Polarization, diversity, and democratic robustness.

In the Madisonian Constitution, fragmented and overlapping institutions of authority are supposed to manage democracy's innate rivalry, channeling competition to serve the public interest. This system of safeguards makes democracy more robust: capable of withstanding and, if need be, adapting to challenges posed by a changing problem environment. In this essay, I suggest why affective polarization poses a special threat to democratic robustness. While most scholars hypothesize that polarization's dangers are that it leads to bimodality and extremism, I highlight a third hypothesized effect: Polarization reduces interest and information diversity in the political system. To be effective, democracy's safeguards rely upon interest diversity, but Madison took that diversity for granted. Unique among democracy's safeguards, federalism builds in a repository for diversity; its structure enables differences between national- and state-expressed interests, even within the same party. This diversity can be democracy hindering, as the United States' history with racially discriminatory politics painfully makes clear, but it can also serve as a reservoir of interest and information dispersion that could protect democracy by restoring the possibility that cross-cutting cleavages emerge.

Medicaid's Political Development Since 1965: How a Fragmented and Unequal Program Has Expanded.

The Medicaid program has changed enormously over the past 60 years from a very restrictive program primarily attached to recipients on public assistance in 1965 to a much more expansive program allowing coverage for persons regardless of marital, parental or employment status. Incorporating the 'medically needy'-an ambiguous concept from the start-allowed states to include many different groups in Medicaid who are not traditionally thought of as poor. In addition, three structural features illuminate why the program has expanded and changed dramatically over time: federalism and intergovernmental financing, the dominance of the private sector, and fragmentation. Unequal treatment among Medicaid covered groups alongside partisan politics create a political discourse that often reveals Medicaid as a public subsidy for stigmatized groups, while hiding Medicaid's reach into the middle-class. This central political ideological tension collides with programmatic realities such that Medicaid strangely often suffers from a residual, retrenchment politics while at the same time benefiting from embeddedness making it extremely difficult to truly turn back the clock on Medicaid's expansion.

Medicaid Home and Community-Based Services in the Wake of the COVID-19 Pandemic.

The need to bolster Medicaid home and community-based services (HCBS) became more evident during the COVID-19 pandemic. This recognition stemmed from the challenges of keeping people safe in nursing homes and the acute workforce shortages in the HCBS sector. This article examines two major federal developments and state responses in HCBS options as a result of the pandemic. The first initiative entails a one-year increase of the federal Medicaid matching rate for HCBS included in the American Rescue Plan Act championed by the Biden administration. The second initiative encompasses administrative flexibilities that permitted states to temporarily expand and modify their existing Medicaid HCBS programs. The article concludes that the effects of the pandemic flexibilities and enhanced federal funding on most state HCBS programs will be limited without continued investment and leadership on the part of the federal government, which is a Biden administration priority. States that make the American Rescue Act and COVID-19 flexibilities initiatives permanent are states that have the fiscal resources and political commitment to expanding HCBS benefits that other states lack. States' different approaches to bolstering Medicaid HCBS during the pandemic may contribute to widening disparities in access and quality of HCBS across states and populations who depend on Medicaid HCBS.

Federalism for Bioethics?

In the wake of the Dobbs decision withdrawing federal constitutional protection for reproductive rights, the United States is in the throes of federalist conflicts. Some states are enacting draconian prohibitions of abortion or gender-affirming care, whereas other states are attempting to shield providers and their patients seeking care. This article explores standard arguments supporting federalism, including that it allows for cultural differences to remain along with a structure that provides for the advantages of common security and commerce, that it provides a laboratory for confined experiments, that it is government closer to the people and thus more informed about local needs and preferences, and that it creates layers of government that can constrain one another and thus doubly protect rights. We contend that these arguments do not justify significant differences among states with respect to the recognition of important aspects of well-being; significant injustices among subnational units cannot be justified by federalism. However, as nonideal theorists, we also observe that federalism presents the possibility of some states protecting rights that others do not. Assuming that movement among subnational units is protected, those who are fortunate enough to be able to travel will be able to access rights they cannot access at home. Nonetheless, movement may not be readily available to minors, people without documentation, people with disabilities, people who lack economic resources, or people who have responsibilities that preclude travel. Only rights protection at the federal level will suffice in such cases.

Whose experts? How federalism shaped psychiatry in the late Habsburg monarchy.

The late Habsburg period (1867-1918) created a constitutional dual monarchy of Austria-Hungary. This paper discusses the role of psychiatry in Cisleithania, both as a developing profession and as a distinct 'policy field'. Tension between psychiatry's academic professionalisation and the creation of public institutions as signature projects by individual crownlands created complex relationships between psychiatry and politics. In federalist Cisleithania, psychiatrists became very 'political': whether employed by the state or a crownland influenced their position on policy, despite claiming that their expert knowledge was 'scientific' and 'objective'. The conflicts between asylum-based and academic psychiatrists mirrored those between the central state and the crownlands. This led to intractable delays in mental health law reform, eventually resolved by Imperial decree in 1916.

Securitization versus sovereignty? Multi-level governance, scientific objectivation, and the discourses of the Canadian and American heads of state during the first wave of the COVID-19 pandemic.

The global health regime is caught in a paradox, whereby connecting "human" to "(inter)national" security to prevent the spread of infectious diseases unwittingly introduces into this complex and expertise-reliant domain of "low politics" the notion of "sovereign decisionism"-states' prerogative to identify a threat and counter it with exceptional measures that may in turn constrain their ability to unilaterally securitize disease. This article introduces an analytical framework presenting three pathways through which state leaders with different conceptions of sovereignty and varying constraints on their legitimacy among their domestic audiences may nevertheless securitize policy domains traditionally considered as falling within the scope of sub-state "low politics." Two of the pathways begin with scientific objectivation rather than politicization, and one trades power concentration for collaboration with sub-state and global authorities. I then compare the Canadian and American responses during the first wave of the coronavirus pandemic to uncover how these contextual factors disposed Donald Trump to politicize COVID-19, while Justin Trudeau emulated the World Health Organization's securitization of the virus without centralizing state powers.

Politics and the Public Health Workforce: Lessons Suggested from a Five-State Study.

Policy Points The United States public health system relies on an inadequate and inefficient mix of federal, state, and local funding. Various state-based initiatives suggest that a promising path to bipartisan support for increased public health funding is to gain the support of local elected officials by providing state (and federal) funding directly to local health departments, albeit with performance strings attached. Even with more funding, we will not solve the nation's public health workforce crisis until we make public health a more attractive career path with fewer bureaucratic barriers to entry. CONTEXT: The COVID-19 pandemic exposed the shortcomings of the United States public health system. High on the list is a public health workforce that is understaffed, underpaid, and undervalued. To rebuild that workforce, the American Rescue Plan (ARP) appropriated $7.66 billion to help create 100,000 new public health jobs. As part of this initiative, the Centers for Disease Control and Prevention (CDC) distributed roughly $2 billion to state, local, tribal, and territorial health agencies for use between July 1, 2021, and June 30, 2023. At the same time, several states have enacted (or are considering enacting) initiatives to increase state funding for their local health departments with the goal of ensuring that these departments can deliver a core set of services to all residents. The differences in approach between this first round of ARP funding and theseparate state initiatives offer an opportunity to compare, contrast, and suggest lessons learned. METHODS: After interviewing leaders at the CDC and other experts on the nation's public health workforce, we visited five states (Kentucky, Indiana, Mississippi, New York, and Washington) to examine, by means of interviews and documents, the implementation and impact of both the ARP workforce funds as well as the state-based initiatives. FINDINGS: Three themes emerged. First, states are not spending the CDC workforce funding in a timely fashion; although the specifics vary, there are several organizational, political, and bureaucratic obstacles. Second, the state-based initiatives follow different political paths but rely on the same overarching strategy: gain the support of local elected officials by providing funding directly to local health departments, albeit with performance strings attached. These state initiatives offer their federal counterparts a political roadmap toward a more robust model of public health funding. Third, even with increased funding, we will not meet the nation's public health workforce challenges until we make public health a more attractive career path (with higher pay, improved working conditions, and more training and promotion opportunities) with fewer bureaucratic barriers to entry (most importantly, with less reliance on outdated civil service rules). CONCLUSION: The politics of public health requires a closer look at the role played by county commissioners, mayors, and other local elected officials. We need a political strategy to persuade these officials that their constituents will benefit from a better public health system.

Impacts of language barriers on healthcare access and quality among Afaan Oromoo-speaking patients in Addis Ababa, Ethiopia.

BACKGROUND: Ethiopia is a multilingual and multinational federation with Addis Ababa serving as both the capital city of Oromia regional state and the seat of the Ethiopian federal government. Nevertheless, only Amharic is considered as the working language of the city and federal offices, including hospitals. As a result, Afaan Oromoo-speaking patients may be facing language barriers in the healthcare settings in Addis Ababa. Language barriers have the capacity to affect patients' experience of care and treatment outcomes. This study, hence, examined the impacts of language barriers on the healthcare access and quality for the Afaan Oromoo-speaking patients in public hospitals in Addis Ababa. METHODS: In-depth interviews with patients (N = 27) and key informant interviews with healthcare providers (N = 9) were conducted in six public hospitals found in Addis Ababa. All the interviews were audio-taped and transcribed verbatim. A thematic analysis technique was employed to address the study objectives. RESULTS: The study participants indicated the widely existing problem of language discordance between patients and healthcare providers. The impacts of language barriers on the patients include preventable medical errors, low treatment adherence, low health-seeking behavior, additional treatment cost, increased length of hospital stays, weak therapeutic relation, social desirability bias, less confidence, and dissatisfaction with the healthcare. For the healthcare providers, language barriers are affecting their ability to take patient history, perform diagnoses and provide treatment, and have also increased their work burden. The use of ad hoc interpreters sourced from bilingual/multilingual patients, patient attendants, volunteer healthcare providers, and other casual people has been reported to deal with the problem of language barriers. CONCLUSION: A significant number of Afaan Oromoo-speaking patients are facing language barriers in accessing quality healthcare in public hospitals in Addis Ababa, and this constitutes structural violence. As a way out, making Afaan Oromoo an additional working language of the public hospitals in Addis Ababa, the assignment of professional interpreters, and a hiring system that promotes the recruitment of qualified multi-lingual healthcare providers are suggested.

Overcoming the challenges facing Nepal's health system during federalisation: an analysis of health system building blocks.

INTRODUCTION: Nepal's move to a federal system was a major constitutional and political change, with significant devolution of power and resources from the central government to seven newly created provinces and 753 local governments. Nepal's health system is in the process of adapting to federalism, which is a challenging, yet potentially rewarding, task. This research is a part of broader study that aims to explore the opportunities and challenges facing Nepal's health system as it adapts to federalisation. METHODS: This exploratory qualitative study was conducted across the three tiers of government (federal, provincial, and local) in Nepal. We employed two methods: key informant interviews and participatory policy analysis workshops, to offer an in-depth understanding of stakeholders' practical learnings, experiences, and opinions. Participants included policymakers, health service providers, local elected members, and other local stakeholders. All interviews were audio-recorded, transcribed, translated into English, and analysed thematically using the six WHO (World Health Organization) health system building blocks as a theoretical framework. RESULTS: Participants noted both opportunities and challenges around each building block. Identified opportunities were: (a) tailored local health policies and plans, (b) improved health governance at the municipality level, (c) improved health infrastructure and service capacity, (d) improved outreach services, (e) increased resources (health budgets, staffing, and supplies), and (f) improved real-time data reporting from health facilities. At the same time, several challenges were identified including: (a) poor coordination between the tiers of government, (b) delayed release of funds, (c) maldistribution of staff, (d) problems over procurement, and (e) limited monitoring and supervision of the quality of service delivery and data reporting. CONCLUSION: Our findings suggest that since federalisation, Nepal's health system performance is improving, although much remains to be accomplished. For Nepal to succeed in its federalisation process, understanding the challenges and opportunities is vital to improving each level of the health system in terms of (a) leadership and governance, (b) service delivery, (c) health financing, (d) health workforce, (e) access to essential medicines and technologies and (f) health information system.

The Wrong Place at the Wrong Time? Territorial Autonomy and Conflict During Regime Transitions.

This article evaluates how territorial autonomy affects ethnic mobilization and conflict during regime transitions. Previous research has highlighted its conflict-inducing role during prominent transition contexts. Alternatively, it has shown its pacifying role in the "average" case, without distinguishing transition periods from stable contexts. Addressing these gaps, we argue that the de-escalatory consequences of autonomy depend on critical stabilizing factors which are themselves "muted" during transitions. We test our expectations in a cross-national analysis, covering all regime transitions between 1946 and 2017. We also revisit the 1989 transition from Communism, focusing on the role of "inherited" autonomy in the post-communist successor states. This enables us to address concerns whereby autonomy is offered to ward off transitions or whereby transitions are themselves induced by mobilization. Our findings indicate that during transitions, territorial autonomy increases the likelihood of ethnic mobilization, government concessions in response, and violent escalation where these are not forthcoming.

Enhancing Federal Revenue under the American Rescue Plan Act: An Opportunity to Bolster State Medicaid Home and Community-Based Services Programs.

The American Rescue Plan Act (ARPA) includes a one-year 10 percentage point increase in the Federal Medical Assistance Percentage for Medicaid-funded home and community-based services (HCBS). The goal is to strengthen state efforts to help older adults and people with disabilities live safely in their homes and communities rather than in institutional settings during the COVID-19 pandemic. This essay provides a detailed description and analysis of this provision, including issues state governments need to consider when expending the additional federal revenue provided. It also draws lessons from the Affordable Care Act's Balancing Incentive Program to suggest insights for the potential of ARPA to promote further growth in Medicaid HCBS programs. It argues that key to success will be consultation with community stakeholders under the auspices of clear and frequent federal guidance and the development of concrete plans with which to expend the additional revenues in the most effective way possible in the limited time frame provided. The essay concludes by highlighting the importance of instituting strategies and processes for maximizing enhanced federal matching funds under ARPA in preparation for subsequent availability of substantial additional federal resources targeting Medicaid HCBS under other proposed initiatives.

The effect of the revision and implementation for environmental protection law on ambient air quality in China.

An unescapable fact is that air pollution has been a problem affecting residents' health and daily life. The Chinese government has been adopting measures to improve air quality for decades. The revise of Environmental Protection Law (the New Law hereafter) enforced in 2015 is one of them. The New Law encourages participations of multiple actors in environmental protection and aggressive punishments violations, playing the central role in the Chinese environmental law system. In order to understand its impacts, we employ the panel data analysis controlling city and month fixed terms to evaluate the effects of the New Law on air quality in 70 cities in China. Furthermore, we combine difference-in-differences (DID) to investigate the time variance of the effect. We find that the implementation of the New Law correlates with reduction of PM2.5, SO2 concentrations and Air Quality Comprehensive Index (AQCI). The effect is non-linear, reducing over time, especially on NO2 concentration and AQCI. In our model, one document reduces NO2 concentration and AQCI by 1.99 µg/m3 and 0.26 points, and the effects decay by 0.93 µg/m3 and 0.16 every year separately. The results indicate the effectiveness of the New Law, while at the same time, China experiences symbolic implementations from local authorizations resulted from environmental decentralization, ambiguous policy statements and interest conflicts.

[COVID-19 pandemic response teams: organization, competencies, and challenges-understanding and using structural realities]. / COVID-19-Pandemiekrisenstäbe: Organisation, Befugnisse und Herausforderungen ­ Strukturelle Gegebenheiten verstehen und nutzen.

BACKGROUND AND AIM: Germany has a federal state system. Pandemic response teams are key instruments of pandemic management. The aim of this article is to describe the structures and powers of pandemic response teams that were explored during a study on the care of the critically ill and dying in times of a pandemic (PallPan). The focus is on health-related pandemic response teams on the national state level (macrolevel) and federal and community level (mesolevel) as well as pandemic response teams in healthcare facilities (microlevel). METHODS: Members of pandemic response teams took part in qualitative semi-structured interviews (October 2020-February 2021). The evaluation was carried out by means of qualitative structuring content analysis. RESULTS: Forty-two persons reported on 43 crisis teams from 14 federal states. Response teams in healthcare facilities and public administration differ primarily with regard to their competencies. Officially predetermined regulations regarding the initiation, personal composition, tasks, responsibilities, and competencies of pandemic response teams are not predefined in Germany. The macrolevel defined the legal and financial conditions for pandemic management. Meso- and microlevel pandemic response teams bear responsibility for maintaining the provision of healthcare. The defaults of local public health authorities are decisive for the pandemic response team's work. Main tasks and measures were the provision of information and the procurement and distribution of resources. DISCUSSION: In terms of preparing for future pandemic situations, the knowledge gained will help to address concerns about maintaining healthcare for specific population groups, such as seriously ill and dying people, to the locally differing responsible bodies, even under pandemic conditions.

Decentralization: A handicap in fighting the COVID-19 pandemic? The response of the regional governments in Spain.

The COVID-19 pandemic has provided an ultimate testing ground for evaluating the resilience and effectiveness of federal and decentralized systems. The article analyses how the Spanish asymmetrical system of decentralization has responded to the pandemic, focusing on the management developed by the sub-central governments (Autonomous Communities) during the first two waves of the pandemic in 2020. The research, which is both quantitative and qualitative, employs multidisciplinary tools and information sources, analyzing and linking fiscal and budgetary sources with the available statistics and information on health. Although the health, economic and social crisis caused by COVID-19 has highlighted appreciable shortcomings related to the decentralized model of territorial organization - in questions of both regional financing and health management - the research concludes that decentralization has not per se been a handicap when confronting the pandemic in Spain.

Public finance in the era of the COVID-19 crisis.

The COVID-19 crisis poses new policy challenges and has spurred new research agendas in public economics. In this article, we selectively reflect on how the field of public economics has been shaped by the COVID-19 pandemic and discuss several areas where more research is necessary. We highlight major changes and inequalities in the labor market and K-12 education, in addition to discussing how technological change creates new challenges for the taxation of income and consumption. We discuss various policy responses to these challenges and the role of fiscal federalism in the context of worldwide crises. Finally, we summarize the key issues discussed at the 2021 International Institute of Public Finance Congress and the papers published in this special issue.

A justification of health policy federalism.

The apportionment of responsibility for health policy within multi-level states should be sensitive to a number of conflicting normative pressures, some of which militate for placing decision-making authority at the higher reaches of policy-making structures, while others would seem to require placing them lower down this structure. The principle of subsidiarity is a structural principle that addresses in a manner that is neutral with respect to these values a way of addressing the conflicting claims of these values. Standard accounts of federalism fare poorly with respect to the criterion of subsidiarity. While central governments are at first glance better equipped to apply such a principle to the issue of the distribution of authority, there are strong empirical grounds for thinking that centralized governments will non-neutrally privilege central authorities in applying the principle. Federal structures that admit of overlapping jurisdictions, and that therefore require that deliberation among federal parties occur as a condition of the problem of the distribution of powers over health care being solved, are most amenable to solving problems of distribution of authority.

Politics and the distribution of federal funds: Evidence from federal legislation in response to COVID-19.

COVID-19 relief legislation offers a unique setting to study how political representation shapes the distribution of federal assistance to state and local governments. We provide evidence of a substantial small-state bias: an additional Senator or Representative per million residents predicts an additional 670 dollars in aid per capita across the four relief packages. Alignment with the Democratic party predicts increases in states' allocations through legislation designed after the January 2021 political transition. This benefit of alignment with a unified federal government operates through the American Rescue Plan Act's size and through the formulas it used to distribute transportation and general relief funds.

Who Counts Where? COVID-19 Surveillance in Federal Countries.

CONTEXT: While the World Health Organization (WHO) has established guidance on COVID-19 surveillance, little is known about implementation of these guidelines in federations, which fragment authority across multiple levels of government. This study examines how subnational governments in federal democracies collect and report data on COVID-19 cases and mortality associated with COVID-19. METHODS: We collected data from subnational government websites in 15 federal democracies to construct indices of COVID-19 data quality. Using bivariate and multivariate regression, we analyzed the relationship between these indices and indicators of state capacity, the decentralization of resources and authority, and the quality of democratic institutions. We supplement these quantitative analyses with qualitative case studies of subnational COVID-19 data in Brazil, Spain, and the United States. FINDINGS: Subnational governments in federations vary in their collection of data on COVID-19 mortality, testing, hospitalization, and demographics. There are statistically significant associations (p < 0.05) between subnational data quality and key indicators of public health system capacity, fiscal decentralization, and the quality of democratic institutions. Case studies illustrate the importance of both governmental and civil-society institutions that foster accountability. CONCLUSIONS: The quality of subnational COVID-19 surveillance data in federations depends in part on public health system capacity, fiscal decentralization, and the quality of democracy.

Affordable but Inaccessible? Contraception Deserts in the US States.

CONTEXT: This article focuses on whether, and the extent to which, the resources made available by Title X-the only federal policy aimed specifically at reproductive health care-are equitably accessible. Here, equitable means that barriers to accessing services are lowest for those people who need them most. METHODS: The authors use geographic information systems (GIS) and statistical/spatial analysis (specifically the integrated two-step floating catchment area [I2SFCA] method) to study the spatial and nonspatial accessibility of Title X clinics in 2018. FINDINGS: The authors find that contraception deserts vary across the states, with between 17% and 53% of the state population living in a desert. Furthermore, they find that low-income people and people of color are more likely to live in certain types of contraception deserts. CONCLUSIONS: The analyses reveal not only a wide range of sizes and shapes of contraception deserts across the US states but also a range of severity of inequity.

Who Stays at Home? The Politics of Social Distancing in Brazil, Mexico, and the United States during the COVID-19 Pandemic.

CONTEXT: Reductions in population mobility can mitigate COVID-19 virus transmission and disease-related mortality. But do social distancing policies actually change population behavior and, if so, what factors condition policy effects? METHODS: We leverage subnational variation in the stringency and timing of state-issued social distancing policies to test their effects on mobility across 109 states in Brazil, Mexico, and the United States. We also explore how conventional predictors of compliance, including political trust, socioeconomic resources, health risks, and partisanship, modify these policy effects. FINDINGS: In Brazil and the United States, stay-at-home orders and workplace closures reduced mobility, especially early in the pandemic. In Mexico, where federal intervention created greater policy uniformity, workplace closures produced the most consistent mobility reductions. Conventional explanations of compliance perform well in the United States but not in Brazil or Mexico, apart from those emphasizing socioeconomic resources. CONCLUSIONS: In addition to new directions for research on the politics of compliance, the article offers insights for policy makers on which measures are likely to elicit compliance. Our finding that workplace closure effectiveness increases with socioeconomic development suggests that cash transfers, stimulus packages, and other policies that mitigate the financial burdens of the pandemic may help reduce population mobility.