Category Archives: Health Care

State Policies, Racial Disparities, and Income Support: A Way to Address Infant Outcomes and the Persistent Black-White Gap?

Source: Jessica Pearlman; Dean E. Robinson, Journal of Health Politics, Policy and Law, Vol. 47 no. 2, April 2022
(subscription required)

From the abstract:
Low birth weight and preterm births vary by state, and Black mothers typically face twice the risk that their white counterparts do. This gap reflects an accumulation of psychosocial and material exposures that include interpersonal racism, differential experience with area-level deprivation such as residential segregation, and other harmful exposures that the authors refer to as “institutional” or “structural” racism. The authors use logistic regression models and a dataset that includes all births from 1994 to 2017 as well as five state policies from this period—Aid to Families with Dependent Children/Temporary Aid for Needy Families, housing assistance, Medicaid, minimum wage, and the earned income tax credit (EITC)—to examine whether these state social policies, designed to provide a financial safety net, are associated with risk reduction of low birth weight and preterm birth to Black and white mothers, and whether variations in state generosity attenuate the racial inequalities in birth outcomes. The authors also examine whether the relationship between state policies and racial inequalities in birth outcomes is moderated by the education level of the mother. We find that the EITC reduces the risk of low birth weight and preterm birth for Black mothers. The impact is much less consistent for white mothers. For both Black and white mothers, the benefits to birth outcomes are larger for mothers with less education.

No Equity without Data Equity: Data Reporting Gaps for Native Hawaiians and Pacific Islanders as Structural Racism

Source: Brittany N. Morey; Richard Calvin Chang; Karla Blessing Thomas; ‘Alisi Tulua; Corina Penaia; Vananh D. Tran; Nicholas Pierson; John C. Greer; Malani Bydalek; Ninez Ponce, Journal of Health Politics, Policy and Law, Vol. 47 no. 2, April 2022
(subscription required)

From the abstract:
Data on the health and social determinants for Native Hawaiians and Pacific Islanders (NHPIs) in the United States are hidden, because data are often not collected or are reported in aggregate with other racial/ethnic groups despite decades of calls to disaggregate NHPI data. As a form of structural racism, data omissions contribute to systemic problems such as inability to advocate, lack of resources, and limitations on political power. The authors conducted a data audit to determine how US federal agencies are collecting and reporting disaggregated NHPI data. Using the COVID-19 pandemic as a case study, they reviewed how states are reporting NHPI cases and deaths. They then used California’s neighborhood equity metric—the California Healthy Places Index (HPI)—to calculate the extent of NHPI underrepresentation in communities targeted for COVID-19 resources in that state. Their analysis shows that while collection and reporting of NHPI data nationally has improved, federal data gaps remain. States are vastly underreporting: more than half of states are not reporting NHPI COVID-19 case and death data. The HPI, used to inform political decisions about allocation of resources to combat COVID-19 in at-risk neighborhoods, underrepresents NHPIs. The authors make recommendations for improving NHPI data equity to achieve health equity and social justice.

The Political Realignment of Health: How Partisan Power Shaped Infant Health in the United States, 1915–2017

Source: Javier M. Rodríguez; Byengseon Bae; Arline T. Geronimus; John Bound, Journal of Health Politics, Policy and Law, Vol. 47 no. 2, April 2022
(subscription required)

From the abstract:
The US two-party system was transformed in the 1960s when the Democratic Party abandoned its Jim Crow protectionism to incorporate the policy agenda fostered by the civil rights movement, and the Republican Party redirected its platform toward socioeconomic and racial conservatism. The authors argue that the policy agendas promoted by the two parties through presidents and state legislatures codify a racially patterned access to resources and power detrimental to the health of all. To test the hypothesis that fluctuations in overall and race-specific infant mortality rates (IMRs) shift between the parties in power before and after the political realignment (PR), the authors apply panel data analysis methods to state-level data from the National Center for Health Statistics for the period 1915 through 2017. Net of trend, overall, and race-specific IMRs were not statistically different between presidential parties before the PR. This pattern, however, changed after the PR, with Republican administrations consistently underperforming Democratic ones. Net of trend, non-Southern state legislatures controlled by Republicans underperform Democratic ones in overall and racial IMRs in both periods.

Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals

Source: Matthew D McHugh, Linda H Aiken, Douglas M Sloane, Carol Windsor, Clint Douglas, Patsy Yates, The Lancet, Vol. 397, issue 10288, May 22, 2021
(subscription required)

From the summary:
Substantial evidence indicates that patient outcomes are more favourable in hospitals with better nurse staffing. One policy designed to achieve better staffing is minimum nurse-to-patient ratio mandates, but such policies have rarely been implemented or evaluated. In 2016, Queensland (Australia) implemented minimum nurse-to-patient ratios in selected hospitals. We aimed to assess the effects of this policy on staffing levels and patient outcomes and whether both were associated.

For this prospective panel study, we compared Queensland hospitals subject to the ratio policy (27 intervention hospitals) and those that discharged similar patients but were not subject to ratios (28 comparison hospitals) at two timepoints: before implementation of ratios (baseline) and 2 years after implementation (post-implementation). We used standardised Queensland Hospital Admitted Patient Data, linked with death records, to obtain data on patient characteristics and outcomes (30-day mortality, 7-day readmissions, and length of stay [LOS]) for medical-surgical patients and survey data from 17 010 medical-surgical nurses in the study hospitals before and after policy implementation. Survey data from nurses were used to measure nurse staffing and, after linking with standardised patient data, to estimate the differential change in outcomes between patients in intervention and comparison hospitals, and determine whether nurse staffing changes were related to it.

We included 231 902 patients (142 986 in intervention hospitals and 88 916 in comparison hospitals) assessed at baseline (2016) and 257 253 patients (160 167 in intervention hospitals and 97 086 in comparison hospitals) assessed in the post-implementation period (2018). After implementation, mortality rates were not significantly higher than at baseline in comparison hospitals (adjusted odds ratio [OR] 1·07, 95% CI 0·97–1·17, p=0·18), but were significantly lower than at baseline in intervention hospitals (0·89, 0·84–0·95, p=0·0003). From baseline to post-implementation, readmissions increased in comparison hospitals (1·06, 1·01–1·12, p=0·015), but not in intervention hospitals (1·00, 0·95–1·04, p=0·92). Although LOS decreased in both groups post-implementation, the reduction was more pronounced in intervention hospitals than in comparison hospitals (adjusted incident rate ratio [IRR] 0·95, 95% CI 0·92–0·99, p=0·010). Staffing changed in hospitals from baseline to post-implementation: of the 36 hospitals with reliable staffing measures, 30 (83%) had more than 4·5 patients per nurse at baseline, with the number decreasing to 21 (58%) post-implementation. The majority of change was at intervention hospitals, and staffing improvements by one patient per nurse produced reductions in mortality (OR 0·93, 95% CI 0·86–0·99, p=0·045), readmissions (0·93, 0·89–0·97, p<0·0001), and LOS (IRR 0·97, 0·94–0·99, p=0·035). In addition to producing better outcomes, the costs avoided due to fewer readmissions and shorter LOS were more than twice the cost of the additional nurse staffing.

Minimum nurse-to-patient ratio policies are a feasible approach to improve nurse staffing and patient outcomes with good return on investment.

US State Policies, Politics, and Life Expectancy

Source: Jennifer Karas Montez, Jason Beckfield, Julene Kemp Cooney, Jacob M. Grumbach, Mark D. Hayward, Huseyin Zeyd Koytak, Steven H. Woolf, Anna Zajacova, Milbank Quarterly, Vol 98, September 2020

Policy points:

  • Changes in US state policies since the 1970s, particularly after 2010, have played an important role in the stagnation and recent decline in US life expectancy.
  • Some US state policies appear to be key levers for improving life expectancy, such as policies on tobacco, labor, immigration, civil rights, and the environment.
  • US life expectancy is estimated to be 2.8 years longer among women and 2.1 years longer among men if all US states enjoyed the health advantages of states with more liberal policies, which would put US life expectancy on par with other high-income countries.


Are Conservative Policies Shortening American Lives?
Source: Lola Butcher, Undark, February 1, 2021

Americans have shorter lives than international peers. Some researchers now say conservative policies may be to blame.

Promoting Good Jobs and a Stronger Economy: How Free Collective-Bargaining States Outperform “Right-to-Work” States

Source: Illinois Economic Policy Institute (ILEPI) and the Project for Middle Class Renewal (PMCR) at the University of Illinois at Urbana-Champaign, February 9, 2021

From the press release:
In an eight-year period of national economic expansion that followed the Great Recession of 2008, the 27 U.S. states that had enacted so-called “right-to-work” laws saw slower economic growth, lower wages, higher consumer debt, worse health outcomes, and lower levels of civic participation than states that had not, according to a new study by the Illinois Economic Policy Institute (ILEPI) and the Project for Middle Class Renewal (PMCR) at the University of Illinois at Urbana-Champaign.

State Employee Health Insurance: Assessing the Scale of State Purchasing Power

Source: John Kaelin, Jim DeWan, Rockefeller Institute of Government, December 2020

From the introduction:
Across the nation, state governments are major purchasers of health insurance for their employees. According to the US Census Bureau, 100 percent of state governments offered health insurance benefits to their employees in 2018. The Census Bureau further reported that state governments provided health insurance benefits to 67.6 percent of their 5.4 million employees in 2018. This total of approximately 3.7 million employees does not include the number of dependents, retirees, or enrollees of local governments, and other public employers that also participate in states’ health insurance programs. In 2012, based on a report published by Pew Charitable Trusts and MacArthur Foundation, total spending exceeded $30 billion covering 2.7 million households.

Between employee benefits and Medicaid programs, states’ spending on health insurance represents a major budgetary item. In 2018, the federal Center for Medicare and Medicaid Services (CMS) reported that health insurance spending for all state and local governments totaled $433.6 billion and that spending has experienced an average annual increase of 3.9 percent over the past five years. In Fiscal Year 2019-20, the state of New York itself spent $22.1 billion on Medicaid and $4.3 billion on employee and retiree health insurance costs. To alleviate these escalating costs, some states have examined options to coordinate purchasing across state programs in an attempt to achieve economies of scale. Recently, California proposed policies to leverage their purchasing of prescription drugs by combining employee health insurance programs with other state programs such as Medicaid and Correctional Health.

The purpose of this policy brief is to examine the extent to which the states in their role of purchasers drive the evolution of the healthcare delivery system. This brief examines the availability of basic financial and cost data relating to state employee insurance programs. It assesses the scale of state health insurance purchasing using existing data and presents results from a preliminary survey of states. We also review the degree to which employee purchasing decisions are coordinated with other state health policy purchasing goals such as Medicaid and the Affordable Care Act (ACA) insurance marketplaces.

Health Benefits In 2020: Premiums In Employer-Sponsored Plans Grow 4 Percent; Employers Consider Responses To Pandemic

Source: Gary Claxton, Anthony Damico, Matthew Rae, Gregory Young, Daniel McDermott, and Heidi Whitmore, Health Affairs, Vol. 39 no. 11, 2020
(subscription required)

From the abstract:
The annual Kaiser Family Foundation Employer Health Benefits Survey is the benchmark survey of the cost and coverage of employer-sponsored health benefits in the United States. The 2020 survey was designed and largely fielded before the full extent of the coronavirus disease 2019 (COVID-19) pandemic had been felt by employers. Data collection took place from mid-January through July, with half of the interviews being completed in the first three months of the year. Most of the key metrics that we measure—including premiums and cost sharing—reflect employers’ decisions made before the full impacts of the pandemic were felt. We found that in 2020 the average annual premium for single coverage rose 4 percent, to $7,470, and the average annual premium for family coverage also rose 4 percent, to $21,342. Covered workers, on average, contributed 17 percent of the cost for single coverage and 27 percent of the cost for family coverage. Fifty-six percent of firms offered health benefits to at least some of their workers, and 64 percent of workers were covered at their own firm. Many large employers reported having “very broad” provider networks, but many recognized that their largest plan had a narrower network for mental health providers.

COVID-19 Projected to Worsen Racial Disparities in Health Coverage

Source: Chris Sloan, Robin Duddy-Tenbrunsel, Samantha Ferguson, Angel Valladares, Thomas Kornfield, Avalere, September 16, 2020

From the summary:
The COVID-19 pandemic is exacerbating existing economic and healthcare inequalities between racial groups in the US. Nationally, employment decreased 13% from February to April 2020; this effect was disproportionately greater among Asian (-18%), Black (-15%), and Hispanic (-17%) workers compared to White (-11%) workers. Avalere analysis suggests that, because of these job losses, at least 1 million Asian, 2 million Black, and 3 million Hispanic people are likely to lose their employer-sponsored health insurance in 2020.

Mortality Rates From COVID-19 Are Lower In Unionized Nursing Homes

Source: Adam Dean, Atheendar Venkataramani, and Simeon Kimmel, Health Affairs, Ahead of Print, September 10, 2020
(subscription required)

From the abstract:
More than 40% of all reported coronavirus disease 2019 (COVID-19) deaths in the United States have occurred in nursing homes. As a result, health care worker access to personal protective equipment (PPE) and infection control policies in nursing homes have received increased attention. However, it is not known if the presence of health care worker unions in nursing homes is associated with COVID-19 mortality rates. Therefore, we used cross-sectional regression analysis to examine the association between the presence of health care worker unions and COVID-19 mortality rates in 355 nursing homes in New York State. Health care worker unions were associated with a 1.29 percentage point mortality reduction, which represents a 30% relative decrease in the COVID-19 mortality rate compared to facilities without health care worker unions. Unions were also associated with greater access to PPE, one mechanism that may link unions to lower COVID-19 mortality rates. [Editor’s Note: This Fast Track Ahead Of Print article is the accepted version of the peer-reviewed manuscript. The final edited version will appear in an upcoming issue of Health Affairs.]