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We investigated racial and ethnic disparities in COVID-19 vaccine uptake, using data from the Centers for Disease Control and Prevention. As of March 29, 2022, uptake of the first dose was higher among Hispanic and Asian people than among White and Black people. In contrast, uptake rates of the booster were higher among Asian and White people than among Black and Hispanic people.

Background Implementation researchers are increasingly using economic evaluation to explore the benefits produced by implementing evidence-based practices (EBPs) in healthcare settings. However, the findings of typical economic evaluations (e.g., based on clinical trials) are rarely sufficient to inform decisions about how health service organizations and policymakers should finance investments in EBPs. This paper describes how economic evaluations can be translated into policy and practice through complementary research on financing strategies that support EBP implementation and sustainment. Main body We provide an overview of EBP implementation financing, which outlines key financing and health service delivery system stakeholders and their points of decision-making. We then illustrate how economic evaluations have informed decisions about EBP implementation and sustainment with three case examples: (1) use of Pay-for-Success financing to implement multisystemic therapy in underserved areas of Colorado, USA, based in part on the strength of evidence from economic evaluations; (2) an alternative payment model to sustain evidence-based oncology care, developed by the US Centers for Medicare and Medicaid Services through simulations of economic impact; and (3) use of a recently developed fiscal mapping process to collaboratively match financing strategies and needs during a pragmatic clinical trial for a newly adapted family support intervention for opioid use disorder. Conclusions EBP financing strategies can help overcome cost-related barriers to implementing and sustaining EBPs by translating economic evaluation results into policy and practice. We present a research agenda to advance understanding of financing strategies in five key areas raised by our case examples: (1) maximize the relevance of economic evaluations for real-world EBP implementation; (2) study ongoing changes in financing systems as part of economic evaluations; (3) identify the conditions under which a given financing strategy is most beneficial; (4) explore the use and impacts of financing strategies across pre-implementation, active implementation, and sustainment phases; and (5) advance research efforts through strong partnerships with stakeholder groups while attending to issues of power imbalance and transparency. Attention to these research areas will develop a robust body of scholarship around EBP financing strategies and, ultimately, enable greater public health impacts of EBPs.

This survey study examines the prevalence of incentive receipt for COVID-19 vaccination and the association of various sociodemographic characteristics with perspectives on incentives’ influence on trust in the COVID-19 vaccine.

Objective:Emergency departments (EDs) are critical sources of care after natural disasters such as hurricanes. Understanding the impact on ED utilization by subpopulation and proximity to the hurricane’s path can inform emergency preparedness planning. This study examines changes in ED utilization for residents of 344 counties after the occurrence of 7 US hurricanes between 2005 and 2016.Methods:This retrospective observational study used ED data from the Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases. ED utilization rates for weeks during and after hurricanes were compared with pre-hurricane rates, stratified by the proximity of the patient county to the hurricane path, age, and disease category.Results:The overall population rate of weekly ED visits changed little post-hurricane, but rates by disease categories and age demonstrated varying results. Utilization rates for respiratory disorders exhibited the largest post-hurricane increase, particularly 2–3 weeks following the hurricane. The change in population rates by disease categories and age tended to be larger for people residing in counties closer to the hurricane path.Conclusions:Changes in ED utilization following hurricanes depend on disease categories, age, and proximity to the hurricane path. Emergency managers could incorporate these factors into their planning processes.

Amid global scarcity of COVID-19 vaccines and the threat of new variant strains, California and other jurisdictions face the question of when and how to implement and relax COVID-19 Nonpharmaceutical Interventions (NPIs). While policymakers have attempted to balance the health and economic impacts of the pandemic, decentralized decision-making, deep uncertainty, and the lack of widespread use of comprehensive decision support methods can lead to the choice of fragile or inefficient strategies. This paper uses simulation models and the Robust Decision Making (RDM) approach to stress-test California’s reopening strategy and other alternatives over a wide range of futures. We find that plans which respond aggressively to initial outbreaks are required to robustly control the pandemic. Further, the best plans adapt to changing circumstances, lowering their stringent requirements to reopen over time or as more constituents are vaccinated. While we use California as an example, our results are particularly relevant for jurisdictions where vaccination roll-out has been slower.

There is an urgent need for an assessment of public health interventions to address coronavirus disease 2019 (COVID-19) and determine when to relax them. This document describes the COVID-19 Decision Support Tool, which is designed to fill that need.

The formulas for distributing funds to states under three block grants (the Community Mental Health Services Block Grant, the Substance Abuse Prevention and Treatment Block Grant, and the Projects for Assistance in Transition from Homelessness program) have not been updated since 1992. RAND researchers conducted this congressionally mandated study to determine whether the formulas should be modified.

RAND researchers analyzed the formulas for distributing funds to states under three block grants for services related to mental health, substance abuse, and homelessness (unchanged since 1992) to determine whether they should be modified.

California Senate Bill 1953 requires structural and nonstructural upgrades to hospital buildings to enhance resilience to seismic events. This report estimates the costs to hospitals of compliance, focusing on the 2030 deadline. The potential costs have raised significant concerns regarding the financial burden on hospital systems and the opportunity costs associated with hospitals investing large pools of capital to implement seismic upgrades.

Motor vehicle crashes account for a large number of deaths and injuries. In the United States, in 2015, more than 35,000 people were killed and approximately 2.44 million were injured in motor vehicle crashes. In 2010, the economic costs associated with motor vehicle crashes in the United States were substantial, estimated to be $242 billion. Fortunately, a wide range of evidence-based interventions, including both policies and programs, can help prevent motor vehicle-related injuries and deaths. In 2014, RAND researchers developed an online tool, the Motor Vehicle Prioritizing Interventions and Cost Calculator for States (MV PICCS), to help determine the costs and effectiveness of various interventions to reduce injuries and deaths from motor vehicle crashes and what interventions together generate the largest reductions in injuries and deaths for a given implementation budget. A 2015 update added two new interventions and produced a series of reports about allocating traffic safety funds. The 2017 update, MV PICCS 3.0, determined whether to add new interventions, updated information on the interventions' effectiveness and costs, and redesigned the tool's user interface to be more user-friendly.

Motor vehicle crashes account for a large number of deaths and injuries. In the United States, in 2015, more than 35,000 people were killed and approximately 2.44 million were injured in motor vehicle crashes. In 2010, the economic costs associated with motor vehicle crashes in the United States were substantial, estimated to be $242 billion. Fortunately, a wide range of evidence-based interventions, including both policies and programs, can help prevent motor vehicle-related injuries and deaths. In 2014, RAND researchers developed an online tool, the Motor Vehicle Prioritizing Interventions and Cost Calculator for States (MV PICCS), to help determine the costs and effectiveness of various interventions to reduce injuries and deaths from motor vehicle crashes and what interventions together generate the largest reductions in injuries and deaths for a given implementation budget. A 2015 update added two new interventions and produced a series of reports about allocating traffic safety funds. The 2017 update, MV PICCS 3.0, determined whether to add new interventions, updated information on the interventions' effectiveness and costs, and redesigned the tool's user interface to be more user-friendly.

The Centers for Disease Control and Prevention's interactive Motor Vehicle Prioritizing Interventions and Cost Calculator for States (MV PICCS) can help state decisionmakers prioritize motor vehicle injury–prevention interventions. For each intervention, MV PICCS calculates the expected number of injuries prevented and lives saved and the costs of implementation. This new version provides a more user-friendly interface and updated data.

ObjectiveAlthough recent emergencies or disasters have underscored the vital role of nongovernmental (NGO) resources, they remain not well understood or leveraged. We intended to develop an assets framework that identifies relevant NGO resources for disaster preparedness and response that can be used to assess their availability at state and local levels.MethodsWe conducted a search of peer-reviewed publications to identify existing asset frameworks, and reviewed policy documents and gray literature to identify roles of NGOs in emergency preparedness, response, and recovery. A standardized data abstraction form was used to organize the results by NGO sector.ResultsWe organized NGO assets into 5 categories: competencies, money, infrastructure or equipment, services, relationships, and data for each of the 11 sectors designated by the Centers for Disease Control and Prevention in the 2011 preparedness capabilities.ConclusionsOur findings showed that the capacity of each sector to capture data on each asset type needs strengthening so that data can be merged for just-in-time analysis to indicate where additional relief is needed. (Disaster Med Public Health Preparedness. 2013;0:1–6)

The Patient Protection and Affordable Care Act (ACA) contains substantial new requirements aimed at increasing rates of health insurance coverage. Because many of these provisions impose additional costs on the states, officials need reliable estimates of the likely impact of the ACA in their state. To demonstrate the usefulness of modeling for state-level decisionmaking, RAND undertook a preliminary analysis of the impact of the ACA on five states—California, Connecticut, Illinois, Montana, and Texas—using the RAND COMPARE microsimulation model. For Connecticut, the model predicts that, in 2016 (the year that all of the provisions in the ACA related to coverage expansion will be fully implemented), the uninsured rate in Connecticut will fall to 5 percent; without the law, it would remain at 11 percent. The model projects that total state government spending on health care will be 10 percent lower for the combined 2011–2020 period than it would be without the ACA, mostly because of federal subsidies for residents who would have been covered by Connecticut's state-run health insurance program (State-Administered General Assistance).

A focused review of recent RAND Health research identified small ideas that could save the U.S. health care system $13 to $22 billion per year, in the aggregate, if successfully implemented. In the substituting lower-cost treatments category, ideas are to reduce use of anesthesia providers in routine gastroenterology procedures for low-risk patients, change payment policy for emergency transport, increase use of lower-cost antibiotics for treatment of acute otitis media, shift care from emergency departments to retail clinics when appropriate, eliminate co-payments for higher-risk patients taking cholesterol-lowering drugs, increase use of $4 generic drugs, and reduce Medicare Part D use of brand-name prescription drugs by patients with diabetes. In the patient safety category, ideas are to prevent three types of health care-associated infections: (1) central line-associated bloodstream infections, (2) ventilator-associated pneumonia, and (3) catheter-associated urinary tract infections; use preoperative and anesthesia checklists to prevent operative and postoperative events; prevent in-facility pressure ulcers; use ultrasound guidance for central line placement; and prevent recurrent falls. Small ideas do not require systemic change; thus, they may be both more feasible to operationalize and less likely to encounter stiff political and organizational resistance.

RAND researchers' model of the child welfare system shows that increasing prevention while also increasing treatment improves system experience and long-term outcomes while paying for itself by reducing lifetime child welfare system costs.

To provide objective analyses about the effects of prevention and treatment programs on child welfare outcomes, RAND researchers built a quantitative model that simulated how children enter and flow through the nation's child welfare system. They then used the model to project how different policy options (preventive services, family preservation treatment efforts, kinship care treatment efforts, and a policy package that combined preventive services and kinship care) would affect a child's pathway through the system, costs, and outcomes in early adulthood. This study is the first attempt to integrate maltreatment risk, detection, pathways through the system, and consequences in a comprehensive quantitative model that can be used to simulate the impact of policy changes. This research suggests that expanding both prevention and treatment is needed to achieve the desired policy objectives: Combining options that intervene at different points in the system and increasing both prevention and treatment generates stronger effects than would any single option. The simulation model identifies ways to increase both targeted prevention and treatment while achieving multiple objectives: reducing maltreatment and the number of children entering the system, improving a child's experience moving through the system, and improving outcomes in young adulthood. These objectives can all be met while also reducing total child welfare system costs. A policy package combining expanded prevention and kinship supports pays for itself: There is a net cost reduction in the range of 3 to 7 percent of total spending (or approximately $5.2 billion to $10.5 billion saved against the current baseline of $155.9 billion) for a cohort of children born over a five-year period.

Rather than forcing a choice between expanding and enhancing either prevention or treatment plans, the child welfare system could find better results by focusing a balance of effort on improving both.

evidence-based treatment (EBT). Our results suggest that the 2-year social costs of depression and PTSD for this cohort will be $923 million. Policy simulations evaluating the savings associated with universal access to EBT suggest that such access would generate cost savings of $138 million (15%). Since 2001, more than 1.64 million U.S. troops have deployed to Operation Iraqi Freedom (OIF) or Operation Enduring Freedom (OEF), a pace unmatched in the history of the all-volunteer force (Tanielian & Jaycox, 2008). The future health-related costs of these deployments will undoubtedly be high because of physical and mental health injuries sustained during war. Calculation of these costs, which the government will be expected to pay, is a difficult task because of the inherent uncertainty underlying all the components that are necessary to construct such an estimate, including the number of people harmed, the number seeking treat- ment, the types of treatment given, the cost associated with treat- ment, and the subsequent outcomes that may befall a service member because of impaired health. In this article, we introduce an innovative method for estimating the future health costs for currently deployed service members that is well equipped to handle and quantify the uncertainty embedded in such a calculation: microsimulation modeling. Unlike standard accounting methods, a microsimulation model takes a hypothetical group of simulated individuals and predicts future cost-related events, allowing the simulated population to experience mental conditions, mental health treatment, and secondary outcomes such as employment. An advantage of the microsimulation approach is that it can treat mental disorders as chronic conditions, allowing for both remission and relapse over time. In addition, the micro- simulation model can be useful for evaluating different policy scenarios. In our case, we were particularly interested in asking the following policy question: If we increase the use of evidence- based treatment, will we save money in the long-run? This type of question would be difficult to evaluate in a standard accounting framework because standard accounting models are based on av- erage expenditures for a population and do not allow for different individuals to experience different treatments, subsequent out- comes, and costs. Data to parameterize the model, including in- formation about the probability of developing mental illness and the probability of remission following treatment, were taken from existing literature. We constructed a simplified microsimulation model that en- abled us to characterize the social cost over a 2-year period for two well-publicized and extremely prevalent health conditions associ- ated with combat exposure: posttraumatic stress disorder (PTSD) and major depression (Hoge, Auchterlonie, & Milliken, 2006

Background. Computer models played an important role in the health care reform debate, and they will continue to be used during implementation. However, current models are limited by inputs, including available data. Aim. We review microsimulation and cell-based models. For each type of model, we discuss data requirements and other factors that may affect its scope. We also discuss how to improve models by changing data collection and data access procedures. Materials and Methods. We review the modeling literature, documentation on existing models, and data resources available to modelers. Results. Even with limitations, models can be a useful resource. However, limitations mustbeclearlycommunicated. Modelingapproachescouldbeimprovedbyenhancing existinglongitudinaldata, improvingaccess tolinkeddata, and developingdata focused on health care providers. Discussion. Longitudinal datasets could be improved by standardizing questions across surveys or by fielding supplemental panels. Funding could be provided to identify causal parameters and to clarify ranges of effects reported in the literature. Finally,a forum for routine communication between modelers and policy makers could be established. Conclusion. Modeling can provide useful information for health care policy makers. Thus, investing in tools to improve modeling capabilities should be a high priority.

Objective: To assess the extent to which the systems in place for prevention and control of routine annual influenza could provide the information and experience needed to manage a pandemic.Methods: The authors conducted a qualitative assessment based on key informant interviews and the review of relevant documents.Results: Although there are a number of systems in place that would likely serve the United States well in a pandemic, much of the information and experience needed to manage a pandemic optimally is not available.Conclusions: Systems in place for routine annual influenza prevention and control are necessary but not sufficient for managing a pandemic, nor are they used to their full potential for pandemic preparedness. Pandemic preparedness can be strengthened by building more explicitly upon routine influenza activities and the public health system’s response to the unique challenges that arise each influenza season (eg, vaccine supply issues, higher than normal rates of influenza-related deaths). (Disaster Med Public Health Preparedness. 2009;3(Suppl 2):S160–S165)

On Sunday, 26 April 2009, the secretary of the U.S. Department of Health and Human Services declared a public health emergency in response to the outbreak of H1N1 influenza (known as swine flu) in the United States. Through an analysis of state and local health department Web sites, we determined whether departments were able to provide online information to their constituents within twenty-four hours of the declaration. The overwhelming majority of state health departments, and more than half of health departments participating in the Cities Readiness Initiative—but only a quarter of smaller, local health departments—were successful in doing so.

The widely cited Census Bureau estimates of the number of uninsured people, based on the Current Population Survey, probably overstate the number of uninsured people. This is because of a...

In this paper we examine the incremental cost of marijuana comorbidity for alcohol, mood and thought diagnoses in hospital settings. We use data from the 1993-2000 National Hospital Discharge Survey to examine the effect on length of stay and the 1995-2000 Florida Hospital Discharge Data to examine charges. General linear modeling (GLM) and propensity score methods are employed to deal with concerns stemming from the distribution of the dependent variables and statistically significant differences in the baseline characteristics of marijuana users versus non-users. Marijuana comorbidity is associated with longer length of stays and higher charges for patients suffering from a primary diagnosis of an alcohol problem. We also find higher average charges for patients suffering from mood disorders, though the finding is not robust across all model specifications. We do not find any significant effects for thought disorders. Findings from this study suggest that a marijuana comorbidity increases the cost of treating patients with alcohol problems and mood disorder diagnoses, implying that there may be real health consequences associated with marijuana abuse and dependence and more work considering this possibility is warranted.

This study had two purposes: (1) to characterize the density of liquor stores and bars that individuals face according to race, economic status, and age in the urban United States and (2) to assess alternative measures of retailer density based on the road network and population.We used census data on business counts and sociodemographic characteristics to compute the densities facing individuals in 9,361 urban zip codes.Blacks face higher densities of liquor stores than do whites. The density of liquor stores is greater among nonwhites in lower-income areas than among whites in lower- and higher-income areas and nonwhites in higher-income areas. Nonwhite youths face higher densities of liquor stores than white youths. The density of liquor stores and bars is lower in higher-income areas, especially for nonwhites.Mismatches between alcohol demand and the supply of liquor stores within urban neighborhoods constitute an environmental injustice for minorities and lower-income persons, with potential adverse consequences for drinking behavior and other social ills. Our results for bars are sensitive to the measure of outlet density as well as population density. Although neither measure is clearly superior, a measure that accounts for roadway miles may reflect proximity to alcohol retailers and thus serve as a useful refinement to the per-capita measure. If so, alcohol policy might also focus on density per roadway mile. Further research on the existence, causes, and consequences of environmental injustice in alcohol retailing is warranted.

Objective To examine trends in youth exposure to alcohol advertising on television across different demographic groups. Methods We used television ratings data on alcohol advertisements to examine trends in exposure between September 1998 and February 2002. Further, we explored the differences in exposure across demographic groups by examining group-level alcohol ad exposure across specific networks, program types, and times of day. Results We found that boys were more exposed than girls and African-Americans are more exposed than whites. Moreover, the race differential appeared to be increasing over time, whereas the gender differential appeared to increase with age. Differences in viewing patterns across race and gender contributed to the observed differences in exposure to alcohol advertising on television. Conclusions These results provide guidance in identifying comparative vulnerabilities in exposure to alcohol advertising on television, and can aid in the development of strategies to inoculate youth against those vulnerabilities.

This paper uses administrative data from two states covering the school years 1987–1988 to 2000–2001 to examine principal turnover and mobility. We use a longitudinal event history modeling approach to examine whether individual characteristics of the principal and the school in which they work are related to different types of principal turnover. We find that over the time period considered, turnover among all school principals was 14 percent in Illinois and 18 percent in North Carolina. Only 20 percent of this turnover was due to principals leaving the system in Illinois; and 13 percent in North Carolina. However, we observe some interesting variation by school characteristics. Specifically, we find that principals in schools with a larger proportion of minority students are more likely to change schools and to leave the principalship, but remain in the system.

I. INTRODUCTION Data from the 2002 National Survey of Drug Use and Health indicate that 16% of youth between the ages of 12 and 17 had used marijuana in the past year and 8% had used in the past month (SAMHSA 2002). These levels of use among youth are troubling given the negative outcomes that are associated with marijuana use. Among other things, marijuana use has been linked to reductions in educational attainment (Bray et al. 2000; Ellickson et al. 1998; Yamada et al. 1996), reduced cognitive ability (Block et al. 1990; Pope and Yurgelun-Todd 1996; Solowij 1998), and negative labor market outcomes (Brook et al. 2002; DeSimone 2002; French et al. 2001; Kaestner, 1991, 1994; Register and Williams, 1992). Although it is not clear that these relationships are causal, they do indicate that at the very least, early marijuana use is a signal for a variety of negative outcomes that can have long-term economic implications. Because of these long-term implications, both researchers and policy makers have considerable interest in developing a better understanding of the relationship between marijuana use and subsequent labor market outcomes. Such an understanding could guide policy makers in their efforts to alleviate problems such as economic disadvantage that are associated with marijuana use. The relationship, however, is complex and may work through several different pathways. An observed association between marijuana use and labor market outcomes may be causal, or it may merely reflect a spurious correlation due to unobserved individual-level factors that affect both marijuana use and labor market outcomes. Even if the relationship is causal, it is not clear in which direction the causality runs. Marijuana use may cause labor market outcomes, but labor market outcomes may also cause marijuana use. If marijuana use causes labor market outcomes, the effect of marijuana use on employment and earnings could be through either a direct or indirect relationship. In the first case, marijuana use may impact cognitive ability or motivation (Block et al. 1990; McGlothin and West 1968; Pope and Yurgelun-Todd 1996; Solowij 1998), thus reducing labor market productivity through such mechanisms as reduced job performance, increased absenteeism, or reduced labor supply. As a result, marijuana users, both current and prior, would be more likely to be unemployed or earning less than those who abstain. Moreover, the cognitive effects of marijuana may be cumulative over time, and thus prior use could have an effect on current job performance independent of current use patterns. In the second case, a negative relationship between marijuana use and employment or earnings could reflect the prior effect of marijuana use on human capital investments, such as education and training, that affect the accumulation of job-related skills. If labor market outcomes cause marijuana use, however, the relationship could be either positive or negative. Economic theory suggests that the increased disposable income associated with higher earnings would lead to an increase in the consumption of marijuana, so long as marijuana is a normal good. This argument would suggest a positive relationship between earnings and marijuana use. However, it could also be argued that poor labor market outcomes (e.g., unemployment) lead to increased marijuana use either because the individual now has more free time and a lower opportunity cost of marijuana use or because the individual uses marijuana to cope with the stress of unemployment. This type of argument would indicate that there is a negative relationship between labor market outcomes and drug use. In either case, the relationship between early marijuana use and later earnings should be minimal once later marijuana use is taken into account. Finally, the observed association between marijuana use and labor market outcomes may not be causal at all, reflecting a spurious correlation attributable to unobserved factors that could affect both marijuana use and labor market outcomes. …

Are older Americans becoming more or less disabled? Unhealthy body weight has increased dramatically, but other data show that disability rates have declined. We use data from the Health and Retirement Study to estimate the association between obesity and disability, and we combine these data with trend estimates of obesity rates from the Behavioral Risk Factor Surveillance Survey. If current trends in obesity continue, disability rates will increase by 1 percent per year more in the 50-69 age group than if there were no further weight gain.

This brief describes an interactive tool that can help statedecisionmakers choose policies that are effective in reducing motor vehicle accidents in their states and appropriate to state budgets, saving lives and reducing economic and societal loss.

According to analysis with a free new tool, allocating increased federal traffic safety funding by cost-effectiveness ratios rather than equally among states would save more than double the number of lives and prevent almost five times the injuries.

This report documents production of an online tool to help assess costs and effectiveness of implementing up to 14 interventions and select those most effective in reducing death and injury from motor vehicle crashes for a given implementation budget.

Objectives. This study sought to estimate how changes in state cigarette excise taxes affect the smoking behavior of pregnant women. Methods. Detailed information about mothers and their pregnancy was used to examine the impact of taxes on the propensity of pregnant women to smoke. The 1989 to 1995 Natality Detail Files were used in conducting analyses to assess the impact of taxes on smoking among different subpopulations. Results. Higher cigarette excise taxes reduced smoking rates among pregnant women. A tax hike of $0.55 per pack would reduce maternal smoking by about 22%. Overall, a 10% increase in price would reduce smoking rates by 7%. Estimates for subpopulations suggested that nearly all would be very responsive to tax changes, including the subpopulations with the highest smoking rates. Conclusions. Smoking rates among pregnant women are responsive to tax hikes.

Drinking among HIV-positive individuals increases risks of disease progression and possibly sexual transmission. We examined whether state alcohol sales policies are associated with drinking and sexual risk among people living with HIV. In a multivariate analysis combining national survey and state policy data, we found that HIV-positive residents of states allowing liquor sales in drug and grocery stores had 70% to 88% greater odds of drinking, daily drinking, and binge drinking than did HIV-positive residents of other states. High-risk sexual activity was more prevalent in states permitting longer sales hours (7% greater odds for each additional hour). Restrictive alcohol sales policies may reduce drinking and transmission risk in HIV-positive individuals.

In this paper, we present evidence of the likely impact of cigarette tax hikes on consumers, governments, and producers. We show that 100 percent of a tax hike is passed onto consumers in the form of higher prices. Using both state and individual-level data, we find a cigarette demand elasticity of -0.30 to -0.50, with long-term elasticities 1.75 times the short-term values. We demonstrate that cigarette taxes have become much more regressive over time as smoking rates among the highest income groups have fallen sharply. One reason for this drop is the large decline in smoking rates for the most educated. Given their ability to shift tax increases onto consumers, tobacco companies bear little of the burden of a tax. We estimate that for every $1 raised in tax revenues, cigarette companies lose only 8 cents in before-tax profits. Using daily stock prices, we conduct an event study examining how new information about litigation and settlement of state Medicaid cases against cigarette manufacturers changed t...

This systematic review sought to identify the best available evidence regarding strategies for allocating scarce resources during mass casualty events (MCEs). Specifically, the review addresses the following questions: (1) What strategies are available to policymakers to optimize the allocation of scarce resources during MCEs? (2) What strategies are available to providers to optimize the allocation of scarce resources during MCEs? (3) What are the public's key perceptions and concerns regarding the implementation of strategies to allocate scarce resources during MCEs? (4) What methods are available to engage providers in discussions regarding the development and implementation of strategies to allocate scarce resources during MCEs?We searched Medline, Scopus, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Global Health, Web of Science®, and the Cochrane Database of Systematic Reviews from 1990 through 2011. To identify relevant non-peer-reviewed reports, we searched the New York Academy of Medicine's Grey Literature Report. We also reviewed relevant State and Federal plans, peer-reviewed reports and papers by nongovernmental organizations, and consensus statements published by professional societies. We included both English- and foreign-language studies.Our review included studies that evaluated tested strategies in real-world MCEs as well as strategies tested in drills, exercises, or computer simulations, all of which included a comparison group. We reviewed separately studies that lacked a comparison group but nonetheless evaluated promising strategies. We also identified consensus recommendations developed by professional societies or government panels. We reviewed existing State plans to examine the current state of planning for scarce resource allocation during MCEs. Two investigators independently reviewed each article, abstracted data, and assessed study quality.We considered 5,716 reports for this comparative effectiveness review (CER); we ultimately included 170 in the review. Twenty-seven studies focus on strategies for policymakers. Among this group were studies that examined various ways to distribute biological countermeasures more efficiently during a bioterror attack or influenza pandemic. They provided modest evidence that the way these systems are organized influences the speed of distribution. The review includes 119 studies that address strategies for providers. A number of these studies provided evidence suggesting that commonly used triage systems do not perform consistently in actual MCEs. The number of high-quality studies addressing other specific strategies was insufficient to support firm conclusions about their effectiveness. Only 10 studies included strategies that consider the public's perspective. However, these studies were consistent in their findings. In particular, the public believes that resource allocation guidelines should be simple and consistent across health care facilities but should allow facilities some flexibility to make allocation decisions based on the specific demand and supply situation. The public also believes that a successful allocation system should balance the goals of ensuring the functioning of society, saving the greatest number of people, protecting the most vulnerable people, reducing deaths and hospitalizations, and treating people fairly and equitably. The remaining 14 studies provided strategies for engaging providers in discussions about allocating and managing scarce medical resources. These studies did not identify one engagement approach as clearly superior; however, they consistently noted the importance of a broad, inclusive, and systematic engagement process.Scientific research to identify the most effective adaptive strategies to implement during MCEs is an emerging area. While it remains unclear which of the many options available to policymakers and providers will be most effective, ongoing efforts to develop a focused, well-organized program of applied research should help to identify the optimal methods, techniques, and technologies to strengthen our nation's capacity to respond to MCEs.

Attempts to explain disparities in access to health care faced by racial and ethnic minorities and other underserved populations often focus on individual-level factors such as demographics, personal health beliefs, and health insurance status. This article proposes an examination of these disparities—and an effort to redress them—through the lens of public health. Public health agencies can link people to needed services such as immunizations, testing, and treatment; ensure the availability of health care; ensure the competency of the public health and personal health care workforce; and evaluate the effectiveness, accessibility, and quality of personal and population-based services. Approaching disparities through a public health framework can provide the foundation for developing more robust evidence to inform additional policies for improving access and reducing disparities.

To estimate the relationship between quality improvement and electronic health record (EHR) adoption in US hospitals.National cohort study based on primary survey data about hospital EHR capability collected in 2003 and 2006 and on publicly reported hospital quality data for 2004 and 2007.Difference-in-differences regression analysis to assess the relationship between EHR adoption and quality improvement for acute myocardial infarction, heart failure, and pneumonia care.Availability of a basic EHR was associated with a significant increase in quality improvement for heart failure (additional improvement, 2.6%; 95% confidence interval [CI], 1.0%-4.1%). However, adoption of advanced EHR capabilities was associated with significant decreases in quality improvement for acute myocardial infarction and heart failure. We observed 0.9% (95% CI, -1.7% to -0.1%) less improvement for acute myocardial infarction quality scores and 3.0% (95% CI, -5.2% to -0.8%) less improvement for heart failure quality scores among hospitals that newly adopted an advanced EHR, and 1.2% (95% CI, -2.0% to -0.3%) less improvement for acute myocardial infarction quality scores and 2.8% (95% CI, -5.4% to -0.3%) less improvement for heart failure quality scores among hospitals that upgraded their basic EHR.Mixed results suggest that current practices for implementation and use of EHRs have had a limited effect on quality improvement in US hospitals. However, potential "ceiling effects" limit the ability of existing measures to assess the effect that EHRs have had on hospital quality. In addition to the development of standard criteria for EHR functionality and use, standard measures of the effect of EHRs on quality are needed.

If all veterans suffering from major depression and posttraumatic stress disorder were to receive evidence-based treatments, policy simulations suggest that cost savings generated would be $138 million (15 percent) over two years.