Implementing automated Medicaid eligibility renewals was not associated with higher levels of program participation.

Increasing participation in Medicaid among eligible individuals is critical for improving access to care among low-income populations. The administrative burdens of enrolling and renewing eligibility are a major barrier to participation. To reduce these burdens, the Affordable Care Act required states to adopt automated renewal processes that use available databases to verify ongoing eligibility. By 2019, nearly all states adopted automated renewals, but little is known about how this policy affected Medicaid participation rates. Using the 2015-2019 American Community Survey, we found that participation rates among nondisabled, nonelderly adults and children varied widely by state, with an average of 70.8% and 90.7%, respectively. Among Medicaid-eligible adults, participation was lower among younger adults, males, unmarried individuals, childless households, and those living in non-expansion states compared with their counterparts. State adoption of automated renewals varied over time, but participation rates were not associated with adoption. This finding could reflect limitations to current automated renewal processes or barriers to participation outside of the eligibility renewal process, which will be important to address as additional states expand Medicaid and pandemic-era protections on enrollment expire.

Persistent Disparities: Trends in Rates of Sheltered Homelessness Across Demographic Subgroups in the USA.

CONTEXT: 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. METHODS: 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. FINDINGS: 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. CONCLUSIONS: 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.

What the Evolution of 1332 Waivers Tells Us about Their Innovative Potential.

Section 1332 of the Affordable Care Act (ACA) provides states unprecedented flexibility to alter federal health policy. The authors analyze state waiver activity from 2019 to 2023, applying a comparative approach to understand waivers proposed by Georgia, Colorado, Washington, Oregon, and Nevada. Much of the waiver activity during this period focused on reinsurance programs. During the Trump administration, the most innovative waiver application was from Georgia, which sought to restructure and decentralize its individual market, moving away from the framework established by the ACA. While the Biden administration suspended Georgia's efforts, Democratic-led states have focused implementing waiver programs supporting and expanding on the ACA. This has included adopting public-option insurance plans offered by private insurers and expanding eligibility for qualified health plans for previously ineligible groups. The authors' analysis offers insights into contemporary health politics, policy durability, and the role of the administrative presidency.

Implementing the White House's Strategic Plan to Save Lives Amid the Opioid Crisis: Reaching for the "North Star".

This Viewpoint discusses the goals of the inaugural National Drug Control Strategy, which as the ambitious agenda of emphasizing harm reduction practices, medications for treating opioid use disorder, and criminal justice reform, as well as supporting long-term recovery and interrupting illicit drug trafficking.

Pivot: partisan policy responses to COVID-19 health disparities.

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.

How do you solve a problem like Maria? The politics of disaster response in Puerto Rico, Florida and Texas.

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.

Technically Accessible, Practically Ineligible: The Effects of Medicaid Expansion Implementation on Chronic Homelessness.

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.

The Good and Evil of Health Policy: Medicaid Expansion, Republican Governors, and Moral Intuitions.

Using moral foundations theory (MFT), this study analyzes how Republican governors employed moral concepts to either build support or opposition to Medicaid expansion. The study examined statements about Medicaid expansion made by all Republican governors as reported in two large newspapers in each governor's state from 28 June 2012 to 31 December 2018. A slight majority of the statements (183 or 58.5%) used moral arguments in support of Medicaid expansion. Governors from both policy camps most frequently used the moral foundations shared by liberals and conservatives: care/harm and fairness/cheating. Those supporting expansion also used loyalty/betrayal, authority/subversion, and sanctity/degradation. Those opposing expansion used liberty/oppression. Policymakers recognize that activating the public's moral intuitions can be an effective way to advance a policy of interest. Those interested in advancing health policies would do well to better understand the kind of moral arguments that are used with potential supporters and arguments that may be used by opponents.

Double-edged sword of federalism: variation in essential health benefits for mental health and substance use disorder coverage in states.

The Affordable Care Act requires all insurance plans sold on health insurance marketplaces and individual and small-group plans to cover 10 Essential Health Benefits (EHB), including behavioral health services. Instead of applying a uniform EHB plan design, the Department of Health and Human Services let states define their own EHB plan. This approach was seen as the best balance between flexibility and comprehensiveness, and assumed there would be little state-to-state variation. Limited federal oversight runs the risk of variation in EHB coverage definitions and requirements, as well as potential divergence from standardized medical guidelines. We analyzed 112 EHB documents from all states for behavioral health coverage in effect from 2012 to 2017. We find wide variation among states in their EHB plan required-coverage, and divergence between medical-practice guidelines and EHB plans. These results emphasize consideration of federated regulation over health insurance coverage standards. Federal flexibility in states benefit design nods to state-specific policymaking-processes and population needs. However, flexibility becomes problematic if it leads to inadequate coverage that reduces access to critical health care services. The EHBs demonstrate an incomplete effort to establish appropriate minimum standards of coverage for behavioral health services.

Infectious disease, public health, and politics: United States response to Ebola and Zika.

Politics, rather than disease characteristics, complicated the United States response to Ebola virus disease and Zika virus. We analyze how media and political elites shaped public opinion of the two outbreaks. We conducted a retrospective analysis of media coverage, Congressional floor speech, and public opinion polls to explain elite cueing and public perceptions of Ebola and Zika. We find evidence of elite cueing by Congress and the media on public opinion. Public opinion of both disease outbreaks initially followed partisan patterns. However, while Ebola public opinion remained partisan, ultimately, opinion emerged of a bipartisan nature for Zika, mirroring elite framing. Public health officials should be aware of how elite cueing shapes policy and prioritizes partisan strategies. Politics and public opinion can focus attention on or away from infectious disease; it can also undermine public health responses by biasing the public's view of a diseases' relative risk.