Our symposium brings to bear novel theory and rigorous empirics on a key topic: the local politics of public health. As a field, urban and local politics has made critical developments in our understanding of social inequality and its implications for democracy. Many social policy components and structures studied in local politics are known as the social or structural determinants of health—high level systems including the built environment and local policies, that have the greatest influence on individual and public health compared to any other factors ( Marmot et al. 2008 ). Yet, urban and local politics has not thought of its contribution to our knowledge of public health directly, despite studying these very systems that overwhelmingly contribute to the health and wellbeing of populations.

Introduction:2024 marked the greatest number of Americans experiencing homelessness ever recorded. Health systems play a pivotal role in caring for unhoused populations, and reducing homelessness decreases healthcare costs and improves health outcomes. As homelessness increases, health systems face mounting pressure to address the social determinants of health, yet little is known about their responses to homelessness. Methods:In 2024, we collected primary data from the 200 largest health systems websites to measure the prevalence of health system homeless mitigation programs and systems-level factors predicting program presence. Results:Over half (56%) of the 200 largest health systems had a homeless mitigation program. The most common program types included affordable and permanent supportive housing, homeless outreach, and shelter medicine. Health systems located in Medicaid expansion states had more than twice the adjusted odds of having a homelessness mitigation program compared with those in non-expansion states (adjusted odds ratio [aOR]: 2.31; 95% CI, 1.11-4.79). Health systems in states with greater shelter capacity were more likely to have a homeless mitigation program, with each additional shelter bed per 10 people experiencing homelessness associated with about 12% higher adjusted odds (aOR: 1.12; 95% CI, 1.01-1.24). Conclusion:As federal spending for safety net programs-including homelessness, housing, and Medicaid-precipitously declines, health systems' homeless mitigation programs may increasingly fill critical policy gaps.

Despite increasing rates of homelessness nationwide, the population of veterans experiencing homelessness continues to decline annually. The U.S. Department of Veterans Affairs (VA) operates in a different policy landscape than other systems seeking to address non-veteran homelessness, including dedicated funding streams to implement their own permanent supportive housing program (PSH). This paper descriptively compares national trends in homeless programming bed inventory and capacity across VA and non-VA homeless response systems from 2017 to 2024. The authors gathered data from HUD to compare trends in annual rates of veteran and non-veteran homelessness and in rates of dedicated veteran and non-veteran beds (emergency shelter, transitional housing, safe havens, rapid re-housing, and PSH), from 2017 to 2024. This research finds that the non-veteran system invests substantially more in emergency shelter compared to all other types of housing, including PSH. By contrast, the veteran system demonstrates the inverse: it invests significantly more in PSH and RRH than in temporary solutions. Veterans experiencing homelessness have substantially greater access to non-emergency shelter resources, specifically permanent supportive housing. This discrepancy is likely due to the VA's early adoption of a housing-first policy, higher federal funding relative to HUD, and access to unique policy levers to secure housing and coordinate supportive services.

Public health capacity can be placed in local public health departments or alternative bureaucracies. Provision of local services through special district (SD) governments has been widely studied in local politics. What have not been examined are the implications of SD governance for the provision of public health services. Public health services are often categorically different from other types of local government services because they address problems affecting the entire local population. Siloing public health governance may influence not only agency capacity to carry out tasks, but the effectiveness and equity of public health solutions. We examine SD governance of local mosquito control in Florida, to analyze differences in policy-design and implementation between SDs and non-SDs across counties. SDs are primarily located in wealthy districts, have substantially greater resources, and provided over limited, sub-county, service-areas. Jurisdictions outside of SD service-provision often have no local mosquito control governance, relying on intergovernmental services.

This study examines the prevalence of specialized police responses to persons experiencing a mental health crisis across U.S. law enforcement agencies and explores whether organizational and community factors are associated with their presence. This study used 2020 data from a nationally representative survey of over 2,500 law enforcement agencies. The primary outcomes included whether agencies implemented one of four responses: (1) designated unit, (2) designated personnel, (3) addressed mental health without designated unit or personnel, or (4) did not address. Logistic regression models assessed factors associated with each response type. Over half (51.0

This article reviews the role of Medicaid waivers in homeless policy and their emerging role as a mechanism to address homelessness. The authors evaluate the political development of waivers in housing and homeless policy over the past thirty years, and they investigate the status of current and approved waivers targeting homelessness. They then consider how waivers may shape homeless policy governance going forward (including the success of existing systems), and they address implementation and efficacy questions related to the role of health care payers in solutions to homelessness. The authors find that the scope of Medicaid waivers for addressing homelessness has always been present, but it significantly expanded after enactment of the Affordable Care Act and more notably following the COVID-19 pandemic. These expansions brought new opportunities for states to fund responses to homelessness through Medicaid social determinants of health provisions providing wraparound medical services for populations at risk of or experiencing homelessness and through time-limited coverage of direct housing costs paired with payment for essential medical services. More than one third of states have an 1115 waiver specifically targeting homelessness, with nearly one in five states including provisions that cover direct housing costs (e.g., rent). Going forward, Medicaid's involvement in homeless policy has the potential to reshape state and local responses to homelessness.

Context: As inequality grows, politically powerful health care institutions-namely Medicaid and health systems-are increasingly assuming social policy roles, particularly related to solutions to homelessness. Medicaid and health systems regularly interact with persons experiencing homelessness who are high users of emergency health services and who experience frequent loss of or inability to access Medicaid services because of homelessness. This research examines Medicaid and health system responses to homelessness, why they may work to address homelessness, and the mechanisms by which this occurs. Methods: The authors collected primary data from Medicaid policies and the 100 largest health systems, along with national survey data from local homelessness policy systems, to assess scope and to measure mechanisms and factors influencing decision-making. Findings: Nearly one third of states have Medicaid waivers targeting homelessness, and more than half of the 100 largest health systems have homelessness mitigation programs. Most Medicaid waivers use local homelessness policy structures as implementing entities. A plurality of health systems rationalizes program existence based on the failure of existing structures. Conclusions: Entrenched health care institutions may bolster local homelessness policy governance mechanisms and policy efficacy. Reliance on health systems as alternative structures, and implementing entities in Medicaid waivers, may risk shifting homelessness policy governance and retrenchment of existing systems.

Objectives: We conduct a rapid review of the post-COVID-19 vaccination efforts undertaken by Denmark, the United States, and Canada. The main areas of focus are threefold: 1) To analyze the timeline of the rollout and access/barriers to vaccinations considering the changing dynamics of COVID-19 and the launch of new generation booster -vaccines across the case countries. 2) To examine sociopolitical factors related to this juxtaposition between lower booster acceptance, despite higher rates of initial vaccine series, in each of the three cases. 3) To determine how each country is moving forward with their ongoing COVID-19 strategies for long-term mitigation planning. Methods: We followed a Most Similar Systems Design (MSSD) framework to select our cases. We analyze country responses amongst high -income, OECD countries, who shared Western or liberal Democracy, with a formal framework of rule of law, presence of a legal authority and the independence of the judiciary, but differ in their rollout and uptake of the vaccine booster. Results: Despite variation in booster uptake, all three countries ' COVID-19 mitigation responses became more similar over time, and each country experienced lower than expected booster uptake. Conclusions: Decline in booster doses across each country was related to broad declines in concern about the virus in each location. However, cases with higher uptake of the initial series and use of NPIs, in Denmark and Canada, continue to fare better in morbidity and mortality from COVID-19, despite dwindling booster uptake. Public Interest Summary: This study looks at how three high income western democracies (Denmark, the United States and Canada) handled the COVID-19 pandemic and booster vaccinations. We briefly look at the initial outbreak of the pandemic, contextualize the initial (pre -booster) vaccination uptake and then assess the booster vaccine uptake. We find that although the countries differ in their approach during the initial stages of COVID-19 and vaccination policy, they all share similarly low booster vaccine uptake. Yet, even with a similarly low booster uptake, each of the countries continue to exhibit differences in morbidity, mortality and disparities associated with COVID-19. The implications of this research are clear - providing access to vaccinations, boosters, testing, and treatment are essential in combating inequalities in COVID-19 outcomes. Overlaying these implications is the importance of a continuously updated national strategy for future pandemics is important.

Why has it been so difficult to reform U.S. policing? We provide a theoretical argument that understanding of the entrenched militarisation and accountability problems of U.S. police departments would benefit from using theory in comparative research on civil–military relations. American police forces undermine local democracy by encroaching upon the decision-making powers of city officials in ways that resemble militaries in fragile democracies. Applying historical and contemporary evidence and existing scholarly research on policing, we explain police militarisation was initiated by civilian leaders of city governments to garner governmental legitimacy, and by-proxy police support, in racialised contexts. Trading off city governments’ institutional strength in order to maintain legitimacy produced opportunities for police insubordination or subversion of city government oversight of police activity. Consequently, cities with low public legitimacy and/or weak municipal institutions, faced with high demands by militarised police departments, may be more likely to experience police subversion of democratic accountability over police activity.

Substantial global attention is focused on how to reduce the risk of future pandemics. Reducing this risk requires investment in prevention, preparedness, and response. Although preparedness and response have received significant focus, prevention, especially the prevention of zoonotic spillover, remains largely absent from global conversations. This oversight is due in part to the lack of a clear definition of prevention and lack of guidance on how to achieve it. To address this gap, we elucidate the mechanisms linking environmental change and zoonotic spillover using spillover of viruses from bats as a case study. We identify ecological interventions that can disrupt these spillover mechanisms and propose policy frameworks for their implementation. Recognizing that pandemics originate in ecological systems, we advocate for integrating ecological approaches alongside biomedical approaches in a comprehensive and balanced pandemic prevention strategy.

Many American cities are in the midst of a homelessness crisis. Through their control over zoning and land use policy, local governments can reduce homelessness by facilitating housing construction and improving housing affordability. Using administrative data and surveys of local public officials, this paper asks whether (and which) cities connect their homelessness and land use policies. We find that cities rarely link homelessness policies with zoning and land use. Cities in California and the Pacific region are generally more likely to make these connections, suggesting an important state role in guiding local homeless and planning policies. Cities with high and low levels of unsheltered homelessness show little difference in their propensity to connect land use and zoning policies with homelessness.

Climate Action is one of the United Nation's Sustainable Development Goals. Yet, despite calls for action, global governments have broadly not taken consequential change to reduce carbon outputs and mitigate warming. Our chapter argues that a primary cause of this inaction is political conflict and policy capacity. Without strong economic incentives and facing constrained resources, governments may opt to proceed with the status quo. Here, health systems present a critical resource to engage nations in climate action. Health systems produce political leverage as major political stakeholders across nations, globally, for engaging in broader climate policy and a wealth of resources inherent to health systems – expertise, funding – to directly implement climate policy. The case study of the city of Toronto in Canada offers lessons for directly involving health systems in subnational climate action as policy stakeholders and implementors, and the co-benefits health system engagement brings to promote climate action intersectorally. Toronto provides an important case for high-latitude countries that will soon be facing climate hazards tropical nations have been grappling with for centuries. Engaging health systems in climate action policy processes may improve the likelihood of success for strengthening resilience and adaptivity to climate related hazards.

Abstract The COVID-19 pandemic of 2020 was one of the rare events that shocked almost every world government simultaneously, thus creating an unusual opportunity to understand how political institutions shape policy decisions. There have been many analyses of what governments did. We focus instead on what they could do, focusing on the institutional politics of agency – how institutions empower rather than how they constrain, and how they affect public policy decisions. We examine public health measures in the first wave (March-September 2020) in Brazil, India, and the U.S. to understand how the interplay of institutions in a complex federal context shaped COVID-19 policy-responses. We find similar patterns of concentrated federal executive agency with limited constraints. In each case, when federal leadership failed public health policy responses, federated, subnational states were left to compensate for these inefficiencies without necessary resources.

How did partisanship influence rhetoric about, public opinion of, and policies that prioritize racial and ethnic health disparities of COVID-19 during the first wave of the pandemic between March and July 2020? In this retrospective, mixed-methods analysis using national administrative and survey data, we found that the rhetoric and policy of shared sacrifice diminished and partisan differences in pandemic policy increased once it became clear to political elites that there were major racial disparities in COVID-19 cases and deaths. We trace how first disparities emerged in data and then were reported in elite, national media, discussed in Congress, and reflected in public opinion. Once racial disparities were apparent, partisan divides opened in media, public opinion, and legislative activity, with Democrats foregrounding inequality and Republicans increasingly downplaying the pandemic. This temporal dimension, focusing on how the diffusion of awareness of inequalities among elites shaped policy in the crucial months of early 2020, is the principal novel finding of our analysis. Overall, there is a clear, partisan policy response to addressing COVID-19 racial disparities across media, public opinion, subnational legislative activity, and congressional deliberations.

Homelessness is a public health crisis affecting millions of Americans every year, with severe consequences for health ranging from infectious diseases to adverse behavioral health outcomes to significantly higher all-cause mortality. A primary constraint of addressing homelessness is a lack of effective and comprehensive data on rates of homelessness and who experiences homelessness. While other types of health services research and policy are based around comprehensive health datasets to successfully evaluate outcomes and link individuals with services and policies, there are few such datasets that report homelessness. Gathering archived data from the US Department of Housing and Urban Development, we created a unique dataset of annual rates of homelessness, nationally, as measured by persons accessing homeless shelter systems, for 11 years (2007–2017, including the Great Recession and prior to the start of the 2020 pandemic). Responding to the need to measure and address racial and ethnic disparities in homelessness, the dataset reports annual rates of homelessness across HUD selected, Census-based racial and ethnic categories. Between 2007 and 2017, across all types of sheltered homelessness, whether individual, family, or total, Black, American Indian or Alaska Native, and Native Hawaiian and Pacific Islander individuals and families were far more likely to experience homelessness than non-Hispanic White individuals and families. Particularly concerning about the rates of homelessness among these populations is the persistent and increasing nature of these disparities across the entire study period. While homelessness is a public health problem, the hazard of experiencing homelessness is not uniformly distributed across different populations. Because homelessness is such a strong social determinant of health and risk factor across multiple health domains, it deserves the same careful annual tracking and evaluation by public health stakeholders as other areas of health and health care.

Oppression and inequality, as critical social and structural determinants of health, are key threats to public health. Democratic stability provides institutional measures to mitigate oppression and inequality. We investigate trends in democratic backsliding in the Organization for Economic Co-operation and Development (OECD) nations, overall, and compare trends in backsliding among specific indicators of democracy relevant to public health based on protections against oppression and inequality. We leverage a comprehensive, longitudinal, data set (V-DEM), capturing key indicators of democracy in OECD nations from 2010 to 2020. Indicators were selected from the scholarly literature on democracy and health for their effects on oppression and inequality. We observe trends over time in democratic stability among OECD nations, overall, and then compare trends in democratic stability or backsliding across OECD nations within categories of democratic indicators established to mitigate oppression and inequality. Democracy is declining across all OECD nations. Broad democratic declines are shown between types of OECD member states. Country income is not necessarily protective for democratic stability. We find specific declines in two measures with immediate implications for public health-Civil Liberties and Integrity of the Courts-across at least half of all OECD nations and a particularly alarming level of change in the United States. Politics shape and limit public health. Declining components of democracy can have both short- and long-term consequences for population health by increasing inequality and reducing mechanisms to protect against oppressive tactics. Public health can play an important role in improving democracy by strengthening accountability.

Objectives:This paper presents an overview of the vaccination policy responses to the COVID-19 pandemic in Denmark, Canada, and the United States until September 1, 2021. The article seeks to understand the reasons for vaccination differences among high-income, liberal democracies. Methods:The country cases were selected based on tiers of population-level vaccination uptake within six months after vaccines became broadly available (for high-income countries). We conducted a rapid review of primary data for each country case. Through a graphical and descriptive analysis, we evaluated common patterns as well as significant divergences in the vaccination rollout across countries and its relationship with COVID-19 health outcomes, government policy responses, resource constraints, and socio-political factors. This inductive analysis provides a sense of how resource constraints compare with current political contexts in each country case that may influence the public's response to a national vaccination strategy. Results:Resources, socio-economic factors, and health outcomes related to COVID-19 do not ensure vaccination policy success as the case of the United States makes clear. Instead, trust in government and health systems appear to promise a higher vaccination uptake and maintained support for measures during a pandemic. Trust in government can be defined as the confidence citizens have that governmental actions will do what is right and perceived as fair. Conclusion:Denmark, the United States, and Canada are high-income liberal democracies with very different vaccine strategies and subsequently different vaccination outcomes across their populations. What appears to be critical to successful vaccination outcomes is high trust in government or health officials, along with the depoliticization of the COVID-19 pandemic among the country's political parties.

CONTEXT:Homeless policy advocates viewed Medicaid expansion as an opportunity to enhance health care access for this vulnerable population. We studied Medicaid expansion implementation to assess the extent to which broadening insurance eligibility affected the functioning of municipal homelessness programs targeting chronic homelessness in the context of two separate governance systems.METHODS:We employed a comparative case study of San Francisco, California, and Shreveport, Louisiana, which were selected as exemplar cases from a national sample of cities across the United States. We conducted elite interviews with a range of local-level stakeholders and combined this data with primary-source documentation.FINDINGS:Medicaid expansion did not substantially enhance the functioning of homelessness programs and policies because of Medicaid access challenges and governance conflicts. Administrative burden and funding limitations contributed to limited provider networks, inadequate service coverage, and lack of linkages between Medicaid enrollment and homelessness programming. Governance conflicts reinforced these functional challenges, with homelessness under the administration of local municipalities and nongovernmental organizations while states administer Medicaid.CONCLUSIONS:Improving access to health care services for persons experiencing homelessness cannot occur without intentional coordination between sectors and levels of government and thus necessitates the development of targeted policies and programs to overcome these challenges.

COVID-19 is not the first, nor the last, public health challenge the US political system has faced. Understanding drivers of governmental responses to public health emergencies is important for policy decision-making, planning, health and social outcomes, and advocacy. We use federal political disaster-aid debates to examine political factors related to variations in outcomes for Puerto Rico, Texas, and Florida after the 2017 hurricane season. Despite the comparable need and unprecedented mortality, Puerto Rico received delayed and substantially less aid. We find bipartisan participation in floor debates over aid to Texas and Florida, but primarily Democrat participation for Puerto Rican aid. Yet, deliberation and participation in the debates were strongly influenced by whether a state or district was at risk of natural disasters. Nearly one-third of all states did not participate in any aid debate. States' local disaster risk levels and political parties' attachments to different racial and ethnic groups may help explain Congressional public health disaster response failures. These lessons are of increasing importance in the face of growing collective action problems around the climate crisis and subsequent emergent threats from natural disasters.