Abstract Context: Development and implementation of multiprogram applications remain understudied. This study estimated enrollment gaps due to administrative burden and state policy environments, and explored state, nonprofit, policy, and caregiver stakeholders' perspectives on application design and implementation. Methods: This mixed methods study included Children's HealthWatch survey responses from 39,321 caregivers of young children (2009-2019), and interviews and focus groups with 25 stakeholders. Administrative burden theory provided a conceptual basis for diagnosing participant-facing system barriers underlying multi-benefit under-enrollment and the Consolidated Framework for Implementation Research (CFIR) characterized contextual determinants of multi-benefit application (i.e., policy innovation) design, implementation, and uptake. Using multinomial and binary logistic regression, enrollment gaps (non-participation in >1 of four safety-net programs: Medicaid, SNAP, TANF, WIC) were analyzed by non-participation reasons (administrative burden costs) and state policy environments (State Safety-Net Generosity Index (SSGI)). Transcripts were analyzed thematically using a hybrid inductive-deductive approach grounded in CFIR. Findings: Enrollment gaps were significantly higher among caregivers reporting compliance and learning costs. Higher SSGI scores (more generous) were associated with significantly lower odds of enrollment gaps. Four qualitative themes emerged: (1) Incentives that help or hurt application implementation and uptake, (2) Benefit implementers' accountability - to and for whom [Subtheme 2.1: Lack of transparency leads to mistrust and 2.2: Governance structures streamline or complicate] (3) (Re)defining efficiency—whose time is valuable? and (4) Meaning of engagement in application design. Conclusions: This study advances administrative burden theory by demonstrating how program applicants' administrative burden costs compound across multiple programs, revealing implementation mechanisms that perpetuate barriers. States working to improve co-enrollment must pay attention to unspoken incentives, reboot efficiency's definition, and deeply engage all stakeholders.
Abstract Context: In March 2021, Congress expanded the Child Tax Credit (CTC) and subsequently allowed those expansions to expire at year-end. This study explored mothers' understanding and perceptions of the expanded CTC and family well-being and economic hardship. Methods: Twenty US-born and immigrant mothers of young children surveyed pre-pandemic in Boston, Minneapolis, and Little Rock participated in follow-up focus groups, in-depth or dyadic interviews (09/2021-05/2022). Mothers shared pandemic-related experiences about economic hardships, family health, and their understanding and perceptions of the CTC. Discussions were transcribed verbatim and analyzed thematically with inductive and deductive approaches. Findings: Six themes resulted: 1) Unclear public communication about the CTC drove misunderstanding and misinformation; 2) Benefit delivery structures created barriers to access; 3) Monthly payments allowed parents to attend to their families' unique needs; 4) Cash facilitated choices that supported parent mental health and self-perception; 5) CTC expiration felt like a broken social contract, and 6) Experiences of racism shaped self-perception and life context. Conclusions: Insufficient outreach and challenges navigating unfamiliar tax systems created access barriers. Advance payments reshaped mothers' self-perception as parents. CTC expiration contributed to a sense of broken trust in government. Permanently expanding the CTC would support family well-being and trust in government.
Abstract Context: Local health departments provide essential public health services, yet many counties lack them, and those that exist struggle with ongoing funding needs. The COVID-19 pandemic politicized public health, raising questions about how political framing affects public willingness to pay for these services. Methods: Participants in a contingent valuation experiment (N = 1,946) were recruited from Lancaster County in south-central Pennsylvania. They received information about local health department services and were randomized into conditions emphasizing either COVID-19 prevention or elevated blood lead level reduction–a less politically salient public health threat. Using interval regression, we estimate willingness to pay (WTP) for local health department services, identify its determinants, and examine treatment effects by party affiliation. Findings: Mean annual WTP for local health department services was $138.22 (95% CI: $121.34, $139.73). Republicans showed a $165.60 lower WTP to pay than Democrats (p < 0.001). We observed no statistical differences within political affiliations to issue framing. Conclusions: Partisan differences in support for local health departments persist, yet preferences remain stable across politicized frames. These findings suggest that polarization in public health attitudes reflects entrenched partisan identities more than frame-dependent views, underscoring the need for strategies that build durable cross-partisan trust and institutional legitimacy.
Abstract Context: Individuals' attitudes towards health policy are affected in part by their own experiences navigating the health care system. In the United States, this experience is comprised of both interactions with insurance providers and those with care providers. This study explores the causal effect of recalling these two types of interactions on policy attitudes. Methods: In a pre-registered survey experiment of N = 1294 US adults, participants are randomly assigned to recall personal experiences with either insurance providers or health care providers, then examine how making these experiences salient shapes preferences and attitudes. Findings: Recalling insurance versus provider experiences does not affect policy attitudes as compared to a control condition. Conclusions: A popular narrative holds that Americans are deeply dissatisfied with insurance coverage, and this dissatisfaction might alter policy attitudes. However, the results of this study suggest that many (though not all) Americans are reasonably satisfied with their insurance, and that even those asked to recall insurance experiences in detail do not become more supportive of government intervention in health care. Thus, interventions seeking to leverage insurance dislike to induce attitude change may need to explicitly make negative experience salient rather than assuming that dissatisfaction is most Americans' default state.
Abstract Context: In 2023, the National Institute on Minority Health and Health Disparities (NIMHD) denied people with disabilities a health disparities population designation. The decision occurred amid growing recognition of ableism as a health determinant and calls to reorient disability research toward health equity. Although reversed, the rejection represents a key episode for understanding how disability is studied in public health. Methods: This article presents a discourse analysis of texts related to the NIMHD rejection. Drawing on meeting materials and reports, the analysis examines discursive strategies used in deliberations, which were synthesized into three themes. Findings: Three themes structured NIMHD's decision-making process: 1) (bio)medical models undermined the recognition of disability as a social position; 2) health disparities were framed as corruptible, both conceptually and administratively vulnerable to the inclusion of disabled people; and 3) characterizing disability as “large and heterogeneous” transformed diversity into institutional risk, justifying the segregation of disabled people from health equity projects. Conclusions: Overall, this case illustrates how ostensibly neutral and scientific reasoning can reproduce ableism and narrow the scope of health disparities research, underscoring the need for equity frameworks that treat disability as a legitimate axis of social inequality not an exception or burden.
The No Surprises Act aimed to accomplish two objectives: protect consumers from surprise medical bills and contain health care costs. While the statute has successfully accomplished its first aim, implementation of the independent dispute resolution (IDR) process-the process within the law intended to settle payment disputes and contain costs-has been wrought with litigation and rulemaking challenges. As a result, implementation has led to unintended consequences that may inadvertently add to, rather than reduce, health care costs. This article provides insights on the successes and challenges of rulemaking, and offers suggestions on how to insulate future policies from legal challenges and issues in implementation.
The Budget Reconciliation Act of 2025 (HR.1) adopts major changes in Medicaid, with far-reaching ramifications for long-term services and supports (LTSS). Although the law creates a new home and community-based services (HCBS) waiver option for beneficiaries "at risk" of institutionalization, its impact will be limited, given widespread Medicaid retrenchment. A national home-equity cap will increasingly require individuals to spend down housing assets to qualify for LTSS coverage. A ten-year moratorium on federal minimum nursing home staffing standards removes a tool for improving quality. New restrictions on states' use of provider taxes and directed payments, combined with substantial reductions in federal Medicaid spending, will constrain state financing. In response, states will likely lower provider reimbursement, tighten eligibility, and restrict the scope and duration of LTSS, particularly HCBS. Shortened retroactive eligibility windows, more frequent eligibility redeterminations, and burdensome workforce requirements will further destabilize the direct care work force and place additional pressure on family caregivers. Absent corrective policy action, HR.1's Medicaid provisions risk further weakening an already inadequate LTSS infrastructure during a period of growing unmet need, when rising demand has outpaced caregiving capacity.
CONTEXT:Front-of-package warning labels on junk foods, first implemented in Chile in 2016, have diffused rapidly despite sustained opposition. This pattern challenges policy diffusion frameworks that inadequately explain how contested regulatory innovations spread. I propose communicative infrastructure-durable channels and routines enabling coordinated cross-national action-as a governance lever in global health policy transfer. METHODS:Mixed-methods comparative case study of Chile, Mexico, and Peru using elite interviews (N = 18), document and media analysis (N≈200), participant observation and public meeting transcripts (2019-2025). Process tracing identified causal mechanisms. FINDINGS:Three communicative mechanisms enabled policy diffusion despite industry contestation: strategic frame adaptation aligned policy rationales with diverse political cultures; coordinated counter-messaging provided policymakers with ready-to-deploy evidence to neutralize industry arguments; and, through networked knowledge exchange, national actors shared implementation lessons, enabling later adopters to design robust policies before adoption. These mechanisms operated synergistically as infrastructure, or systems that proved resilient to political turnover, legal challenges, and corporate resistance. CONCLUSIONS:This study extends policy diffusion theory by theorizing communication as infrastructure and demonstrating how it enables diffusion in contested regulatory spaces where traditional mechanisms prove insufficient. Findings contribute to scholarship on transnational advocacy networks, commercial determinants of health, and South-to-North policy flows.
In this issue, Muruganand et al. report the work of the Oregon Health Services Commission, a group tasked by Governor Kitzhaber with prioritizing coverage for health services in Medicaid so that all people living under the poverty level could be included. Federal and state policy makers continue to search for ways to constrain Medicaid spending. The problem of how to fairly allocate limited resources for healthcare (and other determinants of health) is both urgent and enduring. Allocating limited state and federal funds for Medicaid challenges us to consider equal opportunity, keeping in mind that opportunity benefits not merely from healthcare coverage but from other safety net programs that support housing, education, childcare, nutrition and more. The Oregon Health Services Commission, like other entities then and since, learned that a purely formulaic approach to costs and benefits can create results that fly in the face of moral reason. Participatory budgeting and public deliberations about spending priorities for health, informed by and in conjunction with high quality evidence about costs and outcomes, could inform and perhaps make "just enough" decisions about allocating scarce resources that affect health.
CONTEXT:In 1989, Oregon passed SB 27, overhauling Medicaid by insuring all impoverished residents while explicitly rationing covered treatments. Rather than excluding some of the poor, the state established the Oregon Health Services Commission (OHSC), an eleven-person citizen body tasked with developing a prioritized list of 1,600 condition-treatment pairings based on cost-effectiveness and public values. This effort became central to debates over who should determine the availability of health services in public insurance programs. METHODS:We analyzed a new data source - meeting minutes and internal documents from 1990-1991 - using reflexive thematic analysis in ATLAS.ti. Themes centered on commissioners' emotional experiences, technical challenges, and the role of subjective decision-making, situated within broader discussions of judgement in participatory governance and cost-effectiveness analysis. FINDINGS:The Commission faced profound technical obstacles, namely limited data, methodological uncertainty, and growing frustration under public pressure. As technical approaches faltered, commissioners increasingly relied on collective judgment to complete the list. CONCLUSIONS:The common narrative that the OHSC abandoned technical rigor overlooks the reality that health policy decisions always embed subjective judgements. Its innovation was affording those judgements to citizens rather than experts or politicians. Reliance on subjectivity reflected the nature of cost-effectiveness analyses and participatory governance, not failure.
CONTEXT:In June 2022, the Dobbs decision rescinded abortion rights in the US. Did this mobilize women's healthcare providers, whose jobs and patients' health were impacted? We measure mobilization in two ways: 1. Engagement in a physician-led get-out-the-vote (GOTV) drive; and 2. Turnout in the 2022 midterms. METHODS:Using a novel dataset of 6,205 physicians involved in a healthcare-based GOTV campaign and voter file data, we utilize linear probability models, t-tests, and parametric regression discontinuity analysis to show that women's healthcare providers were more politically engaged than physicians in other specialties. FINDINGS:In 2022, the percentage of GOTV participants specializing in women's health increased by 50% and the share of women's health provider participating in the GOTV program spiked by 4.8-6.7 percentage points (p < 0.05). Regarding turnout, 6.4% of women's health providers were first-time midterm voters, compared to 5.7% for other physicians. Overall, women's health providers were 3.3 percentage points more likely to vote (p < 0.05) in the first post-Dobbs election than other physicians. Among Democratic physicians, women's health providers were 6.3 percentage points more likely to vote than others. CONCLUSIONS:Our findings have implications for mobilization research and GOTV strategies by highlighting that individuals directly impacted by policy changes are motivated to engage politically.
CONTEXT:Arguably, the most pressing issues in Medicare financing today center on Medicare Advantage (MA). Rising MA enrollment may lower TM spending via a spillover effect wherein cost-efficient practices in MA are applied to TM enrollees. At the same time, growing MA enrollment results in a shrinking share of TM enrollees, raising concerns about how MA plans are reimbursed, since MA payments and rebates depend, in part, on average TM spending. METHODS:This study estimates the effect of MA enrollment shares on per-enrollee TM spending using county-level CMS data. TM spending is the product of three factors: a local price index for TM services, average price- and risk-adjusted spending per enrollee ("quantity" of services used), and average TM risk scores. We estimate the effect of MA enrollment shares on each factor. FINDINGS:Increased MA enrollment is associated with a statistically significant reduction in TM price- and risk-adjusted spending. MA enrollment is linked to reduced outpatient service use and reduced use of procedures, tests, imaging, durable medical equipment, and ambulance services among TM enrollees. CONCLUSIONS:Reduced spending in TM from rising MA enrollment is a form of Medicare savings that offsets, to a small degree, the substantial estimated overpayments made to MA plans.
Throughout the first months of President Donald Trump's second term in office, his administration has taken swift action to undermine the role that government health agencies play in the health policy-making process. This article makes the case that the Trump administration's efforts to undermine government health agencies' regulatory authority reflect a dislike and distrust of the people who serve in key civil service roles. It also provides evidence that efforts to roll back regulatory authority are part of a long-standing political strategy to cater to public dislike and distrust of scientific, medical, and academic experts. While the public could provide policy makers with an incentive to protect public health agencies and the people who staff them, recent public opinion research shows that many Americans simply do not know or do not care enough about the Trump administration's actions to call for their elected officials to stop them. This article concludes by offering several health communication strategies and directions for future research (the "science of standing up for science") that might inspire public concern about efforts to roll back government health agencies' regulatory authority and might motivate people to show support for the civil servants who staff those agencies.
Public health is under siege in the United States-particularly the parts of the field that focus on health equity. Although it may be tempting to abandon health equity efforts during this siege, this article argues that would be a mistake for the field. Research on the history of public health has shown that health equity pursuits were essential for building the field, and contemporary research continues to find that health equity pursuits remain popular and are effective for mobilizing large and diverse segments of the population to engage in individual and collective actions that advance the field's goals. The pursuit of equitable and healthy futures may be one of the effective pathways for sustaining the field's future.
Health care cost benchmark programs have emerged as states seek to curb health care cost growth. States feel the adverse effects of rising health care expenditures acutely through Medicaid, employee health benefit programs, and the growing burden of benefit costs on private-sector employers. Beginning with Massachusetts in 2013, eight states have established benchmarks through executive action or legislation. These programs set cost-growth benchmarks and collect data to compare spending trends to the benchmarks at multiple levels, from statewide performance to individual providers and insurers. Many states employ a graduated strategy to promote compliance with benchmarks, ranging from public reporting of provider and insurer performance to imposing sanctions for persistent growth above targets. The effectiveness of these initiatives is not yet clear, in part because most programs are relatively new, and early trends were obscured by the pandemic. Several factors suggest that benchmark programs may ultimately achieve meaningful, sustainable impact, including mounting cost pressures, broad support for transparency, and phased enforcement approaches. However, entrenched interests, the need for ongoing investment in program infrastructure, and the inherent complexity of health care cost containment present significant challenges.
CONTEXT:In the US, the trade-off between incentivizing innovation and providing affordable medicines is managed by government regulation. New medicines are provided a lucrative period of exclusivity that is followed by competitive entry and lower prices. For small-molecule drugs, generic competition is now common, whereas for most biologics, biosimilars are unavailable, and the regulations governing competition are relatively new. METHODS:The authors compared the nominal patent term (time between originator/brand entry and the latest patent expiration date) and effective market life (time between originator/brand entry and biosimilar/generic entry) of the 15 biologics and 141 small molecules experiencing competitive entry during 2015-25. They also examined how litigation outcomes affected these outcomes. FINDINGS:Despite having a much longer nominal patent term, the effective market life of biologics was similar to small-molecule drugs in recent years. Biosimilars were more likely to be launched during active patent litigation, whereas generics were more likely to be launched after settlements. CONCLUSIONS:Although biosimilars are still relatively rare, the patent litigation structure does not appear to be slowing competitive entry for biologics relative to small-molecule drugs. Biosimilar competition may become more common as biologics advance in their life cycle and regulations are brought to bear.
CONTEXT:Scholars have long shown that policies outside health care-such as labor market, housing, and social assistance policies-affect health. Health in All Policies (HiAP) is a collaborative policy approach that integrates health into these sectors. Most research on HiAP adoption focuses on a few well-known cases, highlighting the importance of policy learning and political dynamics. This article updates this knowledge by analyzing the Netherlands alongside Finland and England to ask: How can we understand HiAP adoption in the Netherlands? METHODS:The authors studied the Dutch case using primary and secondary sources and compared it to Finland and England as shadow cases based on existing analyses in secondary sources. FINDINGS:Policy learning is necessary but not sufficient for HiAP adoption. In the Netherlands, adoption was not partisan, yet it was still political. The key factor driving HiAP adoption in the Netherlands was the political salience of health inequality. This factor played this decisive role in the shadow cases as well, albeit less visibly. CONCLUSIONS:The Dutch case shows that HiAP can be a product of coalitional strategies outside legislative politics and can respond to those coalitions' formulations of problems. Policy learning and political salience are both important, but it is their interaction that best explains whether HiAP is adopted.
CONTEXT:Racial inequality remains a central, entrenched characteristic of American health and health care, and racial discourse strongly shapes health politics and policy. Despite this, discussions of race and health are rare in a core site of health policy making-the presidency-although this varies across historical periods and political parties. This study examines the prevalence and nature of racial discourse in 90 years of presidential health speeches, from Franklin D. Roosevelt to Joe Biden, addressing in particular a debate about whether racial discourse rose or fell after the civil rights era. METHODS:The author performed quantitative content analysis and qualitative analysis of 1,359 presidential health speeches from Roosevelt to Biden. FINDINGS:Attention to race was higher among Democrats than Republicans. It rose sharply during the civil rights era and the COVID-19 pandemic but fell during the intervening period, with most presidents discussing race and health less than same-party civil rights-era benchmarks Johnson and Nixon. Qualitative analysis shows that presidents of both parties mainly engaged in positive (though sometimes paternalistic) racial discourse, but they often combined it with universalist or technical language, perhaps meant to reduce white backlash. CONCLUSIONS:The study speaks to debates about the prominence, nature, and causes of racial discourse in policy making and shows how presidents balance racial particularism and universalism.
