distorted government expenditure patterns, which may contribute to resource misallocation and constraints in health financing.\nOur findings contribute to the literature on upstream determinants of health by highlighting the relevance of institutional and political economy factors for population health.\nThe Sustainable Development Goals on combating corruption and improving health are found to be complementary. Efforts to address corruption could align with and support public health objectives.\n\n\n\nContext\nWhile public health research has examined the macro‐level and structural determinants of health, the link between corruption and population health remains underexplored. This study investigates the relationship between corruption and mortality and explores potential pathways underlying this association. In doing so, it contributes to the broader literature on the political economy of health and the upstream factors associated with population health.\n\n\nMethods\nThis study draws on country‐level data from 102 countries spanning 2008‐2018. We use econometric methods, including instrumental variables and the Mundlak approach. To mitigate endogeneity concerns, we employ an instrumental variable approach based on ancestry and oral tradition, using historical cultural factors plausibly related to contemporary corruption levels.\n\n\nFindings\nWe find a significant relationship between corruption and higher mortality rates. Corruption is also linked with weaker fiscal capacity, reduced government funding for health care, distorted resource allocation, and patterns consistent with misallocation of public funds. Additionally, the association between corruption and mortality varies across levels of public goods provision.\n\n\nConclusions\nThis study expands existing research on social determinants of health by highlighting the relevance of institutional and political factors for population health. Addressing corruption could be recognized as a public health priority, given its association with health financing and population health.\n\n"]

  March 24, 2026   doi: 10.1111/1468-0009.70073   open full text
• The 2021 Child Tax Credit and Children's Health and Well‐Being: Evidence From a National Longitudinal Study.
  Guangyi Wang, Daniel F. Collin, Deborah Karasek, Rita Hamad.
  Milbank Quarterly. March 24, 2026
  ["The Milbank Quarterly, Volume 104, Issue 1, Page 116-135, March 2026. ", "\n\n\n\nPolicy Points\n\nEvidence 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.\nCompared 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.\nPolicymakers may need to consider program design features, such as more frequent distribution of unconditional cash benefits, to better support child well‐being.\n\n\nContext\nIn 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.\n\n\nMethods\nWe 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.\n\n\nFindings\nDuring 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.\n\n\nConclusions\nMore 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.\n\n"]

  March 24, 2026   doi: 10.1111/1468-0009.70064   open full text
• A Scoping Review of Certified Nurse‐Midwife and Certified Midwife Care in the United States: Assessing Outcomes Across Six Patient Care Domains.
  Emma Virginia Clark, Robyn Schafer, Rachel Lane Walden, Julie Blumenfeld, Carrie E. Neerland, Katie Page, Mavis N. Schorn, Sanjana Chimata, Heather M. Bradford.
  Milbank Quarterly. March 24, 2026
  ["The Milbank Quarterly, Volume 104, Issue 1, Page 220-291, March 2026. ", "\n\n\n\nPolicy Points\n\nCertified 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.\nIntegration of CNM/CM care remains limited across many US health systems due to scope of practice restrictions and institutional policies.\nGrowing, 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.\n\nContext\nThe 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.\n\n\nMethods\nA 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.\n\n\nFindings\nA 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.\n\n\nConclusions\nThese 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 and explore the role of CNM/CM care within collaborative models to enhance perinatal care quality and accessibility.\n\n"]

  March 24, 2026   doi: 10.1111/1468-0009.70069   open full text
• Extended Pregnancy Medicaid During COVID‐19 and Enrollment and Health Care Use in the Postpartum Year.
  Erica L. Eliason, Maria W. Steenland, Rebecca A. Gourevitch.
  Milbank Quarterly. March 15, 2026
  ["The Milbank Quarterly, EarlyView. ", "\n\n\n\nPolicy Points\n\nThe continuous coverage provision of the March 2020 Families First Coronavirus Response Act resulted in extended postpartum Medicaid for individuals with pregnancy Medicaid coverage, which increased postpartum Medicaid enrollment, improved continuity of coverage, and increased Medicaid‐paid emergency department visits and mental and behavioral health diagnoses in the 3 to 12 months postpartum.\nThese findings provide insight into the extent to which increased coverage translated into changes in postpartum Medicaid‐paid care.\nCommunication and outreach are likely needed to ensure that individuals are aware of and able to use their extended postpartum Medicaid coverage.\n\n\nContext\nBefore the COVID‐19 pandemic, persons with pregnancy Medicaid coverage were typically disenrolled after 60 days postpartum, at which point they could retain Medicaid only if they qualified through another eligibility category (most commonly as a parent). The March 2020 Families First Coronavirus Response Act (FFCRA) extended postpartum Medicaid coverage by requiring states to pause disenrollment in exchange for enhanced federal funding.\n\n\nMethods\nThis study examined 2019‐2022 Medicaid claims data from 15 states to determine the association between extended postpartum Medicaid coverage and Medicaid‐paid care. We employed a continuous difference‐in‐difference design, leveraging variations in FFCRA‐associated eligibility changes (state‐level differences in pre‐FFCRA pregnancy and parental Medicaid eligibility as a percentage of the federal poverty level [FPL]). The study population included individuals with a birth between January 2019 and December 2021 that was paid for by pregnancy Medicaid coverage. The study population was followed for 12 months after childbirth. Outcomes included Medicaid enrollment, continuity of coverage, outpatient and emergency department visits, and pregnancy‐related and mental‐health–related diagnoses. Care outcomes were measured from 3 to 12 months postpartum.\n\n\nFindings\nIn adjusted models, we found that a 100 percentage‐point FPL increase in postpartum Medicaid eligibility under the FFCRA was associated with 2.9 additional months of enrollment (95% CI: 0.9, 4.3), a 27.3 percentage‐point increase in 12‐month continuous Medicaid (95% CI: 2.3, 44.6), 107.2 more emergency department visits per 1,000 beneficiaries (95% CI: 18.7, 167.6), and a 3.2 percentage‐point (95% CI: 1.7, 5.4) increase in services with mental and behavioral health diagnoses.\n\n\nConclusions\nContinuous Medicaid coverage during the FFCRA was associated with longer postpartum enrollment and increases in some health care utilization. However, no increases in Medicaid‐paid outpatient care or care for pregnancy‐related conditions were found, which may have been due to enrollees’ limited awareness of their continued eligibility. Improved communication around extended postpartum Medicaid coverage may improve the translation of coverage into health care access.\n\n"]

  March 15, 2026   doi: 10.1111/1468-0009.70079   open full text
• US State Policy Contexts and Mental Health Among Working‐Age Adults.
  Iliya Gutin, Jennifer Karas Montez, Emily Wiemers, Shannon M. Monnat, Douglas A. Wolf.
  Milbank Quarterly. March 09, 2026
  ["The Milbank Quarterly, EarlyView. ", "\n\n\n\nPolicy Points\n\nStates’ overarching policy contexts are a meaningful yet overlooked predictor of adults’ mental health, with more conservative contexts associated with worse mental health outcomes over a 30‐year period.\nCounterfactual analyses suggest that widespread policy shifts could meaningfully alter the national prevalence of mental distress, positioning state policy contexts as important yet underutilized levers for improving population mental health.\nThese associations are strongest among adults without a college degree, underscoring that state policy contexts may exacerbate existing educational disparities in mental health.\n\n\nContext\nMental health among US working‐age adults notably worsened during the COVID‐19 pandemic, following a steady decades‐long decline. The impact of states’ COVID‐19 policies on mental health has received much attention; however, less is known about the impact of a broader set of long‐standing and overarching state policy contexts. This study examines how working‐age adults’ mental health was associated with states’ policy contexts over 30 years. It also assesses whether the pandemic disrupted the association and whether the association is more pronounced among adults without a college degree.\n\n\nMethods\nWe use nationally representative data on adults ages 25‐64 in the 1993‐2022 waves of the Behavioral Risk Factor Surveillance System (N = 5,891,073), merged with measures of three state policy indices. The outcomes are self‐rated poor mental health days in the last 30 days and extreme distress (poor mental health in all 30 days). The main independent variable is an index that summarizes states’ overarching policy contexts, on a liberal‐to‐conservative continuum, annually from 1993‐2020. Two additional indices summarize states’ COVID‐19 policies, one on in‐person restrictions and a second on economic supports, monthly from March 2020 to December 2022. We estimate the association between states’ overarching policy contexts and mental health, net of covariates, fixed differences between states, and COVID‐19 policies.\n\n\nFindings\nDuring the study period, each unit increase toward state policy conservatism was associated with 0.26 additional days of poor mental health and a 7% higher probability of extreme distress. The pandemic did not disrupt these associations. State policy contexts were a stronger predictor of poor mental health among adults without a college degree than adults with a degree.\n\n\nConclusions\nStates’ overarching policy contexts are an important yet understudied predictor of mental health. Current and proposed changes in state policies may have important consequences for mental health among working‐age adults, their families, and communities.\n\n"]

  March 09, 2026   doi: 10.1111/1468-0009.70077   open full text
• Preemption and Generational Health Equity: The Role of Forced Inaction in Shaping Outcomes.
  Margaret H. Swenson, Lauren D. Boczkowski, Brad Riley, K. Noelle Broughton, Christopher J. Koliba.
  Milbank Quarterly. March 01, 2026
  ["The Milbank Quarterly, EarlyView. ", "\n\n\n\nPolicy Points\n\nWhen 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.\nState 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.\nWhen 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.\n\n\n\n\nContext\nRacial 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.\n\n\nMethods\nThis 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.\n\n\nFindings\nThe 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.\n\n\nConclusions\nThis 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 policymakers should consider the current findings before restricting local policymaking.\n\n"]

  March 01, 2026   doi: 10.1111/1468-0009.70078   open full text
• Long‐Term Changes in Health Care Use and Outcomes Among Groups Maintaining Versus Losing Medicaid Upon Medicare Enrollment.
  Maryssa Pallis, Jane Tavares, Reena Sethi, Kerry Glova, Marc Cohen.
  Milbank Quarterly. February 21, 2026
  ["The Milbank Quarterly, EarlyView. ", "\n\n\n\nPolicy Points\n\nOur analysis indicated that permanent loss of Medicaid was associated with poorer health outcomes, higher mortality, greater out‐of‐pocket costs, and lower preventive health care use relative to those who kept Medicaid or had a temporary disruption.\nAddressing these coverage gaps can improve individual health and reduce systemwide costs.\nPolicymakers should consider increasing eligibility criteria for Medicaid at age 65 years from 100% of the federal poverty level (FPL) to 138% FPL. Eligibility and outreach efforts for Medicare Savings Plans or introducing state‐level Medicaid income disregards from 100% FPL to 138% FPL could mitigate the Medicare Cliff in the absence of federal eligibility reform.\n\n\n\nContext\nAbout 280,000 older adults experience the “Medicare Cliff” each year, becoming eligible for Medicare and losing Medicaid coverage when they turn age 65 years due to discontinuities in financial eligibility criteria. Yet, little is known about the long‐term associations between a loss in Medicaid coverage and health status, health care utilization, and economic status in later life. Our study builds on previous research by longitudinally examining how health outcomes, health utilization measures, and out‐of‐pocket medical expenses change when people experience the Medicare Cliff compared with those who maintain their coverage and those who experience temporary disruptions in coverage.\n\n\nMethods\nUsing longitudinal data from the Health and Retirement Study over the period 1998‐2020, we tracked individuals over a 10‐year follow‐up period from when they first became eligible for Medicare.\n\n\nFindings\nOur analysis indicated that even though respondents with Medicaid prior to Medicare eligibility started with better health overall, permanent loss of Medicaid was associated with poorer health outcomes and higher mortality relative to those who kept Medicaid or had a temporary disruption. Permanent loss of Medicaid was also negatively associated with appropriate health care utilization and positively associated with higher out‐of‐pocket health care spending relative to those who kept Medicaid or had a temporary disruption.\n\n\nConclusions\nFindings show that experiencing the Medicare Cliff is associated with a range of negative outcomes, including increases in overall health care expenditures relative to those who maintain Medicaid eligibility or only lose it temporarily. Addressing the Medicare Cliff issue would therefore lead to improved health outcomes and reduced health care costs. Our analysis provides a strong basis for policymakers to address this coverage discontinuity through specific policies related to Medicaid financial eligibility rules and access to Medicare Savings Plans to financially protect older adults.\n\n"]

  February 21, 2026   doi: 10.1111/1468-0009.70076   open full text
• Instruments Measuring Integrated Care: A Systematic Review of Measurement Properties.
  Mary Ann C. Bautista, Milawaty Nurjono, Yee Wei Lim, Ezra Dessers, Hubertus Jm Vrijhoef.
  Milbank Quarterly. December 19, 2016
  Policy Points: Investigations on systematic methodologies for measuring integrated care should coincide with the growing interest in this field of research. A systematic review of instruments provides insights into integrated care measurement, including setting the research agenda for validating available instruments and informing the decision to develop new ones. This study is the first systematic review of instruments measuring integrated care with an evidence synthesis of the measurement properties. We found 209 index instruments measuring different constructs related to integrated care; the strength of evidence on the adequacy of the majority of their measurement properties remained largely unassessed. Context Integrated care is an important strategy for increasing health system performance. Despite its growing significance, detailed evidence on the measurement properties of integrated care instruments remains vague and limited. Our systematic review aims to provide evidence on the state of the art in measuring integrated care. Methods Our comprehensive systematic review framework builds on the Rainbow Model for Integrated Care (RMIC). We searched MEDLINE/PubMed for published articles on the measurement properties of instruments measuring integrated care and identified eligible articles using a standard set of selection criteria. We assessed the methodological quality of every validation study reported using the COSMIN checklist and extracted data on study and instrument characteristics. We also evaluated the measurement properties of each examined instrument per validation study and provided a best evidence synthesis on the adequacy of measurement properties of the index instruments. Findings From the 300 eligible articles, we assessed the methodological quality of 379 validation studies from which we identified 209 index instruments measuring integrated care constructs. The majority of studies reported on instruments measuring constructs related to care integration (33%) and patient‐centered care (49%); fewer studies measured care continuity/comprehensive care (15%) and care coordination/case management (3%). We mapped 84% of the measured constructs to the clinical integration domain of the RMIC, with fewer constructs related to the domains of professional (3.7%), organizational (3.4%), and functional (0.5%) integration. Only 8% of the instruments were mapped to a combination of domains; none were mapped exclusively to the system or normative integration domains. The majority of instruments were administered to either patients (60%) or health care providers (20%). Of the measurement properties, responsiveness (4%), measurement error (7%), and criterion (12%) and cross‐cultural validity (14%) were less commonly reported. We found <50% of the validation studies to be of good or excellent quality for any of the measurement properties. Only a minority of index instruments showed strong evidence of positive findings for internal consistency (15%), content validity (19%), and structural validity (7%); with moderate evidence of positive findings for internal consistency (14%) and construct validity (14%). Conclusions Our results suggest that the quality of measurement properties of instruments measuring integrated care is in need of improvement with the less‐studied constructs and domains to become part of newly developed instruments.

  December 19, 2016   doi: 10.1111/1468-0009.12233   open full text
• Community‐Academic Partnerships: A Systematic Review of the State of the Literature and Recommendations for Future Research.
  Amy Drahota, Rosemary D. Meza, Brigitte Brikho, Meghan Naaf, Jasper A. Estabillo, Emily D. Gomez, Sarah F. Vejnoska, Sarah Dufek, Aubyn C. Stahmer, Gregory A. Aarons.
  Milbank Quarterly. March 14, 2016
  Policy Points: Communities, funding agencies, and institutions are increasingly involving community stakeholders as partners in research, to provide firsthand knowledge and insight. Based on our systematic review of major literature databases, we recommend using a single term, community‐academic partnership (CAP), and a conceptual definition to unite multiple research disciplines and strengthen the field. Interpersonal and operational factors that facilitate or hinder the collaborative process have been consistently identified, including “trust among partners” and “respect among partners” (facilitating interpersonal factors) and “excessive time commitment” (hindering operational factor). Once CAP processes and characteristics are better understood, the effectiveness of collaborative partner involvement can be tested. Context Communities, funding agencies, and institutions are increasingly involving community stakeholders as partners in research. Community stakeholders can provide firsthand knowledge and insight, thereby increasing research relevance and feasibility. Despite the greater emphasis and use of community‐academic partnerships (CAP) across multiple disciplines, definitions of partnerships and methodologies vary greatly, and no systematic reviews consolidating this literature have been published. The purpose of this article, then, is to facilitate the continued growth of this field by examining the characteristics of CAPs and the current state of the science, identifying the facilitating and hindering influences on the collaborative process, and developing a common term and conceptual definition for use across disciplines. Methods Our systematic search of 6 major literature databases generated 1,332 unique articles, 50 of which met our criteria for inclusion and provided data on 54 unique CAPs. We then analyzed studies to describe CAP characteristics and to identify the terms and methods used, as well as the common influences on the CAP process and distal outcomes. Findings CAP research spans disciplines, involves a variety of community stakeholders, and focuses on a large range of study topics. CAP research articles, however, rarely report characteristics such as membership numbers or duration. Most studies involved case studies using qualitative methods to collect data on the collaborative process. Although various terms were used to describe collaborative partnerships, few studies provided conceptual definitions. Twenty‐three facilitating and hindering factors influencing the CAP collaboration process emerged from the literature. Outcomes from the CAPs most often included developing or refining tangible products. Conclusions Based on our systematic review, we recommend using a single term, community‐academic partnership, as well as a conceptual definition to unite multiple research disciplines. In addition, CAP characteristics and methods should be reported more systematically to advance the field (eg, to develop CAP evaluation tools). We have identified the most common influences that facilitate and hinder CAPs, which in turn should guide their development and sustainment.

  March 14, 2016   doi: 10.1111/1468-0009.12184   open full text
• How Successful Is Medicare Advantage?
  JOSEPH P. NEWHOUSE, THOMAS G. McGUIRE.
  Milbank Quarterly. June 03, 2014
  Context Medicare Part C, or Medicare Advantage (MA), now almost 30 years old, has generally been viewed as a policy disappointment. Enrollment has vacillated but has never come close to the penetration of managed care plans in the commercial insurance market or in Medicaid, and because of payment policy decisions and selection, the MA program is viewed as having added to cost rather than saving funds for the Medicare program. Recent changes in Medicare policy, including improved risk adjustment, however, may have changed this picture. Methods This article summarizes findings from our group's work evaluating MA's recent performance and investigating payment options for improving its performance even more. We studied the behavior of both beneficiaries and plans, as well as the effects of Medicare policy. Findings Beneficiaries make “mistakes” in their choice of MA plan options that can be explained by behavioral economics. Few beneficiaries make an active choice after they enroll in Medicare. The high prevalence of “zero‐premium” plans signals inefficiency in plan design and in the market's functioning. That is, Medicare premium policies interfere with economically efficient choices. The adverse selection problem, in which healthier, lower‐cost beneficiaries tend to join MA, appears much diminished. The available measures, while limited, suggest that, on average, MA plans offer care of equal or higher quality and for less cost than traditional Medicare (TM). In counties, greater MA penetration appears to improve TM's performance. Conclusions Medicare policies regarding lock‐in provisions and risk adjustment that were adopted in the mid‐2000s have mitigated the adverse selection problem previously plaguing MA. On average, MA plans appear to offer higher value than TM, and positive spillovers from MA into TM imply that reimbursement should not necessarily be neutral. Policy changes in Medicare that reform the way that beneficiaries are charged for MA plan membership are warranted to move more beneficiaries into MA.

  June 03, 2014   doi: 10.1111/1468-0009.12061   open full text
• Social Media and Internet‐Based Data in Global Systems for Public Health Surveillance: A Systematic Review.
  Edward Velasco, Tumacha Agheneza, Kerstin Denecke, Göran Kirchner, Tim Eckmanns.
  Milbank Quarterly. March 06, 2014
  Context The exchange of health information on the Internet has been heralded as an opportunity to improve public health surveillance. In a field that has traditionally relied on an established system of mandatory and voluntary reporting of known infectious diseases by doctors and laboratories to governmental agencies, innovations in social media and so‐called user‐generated information could lead to faster recognition of cases of infectious disease. More direct access to such data could enable surveillance epidemiologists to detect potential public health threats such as rare, new diseases or early‐level warnings for epidemics. But how useful are data from social media and the Internet, and what is the potential to enhance surveillance? The challenges of using these emerging surveillance systems for infectious disease epidemiology, including the specific resources needed, technical requirements, and acceptability to public health practitioners and policymakers, have wide‐reaching implications for public health surveillance in the 21st century. Methods This article divides public health surveillance into indicator‐based surveillance and event‐based surveillance and provides an overview of each. We did an exhaustive review of published articles indexed in the databases PubMed, Scopus, and Scirus between 1990 and 2011 covering contemporary event‐based systems for infectious disease surveillance. Findings Our literature review uncovered no event‐based surveillance systems currently used in national surveillance programs. While much has been done to develop event‐based surveillance, the existing systems have limitations. Accordingly, there is a need for further development of automated technologies that monitor health‐related information on the Internet, especially to handle large amounts of data and to prevent information overload. The dissemination to health authorities of new information about health events is not always efficient and could be improved. No comprehensive evaluations show whether event‐based surveillance systems have been integrated into actual epidemiological work during real‐time health events. Conclusions The acceptability of data from the Internet and social media as a regular part of public health surveillance programs varies and is related to a circular challenge: the willingness to integrate is rooted in a lack of effectiveness studies, yet such effectiveness can be proved only through a structured evaluation of integrated systems. Issues related to changing technical and social paradigms in both individual perceptions of and interactions with personal health data, as well as social media and other data from the Internet, must be further addressed before such information can be integrated into official surveillance systems.

  March 06, 2014   doi: 10.1111/1468-0009.12038   open full text
• Shifting the Paradigm: Using HIV Surveillance Data as a Foundation for Improving HIV Care and Preventing HIV Infection.
  Patricia Sweeney, Lytt I. Gardner, Kate Buchacz, Pamela Morse Garland, Michael J. Mugavero, Jeffrey T. Bosshart, R. Luke Shouse, Jeanne Bertolli.
  Milbank Quarterly. July 08, 2013
  Context Reducing HIV incidence in the United States and improving health outcomes for people living with HIV hinge on improving access to highly effective treatment and overcoming barriers to continuous treatment. Using laboratory tests routinely reported for HIV surveillance to monitor individuals’ receipt of HIV care and contacting them to facilitate optimal care could help achieve these objectives. Historically, surveillance‐based public health intervention with individuals for HIV control has been controversial because of concerns that risks to privacy and autonomy could outweigh benefits. But with the availability of lifesaving, transmission‐interrupting treatment for HIV infection, some health departments have begun surveillance‐based outreach to facilitate HIV medical care. Methods Guided by ethics frameworks, we explored the ethical arguments for changing the uses of HIV surveillance data. To identify ethical, procedural, and strategic considerations, we reviewed the activities of health departments that are using HIV surveillance data to contact persons identified as needing assistance with initiating or returning to care. Findings Although privacy concerns surrounding the uses of HIV surveillance data still exist, there are ethical concerns associated with not using HIV surveillance to maximize the benefits from HIV medical care and treatment. Early efforts to use surveillance data to facilitate optimal HIV medical care illustrate how the ethical burdens may vary depending on the local context and the specifics of implementation. Health departments laid the foundation for these activities by engaging stakeholders to gain their trust in sharing sensitive information; establishing or strengthening legal, policy and governance infrastructure; and developing communication and follow‐up protocols that protect privacy. Conclusions We describe a shift toward using HIV surveillance to facilitate optimal HIV care. Health departments should review the considerations outlined before implementing new uses of HIV surveillance data, and they should commit to an ongoing review of activities with the objective of balancing beneficence, respect for persons, and justice.

  July 08, 2013   doi: 10.1111/milq.12018   open full text
• Rewarding Healthy Food Choices in SNAP: Behavioral Economic Applications.
  Michael R. Richards, Jody L. Sindelar.
  Milbank Quarterly. June 12, 2013
  Context American obesity rates continue to escalate, but an effective policy response remains elusive. Specific changes to the Supplemental Nutrition Assistance Program (SNAP) have been proposed as one way to improve nutrition and combat obesity among lower‐income populations. While current SNAP proposals hold promise, some important challenges still remain. Methods We discuss the four most common recommendations for changes to SNAP and their benefits and limitations. We then propose three new delivery options for SNAP that take advantage of behavioral economic insights and encourage the selection of healthy foods. Findings Although the existing proposals could help SNAP recipients, they often do not address some important behavioral impediments to buying healthy foods. We believe that behavioral economics can be used to design alternative policies with several advantages, although we recognize and discuss some of their limitations. The first proposal rewards healthy purchases with more SNAP funds and provides an additional incentive to maintain healthier shopping patterns. The second proposal uses the opportunity to win prizes to reward healthy food choices, and the prizes further support healthier habits. The final proposal simplifies healthy food purchases by allowing individuals to commit their SNAP benefits to more nutritious selections in advance. Conclusions Reforming the delivery structure of SNAP's benefits could help improve nutrition, weight, and overall health of lower‐income individuals. We advocate for more and diverse SNAP proposals, which should be tested and, possibly, combined. Their implementation, however, would require political will, administrative capacity, and funding.

  June 12, 2013   doi: 10.1111/milq.12017   open full text
• Supporting Well‐Being in Retirement through Meaningful Social Roles: Systematic Review of Intervention Studies.
  Ben Heaven, Laura J.E. Brown, Martin White, Linda Errington, John C. Mathers, Suzanne Moffatt.
  Milbank Quarterly. June 12, 2013
  Context The marked demographic change toward greater proportions of older people in developed nations poses significant challenges for health and social care. Several studies have demonstrated an association between social roles in later life and positive health and well‐being outcomes. After retiring from work, people may lose roles that provide purpose and social contacts. The outcomes of interventions to promote social roles in retirement have not been systematically reviewed. Methods We examined three research questions: (1) What kinds of intervention have been developed to promote social roles in retirement? (2) How much have they improved perceived roles? (3) Have these roles improved health or well‐being? We included those studies that evaluated the provision of social roles; used a control or comparison group; targeted healthy retirement‐transition adults who were living in the community; provided an abstract written in English; took place in a highly developed nation; and reported social role, health, or well‐being outcomes. We searched eight electronic databases and combined the results with hand searches. Findings Through our searches, we identified 9,062 unique publications and eleven evaluative studies of acceptable quality, which reported seven interventions that met our inclusion criteria. These interventions varied in year of inception and scope, but only two were based outside North America. The studies rarely reported the quality or meaning of roles. Only three studies used random allocation, thus limiting inferences of causality from these studies. Interventions providing explicit roles and using supportive group structures were somewhat effective in improving one or more of the following: life satisfaction, social support and activity, physical health and activity, functional health, and cognition. Conclusions Social role interventions may improve health and well‐being for people in retirement transition. Future research should improve the quality of intervention and assessment and look at which interventions are most effective and acceptable in facilitating social roles for diverse older populations.

  June 12, 2013   doi: 10.1111/milq.12013   open full text
• The Redefinition of Aging in American Surgery.
  Mark D. Neuman, Charles L. Bosk.
  Milbank Quarterly. June 12, 2013
  Context Adults aged sixty‐five and over account for a large fraction of all surgeries performed in the United States each year. While historical growth in rates of surgery in this population is commonly attributed to financial incentives and technological innovations, the shifts in thought that underpinned the spread of surgery among the U.S. elderly remain largely unexplored. We examined changing perspectives on aging over time in American surgery through two case studies: the expansion of general surgical procedures among older U.S. adults between 1945 and 1965, and the spread of coronary artery bypass grafting (CABG) among the U.S. elderly between 1975 and 1995. Methods For this article, we used close readings of historical journal articles, textbook excerpts, survey reports, and government documents related to surgery and aging. Findings Similar perspectives on aging informed the spread of both general surgical procedures among older adults after World War II and CABG in the elderly from the mid‐1970s onward. In each case, surgeons argued against earlier views that surgery was contraindicated in old age using rhetoric that negated the relevance of age to medical decisions. Furthermore, surgeons elevated other types of information—such as the presence or absence of chronic diseases—to supplant age as an explanation for the high operative mortality rates seen among older patients. By stressing the modifiability of operative risk in the elderly, surgeons’ arguments positioned old age itself as a new surgical “frontier.” Conclusions Surgeons’ arguments for the expansion of surgery among the U.S. elderly over time worked to negate the relevance of age to medical decisions and to portray the wider use of surgery in the elderly as uniformly beneficial. While potentially promoting broader access to surgical care, such perspectives may also have contributed to ongoing health policy challenges by normalizing surgery at any stage in the life‐course, with implications for current patterns of surgical utilization and medical spending.

  June 12, 2013   doi: 10.1111/milq.12014   open full text
• The Effects of Quality of Care on Costs: A Conceptual Framework.
  Teryl K. Nuckols, José J. Escarce, Steven M. Asch.
  Milbank Quarterly. June 12, 2013
  Context The quality of health care and the financial costs affected by receiving care represent two fundamental dimensions for judging health care performance. No existing conceptual framework appears to have described how quality influences costs. Methods We developed the Quality‐Cost Framework, drawing from the work of Donabedian, the RAND/UCLA Appropriateness Method, reports by the Institute of Medicine, and other sources. Findings The Quality‐Cost Framework describes how health‐related quality of care (aspects of quality that influence health status) affects health care and other costs. Structure influences process, which, in turn, affects proximate and ultimate outcomes. Within structure, subdomains include general structural characteristics, circumstance‐specific (e.g., disease‐specific) structural characteristics, and quality‐improvement systems. Process subdomains include appropriateness of care and medical errors. Proximate outcomes consist of disease progression, disease complications, and care complications. Each of the preceding subdomains influences health care costs. For example, quality improvement systems often create costs associated with monitoring and feedback. Providing appropriate care frequently requires additional physician visits and medications. Care complications may result in costly hospitalizations or procedures. Ultimate outcomes include functional status as well as length and quality of life; the economic value of these outcomes can be measured in terms of health utility or health‐status‐related costs. We illustrate our framework using examples related to glycemic control for type 2 diabetes mellitus or the appropriateness of care for low back pain. Conclusions The Quality‐Cost Framework describes the mechanisms by which health‐related quality of care affects health care and health status–related costs. Additional work will need to validate the framework by applying it to multiple clinical conditions. Applicability could be assessed by using the framework to classify the measures of quality and cost reported in published studies. Usefulness could be demonstrated by employing the framework to identify design flaws in published cost analyses, such as omitting the costs attributable to a relevant subdomain of quality.

  June 12, 2013   doi: 10.1111/milq.12015   open full text
• Understanding the Components of Quality Improvement Collaboratives: A Systematic Literature Review.
  ERUM NADEEM, S. SERENE OLIN, LAURA CAMPBELL HILL, KIMBERLY EATON HOAGWOOD, SARAH McCUE HORWITZ.
  Milbank Quarterly. June 12, 2013
  Context In response to national efforts to improve quality of care, policymakers and health care leaders have increasingly turned to quality improvement collaboratives (QICs) as an efficient approach to improving provider practices and patient outcomes through the dissemination of evidence‐based practices. This article presents findings from a systematic review of the literature on QICs, focusing on the identification of common components of QICs in health care and exploring, when possible, relations between QIC components and outcomes at the patient or provider level. Methods A systematic search of five major health care databases generated 294 unique articles, twenty‐four of which met our criteria for inclusion in our final analysis. These articles pertained to either randomized controlled trials or quasi‐experimental studies with comparison groups, and they reported the findings from twenty different studies of QICs in health care. We coded the articles to identify the components reported for each collaborative. Findings We found fourteen crosscutting components as common ingredients in health care QICs (e.g., in‐person learning sessions, phone meetings, data reporting, leadership involvement, and training in QI methods). The collaboratives reported included, on average, six to seven of these components. The most common were in‐person learning sessions, plan‐do‐study‐act (PDSA) cycles, multidisciplinary QI teams, and data collection for QI. The outcomes data from these studies indicate the greatest impact of QICs at the provider level; patient‐level findings were less robust. Conclusions Reporting on specific components of the collaborative was imprecise across articles, rendering it impossible to identify active QIC ingredients linked to improved care. Although QICs appear to have some promise in improving the process of care, there is great need for further controlled research examining the core components of these collaboratives related to patient‐ and provider‐level outcomes.

  June 12, 2013   doi: 10.1111/milq.12016   open full text