Upstream Policy Changes to Improve Population Health and Health Equity: A Priority Agenda.

Policy Points Upstream factors-social structures/systems, cultural factors, and public policy-are primary forces that drive downstream patterns and inequities in health that are observed across race and locations. A public policy agenda that aims to address inequities related to the well-being of children, creation and perpetuation of residential segregation, and racial segregation can address upstream factors. Past successes and failures provide a blueprint for addressing upstream health issues and inhibit health equity.

The Perils of Medicalization for Population Health and Health Equity.

Policy Points Medicalization is a historical process by which personal, behavioral, and social issues are increasingly viewed through a biomedical lens and "diagnosed and treated" as individual pathologies and problems by medical authorities. Medicalization in the United States has led to a conflation of "health" and "health care" and a confusion between individual social needs versus the social, political, and economic determinants of health. The essential and important work of population health science, public health practice, and health policy writ large is being thwarted by a medicalized view of health and an overemphasis on personal health services and the health care delivery system as the major focal point for addressing societal health issues and health inequality. Increased recognition of the negative consequences of a medicalized view of health is essential, with a focus on education and training of clinicians and health care managers, journalists, and policymakers.

Abortion Policy in the United States: The New Legal Landscape and Its Threats to Health and Socioeconomic Well-Being.

Policy Points The historic 2022 Supreme Court Dobbs v Jackson Women's Health Organization decision has created a new public policy landscape in the United States that will restrict access to legal and safe abortion for a significant proportion of the population. Policies restricting access to abortion bring with them significant threats and harms to health by delaying or denying essential evidence-based medical care and increasing the risks for adverse maternal and infant outcomes, including death. Restrictive abortion policies will increase the number of children born into and living in poverty, increase the number of families experiencing serious financial instability and hardship, increase racial inequities in socioeconomic security, and put significant additional pressure on under-resourced social welfare systems.

Associations of 4 Geographic Social Vulnerability Indices With US COVID-19 Incidence and Mortality.

Objectives. To examine and compare how 4 indices of population-level social disadvantage-the Social Vulnerability Index (SVI), the Area Deprivation Index (ADI), the COVID-19 Community Vulnerability Index (CCVI), and the Minority Health-Social Vulnerability Index (MH-SVI)-are associated with COVID-19 outcomes. Methods. Spatial autoregressive models adjusted for population density, urbanicity, and state fixed effects were used to estimate associations of county-level SVI, MH-SVI, CCVI, and ADI values with COVID-19 incidence and mortality. Results. All 4 disadvantage indices had similar positive associations with COVID-19 incidence. Each index was also significantly associated with COVID-19 mortality, but the ADI had a stronger association than the CCVI, MH-SVI, and SVI. Conclusions. Despite differences in component measures and weighting, all 4 of the indices we assessed demonstrated associations between greater disadvantage and COVID-19 incidence and mortality. Public Health Implications. Our findings suggest that each of the 4 disadvantage indices can be used to assist public health leaders in targeting ongoing first-dose and booster or third-dose vaccines as well as new vaccines or other resources to regions most vulnerable to negative COVID-19 outcomes, weighing potential tradeoffs in their political and practical acceptability. (Am J Public Health. 2022;112(11):1584-1588. https://doi.org/10.2105/AJPH.2022.307018).

Association of Social and Demographic Factors With COVID-19 Incidence and Death Rates in the US.

Importance: Descriptive data have revealed significant racial/ethnic disparities in coronavirus disease 2019 (COVID-19) cases in the US, but underlying mechanisms of disparities remain unknown. Objective: To examine the association between county-level sociodemographic risk factors and US COVID-19 incidence and mortality. Design, Setting, and Participants: This cross-sectional study analyzed the association between US county-level sociodemographic risk factors and COVID-19 incidence using mixed-effects negative binomial regression, and COVID-19 mortality using zero-inflated negative binomial regression. Data on COVID-19 incidence and mortality were collected from January 20 to July 29, 2020. The association of social risk factors with weekly cumulative incidence and mortality was also examined by interacting time with the index measures, using a random intercept to account for repeated measures. Main Outcomes and Measures: Sociodemographic data from publicly available data sets, including the US Centers for Disease Control and Prevention's Social Vulnerability Index (SVI), which includes subindices of socioeconomic status, household composition and disability, racial/ethnic minority and English language proficiency status, and housing and transportation. Results: As of July 29, 2020, there were a total of 4 289 283 COVID-19 cases and 147 074 COVID-19 deaths in the US. An increase of 0.1 point in SVI score was associated with a 14.3% increase in incidence rate (incidence rate ratio [IRR], 1.14; 95% CI, 1.13-1.16; P < .001) and 13.7% increase in mortality rate (IRR, 1.14; 95% CI, 1.12-1.16; P < .001), or an excess of 87 COVID-19 cases and 3 COVID-19 deaths per 100 000 population for a SVI score change from 0.5 to 0.6 in a midsize metropolitan county; subindices were also associated with both outcomes. A 0.1-point increase in the overall SVI was associated with a 0.9% increase in weekly cumulative increase in incidence rate (IRR, 1.01; 95% CI, 1.01-1.01; P < .001) and 0.5% increase in mortality rate (IRR, 1.01; 95% CI, 1.01-1.01; P < .001). Conclusions and Relevance: In this cross-sectional study, a wide range of sociodemographic risk factors, including socioeconomic status, racial/ethnic minority status, household composition, and environmental factors, were significantly associated with COVID-19 incidence and mortality. To address inequities in the burden of the COVID-19 pandemic, these social vulnerabilities and their root causes must be addressed.

The Potential and Realized Impact of the Affordable Care Act on Health Equity.

The Affordable Care Act (ACA) was designed with multiple goals in mind, including a reduction in social disparities in health care and health status. This was to be accomplished through some novel provisions and a significant infusion of resources into long-standing public programs with an existing track record related to health equity. In this article, we discuss seven ACA provisions with regard to their intended and realized impact on social inequalities in health, focusing primarily on socioeconomic and racial/ethnic disparities. Arriving at its 10th anniversary, there is significant evidence that the ACA has reduced social disparities in key health care outcomes, including insurance coverage, health care access, and the use of primary care. In addition, the ACA has had a significant impact on the volume/range of services offered and the financial security of community health centers, and through section 1557, the ACA broadened the civil rights landscape in which the health care system operates. Less clear is how the ACA has contributed to improved health outcomes and health equity. Extant evidence suggests that the part of the ACA that has had the greatest impact on social disparities in health outcomes-including preterm births and mortality-is the Medicaid expansion.

Equitable Pandemic Preparedness and Rapid Response: Lessons from COVID-19 for Pandemic Health Equity.

The novel coronavirus pandemic has set in high relief the entrenched health, social, racial, political, and economic inequities within American society as the incidence of severe morbidity and mortality from the disease caused by the virus appears to be much greater in black and other racial/ethnic minority populations, within homeless and incarcerated populations, and in lower-income communities in general. The reality is that the United States is ill equipped to realize health equity in prevention and control efforts for any type of health outcome, including an infectious disease pandemic. In this article, the authors address an important question: When new waves of the current pandemic emerge, or another novel pandemic emerges, how can the United States be better prepared and also ensure a rapid response that reduces rather than exacerbates social and health inequities? The authors argue for a health equity framework to pandemic preparedness that is grounded in meaningful community engagement and that, while recognizing the fundamental causes of social and health inequity, has a clear focus on upstream and midstream preparedness and downstream rapid response efforts that put social and health equity at the forefront.

Interventions to Decrease Use in Prehospital and Emergency Care Settings Among Super-Utilizers in the United States: A Systematic Review.

Interest in high users of acute care continues to grow as health care organizations look to deliver cost-effective and high-quality care to patients. Since "super-utilizers" of acute care are responsible for disproportionately high health care spending, many programs and interventions have been implemented to reduce medical care use and costs in this population. This article presents a systematic review of the peer-reviewed and grey literature on evaluations of interventions to decrease prehospital and emergency care use among U.S. super-utilizers. Forty-six distinct evaluations were included in the review. The most commonly evaluated intervention was case management. Although a number of interventions reported reductions in prehospital and emergency care utilization and costs, methodological and study design weaknesses-especially regression to the mean-were widespread and call into question reported positive findings. More high-quality research is needed to accurately assess the impact of interventions to reduce prehospital and emergency care use in the super-utilizer population.

Moving Upstream to Improve Children's Mental Health Through Community and Policy Change.

Using a social determinants of health framework, we argue that the majority of evidence-based interventions focused on child and adolescent mental health are limited by their focus on individual youth (and sometimes families). While necessary, these interventions are insufficient for addressing the midstream- and upstream/macro-level determinants of mental health in society. We illustrate our perspective through four examples from youth mental health and related services, in which midstream and upstream interventions-i.e., at the community and public policy levels-need to be prioritized along with downstream treatments to improve population mental health and reduce social inequalities in mental health outcomes.

Smoke-Free Policies and Smoking Cessation in the United States, 2003-2015.

(1) Background: Smoking restrictions have been shown to be associated with reduced smoking, but there are a number of gaps in the literature surrounding the relationship between smoke-free policies and cessation, including the extent to which this association may be modified by sociodemographic characteristics. (2) Methods: We analyzed data from the Tobacco Use Supplement to the Current Population Survey, 2003-2015, to explore whether multiple measures of smoking restrictions were associated with cessation across population subgroups. We examined area-based measures of exposure to smoke-free laws, as well as self-reported exposure to workplace smoke-free policies. We used age-stratified, fixed effects logistic regression models to assess the impact of each smoke-free measure on 90-day cessation. Effect modification by gender, education, family income, and race/ethnicity was examined using interaction terms. (3) Results: Coverage by workplace smoke-free laws and self-reported workplace smoke-free policies was associated with higher odds of cessation among respondents ages 40-54. Family income modified the association between smoke-free workplace laws and cessation for women ages 25-39 (the change in the probability of cessation associated with coverage was most pronounced among lower-income women). (4) Conclusions: Heterogeneous associations between policies and cessation suggest that smoke-free policies may have important implications for health equity.

The Potential of Pay-for-Success as a Financing Strategy for Evidence-Based Practices: An Illustration with Multisystemic Therapy.

There is a critical need to identify strategies for financing the implementation of evidence-based practices. We illustrate the potential of pay-for-success financing (PFS)-a strategy in which private investors fund implementation and receive a return on investment from a government payer-using multisystemic therapy as an example. We argue that standard multisystemic therapy (for serious juvenile offenders) and several of its adaptations (for other complex behavioral problems in youth) would be good candidates for PFS in the right contexts. Despite some challenges for policymakers and administrators, PFS has significant potential as a financing strategy for evidence-based practices.

"Pay for Success" Projects: Financing Interventions That Address Social Determinants of Health in 20 Countries.

Over the past eight years, there has been an increase in the use of pay for success (PFS) as a financing tool whereby private investors provide initial funding for preventive health and human service interventions. If an independent evaluator deems the interventions successful, investors are repaid by the government. To better understand how PFS is used, we created a global landscape surveillance system to track and analyze data on all PFS projects that have launched through 2017. We focus on the potential for PFS to improve population health by funding interventions that target the social determinants of health. Our findings show that all launched projects to date have implemented interventions aimed at improving the structural and intermediary social determinants of health, primarily in socioeconomically disadvantaged populations. Although there are some challenges associated with PFS, we believe it is a promising tool for financing interventions aimed at social determinants of health in underserved and marginalized populations.