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Low-income Medicare beneficiaries rely on Medicaid for supplemental coverage but must meet income and asset tests to qualify. We examined states' income and asset tests for full-benefit Medicaid during the period 2006-18 and examined how alternative asset tests would affect eligibility for community-dwelling Medicare beneficiaries ages sixty-five and older. Most states have not updated the dollar limit of Medicaid's asset test since 1989, making the asset test increasingly restrictive in inflation-adjusted terms. We estimated that increasing Medicaid's asset limit by the Consumer Price Index, to Medicare Savings Program levels, or to $10,000 for individuals and $20,000 for couples would increase Medicaid eligibility by 1.7 percent, 4.4 percent, and 7.5 percent, respectively. Simplifying Medicaid's asset test to focus only on certain high-value assets would increase eligibility by 20.5 percent. Increasing asset limits would lessen restrictions on Medicaid eligibility that arise from stagnant asset tests, broadening eligibility for certain low- income Medicare beneficiaries and allowing them to retain higher, yet still modest, savings. [ABSTRACT FROM AUTHOR]

During the COVID-19 pandemic, as immigration and asylum processes were delayed or interrupted, migrants and asylum seekers were stranded at Mexico's northern border. In-transit migrants and asylum seekers are an underserved population, and pandemic preparedness has seldom taken their needs into account. In this article we analyze public health policies developed in Mexico in response to the COVID-19 pandemic and describe how these policies have largely overlooked the needs of vulnerable mobile populations. We reviewed eighty publicly available documents issued by federal, state, and municipal authorities in Mexico between January and September 2020. Only seven policy documents explicitly considered in-transit migrants and asylum seekers and their health care needs. In addition, we identified six major gaps in these policies that, if addressed, would promote greater inclusion of persons in mobility in future pandemic response plans, to protect the health of migrant populations. [ABSTRACT FROM AUTHOR]

New York City has emerged as the global epicenter for the coronavirus disease 2019 (COVID-19) pandemic. The city's public health system, New York City Health + Hospitals, has been key to the city's response because its vulnerable patient population is disproportionately affected by the disease. As the number of cases rose in the city, NYC Health + Hospitals carried out plans to greatly expand critical care capacity. Primary intensive care unit (ICU) spaces were identified and upgraded as needed, and new ICU spaces were created in emergency departments, procedural areas, and other inpatient units. Patients were transferred between hospitals to reduce strain. Critical care staffing was supplemented by temporary recruits, volunteers, and Department of Defense medical personnel. Supplies needed to deliver critical care were monitored closely and replenished to prevent interruptions. An emergency department action team was formed to ensure that the experience of front-line providers was informing network-level decisions. The steps taken by NYC Health + Hospitals greatly expanded its capacity to provide critical care during an unprecedented surge of COVID-19 cases in NYC. These steps, along with lessons learned, could inform preparations for other health systems during a primary or secondary surge of cases. [ABSTRACT FROM AUTHOR]

The Supplemental Nutrition Assistance Program (SNAP) is the largest US food and nutrition assistance program, tasked with improving food security among low-income households. Another federal effort to improve food access is the Healthy Food Financing Initiative (HFFI), which invested tens of millions of dollars to incentivize healthy food retail outlets in areas lacking access to nutritious, fresh food. We explore the intersection of these programs, testing the impact of a new, HFFI-financed full-service supermarket on SNAP participants in an urban food desert. After the supermarket's opening, SNAP participants' food security improved and intake of added sugars declined in the intervention neighborhood, but both were unchanged in a comparison neighborhood without a new supermarket. Intervention neighborhood participants also experienced relative declines in the percentage of daily calories from solid fats, alcoholic beverages, and added sugars. Our findings suggest that HFFI amplifies the effects of SNAP participation on improving food security and dietary quality in food deserts. [ABSTRACT FROM AUTHOR]

Provider organizations are increasingly held accountable for health care spending in vulnerable populations. Longitudinal data on health care spending and use among people experiencing episodes of homelessness could inform the design of alternative payment models. We used Medicaid claims data to analyze spending and use among 402 people who were continuously enrolled in the Boston Health Care for the Homeless Program (BHCHP) from 2013 through 2015, compared to spending and use among 18,638 people who were continuously enrolled in Massachusetts Medicaid with no evidence of experiencing homelessness. The BHCHP population averaged $18,764 per person per year in spending--2.5 times more than spending among the comparison Medicaid population ($7,561). In unadjusted analyses this difference was explained by greater spending in the BHCHP population on outpatient care, including emergency department care, as well as on inpatient care and prescription drugs. After adjustment for covariates and multiple hypothesis testing, the difference was largely driven by outpatient spending. Differences were sensitive to adjustments for risk score, which suggests that housing instability and health risk are meaningfully correlated. This longitudinal analysis improves understanding of health care use and resource needs among people who are homeless or have unstable housing, and it could inform the design of alternative payment models for vulnerable populations. [ABSTRACT FROM AUTHOR]

People who are homeless use more hospital-based care than average, yet little is known about how hospital and shelter use are interrelated. We examined the timing of emergency department (ED) visits and hospitalizations relative to entry into and exit from New York City homeless shelters, using an analysis of linked health care and shelter administrative databases. In the year before shelter entry and the year following shelter exit, 39.3 percent and 43.3 percent, respectively, of first-time adult shelter users had an ED visit or hospitalization. Hospital visits--particularly ED visits--began to increase several months before shelter entry and declined over several months after shelter exit, with spikes in ED visits and hospitalizations in the days immediately before shelter entry and following shelter exit. We recommend cross-system collaborations to better understand and address the co-occurring health and housing needs of vulnerable populations. [ABSTRACT FROM AUTHOR]

The article discusses a study on the Medicare Skilled Nursing Facility Value-Based Purchasing Program (VBP) at skilled nursing facilities (SNF) as of July 2019. Results show that SNFs serving vulnerable populations like African-Americans, Hispanic residents, and Medicaid-pay residents were less likely to receive bonus payments and more likely to be penalized. Also noted are the likely roles of income, assets, and payment source as causes for the findings.

The Bundled Payments for Care Improvement (BPCI) initiative established four models to test whether linking payments for an episode of care could reduce Medicare payments while maintaining or improving quality. Evaluations concluded that model 2, the largest, generally lowered payments without reducing quality for the average beneficiary, but these global results could mask adverse findings among vulnerable subpopulations. We analyzed changes in emergency department visits, unplanned hospital readmissions, and all-cause mortality within ninety days of hospital discharge among beneficiaries with one or more of three vulnerable characteristics--dementia, dual eligibility for Medicare and Medicaid, and recent institutional care--in 105,458 beneficiary episodes in the period October 2013-December 2016. The results for twelve types of medical and surgical BPCI episodes were evaluated relative to results in matched comparison groups. Our findings suggest that BPCI model 2 did not adversely affect care quality for beneficiaries with vulnerabilities. While this conclusion does not discourage the further development of bundled payment models, policy makers should support ongoing research to ensure that vulnerable populations are not adversely affected by these approaches. [ABSTRACT FROM AUTHOR]

The effects of high-deductible health plans (HDHPs) on breast cancer diagnosis and treatment among vulnerable populations are unknown. We examined time to first breast cancer diagnostic testing, diagnosis, and chemotherapy among a group of women whose employers switched their insurance coverage from health plans with low deductibles ($500 or less) to plans with high deductibles ($1,000 or more) between 2004 and 2014. Primary subgroups of interest comprised 54,403 low-income and 76,776 high-income women continuously enrolled in low-deductible plans for a year and then up to four years in HDHPs. Matched controls had contemporaneous low-deductible enrollment. Low-income women in HDHPs experienced relative delays of 1.6 months to first breast imaging, 2.7 months to first biopsy, 6.6 months to incident early-stage breast cancer diagnosis, and 8.7 months to first chemotherapy. High-income HDHP members had shorter delays that did not differ significantly from those of their low-income counterparts. HDHP members living in metropolitan, nonmetropolitan, predominantly white, and predominantly nonwhite areas also experienced delayed breast cancer care. Policies may be needed to reduce out-of-pocket spending obligations for breast cancer care. [ABSTRACT FROM AUTHOR]

The countries of Latin American are aging rapidly. Because most countries in the region lack adequate social protection systems, many Latin American governments have introduced noncontributoiy pension programs to reduce poverty and food shortages. This study assessed the effects of a large national noncontributory pension program on the health and health care use of older people in Colombia. Using an instrumental variables approach that exploited differential rollout of the program across municipalities, we found evidence that the program led to significant but small improvements in self-reported health and reductions in hospitalizations among men. No significant effects were found among women or among men for other health and health care use outcomes. A small noncontributoiy pension was associated with improvements in self-reported measures of health for vulnerable older men, but these effects are small in magnitude. Researchers and policy makers should assess ways to maximize the health benefits of cash transfers to poor older people. [ABSTRACT FROM AUTHOR]

The US health care system needs effective tools to address complex social and environmental issues that perpetuate health inequities, such as food insecurity, education and employment barriers, and substandard housing conditions. The medical-legal partnership is a collaborative intervention that embeds civil legal aid professionals in health care settings to address seemingly intractable social problems that contribute to poor health outcomes and health disparities. More than three hundred health care organizations are home to medical-legal partnerships. This article draws upon national survey data and field research to identify three models of the medical-legal partnership that health care organizations have adopted and the core elements of infrastructure that they share. Financing and commitment from health care organizations are key considerations for sustaining and scaling up the medical-legal partnership as a health equity intervention. [ABSTRACT FROM AUTHOR]

Public health scholarship increasingly recognizes community organizing as a vehicle for unleashing the collective power necessary to uproot socioeconomic inequities at the core of health disparities. In this article we reverse the analytical focus from how organizing can affect health equity, and we consider how the frame of health equity has shaped grassroots organizing. Using evidence from a range of cases in California, we suggest that the health equity frame can guide and justify grassroots groups' efforts to improve the health outcomes of marginalized populations; connect issues such as housing and school discipline to health; and provide a rationale for community organizing groups to directly address the trauma experienced by their own members and staff, who often come from communities at risk for poor health outcomes. [ABSTRACT FROM AUTHOR]

Populations with intensive health care needs and high care costs may be attracted to insurance plans that have high quality ratings, but patients may be likely to disenroll from a plan if their care needs are not met. We assessed the association between publicly reported Medicare Advantage plan star ratings and voluntary disenrollment of incident dialysis patients in the following year over the period 2007-13. We found that Medicare Advantage (MA) plans with lower star ratings had significantly higher rates of disenrollment by incident dialysis patients in the following year. Compared to MA plans with 4.0 or more stars, adjusted disenrollment rates were 3.9 percentage points higher for plans with 3.5 stars, 5.0 percentage points higher for those with 3.0 stars, and 12.1 percentage points higher for those with 2.5 or fewer stars. These findings suggest that low plan quality may lead to increased expenditures, as this high-cost population generally must shift from Medicare Advantage to traditional Medicare upon disenrollment. [ABSTRACT FROM AUTHOR]

Hospitals play an important role in caring for patients in the current opioid crisis, but data on the outcomes and composition of opioid-driven hospitalizations in the United States have been lacking. Nationally representative all-payer data for the period 1993-2014 from the National Inpatient Sample were used to compare the mortality rates and composition of hospitalizations with opioid-related primary diagnoses and those of hospitalizations for other drugs and for all other causes. Mortality among opioid-driven hospitalizations increased from 0.43 percent before 2000 to 2.02 percent in 2014, an average increase of 0.12 percentage points per year relative to the mortality of hospitalizations due to other drugs--which was unchanged. While the total volume of opioid-driven hospitalizations remained relatively stable, it shifted from diagnoses mostly involving opioid dependence or abuse to those centered on opioid or heroin poisoning (the latter have higher case fatality rates). After 2000, hospitalizations for opioid/heroin poisoning grew by 0.01 per 1,000 people per year, while hospitalizations for opioid dependence or abuse declined by 0.01 per 1,000 people per year. Patients admitted for opioid/heroin poisoning were more likely to be white, ages 50-64, Medicare beneficiaries with disabilities, and residents of lower-income areas. As the United States combats the opioid epidemic, efforts to help hospitals respond to the increasing severity of opioid intoxication are needed, especially in vulnerable populations. [ABSTRACT FROM AUTHOR]

Children with special health care needs are believed to be susceptible to inequities in health and health care access. Within the group with special needs, there is a smaller group of children with medical complexity: children who require medical services beyond what is typically required by children with special health care needs. We describe health care inequities for the children with medical complexity compared to children with special health care needs but without medical complexity, based on a secondary analysis of data from the 2005-06 and 2009-10 National Survey of Children with Special Health Care Needs. The survey examines the prevalence, health care service use, and needs of children and youth with special care needs, as reported by their families. The inequities we examined were those based on race/ethnicity, primary language in the household, insurance type, and poverty status. We found that children with medical complexity were twice as likely to have at least one unmet need, compared to children without medical complexity. Among the children with medical complexity, unmet need was not associated with primary language, income level, or having Medicaid. We conclude that medical complexity itself can be a primary determinant of unmet needs. [ABSTRACT FROM AUTHOR]

The Affordable Care Act (ACA) establishes essential health benefits as the coverage standard for health plans sold in the individual and small-group markets for all fifty states and the District of Columbia, including the health insurance Marketplaces. “Pediatric services” is one of the required classes of coverage under the ACA. However, other than oral health and vision care, neither the act nor the regulations for implementing it define what these services should be. We investigated how state benchmark plans—the base plan chosen in each state as the standard or benchmark of coverage in that state under ACA rules—address pediatric coverage in plans governed by the essential health benefits standard. Our review of summaries of all the state benchmark plans found that no state specified a distinct pediatric services benefit class. Furthermore, although benchmark plans explicitly included multiple pediatric conditions, many plans also specifically excluded services for children with special health care needs. The Department of Health and Human Services has made a commitment in the essential health benefits regulations to review its approach for the 2016 plan year. Thus, our findings have implications for future regulations regarding the essential health benefits standard for pediatric services. [ABSTRACT FROM AUTHOR]

Section 340B of the Public Health Service Act provides qualified organizations serving vulnerable populations with deep discounts for some outpatient medications. A 2010 regulatory change widely expanded the 340B program's reach, allowing these organizations to contract with retail pharmacies to dispense medications for eligible patients. Little is known about which medications are dispensed by contract pharmacies under the expanded program. We provide the first comparison of 340B prescriptions and all prescriptions dispensed in contract pharmacies. We used 2012 data from Walgreens, the national leader in 340B contract pharmacies. Medications used to treat chronic conditions such as diabetes, high cholesterol levels, asthma, and depression accounted for an overwhelming majority of all prescriptions dispensed at Walgreens as part of the 340B program. A higher percentage of antiretrovirals used to treat HIV/AIDS were dispensed through 340B prescriptions than through all prescriptions dispensed at Walgreens. The majority of 340B prescriptions dispensed at Walgreens originated at tuberculosis clinics, consolidated health centers, disproportionate-share hospitals, and Ryan White clinics. Our results suggest that 340B contract pharmacies dispense medications used to treat Americans' chronic disease burden and disproportionately dispense medications used by key vulnerable populations targeted by the program. [ABSTRACT FROM AUTHOR]

Spending on specialty medications, which represented a small proportion of US pharmacy spending at the beginning of this decade, is growing by more than 15 percent annually. It is expected to account for approximately half ($235 billion) of total annual pharmacy spending by 2018. Among the numerous reasons for the high cost of this heterogeneous group of medications are the increasing size of target patient populations, the high cost of drug development, and a complex and uncoordinated delivery system. In this article we describe the evolution of the specialty market, characterize the current state of specialty medication use, and articulate key challenges and potential solutions. Fully realizing the potential value of the expanding universe of specialty medications will require collaborative efforts to reduce waste and promote value. Those who prescribe, dispense, deliver, and pay for specialty medications will need to employ a combination of traditional and novel management approaches, such as prior authorization, step therapy, tiered formularies, administration at lower-cost sites, and the unique tools being developed for cancer medications. [ABSTRACT FROM AUTHOR]

As Hurricane Katrina demonstrated in 2005, US health response systems for disasters-typically designed to handle only short-term mass-casualty events-are inadequately prepared for disasters that result in large-scale population displacements. Similarly, after the 2011 Great East Japan Earthquake, Japan found that many of its disaster shelters failed to meet international standards for long-term provision of basic needs and health care for the vulnerable populations that sought refuge in the shelters. Hospital disaster plans had not been tested and turned out to be inadequate, and emergency communication equipment did not function. We make policy recommendations that aim to improve US responses to mass-displacement disasters based on Japan's 2011 experience. First, response systems must provide for the extended care of large populations of chronically ill and vulnerable people. Second, policies should ensure that shelters meet or exceed international standards for the provision of food, water, sanitation, and privacy. Third, hospital disaster plans should include redundant communication systems and sufficient emergency provisions for both staff and patients. Finally,there must be routine drills for responses to mass-displacement disasters so that areas needing improvement can be uncovered before an emergency occurs. [ABSTRACT FROM AUTHOR]

The 2007-09 recession led to an overall slowing in health care spending growth, but it is unclear whether the slowed spending growth had different impacts on adults and children. Although most children are healthy, forgoing routine health care could have long-term adverse implications for public health. Furthermore, children with special health care needs are at risk of adverse outcomes if they do not receive adequate care. Focusing on privately insured families with children, we investigated how out-of-pocket spending trends changed before and during the recession. Medical Expenditure Panel Survey data from the period 2001- 09 revealed that the recession did not affect out-of-pocket spending for most children, but it led to a decline in spending for children with special needs, who had much higher out-of-pocket spending at baseline. Adults had significantly lower out-of-pocket spending during the recession, which suggests that parents may reduce their own medical care in difficult economic times to meet their children's health care needs. [ABSTRACT FROM AUTHOR]

Accountable care organizations (ACOs) are a promising payment model aimed at reducing costs while also improving the quality of care. However, there is a risk that vulnerable populations may not be fully incorporated into this new model. We define two distinct vulnerable populations, clinically at-risk and socially disadvantaged, and we discuss how ACOs may benefit each group. We provide a framework to use in considering challenges for both vulnerable patients and health systems on the path to accountable care. We identify policies that can help overcome these obstacles: strategies that support ACO formation in diverse settings and that monitor, measure, and reward the performance of providers that reach all patients, including vulnerable populations. [ABSTRACT FROM AUTHOR]

Nearly 30 percent of young adults with special health care needs in Ohio lack health insurance, compared to 5 percent of the state's children with special health care needs. As children with such needs become too old for Medicaid or insurance through their parents' employer, they face great challenges in obtaining insurance. Lack of insurance is highly predictive of unmet needs, which in turn are predictive of costly hospital-based encounters. Young adults with special health care needs who are uninsured are more than twice as likely as their peers with insurance to forgo filling prescriptions and getting care and to have problems getting care. Even after insurance status is accounted for, young adults with special health care needs are more likely than children with such needs to not fill prescriptions because of cost and to delay or forgo needed care. This study demonstrates that continuous and adequate health insurance is vital to the continued well- being of children with special health care needs as they transition to young adulthood. [ABSTRACT FROM AUTHOR]

An interview with Patient-Centered Outcomes Research Institute (PCORI) executive director Joe V. Selby is presented. When asked about the relationships of PCORI with the members of the U.S. Congress, he cites the Congress' appreciation on the aspects and likely benefits of comparative effectiveness research. He also notes the potential advantage of PCORI in engaging with wide range of stakeholders. Furthermore, Selby mentions the potential funding of the organization through 2019.

Closures of hospital trauma centers have accelerated since 2001. These closures may disproportionately affect disadvantaged communities. We evaluate how driving time between ZIP code areas and the nearest trauma centers--a proxy for access, given the time-sensitive nature of trauma care--changed nationwide during 2001-07. By 2007, sixty-nine million Americans (24 percent of the population) had to travel farther to the nearest trauma center than they did in 2001, and almost sixteen million people had to travel an additional thirty minutes or more. Communities with disproportionately high numbers of African American residents, uninsured people, and people living in poverty, as well as people living in rural areas, were more likely than others to be thus affected. Because mortality from traumatic injuries has also worsened for these vulnerable populations, policy makers should learn more about the possible connections--and consider such measures as paying trauma centers serving these communities higher amounts for treatment of injuries. [ABSTRACT FROM AUTHOR]

In developed countries some parents have decided not to provide routine vaccinations for their children, while in many developing countries there are inadequate rates of vaccination for various reasons. The consequences for children, and members of the community in which they live, can be significant and even tragic. Although some parents may worry that vaccines will harm their child, there is a broader moral case for vaccination that parents and policy makers should consider. This case has four components: benefits and harms, best interests, community benefits, and justice. This moral case should be central to deliberations about vaccination by parents and policy makers. [ABSTRACT FROM AUTHOR]

Protecting the health of the public--particularly the most vulnerable groups, such as children--requires rethinking current approaches to reducing environmental risks. We review the evolving understanding of the relationship between exposure to chemicals in the environment and disease, as well as the current state of managing those chemicals. We present recommendations to improve current approaches, including changing the burden of proof so that chemicals are not presumed safe in the absence of scientific data. We also propose modernizing approaches to assessing health risks. [ABSTRACT FROM AUTHOR]

Racial or ethnic minority groups and low-income communities have poorer health outcomes than others. They are more frequently exposed to multiple environmental hazards and social stressors, including poverty, poor housing quality, and social inequality. Researchers are grappling with how best to characterize the cumulative effects of these hazards and stressors in order to help regulators and decision makers craft more-effective policies to address health and environmental disparities. In this article we synthesize the existing scientific evidence regarding the cumulative health implications of higher rates of exposure to environmental hazards, along with individual biological susceptibility and social vulnerability. We conclude that current environmental policy, which is focused narrowly on pollutants and their sources, should be broadened to take into account the cumulative impact of exposures and vulnerabilities encountered by people who live in neighborhoods consisting largely of racial or ethnic minorities or people of low socioeconomic status. [ABSTRACT FROM AUTHOR]

A key policy breakthrough occurred nearly twenty years ago with the discovery that children are far more sensitive than adults to toxic chemicals in the environment. This finding led to the recognition that chemical exposures early in life are significant and preventable causes of disease in children and adults. We review this knowledge and recommend a new policy to regulate industrial and consumer chemicals that will protect the health of children and all Americans, prevent disease, and reduce health care costs. The linchpins of a new US chemical policy will be: first, a legally mandated requirement to test the toxicity of chemicals already in commerce, prioritizing chemicals in the widest use, and incorporating new assessment technologies; second, a tiered approach to premarket evaluation of new chemicals; and third, epidemiologic monitoring and focused health studies of exposed populations. [ABSTRACT FROM AUTHOR]

Did the Massachusetts health reforms, which provided near-universal insurance coverage, also address problems of unmet need resulting from the cost of care and of inadequate preventive care for diverse patient groups? We found that nearly a quarter of adults who were in fair or poor health reported being unable to see a doctor because of cost during the implementation of the reforms. We also found that state residents earning less than $25,000 per year were much less likely than higher earners to receive screening for cardiovascular disease and cancer. The state needs to implement new strategies to build on the promise of universal coverage and address specific needs of vulnerable populations, such as limiting out-of-pocket spending for this group. Also, more data are needed on the social determinants of health to identify specific barriers related to cost and access for vulnerable groups that general insurance reforms may not address. [ABSTRACT FROM AUTHOR]

The Oregon Health Plan was created to be a sustainable program that could weather budgetary storms without having to cut enrollees from Medicaid. A 2003 redesign of the program increased premiums, raised cost sharing, and imposed rigid premium payment deadlines for members in the "Standard" version of the program but not for members of the "Plus" version. This paper adds two years of longitudinal data to a previous study on the impacts of these changes. It shows that the redesign was a key factor driving a 77 percent disenrollment rate in the Standard program, from a high of 104,000 enrollees in February 2003 to just 24,000 by the end of the study period, November 2005. Those who were in the Standard plan when the reduced benefits and higher member costs went into effect were also nearly twice as likely to have unmet health care needs compared to those in the Plus plan. These changes underscore that in a period of economic downturn, policy makers must understand the impact of increased cost sharing on vulnerable populations. [ABSTRACT FROM AUTHOR]

Health care is undermined when patients don't receive the benefit of laws intended to address social determinants of health, such as housing and food. Medical-legal partnerships, which now exist in more than 200 clinical sites in the United States, integrate lawyers into health care to address legal problems that create and perpetuate poor health. This paper describes how such medical-legal partnerships can change clinical systems--for example, by adding legal form letters to electronic health records to help low-income patients rectify substandard housing conditions. We recommend the integration of medical-legal partnerships into federal health care programs. [ABSTRACT FROM AUTHOR]

The article presents the contents of a blog on U.S. health affairs as of July 2019. Topics discussed include the challenge of providing pandemic vaccines in low and middle-income countries, the likelihood of fatal crashes for each mile driven by motorists starting at ages 70-74, and the need to reduce low-value care and increase high-value services to maximize the health of vulnerable populations.

The article details the oral health (OH)-activities of charitable organizations and foundations in the U.S. Topics covered include the Missouri Foundation for Health's OH Initiative that helps the underserved in Saint Louis to have access to OH care, the Delta Dental Foundation's awarding of two-million dollars to the University of Michigan's School of Dentistry for the construction of a clinic for special-needs patients, and the Caring for Colorado Foundation's support for OH Colorado.

A response by Jonathan P. Weiner to a letter to the editor about his article on risk adjustment in state health insurance exchanges in the U.S. that was published in the February 2012 issue is presented.

The article presents information on Philip J. Landrigan, dean for Global Health at the Mount Sinai School of Medicine and director of Mount Sinai's Children's Environmental Health Center, who through an article about the vulnerability of children to toxic chemicals makes the case that U.S. chemical regulations should recognize that children are more vulnerable than adults to adverse affects of chemicals. He also played an important role in getting the federal government recognizing children as highly susceptible to deleterious effects of environmental exposures in ways that adults are not. Landrigan started testing the blood of children attending school near an El Paso, Texas, smelting plant in the early 1970s.

An introduction is presented in which the editor discusses various reports within the issue on topics including the environmental health landscape in the U.S., the effects of roughly 83,000 manufactured chemicals on the market, and the potential effects of bisphenol A on fetuses, infants, and young children.