Health Care Access and Utilization and the Latino Health Paradox.

BACKGROUND: The Latino health paradox is the phenomenon whereby recent Latino immigrants have, on average, better health outcomes on some indicators than Latino immigrants who have lived in the United States longer and US-born Latinos and non-Latino Whites. This study examined whether the paradox holds after accounting for health care access and utilization. METHODS: The 2019-2020 National Health Interview Survey data were used. The main predictors included population groups of foreign-born and US-born Latinos (Mexican or non-Mexican) versus US-born non-Latino Whites. Predicted probabilities of health outcomes (self-reported poor/fair health, overweight/obesity, hypertension, coronary heart disease, diabetes, cancer, and depression) were calculated and stratified by length of residence in the United States (<15 or ≥15 years) among foreign-born Latinos and sex (female or male). Multivariable analyses adjusted for having a usual source of care other than the emergency department, health insurance, a doctor visit in the past 12 months, predisposing and enabling factors, and survey year. RESULTS: After adjusting for health care access, utilization, and predisposing and enabling factors, foreign-born Latinos, including those living in the United States ≥15 years, had lower predicted probabilities for most health outcomes than US-born non-Latino Whites, except overweight/obesity and diabetes. US-born Latinos had higher predicted probabilities of overweight/obesity and diabetes and a lower predicted probability of depression than US-born non-Latino Whites. CONCLUSIONS: In this national survey, the Latino health paradox was observed after adjusting for health care access and utilization and predisposing and enabling factors, suggesting that, although these are important factors for good health, they do not necessarily explain the paradox.

Spatial Heterogeneity in Fatal Overdose Rate Trends in Mexican Cities: 2005-2021.

Objectives. To describe national and city-level fatal drug overdose trends between 2005 and 2021 in Mexico. Methods. We calculated fatal overdose rates at the city level in 3-year periods from 2005 to 2021 and annually at the national level for people aged 15 to 64 years in Mexico. We calculated rate differences and rate ratios for each city between periods. Results. The national fatal overdose rate was 0.53 overdose deaths per 100 000 population and was almost twice as high in urban than in nonurban areas. The national fatal overdose rate was stable over the period 2005 to 2014 and increased monotonically to a peak in 2021. Fatal overdose rates varied across cities. Cities with the 8 highest fatal overdose rates in the period were all in states along the US-Mexico border. Conclusions. Fatal overdoses have doubled over the past 15 years in Mexico. Overdose rates are particularly high and increasing in cities close to the US-Mexico border. Public Health Implications. There is a need for enhanced overdose surveillance data and coordinated harm reduction strategies, particularly in the northern border region of Mexico. (Am J Public Health. 2024;114(7):705-713. https://doi.org/10.2105/AJPH.2024.307650).

Trends in the contribution of greenhouse gas emissions from food and beverage purchases in Mexico: 1989-2020.

BACKGROUND: Assessing the trends in dietary GHGE considering the social patterning is critical for understanding the role that food systems have played and will play in global emissions in countries of the global south. Our aim is to describe dietary greenhouse gas emissions (GHGE) trends (overall and by food group) using data from household food purchase surveys from 1989 to 2020 in Mexico, overall and by education levels and urbanicity. METHODS: We used cross-sectional data from 16 rounds of Mexico's National Income and Expenditure Survey, a nationally representative survey. The sample size ranged from 11,051 in 1989 to 88,398 in 2020. We estimated the mean total GHGE per adult-equivalent per day (kg CO2-eq/ad-eq/d) for every survey year. Then, we estimated the relative GHGE contribution by food group for each household. These same analyses were conducted stratifying by education and urbanicity. RESULTS: The mean total GHGE increased from 3.70 (95%CI: 3.57, 3.82) to 4.90 (95% CI 4.62, 5.18) kg CO2-eq/ad-eq/d between 1989 and 2014 and stayed stable between 4.63 (95% CI: 4.53, 4.72) and 4.89 (95% CI: 4.81, 4.96) kg CO2-eq/ad-eq/d from 2016 onwards. In 1989, beef (19.89%, 95% CI: 19.18, 20.59), dairy (16.87%, 95% CI: 16.30, 17.42)), corn (9.61%, 95% CI: 9.00, 10.22), legumes (7.03%, 95% CI: 6.59, 7.46), and beverages (6.99%, 95% CI: 6.66, 7.32) had the highest relative contribution to food GHGE; by 2020, beef was the top contributor (17.68%, 95%CI: 17.46, 17.89) followed by fast food (14.17%, 95% CI: 13.90, 14.43), dairy (11.21%, 95%CI: 11.06, 11.36), beverages (10.09%, 95%CI: 9.94, 10.23), and chicken (10.04%, 95%CI: 9.90, 10.17). Households with higher education levels and those in more urbanized areas contributed more to dietary GHGE across the full period. However, households with lower education levels and those in rural areas had the highest increase in these emissions from 1989 to 2020. CONCLUSIONS: Our results provide insights into the food groups in which the 2023 Mexican Dietary Guidelines may require to focus on improving human and planetary health.

Food and beverage purchases at formal and informal outlets in Mexico.

OBJECTIVE: To examine food and beverage purchasing patterns across formal and informal outlets among Mexican households' and explore differences by urbanicity and income. DESIGN: Cross-sectional study of a nationally representative sample of households. We calculated the proportion of total food and beverage expenditure in each household by food outlet type overall and by urbanicity and income. We defined informal outlets as those which are not registered or regulated by tax and fiscal laws. Since some of the outlets within community food environments do not fall in clear categories, we defined a continuum from formal to informal outlets, adding mixed outlets as a category. SETTING: Mexico. PARTICIPANTS: Mexican households (n 74 203) from the 2018 National Income and Expenditure Survey. RESULTS: Of the total food and beverage purchases, outlets within the formal food sector (i.e. supermarkets and convenience stores) accounted for 15 % of the purchases, 13 % of purchases occurred in outlets within the informal food sector (i.e. street markets, street vendors and acquaintances) and 70 % in fiscally mixed outlets (i.e. small neighbourhood stores, specialty stores and public markets). Across levels of urbanicity and income, most food and beverage purchases occurred in mixed outlets. Also, purchases in informal and mixed outlets decreased as levels of urbanicity and income increased. In contrast to informal outlets, purchases in formal outlets were most likely from richer households and living in larger sized cities. CONCLUSIONS: Understanding where Mexican households shop for food is relevant to create tailored interventions according to food outlet type, accounting for regulatory and governance structures.

Potential impacts of policies to reduce purchasing of ultra-processed foods in Mexico at different stages of the social transition: an agent-based modelling approach.

OBJECTIVES: To develop a simulation framework for assessing how combinations of taxes, nutrition warning labels and advertising levels could affect purchasing of ultra-processed foods (UPF) in Latin American countries and to understand whether policies reinforce or reduce pre-existing social disparities in UPF consumption. DESIGN: We developed an agent-based simulation model using international evidence regarding the effect of price, nutrition warning labels and advertising on UPF purchasing. SETTING: We estimated policy effects in scenarios representing two stages of the 'social transition' in UPF purchasing: (1) a pre-transition scenario, where UPF purchasing is higher among high-income households, similar to patterns in Mexico; and (2) a post-transition scenario where UPF purchasing is highest among low-income households, similar to patterns in Chile. PARTICIPANTS: A population of 1000 individual agents with levels of age, income, educational attainment and UPF purchasing similar to adult women in Mexico. RESULTS: A 20 % tax would decrease purchasing by 24 % relative to baseline in both the pre- and post-transition scenarios, an effect that is similar in magnitude to that of a nutrition warning label policy. A 50 % advertising increase or decrease had a comparatively small effect. Nutrition warning labels were most effective among those with higher levels of educational attainment. Labelling reduced inequities in the pre-transition scenario (i.e. highest UPF purchasing among the highest socio-economic group) but widened inequities in the post-transition scenario. CONCLUSIONS: Effective policy levers are available to reduce UPF purchasing, but policymakers should anticipate that equity impacts will differ depending on existing social patterns in UPF purchasing.

State Policies that Impact the Design of Children's Mental Health Services: A Modified Delphi Study.

To identify the state-level policies and policy domains that state policymakers and advocates perceive as most important for positively impacting the use of children's mental health services (CMHS). We used a modified Delphi technique (i.e., two rounds of questionnaires and an interview) during Spring 2021 to elicit perceptions among state mental health agency officials and advocates (n = 28) from twelve states on state policies that impact the use of CMHS. Participants rated a list of pre-specified policies on a 7-point Likert scale (1 = not important, 7 = extremely important) in the following policy domains: insurance coverage and limits, mental health services, school and social. Participants added nine policies to the initial list of 24 policies. The "school" policy domain was perceived as the most important, while the "social" policy domain was perceived as the least important after the first questionnaire and the second most important policy domain after the second questionnaire. The individual policies perceived as most important were school-based mental health services, state mental health parity, and Medicaid reimbursement rates. Key stakeholders in CMHS should leverage this group of policies to understand the current policy landscape in their state and to identify gaps in policy domains and potential policy opportunities to create a more comprehensive system to address children's mental health from a holistic, evidence-based policymaking perspective.

Telehealth Benefits Offered by Medicare Advantage Plans in 2020.

OBJECTIVE: The objective of this study was to analyze new telehealth benefits offered by Medicare Advantage (MA) plans in 2020 and examine plan characteristics associated with the provision of the new telehealth benefits. RESEARCH DESIGN: Using publicly available data from the Centers for Medicare and Medicaid Services, we identified unique MA plans with at least 1 enrollee in January 2020. We examined whether plans offered any new telehealth benefits in 2020, the 20 most common types of telehealth services covered, and cost-sharing. Next, we used multivariable logistic regression to identify associations between offering any telehealth benefits and plan characteristics. We conducted a similar analysis for each of the 3 most commonly covered telehealth services. RESULTS: Of 2992 unique MA plans, 58.1% offered new telehealth benefits in 2020. The most frequently covered services were primary care, mental health, and urgent care. Coverage for other types of services was limited. Our multivariable logistic regression showed that offering any new telehealth benefits was not more common among plans in rural areas, but was more likely among national plans, those with a monthly premium, those with >3540 enrollees, and those with a star rating of 4.0-4.5. The new telehealth benefits were less likely to be provided by for-profit plans. Overall, findings remained similar when analyzed according to the type of services. CONCLUSIONS: MA plans are embracing new telehealth benefits, but there is room for improvement. Policymakers should consider how to accelerate the adoption curve of telehealth in MA plans.

Are price discounts on sugar-sweetened beverages (SSB) linked to household SSB purchases? - a cross-sectional study in a large US household and retail scanner database.

BACKGROUND: Price promotions on sugar-sweetened beverages (SSBs) are commonly used by retailers to provide economic incentives for purchasing. Surprisingly, there is a lack of high-quality articles that examine the frequency and magnitude of sugary beverage discounting and consumer responses to discounts. The objective of this study is to quantify the association between exposure to price discounts and SSB purchases. METHODS: This cross-sectional study linked 2016 SSB consumption data from a U.S. household consumer panel (analytic sample N = 11,299 households) and weekly prices at stores where they shopped. We derived percent of the time SSBs were discounted (annual promotion frequency) and the amount of the discount (annual promotion magnitude) and assessed their association with household annual per capita SSB purchase ounces. Linear regression models adjusted for household size, income per capita, age, education, presence of children, race, occupation, region, and urbanicity. We also evaluated whether the association between promotion and purchase varied by socioeconomic status and race subgroups. Data were analyzed in 2019-2020. RESULTS: On average, households were exposed to SSBs price promotions 44% of the time. A 10-percentage point increase in annual SSB promotion frequency was associated with 13.7% increase in annual per capita purchasing (P < 0.0001), and a 1-percentage point increase in annual SSB promotion magnitude was associated with 15.3% increase in annual per capita purchasing (P < 0.0001). These associations did no vary significantly across socioeconomic status and race subgroups (Interaction P > 0.2). CONCLUSIONS: More frequent and deeper price promotion was associated with higher annual per capita SSB purchases. Restricting SSB price promotions may be effective at reducing SSB consumption.

Financial Performance of Medicare Advantage Contracts in 2014 and Plan Renewal, Consolidation, and Termination Rates in the Subsequent Year.

BACKGROUND: Starting in 2014, the Affordable Care Act mandated that Medicare Advantage (MA) contracts spend at least 85% of total revenue on claims and quality improvement [ie, the medical loss ratio (MLR)] and submit revenue and cost data annually in MLR reports. These reports can improve transparency of the financial performance of MA contracts. However, little is known about revenues and costs of insurers that participate in MA and its impacts on status changes in the following year. OBJECTIVE: To characterize revenues and costs of MA contracts in 2014, with a focus on MLRs and gross margins, and to assess heterogeneity in subsequent-year plan renewal and termination rates by gross margins. RESEARCH DESIGN: Cross-sectional data from MLR reports submitted in 2014 by MA contracts and from 2015 Part C & D Plan Crosswalk Files regarding plan renewal, termination, and other status changes from 2014 to 2015. SUBJECTS: Three hundred eighty-nine MA contracts. MEASURES: Primary outcomes are MLRs and gross margins. RESULTS: MLRs averaged 93% in 2014; 11% of contracts reported MLRs of at least 100%. Fifty-six percent reported negative margins, or costs that exceeded revenues. Seventeen percent of plans in contracts in the lowest quartile of gross margins were terminated in 2015, compared to under 5% of plans in the highest-margin contracts. CONCLUSIONS: In 2014, MA contracts reported MLRs greater than the mandatory minimum of 85%. Gross margins likely contribute to trends in plan and insurer availability. MLR reports from subsequent years can help explain fluctuations in insurers' participation in MA.

Association of maternal characteristics with latino youth health insurance disparities in the United States: a generalized structural equation modeling approach.

BACKGROUND: Disparities in access to care persist for Latino youth born in the United States (US). The association of maternal characteristics, such as maternal citizenship status and insurance coverage, on youth health insurance coverage is unclear and is important to examine given the recent sociopolitical shifts occurring in the US. METHODS: We analyzed pooled cross-sectional data from the 2010-2018 National Health Interview Survey to examine the association of Latina maternal citizenship status on maternal insurance coverage status and youth uninsurance among US-born Latino youth. Our study sample consisted of 15,912 US-born Latino youth (ages < 18) with linked mothers. Our outcome measures were maternal insurance coverage type and youth uninsurance and primary predictor was maternal citizenship status. Generalized structural equation modeling was used to examine the relationships between maternal characteristics (maternal citizenship, maternal insurance coverage status) and youth uninsurance. RESULTS: Overall, 7% of US-born Latino youth were uninsured. Just 6% of youth with US-born mothers were uninsured compared to almost 10% of those with noncitizen mothers. Over 18% of youth with uninsured mothers were uninsured compared to 2.2% among youth with mothers who had private insurance coverage. Compared to both US-born and naturalized citizen Latina mothers, noncitizen Latina mothers had 4.75 times the odds of reporting being uninsured. Once adjusted for predisposing, enabling, and need factors, maternal uninsurance was strongly associated with youth uninsurance and maternal citizenship was weakly associated with youth uninsurance among US-born Latino youth. CONCLUSION: Maternal citizenship was associated with both maternal uninsurance and youth uninsurance among US-born Latino youth. Federal- and state-level health policymaking should apply a two-generational approach to ensure that mothers of children are offered affordable health insurance coverage, regardless of their citizenship status, thus reducing uninsurance among US-born Latino youth.

Cardiovascular disease behavioral risk factors among Latinos by citizenship and documentation status.

BACKGROUND: Studies have observed that recent Latino immigrants tend to have a physical health advantage compared to immigrants who have been in the US for many years or Latinos who are born in the United States. An explanation of this phenomenon is that recent immigrants have positive health behaviors that protect them from chronic disease risk. This study aims to determine if trends in positive cardiovascular disease (CVD) risk behaviors extend to Latino immigrants in California according to citizenship and documentation status. METHODS: We examined CVD behavioral risk factors by citizenship/documentation statuses among Latinos and non-Latino US-born whites in the 2011-2015 waves of the California Health Interview Survey. Adjusted multivariable logistic regressions estimated the odds for CVD behavioral risk factors, and analyses were stratified by sex. RESULTS: In adjusted analyses, using US-born Latinos as the reference group, undocumented Latino immigrants had the lowest odds of current smoking, binge drinking, and frequency of fast food consumption. There were no differences across the groups for fruit/vegetable intake and walking for leisure. Among those with high blood pressure, undocumented immigrants were least likely to be on medication. Undocumented immigrant women had better patterns of CVD behavioral risk factors on some measures compared with other Latino citizenship and documentation groups. CONCLUSIONS: This study observes that the healthy Latino immigrant advantage seems to apply to undocumented female immigrants, but it does not necessarily extend to undocumented male immigrants who had similar behavioral risk profiles to US-born Latinos.

Time Spent Eating, by Immigrant Status, Race/Ethnicity, and Length of Residence in the United States.

INTRODUCTION: Time spent eating is associated with obesity and diet-related diseases. We examined the association between time adults spent eating, immigrant status, race/ethnicity, and race/ethnicity among adults in the United States. METHODS: We used multivariate linear regression to analyze a cross-sectional, nationally representative sample of respondents aged 19 years or older (N = 192,486) from the 2016 American Time Use Survey. The outcome measures were time spent per day on primary eating and drinking and secondary eating. The predictors were immigrant status, race/ethnicity, and years spent living in the United States. RESULTS: Multivariate adjusted minutes per day spent on primary eating and drinking were 66.4 for noncitizens, 66.5 for naturalized citizens, and 60.1 for US-born individuals. Multivariate adjusted minutes per day spent on secondary eating were 11.1 for noncitizens, 12.2 for naturalized citizens, and 12.9 for US-born individuals. Minutes per day spent on primary eating and drinking for immigrants by length of residence in the United States was 69.7 minutes for 5 years or less of residence, 67.9 minutes for 6 to 10 years of residence, 63.6 minutes for 11 to 15 years of residence, and 63.6 minutes for more than 15 years of residence. Minutes per day spent on secondary eating for immigrants by length of residence was 5.5 minutes for 5 years or less of residence, 9.7 minutes for 6 to 10 years of residence, 8.4 minutes for 11 to 15 years of residence, and 12.6 minutes for more than 15 years of residence. CONCLUSION: Time spent eating varied by immigrant status and length of residence in the United States.

Depression and alcohol misuse among older adults: exploring mechanisms and policy impacts using agent-based modelling.

PURPOSE: To: (1) explore how multi-level factors impact the longitudinal prevalence of depression and alcohol misuse among urban older adults (≥ 65 years), and (2) simulate the impact of alcohol taxation policies and targeted interventions that increase social connectedness among excessive drinkers, socially isolated and depressed older adults; both alone and in combination. METHODS: An agent-based model was developed to explore the temporal co-evolution of depression and alcohol misuse prevalence among older adults nested in a spatial network. The model was based on Los Angeles and calibrated longitudinally using data from the Multi-Ethnic Study of Atherosclerosis. RESULTS: Interventions with a social component targeting depressed and socially isolated older adults appeared more effective in curbing depression prevalence than those focused on excessive drinkers. Targeting had similar impacts on alcohol misuse, though the effects were marginal compared to those on depression. Alcohol taxation alone had little impact on either depression or alcohol misuse trajectories. CONCLUSIONS: Interventions that improve social connectedness may reduce the prevalence of depression among older adults. Targeting considerations could play an important role in determining the success of such efforts.

Examining the possible impact of daily transport on depression among older adults using an agent-based model.

OBJECTIVES: Daily transport may impact depression risk among older adults through several pathways including facilitating the ability to meet basic needs, enabling and promoting contact with other people and nature, and promoting physical activity (e.g. through active transportation such as walking or walking to public transit). Both daily transport and depression are influenced by the neighborhood environment. To provide insights into how transport interventions may affect depression in older adults, we developed a pilot agent-based model to explore the contribution of daily transport and neighborhood environment to older adults' depression in urban areas. METHOD: The model includes about 18,500 older adults (i.e. agents) between the ages of 65 and 85 years old, living in a hypothetical city. The city has a grid space with a number of neighborhoods and locations. Key dynamic processes in the model include aging, daily transport use and feedbacks, and the development of depression. Key parameters were derived from US data sources. The model was validated using empirical studies. RESULTS: An intervention that combines a decrease in bus fares, shorter bus waiting times, and more bus lines and stations is most effective at reducing depression. Lower income groups are likely to be more sensitive to the public transit-oriented intervention. CONCLUSION: Preliminary results suggest that promoting public transit use may be a promising strategy to increase daily transport and decrease depression. Our results may have implications for transportation policies and interventions to prevent depression in older adults.

Complex Systems Approaches to Understand Drivers of Mental Health and Inform Mental Health Policy: A Systematic Review.

We conducted a systematic review of studies employing complex systems approaches (i.e., agent based and system dynamics models) to understand drivers of mental health and inform mental health policy. We extracted key data (e.g., purpose, design, data) for each study and provide a narrative synthesis of insights generated across studies. The studies investigated drivers and policy intervention strategies across a diversity of mental health outcomes. Based on these studies and the extant literature, we propose a typology of mental health research and policy areas that may benefit from complex systems approaches.

Insurance Coverage and Utilization Improve for Latino Youth but Disparities by Heritage Group Persist Following the ACA.

OBJECTIVE: Latino youth experience worse access to and utilization of health care compared with non-Latino "white" youth, with inequities persisting following the implementation of the Affordable Care Act (ACA). To better understand these disparities, we examine changes in youth's access and utilization associated with the ACA for different Latino heritage groups relative to whites. STUDY DESIGN: We use 6 years (2011-2016) of National Health Interview Survey data to examine Latino youth's insurance coverage and health care utilization by heritage group, nativity, and parental language. The dependent measures of utilization included well-child, emergency department, and physician visits. We used multivariable logistic regression models to estimate the odds of each dependent measure and interacted heritage group and time period [2011-2013 (pre-ACA) versus 2014-2016 (post-ACA)] to examine how changes associated with the ACA varied by group. RESULTS: Insurance coverage and well-child visits improved among youth overall following implementation of the ACA. Although Mexican and Central or South American youth experienced the largest absolute increase in coverage, they still had high levels of uninsurance post-ACA (9.9% and 9.1%, respectively). Disparities in coverage between Puerto Rican and white youth improved, while disparities in well-child visits between Mexican and white youth worsened. Little to no movement was observed in disparities by nativity and parental language. CONCLUSIONS: Most disparities in insurance and utilization across Latino heritage groups and white youth persisted post-ACA despite significant gains within groups. Although disparities for Puerto Rican youth have improved, Mexican and Central or South American youth continue to experience disparities.

Health Care Access and Physical and Behavioral Health Among Undocumented Latinos in California.

BACKGROUND: This paper provides statewide estimates on health care access and utilization patterns and physical and behavioral health by citizenship and documentation status among Latinos in California. METHODS: This study used data from the 2011-2015 California Health Interview Survey to examine health care access and utilization and physical and behavioral health among a representative sample of all nonelderly Latino and US-born non-Latino white adults (N=51,386). Multivariable regressions estimated the associations between the dependent measures and citizenship/documentation status among Latinos (US-born, naturalized citizen, green card holder, and undocumented). RESULTS: Adjusted results from multivariable analyses observed worse access and utilization patterns among immigrant Latinos compared with US-born Latinos, with undocumented immigrants using significantly less health care. Undocumented Latinos had lower odds of self-reporting excellent/very good health status compared with US-born Latinos, despite them having lower odds of having several physical and behavioral health outcomes (overweight/obesity, physician-diagnosed hypertension, asthma, self-reported psychological distress, and need for behavioral health services). Among those reporting a need for behavioral health services, access was also worse for undocumented Latinos when compared with US-born Latinos. CONCLUSIONS: Patterns of poor health care access and utilization and better physical and behavioral health are observed across the continuum of documentation status, with undocumented immigrants having the worst access and utilization patterns and less disease. Despite fewer reported diagnoses and better mental health, undocumented Latinos reported poorer health status than their US-born counterparts.

The Affordable Care Act Attenuates Financial Strain According to Poverty Level.

We use data from the 2011-2016 National Health Interview Survey to examine how the Patient Protection and Affordable Care Act (ACA) has influenced disparities in health care-related financial strain, access to care, and utilization of services by categories of the Federal Poverty Level (FPL). We use multivariable regression analyses to determine the ACA's effects on these outcome measures, as well as to determine how changes in these measures varied across different FPL levels. We find that the national implementation of the ACA's insurance expansion provisions in 2014 was associated with improvements in health care-related financial strain, access, and utilization. Relative to adults earning more than 400% of the FPL, the largest effects were observed among those earning between 0% to 124% and 125% to 199% of the FPL after the implementation of the ACA. Both groups experienced reductions in disparities in financial strain and uninsurance relative to the highest FPL group. Overall, the ACA has attenuated health care-related financial strain and improved access to and the utilization of health services for low- and middle-income adults who have traditionally not met income eligibility requirements for public insurance programs. Policy changes that would replace the ACA with less generous age-based tax subsidies and reductions in Medicaid funding could reverse these gains.

A Case Study of the Philadelphia Sugar-Sweetened Beverage Tax Policymaking Process: Implications for Policy Development and Advocacy.

CONTEXT: Policymakers are increasingly proposing sugar-sweetened beverage (SSB) taxes as an evidence-based strategy to reduce chronic disease risk; and local health departments (LHDs) are well-positioned to play a role in SSB policy development and advocacy. However, most SSB tax proposals fail to become law and limited empiric guidance exists to inform advocacy efforts. In June 2016, Philadelphia, Pennsylvania, passed an SSB tax. OBJECTIVE: To identify features of the Philadelphia SSB tax policymaking process that contributed to the proposal's passage. DESIGN: Qualitative case study. Semistructured interviews were conducted with key informants closely involved with the policymaking process. Interviews were audio-recorded and transcribed. Local news media about the SSB tax proposal were analyzed to triangulate interview findings. Analysis was conducted in NVivo 10 using inductive qualitative content analysis. SETTING: Philadelphia, Pennsylvania, during the SSB tax policymaking in process. PARTICIPANTS: Nine key informants (2 city councilpersons, 4 city agency officials, 1 community-based advocate, 1 news reporter, and 1 researcher). RESULTS: The Philadelphia SSB tax proposal was introduced with the explicit goal of financing universal prekindergarten and deliberately not framed as a health intervention. This framing shifted contentious debates about government involvement in individual behavior toward discussions about how to finance universal prekindergarten, a goal for which broad support existed. The LHD played an important role in communicating research evidence about potential health benefits of the SSB tax proposal at the end of the policymaking process. CONCLUSIONS: During local SSB tax policy development processes, LHD officials and other advocates should encourage policymakers to design SSB tax policies so that revenue is directed toward community investments for which broad public support exists. When communicating with policymakers and the public, LHDs should consider emphasizing how SSB tax revenue will be used in addition to presenting evidence about the potential health benefits of the SSB tax at the local level.